Abstract
Objectives:
The COVID-19 pandemic changed the setting of education for many children in the U.S. Understanding COVID-19 vaccination coverage by educational setting is important to develop targeted messages, increase parents’ confidence in COVID-19 vaccines, and protect all children from severe effects of COVID-19 infection.
Study Design/Methods:
Using data from the Household Pulse Survey (n =25,173) collected from December 9-19, 2022, January 4-16, 2023, and February 1-13, 2023, this study assessed factors associated with COVID-19 vaccination and reasons for non-vaccination among school-aged children 5-11 and adolescents 12-17 by educational setting.
Results:
Among children 5-11 years, COVID-19 vaccination coverage was higher among those who received in-person instruction (53.7%) compared to those who were homeschooled (32.5%). Furthermore, among adolescents 12-17 years, COVID-19 vaccination coverage was higher among those who received in-person instruction (73.5%) or virtual/online instruction (70.1%) compared to those who were homeschooled (51.0%). Children and adolescents were more likely to be vaccinated if the parental respondent had been vaccinated compared to those who had not. Among children and adolescents who were homeschooled, main reasons for non-vaccination were concern about side effects (45.4-51.6%), lack of trust in COVID-19 vaccines (45.0-50.9%), and lack of trust in the government (32.7-39.2%).
Conclusions:
Children and adolescents who were home-schooled during the pandemic had lower vaccination coverage than those who attended school in person, and adolescents who were home-schooled had lower vaccination coverage than those who received virtual instruction. Based on the reasons for non-vaccination identified in this study, increasing parental confidence in vaccines, and reducing barriers to access are important for supporting COVID-19 vaccination for school-age children.
Keywords: COVID-19 vaccination, vaccine hesitancy, vaccine confidence, disparities, educational setting, homeschool
Introduction
The COVID-19 pandemic changed the setting of education for many children in the U.S., with more children receiving virtual learning or homeschooling during the pandemic than prior to the pandemic.1,2 While COVID-19 vaccines were recommended for children 5 – 17 years as of November 2021,3 disparities in COVID-19 vaccination coverage were found by age group, race/ethnicity, parental educational attainment, annual household income, and other factors. 4–7 Vaccine hesitancy is defined as the “delay in acceptance or refusal of vaccination despite availability of vaccination services.” 8 As of May 10, 2023 (date of the end of the Public Health Emergency for COVID-19), COVID-19 vaccination (≥1 dose) was 40.0% for children 5-11 years and 72.2% for children 12-17 years. 9 Vaccination with the updated (bivalent) booster dose was 4.8% for children 5-11 years and 7.8% for children 12-17 years. 9 Despite bivalent booster doses being recommended for children and adolescents since September, 2022, uptake remains low due to access issues, vaccine hesitancy, or other barriers. 3 Previous studies found that parental hesitancy toward COVID-19 vaccines for their children or adolescents stemmed from concerns about potential side effects, lack of trust in vaccines, and the belief that vaccines are not needed, but similar investigations of disparities in COVID-19 vaccination coverage by educational setting (e.g., in-person instruction, virtual instruction, homeschool, or other) and potential reasons for non-vaccination by educational setting are lacking.10–13
Some studies suggest that parents may be motivated to homeschool to avoid school vaccine mandates.14,15 Furthermore, parents who choose to homeschool children or enroll them in virtual/remote learning may have greater concerns over vaccine safety and effectiveness than those who enroll their children in in-person learning, and may choose non-in-person educational settings as an alternative strategy to reduce risk of infection among their children.15–17 One study found lower COVID-19 vaccination coverage among adolescents who were homeschooled compared to those who attended public or private schools.10 Studies show that the number of homeschooled children increased during the pandemic, and many parents who homeschool their children may be more hesitant toward the COVID-19 vaccines than other parents.2,14
COVID-19 vaccines are needed to protect children and adolescents from severe outcomes such as hospitalizations and deaths caused by COVID-19 infection. During January 2022, at the peak of the transmission of the Omicron variant, there were 6,372 COVID-19 cases and 4.4 deaths per 100,000 children 5-17 years.18,19 While studies showed that attack rates in school settings are low, 20–22 many parents feared COVID-19 exposure from schools or side effects from vaccines.11,23–25
The goal of this study was to assess and compare prevalence of COVID-19 vaccination among school-aged children 5-11 years and adolescents 12-17 years by educational setting using a large, nationally representative survey of U.S. households. Understanding COVID-19 vaccination coverage of children and adolescents by educational setting and reasons for non-vaccination is important for developing targeted vaccination promotion messages for diverse educational settings as well as to increase parents’ confidence in COVID-19 vaccines and protect all children from severe effects of COVID-19 infection.
Methods
Study Design
Since 2020, the U.S. Census Bureau has conducted the Household Pulse Survey (HPS) to understand how the coronavirus pandemic and other emergent issues are impacting households across the country from a social and economic perspective in collaboration with 16 other Federal agencies and offices.26 The agencies collaborated on the design and provided content for the HPS, which was reviewed and approved by the Office on Management and Budget. COVID-19 questions on the HPS were similar to questions on other national surveys, such as the National Immunization Survey, and coverage data were similar to provider-reported vaccinations. 9,27 The methodology of the HPS has been published previously and details of the sample size determination are reported on page 3. 28 The HPS is a nationally representative cross-sectional household survey of adults aged ≥18 years that is currently on a two-weeks on, two-weeks off collection and dissemination approach. Non-institutionalized adults aged ≥18 years in the United States were selected from the Census Bureau’s Master Address File and contacted via email and/or text. The 20-minute survey was conducted online using Qualtrics as a data collection platform. No compensation was provided for participation in the survey. Only publicly available survey data were used for the analysis presented in this paper. According to the methodology report available with the survey data, 28 participants were informed and agreed prior to the beginning of the survey that the survey is confidential and that the collection, monitoring, recording, and use of the information that they provide can be used for any lawful government purposes. Participants could skip any question that they chose. Data were collected from December 9-19, 2022 (response rate=6.7%), January 4-16, 2023 (response rate=6.4%); and February 1-13, 2023 (response rate = 7.0%)28
This analysis included only respondents with children aged 5 to 17 years living in the household (n=36,618) to reflect school aged children. Respondents could be anyone (i.e., parents, grandparents, aunts/uncles, older siblings, or other family members) living with children in the household, but hereafter referred to as “parents” for simplicity. To distinguish trends by child age group (5-11 years and 12-17 years), the analyses were restricted to parents with children in only one age group (n=25,173). Per Emory University Institutional Review Board determination assessments, this study is not considered human subjects research.
