ABSTRACT
Background:
Irrespective of the availability of a safe and effective COVID-19 vaccine and its success rate in adults, administering vaccines to children remains a challenge for healthcare workers. Children’s vaccine hesitancy among parents remains substantial and is exacerbated due to misleading information. In the present study, we aimed to investigate the hesitancy of parents and their concern about the vaccination and clinical characteristics of COVID-19 in their children.
Methods:
A cross-sectional web-based and offline survey comprised of questions about the demographic of children, the status of COVID-19 infection, its severity, vaccination status, sources of information, willingness, concerns and attitude of parents to vaccinate their children against the COVID-19 virus, was conducted. Overall, 846 responses from parents fulfilling the inclusion criteria were analysed by GraphPad Prism 5.
Results:
Out of the 846 responses, 51.2% (n = 433) of children were vaccinated against COVID-19. Out of vaccinated children (51.2%), 60.3% (n = 261) had experienced adverse events. Around 21% (n = 98) of children had a history of exposure to the SARS-CoV-2 virus. Among the infected children, 14.3% were asymptomatic and 85.7% had symptoms. Approximately 8% of children had comorbidities, with chronic lung diseases and asthma being the most common. Among the 846 participating parents, 59.5% were mothers and the remaining 40.5% were fathers. A total of 2.7% and 22.2% of parents were found hesitant to administer the COVID-19 vaccine to their children aged 15–18 years and below 15 years, respectively. Among hesitant parents, mothers were found slightly more hesitant as compared to fathers. Also, 35.5% of parents were found hesitant about their own COVID-19 vaccination. Furthermore, the concern for COVID-19 vaccine unwillingness among parents is that a child has already achieved natural immunity after COVID-19 infections (76.8%) followed by vaccine safety and its side effects. The motivating factors to convince parents for their children’s COVID-19 vaccination were if their doctors recommend it, followed by detailed information on vaccine side effects and efficacy in children. The most trusted source of information for the parents was found to be the healthcare workers.
Conclusion:
These results suggest that data and reviews regarding the safety and efficacy of the COVID-19 vaccine readily available in the public domain could serve as a highly effective strategy for promoting and implementing widespread vaccination among children. By providing easily accessible and comprehensive information, public health authorities can address parental concerns, dispel misconceptions and foster a greater sense of trust in the vaccination process.
Keywords: Children, coronavirus, COVID-19 vaccine, parents, vaccine hesitancy
Introduction
The global pandemic caused due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) depicts a peculiar pattern of infection among children as compared to adults.[1,2] As of June 24, 2023, 1847 child deaths due to COVID-19 have been reported globally despite epidemiological studies showing reduced severity and mortality among children compared to adults.[3,4] As the epidemic progresses, more direct and indirect health effects of SARS-CoV-2 become apparent implicating a differential pathogenesis of SARS-CoV-2.[3,4] The side effects of COVID-19 have had serious repercussions on children’s mental and physical health. A non-negligible fraction of children with COVID-19 were reported to suffer from a potent post-infection inflammation known as multisystem inflammatory syndrome (MIS-C).[5] In addition, several studies have demonstrated that severe COVID-19 and mortality among children were due to MIS-C.[6,7,8]
Multiple pieces of evidence have confirmed the effectiveness of COVID-19 vaccines in reducing severe illness and fatalities caused by coronavirus infections.[9,10] As a result, it is crucial to achieve high vaccination coverage among both adults and children to bring an end to the emergency phase of the coronavirus infection. The government of India has officially approved the Covaxin (BB152) vaccine (Bharat Biotech, Hyderabad, India) for children aged 15–18 years from January 3, 2022.[11] However, Covaxin (BB152) use for the younger children (<12 years) is still under clinical trial. Similarly, other COVID-19 vaccines such as Corbevax (developed by Biological E limited) and ZyCoV-D (developed by Zydus Cadila) for children aged 5–17 years and 12–17 years respectively are under phase 3 of the clinical trial.[12]
Irrespective of successful COVID-19 vaccination in adults and its pivotal role in mitigating the emergency phase of coronavirus, vaccination in children is a challenge for policymakers. Since parents are caregivers or guardians of children, acceptance and hesitancy of the COVID-19 vaccine by parents for their children is a critical key factor in contributing to the successful mass vaccination drive. According to the World Health Organization (WHO), vaccine hesitancy is a significant factor contributing to the global health threat.[13] Numerous parameters such as complacency, convenience and confidence regarding the safety, efficacy and side effects of COVID-19 vaccine influenced the hesitancy of parents towards vaccines.[14,15] Therefore, evaluating parents’ hesitancy and their concern towards the COVID-19 vaccine for their children will aid in tracking the misinformation about vaccines that will further assist in designing strategies for the successful rollout of the COVID-19 vaccine among children. Thus, the objective of the present study was to investigate the hesitancy among parents of children aged 15–18 years and below 15 years and their attitude towards vaccination of children against the COVID-19 virus.
