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. Author manuscript; available in PMC: 2025 Jul 1.
Published in final edited form as: J Pediatr Health Care. 2024 Mar 2;38(4):456–467. doi: 10.1016/j.pedhc.2024.01.009

Exploring Hesitancy, Motivations, and Practical Issues for COVID-19 Vaccination among Vaccine Hesitant Adopter Parents Using the Increasing Vaccination Model

Rachel S Purvis 1, Ramey Moore 1, Don E Willis 1, Ji Li 2, James P Selig 2, Shashank Kraleti 3, Tabasum Imran 4, Pearl A McElfish 1,*
PMCID: PMC11222047  NIHMSID: NIHMS1963698  PMID: 38430095

Abstract

Introduction:

COVID-19 vaccination coverage among children remains low, and many parents report being hesitant to get their child(ren) vaccinated. This study explores factors influencing hesitancy and the facilitators that helped hesitant adopter parents choose to vaccinate their child(ren) against COVID-19 despite their hesitancy.

Method:

We use a qualitative descriptive design with individual interviews (n=20) to explore COVID-19 vaccine hesitancy and facilitators of vaccination among hesitant adopter parents. The Increasing Vaccination Model domains (thoughts and feelings, social processes, and practical issues) provided the framework for initial coding, and the research team identified nine emergent themes.

Results:

Findings document the factors influencing hesitancy and the facilitators motivating COVID-19 vaccination among hesitant adopter parents.

Discussion:

Findings fill the gap in the literature by providing hesitant adopters’ lived experience, perspectives on vaccine hesitancy, and the influential factors that helped participants overcome their hesitancy and choose to vaccinate their child(ren) against COVID-19.

Keywords: vaccine hesitancy, COVID-19 vaccine, hesitant adopters, parents/guardians, Increasing Vaccination Model

Introduction

COVID-19 can cause severe respiratory illness in children that can lead to hospitalization and death (Shi et al., 2022). Children with underlying medical conditions are at an increased risk for these negative COVID-19 outcomes (Miller et al., 2022). Even when children have no symptoms or mild symptoms, they can spread COVID-19 infection (Yonker et al., 2020). Despite the broad availability of the vaccine, COVID-19 vaccination coverage among children remains low with less than half (~44%) of children six months to 17 years old having received any doses of the COVID-19 vaccine as of May 2023 (American Academy of Pediatrics, 2023). COVID-19 vaccination coverage in the US is lowest among southeastern states with Arkansas ranking 44th for pediatric COVID-19 vaccination (Murthy et al., 2023).

Recent quantitative analysis has shown that parents of younger children, with lower income, and with less education reported greater hesitancy about vaccinating their child against COVID-19 (Rane et al., 2022; Sehgal et al., 2023; Szilagyi et al., 2021; Teasdale et al., 2021; Teasdale et al., 2022). These studies documented that COVID-19 vaccine-hesitant parents reported vaccine safety, possible vaccine side effects, the newness of the vaccine, and a lack of need as the primary reasons for their hesitancy (Sehgal et al., 2023; Szilagyi et al., 2021; Teasdale et al., 2021). Vaccine hesitancy is a critical obstacle to preventing and mitigating vaccine-preventable diseases (World Health Organization, 2019). Vaccine hesitancy does not always result in the refusal of a vaccine and can co-occur with vaccination (Hallgren et al., 2021; Moore et al., 2021; Purvis et al., 2021; Willis et al., 2023a; Enkel et al., 2018). We define vaccine hesitancy as an attitude about vaccination to avoid conflating hesitancy with the behavior of vaccination itself (Bussink-Voorend et al., 2022; Larson et al., 2022).