COVID-19 Vaccination and Reasons for Non-Vaccination
To identify households with children, respondents were asked: “In your household, are there… Children under 5 years old? Children 5 through 11 years old? Children aged 12–17 years?” Among households with children 5-11 or 12-17 years, respondents were asked, “For the children in this household, how long ago was their most recent dose of the COVID-19 vaccine or booster?” Responses of “On or after October 15, 2022 [when the bivalent booster was widely available],” “Before October 15, 2022 but less than a year ago,” or “More than a year ago” were categorized as vaccinated; responses of “Not vaccinated” were kept as not vaccinated.
Among respondents whose children were not vaccinated, respondents were asked: “Which of the following, if any, are reasons that the parents or guardians of children living in your household may not or will not get a vaccine for all of the children?” Response options, for which respondents could select all that applied, were: 1) concern about possible side effects of a COVID-19 vaccine for children; 2) plan to wait and see if it is safe and may get it later; 3) not sure if a COVID-19 vaccine will work for children; 4) don’t believe children need a COVID-19 vaccine; 5) the children in this household are not members of a high-risk group; 6) the children’s doctor has not recommended it; 7) don’t trust COVID-19 vaccines; 8) don’t trust the government; and 9) other.
Educational setting
Educational setting was assessed by the following question, “During the last 7 days, how did the children in this household receive their education?” Responses of “Children received in-person instruction from a teacher at their school” were categorized as receiving in-person instruction. For children who did not receive in-person instruction, responses of “Children received virtual/online instruction from a teacher in real time,” “Children learned on their own using online materials provided by their school,” or “Children learned on their own using paper materials provided by their school” were categorized as receiving virtual instruction/learned on their own. For children who did not receive in-person instruction or virtual instruction, responses of “Children learned on their own using materials that were not provided by their school” were categorized as “homeschooled.” Finally, responses of “Children did not participate in any learning activities because their school was closed,” “Children were sick and could not participate in education,” “Children were on summer break,” or “other.” For some analyses where sample size was low, educational setting was categorized as “in-person instruction” or “other” (which included virtual instruction, homeschool, or other).
Independent Variables
Sociodemographic factors assessed for parents of children 5-17 years were respondent age group, sex, race/ethnicity, highest educational attainment, annual household income, health insurance status, respondent vaccination status, respondent history of COVID-19 infection, Census region, and Health and Human Services (HHS) region. 29
Statistical Analysis
Sociodemographic characteristics were assessed for parents of children aged 5-11 and 12-17 years. Child and adolescent COVID-19 vaccination coverage (≥1 dose) were each assessed overall, by educational setting, respondent sociodemographic characteristics, and HHS region. Multivariable regression analyses were conducted to examine factors associated with the prevalence of child and adolescent COVID-19 vaccination (≥1 dose) for each educational setting using two-tailed significance testing. Reasons for not vaccinating among each age group were assessed overall and by educational setting, and were compared across educational settings using simple regression models. Results were considered statistically significant at p < 0.05. Analyses accounted for the survey design and weights to ensure a representative sample in Stata (version 18.0).
Results
There were 10,416 households with children aged 5-11 years, and 14,757 households with children 12-17 years in the study (Supplemental Table). Among children 5-11 years, 84.9% received in-person instruction, 1.6% received virtual instruction, 5.4% were homeschooled, and 8.1% received other/no instruction in the 7 days prior to the survey. Among adolescents 12-17 years, 77.9% received in-person instruction, 4.1% received virtual instruction, 7.5% were homeschooled, and 10.5% received other/no instruction in the 7 days prior to the survey.
Among children 5-11 years, COVID-19 vaccination coverage was 51.6% overall, with higher vaccination coverage among those who received in-person instruction (53.7%) compared to those who were homeschooled (32.5%) (Table 1). Among adolescents 12-17 years, COVID-19 vaccination coverage was 70.7% overall, with higher vaccination coverage among those who received in-person instruction (73.5%) or virtual/online instruction (70.1%) compared to those who are homeschooled (51.0%) (Table 2). For children and adolescents, vaccination coverage for in-person instruction was higher compared to homeschooling across most sociodemographic characteristics (Tables 1 and 2). In general, children and adolescents that received in-person instruction were more likely to be vaccinated against COVID-19 if the parental respondent was male, self-identified as non-Hispanic other/multiple races, had higher education, or had been vaccinated compared to their respective counterparts (Tables 1 and 2). Children and adolescents who were homeschooled were more likely to have been vaccinated against COVID-19 if the parental respondent self-identified as Hispanic, had health insurance, had been vaccinated, or did not have a prior COVID-19 infection compared to their respective counterparts.
Table 1.