Material and Methods
Study design
We conducted a cross-sectional online and offline survey among Indian parents between March and June 2022. We identified variables from our previous published study carried out by Jetly et al.[16] and conceptualized the present study on parents’ hesitancy towards COVID-19 vaccination for their children. The survey questionnaire was formulated by incorporating questions based on expert opinion and obtained through consultations with senior physicians (who were involved in treatment and management of COVID-19) across four leading government hospitals of Delhi-NCR and input from academic colleagues. The survey study was based on the ICMR-approved guidelines. The survey questionnaire included questions about the demographics of children and parents, comorbidities among children, the incidence of COVID-19 among children, parental hesitancy and attitude towards vaccinating their children with the COVID-19 vaccine and source of information about the COVID-19 vaccine. An online survey was conducted via Google form, and an offline survey was conducted with the assistance of skilled healthcare professionals (trained under clinicians). The snowball sampling method was used to collect the data. The detailed procedure for collecting offline forms has also been described earlier in Arora et al.[17] Briefly, Accredited Social Health Activist (ASHA) who were working under the supervision of doctors associated with the Delhi Government Hospital collected the filled form via a door-to-door survey. For conducting the present survey, they were explained to include parents with children under the age of 18 years.
The only inclusion criterion considered was the survey administered to Indian parents who have at least one child under the age of 18 years and the given informed consent. We excluded those who did not provide complete information or parents without children. The present study involving the Google survey questionnaire was approved by the Institutional Ethics Committee (ACBR/IHEC/DS-COVID6/02-2022) of the Delhi School of Public Health, IoE and Dr. B.R. Ambedkar Centre for Biomedical Research (ACBR), University of Delhi, India.
Statistical analyses
The data used in the present study was collected from both an online and offline cross-sectional survey of Indian parents. Descriptive statistics were used to calculate hesitancy, concerns and motivating factors among parents of children aged 15–18 years and below 15 years. A total of 900 responses from Indian parents were collected through the snowball sampling method. Overall, 846 responses from parents fulfilling the inclusion criteria were analysed by GraphPad Prism 5 [Figure 1].
Figure 1.
Flow chart of the number of parents included in the study
Results
Demographic profile of children
Table 1 presents the demographic profile of the 846 children surveyed, with 49.5% being male and 50.5% female. Among them, 60.9% (n = 515) were aged between 0 and 14 years, while 39.1% (n = 331) were between 15 and 18 years. The majority of children had blood group B (34.0%), followed by blood groups A (26.9%), O (24.5%) and AB (14.7%). Most participants (81.9%) were from urban areas, followed by sub-urban (11%) and rural areas (7%). Regarding vaccination, 25% of children had received a flu vaccine between September 2019 and last date of our form collection. For COVID-19, 51.1% of children had been vaccinated, with 36.8% receiving both doses and 14.3% getting a single dose. Out of 433 vaccinated children, 60.3% (n = 261) had experienced adverse events, with most (64%) reporting them after one dose. Of the parents, 21% (n = 98) reported their children’s history of exposure to the SARS-CoV-2 virus, while 79% (n = 369) had not contracted COVID-19. Among the infected, 14.3% (n = 14) were asymptomatic, and 85.7% (n = 84) had symptoms. Among symptomatic cases, 64.3% (n = 54) experienced mild symptoms, 34.5% (n = 29) moderate symptoms and 1.2% (n = 1) severe symptoms. Approximately 8% of children had comorbidities, with chronic lung diseases, asthma, obesity and diabetes being the most common [Figure 2].