People who become vaccinated while hesitant (i.e., ‘hesitant adopters’) are understudied in the literature due to a lack of clarity and issues in operationalizing the definition of vaccine hesitancy, with some studies conceptualizing vaccination as an indicator of non-hesitancy (Daly et al., 2021; MacDonald & Hesitancy, 2015; Padamsee et al., 2022). An emerging body of research has begun to profile hesitant adopters and understand the processes that lead them to become vaccinated (Hallgren et al., 2021; Moore et al., 2022; Moore et al., 2021; Purvis et al., 2022; Purvis et al., 2021; Willis et al., 2023a). However, literature has yet to focus on pediatric vaccination among hesitant adopter parents. Parents who were hesitant and chose to vaccinate their child(ren) anyway may provide critical information about the process of becoming vaccinated despite feelings of indecision.

This study was informed by the Increasing Vaccination Model (IVM) which conceptualizes the process and context of vaccination behavior to inform and develop interventions for increasing vaccine uptake (Brewer et al., 2017; Brewer, 2021). The IVM posits that vaccination behavior is the result of what an individual thinks and feels about vaccines and the influence of social processes (networks, norms, and interactions). Thoughts and feelings and social processes influence vaccination behavior, in part, by shaping a person’s motivations to vaccinate as well as their vaccine hesitancy. The IVM also identifies practical issues such as the availability of vaccines as an influence on vaccination (Brewer et al., 2017; Brewer, 2021).

The present study fills gaps in the literature by providing qualitative analyses of hesitant adopter parents whose child(ren) became vaccinated despite parents’ feelings of vaccine hesitancy. This paper explores the factors influencing vaccine hesitancy and the facilitators that helped hesitant adopter parents choose to vaccinate their child(ren) against COVID-19 despite their hesitancy.

Methods

Study design and approach

The research team selected a qualitative descriptive design (Colorafi & Evans, 2016) using individual interviews to explore COVID-19 vaccine hesitancy and facilitators of vaccination among hesitant adopter parents who had their child(ren) vaccinated despite their hesitancy. The Institutional Review Board at the University of Arkansas for Medical Sciences reviewed and approved all study materials and procedures (IRB#274483).

Study sample, participant recruitment, consent, and remuneration

Potential participants were identified from a larger quantitative sample of 2,201 adult Arkansans who were surveyed in October 2022 and agreed to be contacted for a follow-up interview. The survey captured sociodemographic information (age, sex, race and ethnicity, marital status, highest level of education, healthcare coverage), COVID-19 vaccine hesitancy, and COVID-19 vaccination status of the eligible child(ren). Using a modified version of a vaccine hesitancy question developed by Quinn et al. (Quinn et al., 2019), survey respondents were asked if they were “not at all,” “a little,” “somewhat,” or “very” hesitant about the COVID-19 vaccine. We define any respondent reporting any level of hesitancy as a ‘vaccine-hesitant’ person. To be included in a qualitative interview, potential participants had to be adults ≥18 years old, had to report some level of COVID-19 vaccine hesitancy, and had to have their eligible child(ren) vaccinated against COVID-19. One hundred and ten (110) met the inclusion criteria and were sent an email by study staff inviting them to participate in an interview. Twenty participants responded affirmatively to the email, completed the interview, and comprised the qualitative sample. The study staff reviewed the study information sheet with participants and answered any questions before the interview started. When the interview started, participants gave their verbal consent to participate, and they were provided with a $50 gift card upon completion of the interview in appreciation of their time.

Instrument

The research team developed a semi-structured interview guide to facilitate and ensure consistency across the interviews. Researchers selected the Increasing Vaccination Model (IVM) domains (thoughts and feelings, social processes, and practical issues) (Brewer, 2021) as the framework informing interview guide questions and probes. Interview guide questions asked participants to describe their thoughts and feelings about vaccines, especially the COVID-19 vaccine. Researchers asked participants about their thoughts and feelings about vaccinating their child(ren) against COVID-19, including any concerns about or motivations for getting their child(ren) vaccinated. Researchers asked participants to discuss the influential social processes and information they accessed when deciding to vaccinate and to describe the practical issues of accessing the COVID-19 vaccine for their eligible child(ren). The research team reviewed and refined the interview guide questions three times.