Child COVID-19 vaccination coverage (≥1 dose) by educational setting and parental sociodemographic characteristics, United States, Household Pulse Survey, December 9, 2022 – February 13, 2023
| Overall (n=10,416) | In-person instructiona (n=9,099) | aPR (95%CI) | Virtual Instructionb (n=145) | aPR (95%CI) | Homeschool c (n=509) | aPR (95%CI) | Other/none (n=663) | aPR (95%CI) | |
|---|---|---|---|---|---|---|---|---|---|
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |||||
| Overall | 51.6 (49.6, 53.6) | 53.7 (51.5, 56.0)* | 39.6 (28.0, 51.1) | 32.5 (26.6, 38.4) | 44.5 (37.3, 51.7)* | ||||
| Age Groups (in years) | |||||||||
| 18-29 | 39.7 (31.6, 47.8) | 37.2 (28.8, 45.6)* | 1.00 | d | 1.00 | 71.9 (42.4, 100.0) | 1.00 | d | 1.00 |
| 30-39 | 42.1 (38.9, 45.2) | 44.7 (41.6, 47.9)* | 1.00 (0.82, 1.23) | d | 0.51 (0.16, 1.65) | 15.6 (7.6, 23.7) | 1.15 (0.29, 4.54) | 37.6 (27.0, 48.3)* | 0.63 (0.33, 1.22) |
| 40-49 | 62.8 (59.7, 65.9) | 65.0 (61.8, 68.1)* | 1.22 (1.01, 1.48) | 46.1 (26.9, 65.4) | 0.82 (0.31, 2.20) | 46.1 (35.5, 56.6) | 2.06 (0.55, 7.74) | 50.2 (37.2, 63.2) | 0.66 (0.30, 1.44) |
| ≥50 | 52.9 (48.2, 57.6) | 55.5 (50.2, 60.8)* | 1.12 (0.93, 1.36) | 44.3 (22.4, 66.3) | 1.22 (0.49, 3.04) | 33.2 (20.3, 46.1) | 1.85 (0.48, 7.18) | 44.2 (32.8, 55.6) | 0.69 (0.34, 1.40) |
| Sex | |||||||||
| Male | 55.1 (51.8, 58.4) | 57.3 (53.6, 61.0)* | 1.00 | 41.4 (22.8, 59.9) | 1.00 | 32.0 (21.8, 42.2) | 1.00 | 50.7 (37.7, 63.8)* | 1.00 |
| Female | 48.7 (46.2, 51.3) | 50.7 (48.0, 53.4)* | 0.93 (0.87, 0.99) | 38.2 (23.0, 53.4) | 1.39 (0.89, 2.17) | 33.0 (24.8, 41.3) | 1.31 (0.93, 1.84) | 39.8 (30.9, 48.7) | 0.82 (0.57, 1.19) |
| Race/ethnicity | |||||||||
| NH white | 49.1 (46.9, 51.3) | 51.3 (48.9, 53.6)* | 1.00 | 32.0 (16.1, 47.9) | 1.00 | 32.2 (23.8, 40.7) | 1.00 | 37.7 (26.9, 48.5) | 1.00 |
| NH black | 47.8 (41.4, 54.2) | 49.8 (42.3, 57.4)* | 1.06 (0.94, 1.19) | 51.3 (21.2, 81.4) | 1.75 (0.85, 3.58) | 21.3 (10.1, 32.5) | 0.92 (0.59, 1.46) | 47.4 (29.6, 65.2)* | 1.76 (1.12, 2.77) |
| Hispanic | 52.3 (46.9, 57.7) | 53.9 (47.9, 59.9) | 1.14 (1.00, 1.31) | d | 0.84 (0.35, 2.01) | 35.6 (16.9, 54.3) | 1.60 (1.09, 2.34) | 50.7 (31.4, 70.1) | 1.44 (0.87, 2.361 |
| NH other/multiple races | 66.8 (61.9, 71.8) | 70.1 (64.5, 75.7)* | 1.14 (1.05, 1.24) | 57.0 (34.3, 79.7) | 2.14 (1.17, 3.93) | 44.0 (22.1, 66.0) | 1.10 (0.71, 1.70) | 50.6 (37.6, 63.7) | 0.25 (0.88, 1.78) |
| Educational Status | |||||||||
| High school or less | 41.0 (36.3, 45.6) | 42.4 (36.6, 48.3) | 1.00 | d | 1.00 | 28.0 (11.9, 44.1) | 1.00 | 38.7 (25.8, 51.6) | 1.00 |
| Some college or Associate’s degree | 43.4 (40.4, 46.3) | 44.7 (41.5, 47.8)* | 0.97 (0.84, 1.12) | 39.7 (22.9, 56.6) | 1.40 (0.62, 3.17) | 29.7 (22.1, 37.2) | 0.82 (0.48, 1.41) | 41.2 (29.8, 52.7) | 0.90 (0.55, 1.48) |
| Bachelor’s degree | 66.4 (63.6, 69.1) | 68.2 (65.6, 70.9)* | 1.21 (1.05, 1.39) | 58.9 (38.5, 79.3) | 2.01 (0.82, 4.93) | 41.6 (28.1, 55.0) | 0.72 (0.39, 1.32) | 59.8 (48.3, 71.4) | 1.35 (0.89, 2.05) |
| Above college graduate | 72.9 (70.5, 75.4) | 74.9 (72.3, 77.6)* | 1.23 (1.06, 1.42) | 61.6 (34.4, 88.7) | 1.35 (0.62, 2.93) | 41.3 (28.8, 53.8) | 0.86 (0.49, 1.51) | 64.3 (54.4, 74.1)* | 1.45 (0.93, 2.26) |
| Annual Household Income | |||||||||
| <$35,000 | 40.6 (35.7, 45.4) | 41.7 (36.1, 47.2)* | 1.00 | d | 1.00 | 23.2 (12.9, 33.5) | 1.00 | 40.9 (27.9, 54.0)* | 1.00 |
| $35,000-$49,999 | 40.8 (34.2, 47.4) | 41.6 (34.1, 49.2) | 0.97 (0.80, 1.19) | d | 1.12 (0.51, 2.49) | d | 1.77 (0.89, 3.53) | 39.8 (21.2, 58.3) | 1.11 (0.65, 1.88) |
| $50,000-$74,999 | 41.9 (37.5, 46.3) | 43.4 (38.5, 48.3) | 0.93 (0.80, 1.08) | d | 0.64(0.20, 2.02) | 41.6 (22.1, 61.1) | 1.30 (0.75, 2.26) | 29.0 (15.1, 42.9) | 0.75 (0.42, 1.32) |
| ≥$75,000 | 61.6 (59.0, 64.3) | 63.1 (60.3, 65.9)* | 1.15 (1.01, 1.31) | d | 1.01(0.40, 2.52) | 34.9 (24.1, 45.7) | 1.33 (0.77, 2.32) | 58.2 (45.1, 71.4)* | 1.47 (0.90, 2.42) |
| Did not report | 44.9 (36.2, 53.5) | 61.4 (46.8, 76.1)* | 1.25 (1.00, 1.55) | d | 1.71(0.68, 4.29) | 31.9 (19.6, 44.3) | 1.48 (0.83, 2.65) | 42.3 (25.7, 58.9) | 0.50 (0.13, 1.96) |
| Insurance status | |||||||||
| Insured | 52.7 (50.7, 54.7) | 54.5 (52.3, 56.6)* | 1.00 | 37.9 (25.2, 50.6) | 1.00 | 36.7 (29.7, 43.7) | 1.00 | 42.9 (35.0, 50.9) | 1.00 |
| Not insured | 44.3 (35.7, 52.9) | 45.5 (35.5, 55.5)* | 1.14 (0.96, 1.34) | 57.0 (24.5, 89.4)* | 1.58 (0.71, 3.51) | d | 0.22 (0.06, 0.77) | 57.5 (37.7, 77.2)* | 1.57 (0.92, 2.69) |
| Respondent COVID-19 vaccination status | |||||||||
| Yes | 62.4 (60.1, 64.7) | 64.1 (61.6, 66.7)* | 1.00 | 48.1 (34.9, 61.4) | 1.00 | 53.3 (45.0, 61.6) | 1.00 | 51.1 (42.4, 59.7) | 1.00 |
| No | 8.6 (3.9, 13.3) | 8.1 (3.7, 12.5)* | 0.14 (0.08, 0.26) | d | 0.20 (0.04, 0.97) | d | 0.03 (<0.01, 0.19) | d | 0.44 (0.12, 1.61) |
| Respondent COVID-19 status | |||||||||
| Yes | 54.0 (51.3, 56.7) | 51.8 (48.9, 54.8)* | 0.86 (0.80, 0.93) | 59.6 (44.5, 74.7)* | 2.14 (1.42, 3.23) | 30.4 (22.9, 38.0) | 0.69 (0.52, 0.93) | 46.9 (37.0, 56.9)* | 0.91 (0.68, 1.20) |
| No | 50.5 (48.0, 52.9) | 56.8 (53.9, 59.7)* | 1.00 | 24.0 (11.8, 36.3) | 1.00 | 38.4 (28.8, 48.1) | 1.00 | 43.8 (31.9, 55.6) | 1.00 |
| Region | |||||||||
| Northeast | 62.3 (57.2, 67.4) | 63.9 (58.3, 69.6)* | 1.00 | 68.9 (44.6, 93.1)* | 1.00 | 40.0 (21.7, 58.3) | 1.00 | 43.8 (25.8, 61.9) | 1.00 |
| Midwest | 47.1 (43.8, 50.5) | 49.8 (46.2, 53.5)* | 0.91 (0.84, 0.99) | d | 0.76 (0.35, 1.69) | 34.0 (21.1, 46.9) | 0.64 (0.39, 1.06) | 33.4 (21.6, 45.2) | 1.10 (0.66, 1.82)) |
| West | 59.7 (56.0, 63.4) | 61.0 (57.1, 65.0)* | 0.94 (0.87, 1.02) | 47.3 (26.7, 67.8) | 1.11 (0.56, 2.21) | 42.7 (30.0, 55.4) | 0.82 (0.53, 1.27) | 59.5 (48.0, 71.1)* | 1.55 (0.98, 2.43 |
| South | 44.9 (41.9, 47.9) | 47.0 (43.6, 50.4)* | 0.82 (0.76, 0.90) | d | 0.67 (0.28, 1.58) | 25.7 (16.7, 34.6) | 0.80 (0.54, 1.18) | 40.4 (27.3, 53.5)* | 1.19 (0.71, 2.00) |
Abbreviations: CI=confidence interval
Note: All percentages are weighted.