Table 1.
Demographic profile of children (n=846)
| Variables | n (%) |
|---|---|
| Gender | |
| Males | 419 (49.5) |
| Females | 427 (50.5) |
| Age groups (Years) | |
| 0-14 | 515 (60.9) |
| 15-18 | 331 (39.1) |
| Blood groups | |
| A+/A- | 182/18 (24.5/2.4) |
| B+/B- | 208/45 (28.0/6.0) |
| O+/O- | 149/33 (20.0/4.4) |
| AB+/AB- | 57/52 (7.7/7.0) |
| Place | |
| Urban | 693 (81.9) |
| Sub-urban | 91 (10.8) |
| Rural | 62 (7.3) |
| Did your child receive flu vaccine any time between September 2019 and today? | |
| Yes | 208 (24.6) |
| No | 638 (75.4) |
| Is your child vaccinated with COVID-19 Vaccine? | |
| Yes, one dose | 121 (14.3) |
| Yes, both doses | 312 (36.8) |
| No | 80 (9.5) |
| Not Available | 333 (39.4) |
| Did child experienced adverse events following the immunization? (n=261) | |
| Yes, after one dose | 167 (64.0) |
| Yes, after both doses | 94 (36.0) |
| Did your child suffer from COVID-19? (n=467) | |
| Yes (Not tested) | 59 (12.6) |
| Yes (Tested) | 39 (8.4) |
| No | 369 (79.0) |
| If yes COVID positive, how many times? (n=66) | |
| Once | 60 (90.9) |
| Twice | 6 (9.1) |
| If yes COVID +, what type it was (n=98) | |
| Asymptomatic | 14 (14.3) |
| Symptomatic | 84 (85.7) |
| Mild | 54/84 (64.3) |
| Moderate | 29/84 (34.5) |
| Severe | 1/84 (1.2) |
| Does your child suffer from any medical condition/disease/comorbidity that put child at risk of getting COVID infection. | |
| Yes | 68 (8.0) |
| No | 778 (92.0) |
Figure 2.
Comorbidities among children
Parental hesitancy towards vaccinating their children against COVID-19
Out of the 846 parents surveyed, 59.5% were mothers (n = 503) and the remaining 40.5% (n = 343) were fathers. Around 97.3% (n = 495) of parents expressed willingness to vaccinate their children aged 15–18 years against COVID-19 in the future while 22.2% (n = 154) of the parents of children below 15 years were hesitant [Table 2]. Among parents, mothers were found to be more hesitant to vaccinate their children (aged 15–18 years and below 15 years) than fathers [Table 3]. However, gender difference was not significant among hesitant parents. Additionally, 16.8% of parents were hesitant to vaccinate their children even if schools mandate it. However, 79% of parents were still intent on vaccinating their children, even if they had a previous COVID-19 infection [Table 2]. Interestingly, 35.5% (n = 300) of parents were hesitant to take the COVID-19 vaccine themselves, and 17.6% were unsatisfied after taking the COVID-19 vaccine.
Table 2.
Parental hesitancy towards vaccinating their children with COVID-19 vaccine
| Variables | n (%) |
|---|---|
| If your child (15–18 year) is not yet vaccinated, are you willing to give COVID-19 vaccine in future? | |
| Yes | 495 (97.3) |
| No | 14 (2.7) |
| Are you willing to give COVID-19 vaccine to your child (below 15 year) if available in future? | |
| Yes | 539 (77.8) |
| No | 154 (22.2) |
| Are you willing to give COVID vaccine If school mandate COVID vaccination for children, when available? | |
| Yes | 704 (83.2.0) |
| No | 142 (16.8) |
| Are you willing to give COVID vaccine to your child even after he/she was COVID positive earlier. | |
| Yes | 537 (79.0) |
| No | 143 (21.0) |
| Were you reluctant/hesitant to take COVID vaccination for yourself? | |
| Yes | 300 (35.5) |
| No | 546 (64.5) |
| If yes reluctant, are you satisfied now after taking COVID vaccination? | |
| Yes | 697 (82.4) |
| No | 149 (17.6) |
Table 3.