Data collection

Two qualitative researchers (RP and RM) with over seven years of qualitative experience conducted participant interviews between November 2022 and January 2023. Participants were assigned to an interviewer based on availability, and the study staff emailed participants a unique meeting invitation for their scheduled interview date and time. Interviews were conducted over Zoom and varied in length, ranging between 25–60 minutes. All interviews were recorded, and a professional transcription service developed verbatim transcripts from the interview recordings.

Qualitative data analysis

The research team used the IVM framework (thoughts and feelings, social processes, and practical issues) as a priori codes for initial, preliminary coding. The transcripts were uploaded to a password-protected MAXQDA 2020 project file for coding (MAXQDA, 1989–2015). The lead author and two co-authors conducted a thematic content analysis using an iterative approach of reading and re-reading interview transcripts to identify patterns, interpret meaning, and label data segments with initial emergent codes (Burla et al., 2008; Hsieh & Shannon, 2005; Rubin & Rubin, 2005). The research team used IVM a priori codes (thoughts and feelings, social processes, and practical issues) during preliminary coding to label data segments and used summary emergent codes to organize the data for focused coding. The lead author identified, defined, and incorporated all codes in a preliminary codebook, and two coauthors used this codebook to perform confirmation coding. The research team met every other week to review and discuss coded transcripts to resolve any discrepancies in the interpretation of the data with discussion and debate by consensus. The research team revised the codebook three times, refining code definitions and incorporating new emergent codes as needed into a revised codebook that guided focused coding (Rolfe, 2006). The research team critically reviewed the data, analysis summaries, codebooks, and all coded data segments as a team to ensure analytic rigor and reliability. Hennink et al., 2011). To identify concepts and categories and develop themes, the researchers used a constant comparison technique that compares and contrasts each datum with all other data in an iterative process. Researchers selected exemplary quotes most representative of these themes and organized them below within the themes they best represent. We also present descriptive sociodemographic characteristics of interview participants.

Results

Participant characteristics

Seven participants (35.00%) were male, 13 participants (65.00%) were female, and the average age of participants was 43 years old. Among the 20 interviews, 13 participants (65.00%) identified as White, four participants (20.00%) identified as African-American, two participants (10.00%) identified as Hispanic, and one participant (5.00%) identified as multiracial. Thirteen participants (65.00%) reported being married, three participants (15.00%) reported being divorced, one participant (5.00%) reported being widowed, and three participants (15.00%) reported having never been married. Four participants (20.00%) reported having a high school diploma or equivalent, four participants (20.00%) reported attending some college or university, two participants (10.00%) reported attaining an associate degree, five participants (25.50%) reported having a bachelor’s degree, and five participants (25.50%) reported having a graduate degree. The majority of participants (95.00%) reported having health healthcare coverage, while one participant (5.00%) reported having no healthcare coverage (see Table 1).

Table 1.

Descriptive Statistics for COVID-19 Vaccine Hesitant Adopter Parents Who Completed an Interview (n=20)

Mean SD
Age 43.45 8.67
Frequency (Percent %)
Sex
Male 7 (35.00)
Female 13 (65.00)
Race and Ethnicity
African-American 4 (20.00)
Hispanic 2 (10.00)
Multiracial/other 1 (5.00)
White 13 (65.00)
Marital Status
Married 13 (65.00)
Divorced 3 (15.00)
Widowed 1 (5.00)
Never married 3 (15.00)
Education
High school diploma or equivalent 4 (20.00)
Some college, no degree 4 (20.00)
Associate degree (AA, AS) 2 (10.00)
Bachelor’s degree (BA, BS, AB) 5 (25.50)
Graduate degree (MA, prof, PhD) 5 (25.50)
Healthcare Coverage
No 1 (5.00)
Yes 19 (95.00)
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Note: SD=standard deviation