p<0.05 in a t-test comparing the proportion of vaccinated children for a given educational setting (e.g., in-person instruction) with a given demographic level (e.g., 18-29 years) to the proportion of vaccinated children who were homeschooled with that given demographic level.
In-person instruction was defined as anyone who has received in-person instruction from a teacher at their school in the last 7 days
Virtual instruction was defined as anyone who did not receive in-person instruction and received virtual/online instruction from a teacher in real time, learned on their own using on-line materials provided by their school, or learned on their own using paper materials provided by their school in the last 7 days
Homeschool was defined as anyone who did not receive in-person or virtual instruction and learned on their own using materials that were not provided by their school in the last 7 days
Estimates were suppressed due to RSE > 30%
Table 2.
Adolescent COVID-19 vaccination coverage (≥1 dose) by educational setting and parental sociodemographic characteristics, United States, Household Pulse Survey, December 9, 2022 – February 13, 2023
| Overall (n=14,757) | In-person instructiona (n=12,441) | aPR (95%CI) | Virtual instructionb (n=458) | aPR (95%CI) | Homeschool c (n=850) | aPR (95%CI) | Other/none (n=1008) | aPR (95%CI) | |
|---|---|---|---|---|---|---|---|---|---|
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |||||
| All | 70.7 (69.3, 72.1) | 73.5 (72.0, 75.0)* | 70.1 (62.2, 77.9)* | 51.0 (44.5, 57.5) | 63.8 (58.9, 68.8)* | ||||
| Age Groups (in years) | |||||||||
| 18-29 | 73.9 (68.0, 79.8) | 78.1 (72.4, 83.9) | 1.00 | 92.6 (77.1, 100.0)* | 1.00 | 53.8 (28.8, 78.8) | 1.00 | 58.9 (36.6, 81.1) | 1.00 |
| 30-39 | 54.5 (49.3, 59.6) | 57.7 (52.2, 63.2)* | 0.86 (0.78, 0.95) | 61.3 (31.0, 91.7) | 0.73 (0.53, 1.02) | 36.8 (19.4, 54.1) | 1.02 (0.70, 1.49) | 38.8 (25.3, 52.4) | 0.94 (0.58, 1.51) |
| 40-49 | 67.9 (65.8, 70.0) | 70.2 (68.0, 72.5)* | 0.93 (0.87, 0.99) | 64.8 (54.5, 75.0)* | 0.70 (0.52, 0.94) | 50.0 (43.1, 57.0) | 0.93 (0.70, 1.24) | 59.9 (49.2, 70.5) | 1.01 (0.66, 1.55) |
| ≥50 | 76.2 (74.1, 78.3) | 79.2 (76.9, 81.4)* | 0.95 (0.90, 1.01) | 71.6 (59.4, 83.8)* | 0.77 (0.58, 1.01) | 53.8 (45.8, 61.8) | 0.82 (0.62, 1.08) | 73.3 (67.3, 79.2)* | 1.16 (0.79, 1.71) |
| Sex | |||||||||
| Male | 72.5 (70.3, 74.8) | 75.5 (73.4, 77.6)* | 1.00 | 71.9 (59.3, 84.5)* | 1.00 | 53.3 (42.3, 64.4) | 1.00 | 65.2 (57.8, 72.6) | 1.00 |
| Female | 68.9 (67.3, 70.5) | 71.7 (69.9, 73.5)* | 0.96 (0.93, 0.99) | 68.2 (58.1, 78.3)* | 0.99 (0.85, 1.15) | 49.0 (41.3, 56.7) | 0.87 (0.70, 1.07) | 62.1 (54.4, 69.8)* | 1.03 (0.88, 1.20) |
| Race/ethnicity | |||||||||
| NH white | 66.8 (65.0, 68.5) | 70.3 (68.7, 71.8)* | 1.00 | 54.3 (43.5, 65.0) | 1.00 | 47.0 (40.3, 53.7) | 1.00 | 53.8 (46.6, 61.0) | 1.00 |
| NH black | 73.0 (67.8, 78.3) | 76.8 (71.7, 81.9)* | 1.09 (1.03, 1.17) | 86.5 (73.5, 99.4)* | 1.51 (1.07, 2.12) | 46.2 (24.5, 67.9) | 1.31 (1.04, 1.64) | 65.0 (49.5, 80.4) | 1.26 (1.06, 1.50) |
| Hispanic | 74.7 (70.4, 79.1) | 76.0 (71.1, 81.0) | 1.07 (1.01, 1.13) | 85.6 (75.0, 96.3)* | 1.05 (0.87, 1.26) | 65.8 (48.6, 83.0) | 1.49 (1.10, 2.00) | 68.9 (59.1, 78.7) | 1.11 (0.90, 1.36) |
| NH other/multiple races | 81.5 (78.1, 84.9) | 84.5 (81.3, 87.8)* | 1.08 (1.04, 1.12) | 73.9 (54.0, 93.8) | 1.01 (0.84, 1.23) | 52.3 (27.7, 76.9) | 1.05 (0.76, 1.46) | 81.5 (71.4, 91.6)* | 1.09 (0.93, 1.30) |
| Educational Status | |||||||||
| High school or less | 61.0 (58.1, 63.8) | 62.9 (59.1, 66.7)* | 1.00 | 67.3 (53.8, 80.8)* | 1.00 | 48.4 (38.9, 57.9) | 1.00 | 59.7 (52.0, 67.4) | 1.00 |