Gender disparity in parental hesitancy towards COVID-19 vaccination for children
| Variables | Total hesitant | Male (%) | Female (%) |
|---|---|---|---|
| Hesitant for vaccinating children (15–18 years) against COVID-19 | 14 | 6 (42.9) | 8 (57.1) |
| Hesitant for vaccinating children (below 15 years) against COVID-19 | 154 | 72 (46.8) | 82 (53.2) |
Causes of Concern among parents towards vaccinating their children with COVID-19 vaccine
About 68.1% (n = 576, 576/846) had concerns about COVID-19 vaccination in their children. To understand the reasoning behind vaccine hesitancy, we further asked the parents for their concern and reluctance against COVID-19 vaccination for their children. As shown in Figure 3, the most common reason cited for COVID-19 vaccine unwillingness among parents is that a child has already achieved natural immunity after COVID-19 infections (76.8%). The concern of parents in second place was safety (73.5%) and side effects or adverse events (70.3%) of COVID-19 vaccination in children. Around 55.1% of parents believed that the COVID-19 vaccine for children was not a solution to end the pandemic. In addition, 21.2% of parents had concerns about the effectiveness of the COVID-19 vaccine in children.
Figure 3.
Concern of parents towards vaccinating their children with COVID-19 vaccine
Motivation to get vaccinated
It is crucial to understand the motivating factors for hesitant parents regarding their children’s COVID-19 vaccination. Among them, 54.2% are convinced if their doctors recommend it, while 30.3% seek detailed information on vaccine side effects and efficacy in children [Figure 4]. Additionally, 8% are influenced by observing other children’s response to the vaccine, and 7% await approval from legal authorities for vaccinating children against COVID-19.
Figure 4.
Motivating factors by parents to decide them to vaccinate their children
Most trusted source of information on COVID-19 vaccination
Figure 5 shows parents’ most credible sources of information for vaccinating their children against COVID-19. Healthcare workers were the most trusted source (47.4%), followed by social media (24%), news channels (20%) and family friends (6.9%).
Figure 5.
Source of information among parents for the children’s COVID-19 vaccine
Discussion
Although COVID-19 vaccination efforts for adults have been widely effective, spreading the vaccination to children presents distinct challenges. The WHO recognizes vaccine hesitancy as a major factor contributing to global health risks, underscoring the critical role of parental decisions in determining vaccination uptake. Since parents are the primary carers of children, their acceptance or reluctance to vaccinate children against COVID-19 significantly impacts the overall success of mass vaccination initiatives targeting the younger population. Hence, the purpose of the study was to investigate parental hesitancy regarding vaccination for children under 15 years old and between 15 and 18 years old. Additionally, we explored the specific concerns of parents that might be barriers to vaccinating their children against COVID-19. Our findings revealed that parents of children below 15 years showed higher levels of hesitancy (22.2%) towards COVID-19 vaccination compared to parents of children aged 15–18 years (2.7%). In line with our results, a separate study in Japan also reported a significant proportion (33.5%) of hesitancy among parents of children under 14 years old.[18] Similarly, another study among Thai parents carried out by Kitro et al.[19] found a significantly higher COVID-19 vaccine hesitancy among parents of children under the age of 12 years than the parents of older children. Contrary to the previous Indian cross-sectional study,[20] our research revealed a significantly higher rate of COVID-19 vaccine acceptance among parents. This acceptance level was nearly comparable to that observed in similar studies conducted in China (73%), New Zealand (80%) and England (89%).[21,22,23] Furthermore, our results are consistent with the previous studies, revealing a slightly higher hesitancy among mothers compared to fathers regarding COVID-19 vaccination for their children.[24,25,26]
Attitudes and experiences of parents are important parameters to assess parents’ willingness to vaccinate their children against the COVID-19 virus. In our study, 35.5% of parents were reluctant to take the COVID-19 vaccine for themselves, depicting that parents’ intentions play a significant role in determining their willingness to vaccinate their children, and our results are in agreement with the previous studies done by Horiuchi et al. and Wan et al.[18,27] Surprisingly, 17.6% of parents are still not satisfied with their own COVID-19 vaccination, indicating the dire need to educate the general population pertinent to the recommended COVID-19 vaccination.