Qualitative findings

The research team explored reasons for hesitancy, motivations for vaccination, and practical issues related to COVID-19 vaccination using the IVM to define a priori codes that included thoughts and feelings, and social processes to examine hesitancy and motivations among hesitant adopter parents. Researchers identified nine emergent themes within these primary domains. Within the domain of thoughts and feelings, researchers identified four emergent themes: safety concerns, perceived risk of COVID-19, and protect and prevent significant illness. Within the domain of social processes, researchers identified five emergent themes: rumors or conspiracies about vaccines, discrimination and historical trauma, social norms, information sharing, and direct recommendations. Within the domain of practical issues, researchers identified one emergent theme: accessibility of the COVID-19 vaccine.

Thoughts and feelings

Safety concerns.

When thoughts and feelings contributed to their hesitancy, participants discussed the safety concerns they had about the COVID-19 vaccine and vaccination, with a focus on possible short-term or long-term side effects and that the COVID-19 vaccine was a ‘new’ vaccine. Another participant discussed concerns related to more short-term side effects: “One of my children has a history of anaphylaxis so, we had some different concerns with her, especially when the Moderna shot came out that some folks were having allergic reactions to.” (49632146 White female) A participant who worked in an OB/GYN office explained, “I have seen lots of patients come in who have had issues with irregular menstrual bleeding, abnormal bleeding, things like that since either having COVID or having the vaccine. And so, I know that those are effects that it has not been around long enough to know exactly why those effects are happening or what kind of long-term effects could be related to that.” (42664156 White female) Participants reported they were worried about the COVID-19 vaccine’s safety because it was a new and untested vaccine. A participant who was a nurse said, “We’re seeing problems, now, related to that vaccine. And I feel like it was just put out there too [quickly.] I do worry about the side effects later on, and especially, having these babies take it.” (45260584 White female) Another participant reported, “I knew it was another vaccine. It’s just-they did it really quick so that was the only big thing for me. How did they put all of that stuff together to make it safe and-and make it effective?” (50492804 White female) Another participant described her concern: “The thing that worried me is it had not been done before. And so, it was uncharted territory. We didn’t know. Although there had been testing done, I was really concerned [about] how much my kid’s [going to] respond to this, react to this.” (54361771 African-American female)

Overall, participants discussed the newness of the COVID-19 vaccine and side effects as safety concerns that contributed to their feelings of hesitancy. One participant said, “Initially I actually didn’t want to just because [of] the unfamiliarity of what’s actually in the vaccines itself [and] there were so many side effects that were being mentioned about the vaccines that made me a little bit weary.” (50244610 African-American female). Participants also discussed the influence of research despite the newness of the vaccine: “The only concern is just how fast it was tracked. But my understanding is, you know, things like mRNA have been researched before now. They just haven’t been used in this capacity. So, um, that was kind of like, ‘Whoa, this is really quick.’ But knowing that there’s been research done, I thought, ‘Why, uh, why am I pushin’ it off for them?’ I immediately got it, [laughter] you know.” (54361771 African-American female)

Perceived risk of COVID-19.

Within the thoughts and feelings domain, participants discussed their perceptions of the perceived risk of the COVID-19 virus and the influence this had on their decision to vaccinate an eligible child(ren) despite their hesitancy. Participants described how concerns about coronavirus infection and complications outweighed the concerns about risks from the vaccine. A participant stated, “The initial fear that everyone had from the infection itself. Kind of the mass panic that there was [I] didn’t feel like at that point the risk of the unknown of the vaccine outweighed the risk of the infection itself.” (42664156 White female) A participant explained, “It was this active danger that was changing everyone’s lives and very prominent in the news and in my social lives. And so, it seemed like this was a scary thing. And so, any scariness that I had associated with a medicine and a needle was overweighed by the scariness of the virus.” (54381154 White female) Another participant said, “I was in contact with people that passed away due to Covid 19, When everything started, I was very scared.” (51145138 Hispanic female)

Protecting and preventing significant illness.