| Some college or Associate’s degree | 67.4 (64.7, 70.1) | 69.2 (66.6, 71.8)* | 1.04 (0.98, 1.10) | 68.0 (55.5, 80.6)* | 0.86 (0.70, 1.05) | 50.0 (41.9, 58.1) | 0.96 (0.78, 1.18) | 64.8 (54.0, 75.5)* | 1.00 (0.87, 1.16) |
| Bachelor’s degree | 80.7 (78.8, 82.7) | 82.6 (80.5, 84.7)* | 1.13 (1.07, 1.19) | 73.3 (61.6, 85.1) | 0.93 (0.77, 1.12) | 61.9 (52.3, 71.6) | 1.05 (0.84, 1.32) | 70.3 (59.7, 80.9) | 1.05 (0.88, 1.24) |
| Above college graduate | 87.8 (86.1, 89.4) | 88.5 (86.8, 90.2)* | 1.17 (1.10, 1.25) | 91.7 (84.3, 99.1)* | 1.02 (0.85, 1.23) | 62.4 (51.0, 73.8) | 1.04 (0.80, 1.36) | 86.7 (79.4, 93.9)* | 1.12 (0.97, 1.28) |
| Annual Household Income | |||||||||
| <$35,000 | 61.5 (57.7, 65.4) | 62.7 (57.7, 67.7)* | 1.00 | 72.8 (58.2, 87.5)* | 1.00 | 42.5 (30.3, 54.8) | 1.00 | 58.6 (47.1, 70.0)* | 1.00 |
| $35,000-$49,999 | 61.7 (56.5, 67.0) | 67.1 (61.4, 72.8)* | 1.05 (0.97, 1.15) | 48.7 (26.6, 70.8) | 1.02 (0.68, 1.54) | 45.1 (29.4, 60.8) | 0.98 (0.74, 1.29) | 46.8 (29.2, 64.5) | 0.62 (0.41, 0.93) |
| $50,000-$74,999 | 69.3 (65.1, 73.5) | 69.2 (64.5, 73.9) | 1.08 (1.00, 1.17) | 69.9 (51.4, 88.4) | 1.02 (0.80, 1.29) | 70.9 (58.4, 83.4) | 1.15 (0.88, 1.51) | 67.6 (50.9, 84.4) | 0.91 (0.71, 1.18) |
| ≥$75,000 | 77.6 (75.9, 79.4) | 78.9 (77.1, 80.6)* | 1.05 (0.99, 1.12) | 74.8 (63.8, 85.8)* | 1.05 (0.80, 1.37) | 53.5 (41.2, 65.8) | 1.10 (0.86, 1.40) | 75.0 (67.3, 82.8)* | 1.01 (0.85, 1.21) |
| Did not report | 59.6 (53.4, 65.8) | 77.9 (70.1, 85.8)* | 1.03 (0.93, 1.14) | 98.6 (94.2, 100.0)* | 1.07 (0.83, 1.37) | 45.2 (34.0, 56.4) | 1.11 (0.75, 1.66) | 62.2 (49.2, 75.1) | 1.02 (0.80, 1.29) |
| Insurance status | |||||||||
| Insured | 72.8 (71.2, 74.3) | 74.4 (72.9, 76.0)* | 1.00 | 74.0 (66.5, 81.5)* | 1.00 | 57.1 (50.5, 63.8) | 1.00 | 66.1 (60.6, 71.7)* | 1.00 |
| Not insured | 55.8 (49.6, 61.9) | 60.1 (52.9, 67.2) | 1.05 (0.94, 1.17) | d | 1.02 (0.70, 1.49) | d | 0.72 (0.52, 0.99) | 51.0 (32.2, 69.8) | 0.89 (0.70, 1.13) |
| Respondent COVID-19 vaccination status | |||||||||
| Yes | 84.0 (82.5, 85.5) | 85.1 (83.7, 86.6)* | 1.00 | 88.8 (83.7, 93.9)* | 1.00 | 74.3 (66.5, 82.1) | 1.00 | 78.8 (72.9, 84.7) | 1.00 |
| No | 12.9 (10.2, 15.5) | 12.9 (10.0, 15.9) | 0.16 (0.13, 0.20) | d | 0.13 (0.07, 0.25) | d | 0.14 (0.06, 0.36) | d | 0.23 (0.10, 0.54) |
| Respondent COVID-19 status | |||||||||
| Yes | 74.6 (72.6, 76.6) | 71.6 (69.5, 73.6)* | 0.95 (0.91, 0.98) | 64.2 (51.7, 76.6) * | 0.91 (0.77, 1.07) | 45.3 (36.2, 54.4) | 0.79 (0.65, 0.96) | 61.3 (55.2, 67.4)* | 0.96 (0.82, 1.11) |
| No | 68.5 (66.6, 70.4) | 76.4 (74.1, 78.7)* | 1.00 | 74.6 (62.7, 86.5) | 1.00 | 64.0 (55.5, 72.5) | 1.00 | 69.3 (62.2, 76.3) | 1.00 |
| Region | |||||||||
| Northeast | 79.0 (75.6, 82.4) | 80.3 (76.6, 84.1)* | 1.00 | 92.3 (82.3, 100.0)* | 1.00 | 52.3 (27.9, 76.8) | 1.00 | 80.8 (71.4, 90.1)* | 1.00 |
| Midwest | 65.8 (63.4, 68.1) | 68.1 (65.2, 70.9)* | 0.93 (0.88, 0.98) | 52.0 (37.5, 66.5) | 0.86 (0.68, 1.08) | 48.0 (34.5, 61.5) | 0.71 (0.49, 1.02) | 61.7 (51.4, 72.0) | 0.95 (0.81, 1.12) |
| West | 76.0 (72.9, 79.2) | 77.1 (73.7, 80.4)* | 1.01 (0.96, 1.06) | 81.0 (69.8, 92.2)* | 1.00 (0.83, 1.20) | 62.6 (52.8, 72.4) | 0.64 (0.46, 0.90) | 74.2 (64.1, 84.4) | 1.08 (0.91, 1.27) |
| South | 66.0 (63.8, 68.3) | 70.9 (68.4, 73.3)* | 0.96 (0.92, 1.00) | 63.7 (49.3, 78.2) | 0.79 (0.59, 1.06) | 47.1 (38.0, 56.3) | 0.62 (0.43, 0.90) | 49.5 (39.8, 59.2) | 0.77 (0.62, 0.96) |
Abbreviations: CI=confidence interval
Note: All percentages are weighted.
p<0.05 in a t-test comparing the proportion of vaccinated adolescents for a given educational setting (e.g., in-person instruction) with a given demographic level (e.g., 18-29 years) to the proportion of vaccinated adolescents who were homeschooled with that given demographic level.