A significant proportion of parents believed that their children do not require COVID-19 vaccination as they had a history of COVID-19 infection and had developed natural immunity against SARS-CoV-2. Therefore, to provide accurate and reliable information to individuals and communities and dispel misconceptions, public health campaigns play a crucial role in educating the public. By disseminating correct information about the benefits of COVID-19 vaccination, including the potential for added protection even for those who have previously been infected, these campaigns can help address vaccine hesitancy and encourage parents to make informed decisions for their children’s health. Fostering a clear understanding of how natural immunity and vaccination work together can contribute to more comprehensive and effective strategies for controlling the spread of COVID-19 and its variants. More than 70% of the parents had concerns about the safety and side effects of the COVID-19 vaccine. Several other studies also reported a similar concern indicating that vaccine safety is essential in building parents’ trust in vaccines.[20,28] Therefore, to build parents’ trust, health authorities and healthcare providers should communicate transparently and effectively about the benefits and safety of COVID-19 vaccines for children.
Additionally, when we inquired about the factors that could persuade parents to vaccinate their children, a significant 54.2% of parents stated that they would be more inclined to vaccinate if their doctor recommended it which highlights the influence of healthcare providers in shaping parental decisions. The results are a replication of our previous study conducted among people aged ≥18 years, where 33.3% of respondents were convinced of COVID-19 vaccination for themselves, once their doctors approved it.[16] Therefore, incorporating healthcare professionals into awareness programs, providing them with the latest vaccine information and equipping them with effective communication strategies are key steps in addressing parental hesitancy and promoting COVID-19 vaccination for children. Their influence can go a long way in ensuring that accurate and reliable information reaches parents, leading to better-informed decisions about vaccination. Furthermore, our research revealed that healthcare professionals were the most trusted source of information for parents, followed by social media. Our results are consistent with the previous survey study conducted in the United States where the key source of information for their children’s COVID-19 vaccination was a paediatrician.[29] Also, previous studies showed the impact of healthcare recommendations on reducing COVID-19 vaccine hesitancy.[30,31] To address parental hesitancy towards childhood COVID-19 vaccination, it is crucial to disseminate reliable information through healthcare professionals, official government websites and social media platforms. Public health campaigns should provide accurate comprehensive information about COVID-19 vaccines, addressing myths and misconceptions on its safety and efficacy to enhance parents’ acceptance of vaccinating their young children. These campaigns can use multiple channels, including television, radio, social media and community outreach. It is imperative to ensure that parents have access to reliable and up-to-date information to make informed decisions for the health and safety of their children. Public health efforts should emphasize the importance of vaccination as a key tool in controlling the spread of the virus and achieving herd immunity, thereby safeguarding both individual and community well-being.
Conclusion
In conclusion, despite the global vaccination drive leading to a reduction in the severity and mortality of COVID-19 cases, the reluctance of parents to vaccinate their children, particularly those below the age of 15 years, remains a growing concern. Paediatricians play a crucial role in engaging with parents, guiding them to comprehend the significance of administering the recommended COVID-19 vaccine for children. Providing evidence-based information through various communication channels can empower parents to make well-informed choices about vaccinating their children and contribute to overall public health efforts.
Ethics approval
The present study has been approved by the Institutional Human Ethics Committee of Delhi School of Public Health, IoE and Dr. B.R. Ambedkar Centre for Biomedical Research, University of Delhi, India, as per ICMR guidelines (ACBR/IHEC/DS-COVID6/02-2022).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgements
We thank Prof. Savita Roy (Principal, Daulat Ram College, University of Delhi) and Prof. Ravi Toteja (Principal, Acharya Narendra Dev College, University of Delhi) for their logistic support and cooperation.
References
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