Within the thoughts and feelings domain, participants discussed how protecting their child(ren), themselves, their extended family, and the broader community from significant illness influenced their decision and motivated them to get their child(ren) vaccinated against COVID-19. One participant stated, “I didn’t want my kids to die.” (43575619 Multiracial/Other male) Another participant explained, “I just kind of wanted to do anything to prevent, you know, from possibly getting COVID. I had mine and so I just felt like they needed theirs as well.” (48030030 White female). A participant reported, “It’s not a like a mandatory thing or anything like that, but since the school season is about to start or the school is—ongoing school season, all the kids are having various kinds of sickness or diseases. This might help them prevent getting COVID. I’m like, okay, I want peace of mind.” (55205113 Multiracial/Other male)

Some participants described vaccinating their child(ren) because they wanted to protect other vulnerable family members from exposure to COVID-19. A participant explained how her concern for protecting her father’s health influenced her decision to vaccinate: “I didn’t want them to get their grandfather sick. They’re in public school. I thought it was really easy for them to get sick. I figured they’d probably get over it, but we see my father often. My father was not [going to] get vaccinated, and that became clear so, it was to protect him that was the primary reason.” (54381154 White female) Another participant said, “The health of my dad and [my daughter’s] relationship with him because she was in school and should she have brought something home and [he] got it and something happened, she wouldn’t have been able to handle that,” (42664156 White female) linking their decision to vaccinate their child(ren) with protecting the health of another family member. Other participants discussed protecting their health as a motivation for vaccinating their child(ren). A participant with several chronic conditions and whose grandchildren live with him encouraged their vaccination because “they [were] going back and forth to school, [and] participate in sports and different things like that, and [if] they went to school and brought something home, then I’d have a chance I could’ve caught it.” (51695305 African-American male)

Several participants cited the protection of their child(ren) along with the protection of the broader communities including those that were not part of their family in their motivations to vaccinate their child(ren) against COVID-19. When describing their primary motivation to vaccinate, a participant said, “[Trying] to protect her, as well as [trying] to protect those around us, [trying] to do-do things for the greater good, as opposed to just my personal beliefs.” (48567255 White male) Another participant reported that they vaccinated their child(ren) because they “think it’s important in terms of protecting my kids. And then I think it’s important to protect the people around them who are at higher risk than they are of negative effects if they were exposed and got the virus.” (49632146 White female) A participant said, “We wanted to avoid COVID, avoid spreading COVID, and just try to end the pandemic—end the shutdown. We just really were trying to participate as a community, like as part of the world trying to just end it. That was kind of a big motivation. And for [us] to have more freedom.” (52331974 White female)

Social processes

Rumors or conspiracies about vaccines.

Within the domain of social processes, participants described rumors or conspiracies they had heard about the COVID-19 vaccine, which they linked with their vaccine hesitancy. A participant explained, “I just kept hearing a lot of things like, ‘Oh, you don’t want to put these heavy metals straight into your child’s bloodstream,’ and this [kind of] thing.” (54381154 White female) Another participant said, “Do we really need this? Is the government just pushing it on us? You know, population control, all those kinds of theories that were out there running around.” (48030030 White female) Participants discussed how rumors about possible side effects impacted vaccination decisions. A participant reported, “We heard all kinds of stories and rumor mills about the side effects of the shot and after-effects of the shot, and the only one that really gave me pause was reports of myocarditis, especially with young men because I have two young men.” (49632146 White female)

Other participants described their attempts to avoid the rumors, conspiracies, and misinformation about the COVID-19 vaccine. One participant explained that she and her husband, “decided to actually not speak to other people about it. And the reason why is whenever you were to speak about COVID it’ll always be like some [kind of] conspiracy and they say, ‘Oh, the government’s just trying to put more things into your body to monitor you and things like that.’” (50244610 African-American female) Another participant explained, “There’s this cultural just fear of the government putting something in the bodies of African-Americans [and] typically when someone tells me that they’ve seen something on social media, unfortunately, I just blow it off.” (54361771 African-American female) Other participants explained, “You have so much stuff on social media [and] there’s so much false information out there [because] a lot of people are against it, and they have a lot on the negative side to say about a new vaccine” (50492804 White female) and “I tried to just [kind of] tune everything out a little bit almost [because] there was so much conflicting information.” (52331974 White female)

Discrimination and historical trauma.