In-person instruction was defined as anyone who has received in-person instruction from a teacher at their school in the last 7 days
Virtual instruction was defined as anyone who did not receive in-person instruction and received virtual/online instruction from a teacher in real time, learned on their own using on-line materials provided by their school, or learned on their own using paper materials provided by their school in the last 7 days
Homeschool was defined as anyone who did not receive in-person or virtual instruction and learned on their own using materials that were not provided by their school in the last 7 days
Estimates were suppressed due to RSE > 30%
Vaccination coverage also differed by HHS regions and educational setting for children and adolescents (Table 3). Vaccination coverage for in-person instruction was highest for children (65.5%) and adolescents (84.8%) in region 1. Among children, vaccination coverage was lowest in region 4 among those who received in-person instruction (41.7%) or other educational settings (28.5%). Among adolescents, vaccination coverage was lowest in region 4 among those who received in-person instruction (67.1%) and in region 6 among those who were homeschooled (44.5%) (Table 3). Vaccination coverage among those who received in-person instruction was higher than those who were homeschooled for regions 3, 4, 5, and 8 for both children and adolescents.
Table 3.
COVID-19 vaccination coverage (≥1 dose) by age group, HHS region a, and educational settings, United States, Household Pulse Survey, December 9, 2022 – February 13, 2023
| Children 5-11 years | Adolescents 12-17 years | |||||
|---|---|---|---|---|---|---|
| Overall (n=10,416) | In-person instructionb (n=9,099) (reference) | Other/nonec (n=1,317) | Overall (n=14,757) | In-person instructionb (n=12,441) (reference) | Other/nonec (n=2,316) | |
|
| ||||||
| % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | % (95% CI) | |
| HHS Region 1 | 65.5 (60.5, 70.4) | 68.0 (62.7, 73.3) | 41.3 (28.5, 54.2)* | 84.8 (80.8, 88.9) | 85.6 (81.2, 90.1) | 80.4 (68.8, 91.9) |
| HHS Region 2 | 67.4 (58.2, 76.6) | 67.5 (57.5, 77.5) | 65.5 (44.0, 86.9) | 79.5 (73.6, 85.4) | 80.0 (73.8, 86.3) | 76.8 (59.0, 94.7) |
| HHS Region 3 | 54.7 (50.3, 59.0) | 59.0 (53.9, 64.2) | 29.4 (18.0, 40.9)* | 76.0 (72.2, 79.8) | 79.6 (75.8, 83.3) | 60.8 (48.7, 72.9)* |
| HHS Region 4 | 39.5 (35.7, 43.3) | 41.7 (37.4, 46.1) | 28.5 (21.2, 35.8)* | 63.7 (60.5, 66.9) | 67.1 (63.7, 70.4) | 53.3 (46.4, 60.3)* |
| HHS Region 5 | 47.3 (43.6, 51.0) | 49.9 (45.7, 54.1) | 33.6 (24.0, 43.3)* | 65.9 (62.7, 69.2) | 68.2 (64.3, 72.0) | 56.1 (46.7, 65.5)* |
| HHS Region 6 | 46.7 (41.1, 52.3) | 47.4 (41.1, 53.7) | 42.4 (23.7, 61.1) | 64.5 (60.2, 68.8) | 71.5 (66.4, 76.6) | 44.5 (35.0, 54.0)* |
| HHS Region 7 | 47.5 (41.8, 53.2) | 50.5 (44.4, 56.7) | 33.9 (18.5, 49.2)* | 66.2 (61.7, 70.7) | 68.7 (64.3, 73.1) | 55.7 (42.8, 68.7) |
| HHS Region 8 | 51.7 (46.8, 56.5) | 54.4 (49.2, 59.5) | 33.8 (17.7, 49.9)* | 66.6 (62.4, 70.8) | 70.5 (65.8, 75.1) | 51.1 (38.8, 63.3)* |
| HHS Region 9 | 61.4 (56.0, 66.8) | 62.5 (56.4, 68.5) | 56.2 (43.5, 68.9) | 78.6 (74.4, 82.8) | 78.9 (74.2, 83.6) | 77.8 (69.9, 85.8) |
| HHS Region 10 | 59.2 (55.5, 62.9) | 60.3 (56.2, 64.3) | 54.5 (42.8, 66.2) | 72.1 (67.9, 76.2) | 74.4 (69.9, 78.9) | 61.0 (51.0, 71.1)* |
Abbreviations: HHS=Health and Human Services; CI=confidence interval
Note: All percentages are weighted.
p<0.05 in a t-test comparing the proportion of vaccinated children/adolescents who received in-person instruction within a given region (e.g., region 1) to the proportion of vaccinated children/adolescents who received other/no instruction within that given region.
HHS regions: Region 1 - Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont; Region 2 - New Jersey, New York; Region 3 - Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, and West Virginia; Region 4 - Alabama, Florida, Georgia, Kentucky, Mississippi, North Carolina, South Carolina, and Tennessee; Region 5 - Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin; Region 6 - Arkansas, Louisiana, New Mexico, Oklahoma, and Texas; Region 7 - Iowa, Kansas, Missouri, and Nebraska; Region 8 - Colorado, Montana, North Dakota, South Dakota, Utah, and Wyoming; Region 9 - Arizona, California, Hawaii, Nevada; Region 10 - Alaska, Idaho, Oregon, and Washington.
In-person instruction was defined as anyone who received in-person instruction from a teacher at their school in the last 7 days
Other/no instruction was defined as anyone who received virtual instruction, were homeschooled, or did not participate in any learning activities, in the last 7 days
Reasons for non-vaccination differed by child age group and educational setting. Main reasons for non-vaccination of children who received in-person instruction and those who received virtual instruction were concern about side effects (56.7-60.1%) and lack of trust in COVID-19 vaccines (35.5-39.0%) (Table 4). Among children who were homeschooled, main reasons for non-vaccination were concern about side effects (51.6%), lack of trust in COVID-19 vaccines (45.0%), and lack of trust in the government (39.2%). Lack of trust in COVID-19 vaccines (45.0%) and lack of trust in the government (39.2%) was higher among parents of homeschooled children than parents of children who received in-person instruction (35.5% and 26.2%, respectively). Among adolescents who received in-person instruction and those who received virtual/online instruction, main reasons for non-vaccination were concern about side effects (52.5-56.8%), lack of trust in COVID-19 vaccines (46.6-57.2%), and lack of trust in the government (30.7-44.0%). Among adolescents who were homeschooled, main reasons for non-vaccination were lack of trust in COVID-19 vaccines (50.9%), concerns about side effects (45.4%), and lack of trust in the government (32.7%).