Within the domain of social processes, some minority participants cited discussions within their social network of historical trauma related to research misconduct and experiences of contemporary racial discrimination as factors contributing to their hesitancy. One participant said, “The people that I know that are against being vaccinated, they are, um, lot of ‘em have referenced, like, the Tuskegee experiments, and then the sterilizing that happened in North Carolina with black women … There’s this cultural just fear of the government putting something in the bodies of African-Americans.” (54361771 African-American female)

Social norms.

Within the domain of social processes, participants described how the social norms in support of COVID-19 vaccination among those in their social network helped them decide to get their child(ren) vaccinated despite their hesitancy. One participant reported, “I just heard that there was a vaccine, and we knew a lot of people, friends, and acquaintances who were getting it, and we decided to do it—the community, it seemed like everybody was doing it and so it just seemed like the right thing to do.” (52331974 White female) Another participant described support for vaccination in her social network that helped address their hesitancy: “My oldest boy made sure his whole family had it, and my mom was one of the first ones at her work to get the COVID vaccine and she didn’t have any problems, so she was always, ‘You got to get it’… [and] my boss motivated a lot of people at work to get it because they gave an incentive.” (50492804 White female) One participant discussed the social support for vaccination within her family: “We all agreed very quickly on COVID-19 vaccination.” (51148839 White female) A participant explained that the majority of their child(ren)’s social network had been vaccinated: “I think most of their close friends are. Yes. There are a couple notable exceptions. But I would say, by far, the most significant portion are vaccinated.” (49632146 White female) Another participant said, “I think most of my family and friends are vaccinated except for my husband and one of my sisters. Everyone else is.” (53433646 Hispanic female)

Information sharing.

Within the IVM domain of social processes, participants described sharing information related to COVID-19 vaccination within their social network including family, friends, and co-workers, many of whom were also healthcare providers, as people they trusted to share information about the COVID-19 vaccine that helped them overcome their hesitancy. A participant who worked in a healthcare clinic stated, “We talked about it a lot at work amongst the different providers. I can remember [talking] about it a lot and just they had different knowledge than what I had and were able to understand different parts of it and explain it in different ways. (42664156 White female) Another participant described sharing information with her co-workers about possible side effects: “The physician that I work for has kids the same age as mine, and we kind of talked through it, and a couple of other nurses also have kids my age, and so we just kind of talked about it and what they were seeing and what they thought.” (48030030 White female)

Other participants shared information about the vaccine in conversations with family and friends who were often healthcare providers themselves. A participant explained the influence of family members on the decision-making process: “Their grandfather is a physician of 40 years. And a research scientist. And so, he had a great deal of conversation with me. My mother is a critical care nurse. She had a great deal of conversation with me. And just the importance of [vaccination] and really what made me just go ahead and do it.” (54361771 African-American female) Another participant said, “One of my aunts is working as a nurse. And we talk to each other during weekends, and [ask] her, ‘Okay, hey, this vaccine is out, and the government is saying kids need to get vaccinated. What are your thoughts on that?’ And she’s like, ‘Yeah. It’s good, even if you get COVID, the symptoms might be mild, not like life-threatening or anything like that.’” (55205113 Multiracial/Other male) The participant also described conversations with “a couple of friends—one is a pharmacist; one is a nurse. So, we talked to them [and our] conversations kind of helped me think through it and then [get the] shots for [my kids].” (55205113 Multiracial/Other male)

Direct recommendations.

Within the social processes domain in the IVM, participants discussed the influence of recommendations from healthcare providers, employers, and school administrators on their vaccine hesitancy. A participant described their child’s healthcare provider’s influential vaccine recommendation: “He is a big supporter and encourager of vaccinating for COVID. He really would just recommend it, his personal recommendation. Of course, if you have questions, he will answer them.” (54361771 African-American female) Another participant discussed their child’s annual wellness visit and the healthcare provider’s recommendation: “He said, ‘Listen, I can’t tell you what to do, obviously. But I can tell you that I feel totally comfortable with it. There’s been a lot of research. It went fast, but there’s been a lot of research.’ And so, I asked him, ‘Okay if this was your kid, what would you do?’ and he said, ‘I would get it in a heartbeat.’” (51148839 White female)

Some participants discussed how recommendations from employers and school administrators influenced their COVID-19 vaccine decision-making process. A participant explained their employer’s recommendation: “I asked him what he thought about children being vaccinated and he really encouraged us to do so.” (53433646 Hispanic female) Another participant said, “The school authorities also mentioned, it is good to get a COVID shot for [my] kids.” (55205113 Multiracial/Other male) A participant reported the school’s requirement encouraged them to vaccinate her child(ren) “so they were capable of going back to school and just [kind of] resuming life a little bit easier.” (50244610 African-American female)

Other participants did not recall receiving a provider’s recommendation for COVID-19 vaccination. A participant explained that her pediatrician encouraged immunization: “The ones that are on their list that are mandatory per age, they definitely recommend, and they do a great job of promoting vaccines but not great for the COVID vaccine…it’s not a conversation unless you ask.” (48018934 White female) Another participant described trying to get a recommendation: “That process was really frustrating, to be honest. I tried to talk to our pediatrician’s office and get a recommendation from them initially and didn’t get to a point where I felt like I had gotten a strong recommendation [in] either direction.” (49632146 White female)

Practical issues

Accessibility of the COVID-19 vaccine.

Within the practical issues domain, some participants discussed easy access while others discussed the difficulty that they had in accessing the COVID-19 vaccine for their child(ren). Some participants described an easier process for accessing the COVID-19 vaccine for their child(ren). Describing the process of vaccinating two children, a participant said, “It was extremely easy. With the four-year-old, we had to schedule appointments with her pediatrician’s office, but it was easy. They do [them] on Tuesdays. They gave us a great time. With the seven-year-old, it was super easy—he could go to Walgreens.” (54361771 African-American female) Another participant said, “Once they hit their age and they were in that approval bucket, we just went to Walmart and got [the vaccine] and it was super easy. We walked in. It was no big deal. The pharmacist was ready to roll, and that was it.” (51148839 White female) A participant described how the local health department had offered a COVID-19 vaccine clinic specifically for children with expanded hours: “It was easy. You bring your child to get vaccinated and just show up [on the specific days] … she’s had all of her shots there so she’s already in there and we just showed up and she got called right in and she had her shot. I think they stayed open till 6:00 p.m. those three days.” (50492804 White female) Another participant described COVID-19 vaccination for their two children: “They actually [were vaccinated] at their school, which I thought was amazing.” (48018934 White female)

Attempting to vaccinate their child before school started, a participant reported, “Clinics were booked. They didn’t have any more dates and times [and] I finally got her in [a clinic] and that’s actually when they were [now] accepting walk-ins.” (50244610 African-American female) Even among those who had vaccinated one child, they were having difficulty accessing the vaccine for other children. One participant discussed why their youngest child (15 months old) was not vaccinated and explained, “I know it’s not available through my pediatrician. I would actually have to go to the health department; [it] is the only location that I can get it for a child so young, um, so that is why she does not have it. So, we got all of our children’s vaccines as soon as they were available, except for my youngest due to where we have to go.” (48018934 White female) Another participant discussed the difficulty of accessing a COVID-19 booster shot for her son: “We have had good access because we’ve had local pharmacies just [doing] walk-in, with pretty easy access. And so, I didn’t call and ask around ahead of time. I just assumed we could do what we did last time and walk in and get it. We walked in and tried, and they didn’t have it. So, we walked into another one and tried, and they didn’t have it. I found it in town, so we’ll try again tonight and see what happens.” (49632146 White female)