Table 4.
Reasons for not vaccinating children and adolescents, by educational setting, United States, Household Pulse Survey, December 9, 2022 – February 13, 2023
| Overall | In person instruction a | Virtual instruction b | Homeschool c | Other/none | |
|---|---|---|---|---|---|
|
| |||||
| n (%) | % (95%CI) | % (95%CI) | % (95%CI) | % (95%CI) | |
| Reasons for not vaccinating children 5-11 years | |||||
| Concern about possible side effects of a COVID-19 vaccine for children | 2,137 (55.5) | 56.7 (52.8, 60.5) | 60.1 (41.9, 78.3) | 51.6 (42.7, 60.5) | 46.4 (35.4, 57.4) |
| Plan to wait and see if it is safe and may get it later | 842 (23.7) | 23.7 (20.8, 26.5) | 26.4 (11.3, 41.5) | 19.4 (11.1, 27.6) | 26.7 (16.1, 37.2) |
| Not sure if a COVID-19 vaccine will work for children | 277 (8.8) | 8.6 (6.6, 10.5) | d | 13.5 (6.4, 20.6) | d |
| Don’t believe children need a COVID-19 vaccine | 1,138 (29.0) | 29.4 (26.7, 32.1) | d | 33.1 (25.8, 40.5) | 23.9 (15.7, 32.2) |
| The children in this household are not members of a high-risk group | 1,240 (30.6) | 32.4 (29.4, 35.4) | d | 27.6 (19.1, 36.0) | 15.2 (10.9, 19.4)* |
| The children’s doctor has not recommended it | 489 (14.2) | 14.2 (11.3, 17.1) | d | 16.5 (8.9, 24.1) | 11.9 (5.5, 18.2) |
| Parents or guardians in this household do not vaccinate their children | 140 (4.2) | 3.3 (2.3, 4.2) | d | d | d |
| Don’t trust COVID-19 vaccines | 1,301 (36.0) | 35.5 (32.6, 38.5)* | 39.0 (21.9, 56.1) | 45.0 (37.1, 52.9) | 32.7 (22.7, 42.8) |
| Don’t trust the government | 948 (27.4) | 26.2 (23.1, 29.4)* | d | 39.2 (29.8, 48.6) | 27.7 (18.9, 36.5) |
| Other | 403 (9.6) | 9.5 (7.7, 11.3) | d | 14.7 (8.2, 21.1) | 7.8 (3.6, 12.0) |
| Reasons for not vaccinating adolescents 12-17 years | |||||
| Concern about possible side effects of a COVID-19 vaccine for children | 1797 (51.9) | 52.5 (48.6, 56.3) | 56.8 (40.2, 73.4) | 45.4 (35.4, 55.5) | 52.4 (41.5, 63.3) |
| Plan to wait and see if it is safe and may get it later | 456 (15.2) | 15.3 (12.8, 17.9) | d | 14.2 (7.2, 21.2) | d |
| Not sure if a COVID-19 vaccine will work for children | 208 (5.1) | 5.4 (4.1, 6.7) | d | d | d |
| Don’t believe children need a COVID-19 vaccine | 1026 (28.0) | 30.1 (26.5, 33.7) | 18.9 (8.4, 29.4) | 26.7 (19.8, 33.5) | 18.4 (10.3, 26.5) |
| The children in this household are not members of a high-risk group | 1142 (29.4) | 29.4 (26.6, 32.2) | 35.1 (20.2, 49.9) | 28.4 (20.6, 36.2) | 28.2 (15.0, 41.3) |
| The children’s doctor has not recommended it | 321 (10.8) | 11.3 (8.6, 13.9) | 14.8 (2.6, 27.0) | 7.1 (2.6, 11.7) | 9.7 (3.6, 15.8) |
| Parents or guardians in this household do not vaccinate their children” | 173 (6.9) | 7.1 (4.7, 9.5) | d | 9.2 (3.6, 14.8) | 4.1 (0.8, 7.3) |
| Don’t trust COVID-19 vaccines | 1572 (46.6) | 46.6 (42.6, 50.6) | 57.2 (40.6, 73.8) | 50.9 (40.2, 61.6) | 38.7 (24.8, 52.6) |
| Don’t trust the government | 1060 (32.1) | 30.7 (27.2, 34.1) | 44.0 (28.4, 59.6) | 32.7 (22.8, 42.5) | 36.0 (22.0, 50.1) |
| Other | 418 (11.1) | 10.8 (8.9, 12.7) | d | 10.5 (5.8, 15.2) | 12.3 (7.3, 17.3) |
Abbreviations: CI=confidence interval
Note: All percentages are weighted.
p<0.05 in a t-test comparing each reason for not vaccinating children or adolescents for a given educational setting (e.g., in-person instruction) compared to children or adolescents who were homeschooled.
In-person instruction was defined as anyone who received in-person instruction from a teacher at their school in the last 7 days
Virtual instruction was defined as anyone who did not receive in-person instruction and received virtual/online instruction from a teacher in real time, learned on their own using on-line materials provided by their school, or learned on their own using paper materials provided by their school in the last 7 days
Homeschool was defined as anyone who did not receive in-person or virtual instruction and learned on their own using materials that were not provided by their school in the last 7 days
Estimates were suppressed due to RSE > 30%
Discussion
This study found disparities in COVID-19 vaccination coverage by educational setting; specifically, children and adolescents who were homeschooled during the pandemic had lower coverage than children or adolescents who attended school in person or adolescents who received virtual instruction. These disparities were evident across most sociodemographic characteristics and region, with regions 3-5 and 8 having some of the greatest disparities in vaccination coverage between in-person and other educational settings for children and adolescents. Furthermore, lack of health insurance was associated with lower probability of COVID-19 vaccination among parents of homeschooled children, suggesting the need to improve access to vaccines. Since the number of adults/parents with children who were taught entirely in their homes doubled between the spring and fall 2020, 2 understanding reasons for disparities in vaccination coverage for these populations are critically important. These results suggest that more efforts are needed to understand reasons for the differences in vaccination coverage by educational setting and region so that messages and interventions can be tailored to protect all children from vaccine preventable diseases.
Due to small sample sizes, the study could not detect any statistically significant differences in reasons for non-vaccination between children/adolescents who received virtual instruction and those who were homeschooled. However, the main reasons for non-vaccination among parents of all children and adolescents were concerns about side effects, lack of trust in COVID-19 vaccines, lack of trust in the government, and the belief that children do not need a COVID-19 vaccine. These results reinforce the importance of providing information to parents about the safety and effectiveness of COVID-19 vaccines for their children, as well as addressing misinformation about COVID-19 vaccines, to increase parents’ confidence in vaccines and willingness to vaccinate their children and adolescents for COVID-19.30 Studies have shown that using motivational interviewing by healthcare providers to inform patients about vaccination while supporting the patient’s decision-making can and beliefs increase mothers’ intention to vaccinate their children.25,31,32 Healthcare providers are ranked as one of the top sources for accurate vaccine information among adults.33 Thus, encouraging healthcare providers to recommend and underscore the importance of vaccination in reducing severe COVID-19 may help reduce vaccine hesitancy and increase vaccination rates, particularly for those with the greatest disparities in COVID-19 vaccine coverage. 34,35 Addressing medical mistrust and further strengthening relationships with providers could also increase positive intentions towards vaccines and vaccine uptake. 36 Alternative avenues of communication may be necessary to help increase vaccination uptake and confidence for children who do not attend in-person school and those who are hard to reach (e.g., those with healthcare access barriers). Effective messages about the benefits of vaccination delivered by trusted messengers, such as community and faith-based leaders may help to mitigate barriers related to mistrust, misinformation, and lack of adequate information and improve vaccine confidence. 35 Furthermore, presenting vaccine information in community-located town halls, working with vaccine ambassadors to advocate for COVID-19 vaccination, and engaging peers in the community to share their vaccination experience may help reach people where they live. Social media platforms may also offer avenues to reach individuals who may choose alternative healthcare modalities. Moreover, working with community organizations, such as social or other health services to develop a plan to vaccinate people they serve can increase access for those who live in rural or hard-to-reach areas. Lastly, reminders about upcoming vaccinations and offering COVID-19 vaccines at every eligible opportunity, including scheduled preventative or ad-hoc sick visits, can help reduce missed opportunities for vaccination. 36 Continued efforts are needed to ensure all children, particularly those in hard-to-reach areas and families, are protected from severe consequences of COVID-19.
While some U.S. regions had higher COVID-19 vaccination coverage for children and adolescents who received in-person instruction compared to other types of instruction, it is unclear whether the difference is due to greater parental vaccine confidence, local policies, school vaccination requirements for COVID-19, burden of infection, media coverage, or influencers. Currently, only Washington DC has COVID-19 mandates for children, but California and Illinois had COVID-19 mandates previously, as may have other local counties and towns did throughout the pandemic. 39,40 Other local factors, such as the burden of infection, media coverage of COVID-19 transmission or vaccination, and messages from influencers could affect attitudes and perceptions toward the COVID-19 vaccine.41–43 As a result, it is difficult to determine whether the higher vaccination coverage found in some regions may be due to mandates, local policies, or other factors that drove parents’ decisions about school setting. However, higher COVID-19 vaccination coverage found in region 1 for in-person settings is consistent with other studies which found higher vaccination coverage in region 1 for other school mandated vaccines, suggesting that this area may have high access to vaccines and confidence in vaccines.44,45 Reducing barriers to access, as well as increasing confidence in vaccines for all parents, is important for achieving high vaccination coverage for children and adolescents.
Other studies have found lower vaccination coverage among homeschooled children, which may have contributed to higher rates of vaccine preventable diseases. 46 For example, a study in California found that almost 30% of parents stated that their youngest child in grade K-8 was not up-to-date on immunizations at kindergarten-entry and 56% reported that they made the decision to homeschool their child after the implementation of immunization mandates. 14 This study, and another study found that homeschooling parents were uncertain about the risk from vaccine-preventable diseases, concerned about the efficacy and safety of vaccines, and confused about conflicting vaccine information. 14,47 These concerns were also expressed among parents of children with chronic conditions, as evident by only 38.8% of parents in Italy who were willing to vaccinate their children against COVID-19 from December 2021 to January 2022. 48,49 Reducing concerns around vaccination is important for protecting children from vaccine preventable diseases, especially among those who may have medical conditions that place them at a higher risk for severe COVID-19 outcomes. Further research should specifically examine attitudes, thoughts, beliefs, and barriers to COVID-19 vaccination among parents of homeschooled children and adolescents so that tailored messages and strategies can be developed to increase coverage in this population.
While the Household Pulse Survey is one of the largest, nationally representative surveys on COVID-19 vaccination in the U.S., the data may be subject to several limitations. First, although the sampling methods and data weighting were designed to produce nationally representative results, respondents might not be fully representative of the general U.S. adult population.26 Second, vaccination status of respondents and their children/adolescents was self-reported and may have been subject to recall or social desirability bias. Third, low sample sizes for virtual and homeschooled children and adolescents may have reduced the power to detect statistically significant results between these groups and the in-person instruction groups. Fourth, some children and adolescents may have been classified as having an educational setting of other/none solely due to the timing of the survey overlapping the school’s winter break. Finally, the HPS had a low response rate (<10%), although the non-response bias assessment conducted by the Census Bureau found that the survey weights mitigated most of this bias.50
This is one of the first studies to examine COVID-19 vaccination among children and adolescents by educational setting. With the rise in number of children and adolescents who were homeschooled or received virtual instruction during the pandemic, ensuring that all children receive the recommended doses of COVID-19 vaccinations are important for protecting them against negative consequences of infection. With the end of the official COVID-19 pandemic, and the return of children to in-person instruction, ensuring that children are up-to-date with COVID-19 vaccines could protect them and their communities from harmful health outcomes. Reducing barriers to access and increasing parental confidence in vaccines are important for the safe return of children and adolescents to in-person educational settings, as well as increased protection for families and communities against infection from COVID-19.
Supplementary Material
Social media:
COVID-19 vaccination coverage is lower for homeschooled children and adolescents than for those who receive in-person or virtual instruction. Increasing vaccination coverage and confidence is important for the safety of children and adolescents in all educational settings.
Acknowledgements:
The authors would like to thank LL for her initial analyses on this study.
Funding/Support:
No funding was secured for this study. Laura Corlin was supported by Tufts University. Robert Bedanrczyk was supported by National Cancer Institute (NCI) grant number R37 CA234119.
Footnotes
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Conflict of Interest Disclosures (includes financial disclosures): The authors have no conflicts of interest relevant to this article.
The data that support the findings of this study are openly available at https://www.census.gov/programs-surveys/household-pulse-survey/datasets.html.
References
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