Discussion

This exploratory study documented influences on hesitancy and facilitators of vaccination among COVID-19 vaccine hesitant adopter parents who had their eligible child(ren) vaccinated against COVID-19 despite their hesitancy. The IVM framework guided analysis, and nine themes emerged within the IVM domains of thoughts and feelings, social processes, and practical issues. Participants discussed safety concerns about COVID-19 vaccines and linked their hesitancy with their perceptions of the vaccine as new, untested, and with unknown side effects. These findings are consistent with quantitative research documenting parental concerns related to vaccine safety in which respondents have reported the newness of the vaccine and possible side effects as reasons for hesitancy (Alalmaei Asiri et al., 2023; Savitsky et al., 2023; Sehgal et al., 2023; Szilagyi et al., 2021; Teasdale et al., 2021; Temsah et al., 2021). Our study provides unique qualitative information from documenting parents’ concerns in their own words.

Participants described how their perceptions of the risk of exposure to COVID-19 and the possibility of serious illness for their child(ren) influenced their decision-making process. This finding supports research documenting the perceived severity of COVID-19 for their child(ren) as a predictor of COVID-19 vaccine intention among parents and caregivers before the availability of pediatric doses (Ellithorpe et al., 2022). Participants discussed being motivated to vaccinate their child(ren) despite their hesitancy because of the vaccine’s protection against and prevention of serious COVID-19-related illness. Participants said the risks associated with COVID-19 infection outweighed their concerns about the COVID-19 vaccine, which helped them overcome their hesitancy to get their child(ren) vaccinated. This finding is consistent with prior research including a survey of US adults (which) found that risk perceptions of the severity of and susceptibility to COVID-19 were significantly associated with vaccine uptake (Viswanath et al., 2021). This finding supports those of a recent scoping review to identify the prevalence of and the influential factors on the intention to vaccinate which found that protection from COVID-19 was among the prominent factors associated with COVID-19 vaccine uptake (AlShurman et al., 2021). This article adds new insight regarding how hesitant parents weigh their perceptions of the risk of the vaccine against the protection the vaccine offers.

In addition to protecting their child(ren), participants described wanting to protect the health of other family members or themselves who may be exposed to COVID-19 via contact with their child(ren). Participants cited that preventing the spread of COVID-19 motivated them to vaccinate their child(ren) despite their hesitancy. These findings support research on parental intention to vaccinate that found a high proportion of parents reported the COVID-19 vaccine as beneficial and important for their child(ren)’s health and the health of others (Szilagyi et al., 2021).

Participants said they were hesitant to have their child vaccinated because of the rumors or conspiracies about the COVID-19 vaccine they had heard within their social networks. These findings provide important context to the impact of conspiracies on vaccine intention as documented by a recent study that found participants who believed conspiracies reported their intention to vaccinate was 3.9 times lower than participants who disbelieved conspiracies (Earnshaw et al., 2020). One participant explained the impact of experiences of racial discrimination and historical trauma related to previous research misconduct on the vaccine hesitancy of African-American parents. This finding supports previous research that has documented structural barriers related to the historical influence of stigma against the African-American community and the resulting distrust of healthcare providers and government authorities encouraging vaccination (Zhang et al., 2022).

Participants reported that strong social norms in favor of COVID-19 vaccination among their family, friends, and co-workers helped them overcome their hesitancy and choose vaccination. This is consistent with prior research that demonstrates social norms related to COVID-19 vaccination can influence a person’s vaccine behavior as they choose to get vaccinated to align with the behaviors and expectations of their social network. For example, a recent study of Canadian mothers found social norms and sharing among social networks were critical in maternal vaccination decision-making (Davidson et al., 2023). Participants described how sharing information about the COVID-19 vaccine with trusted sources that included family, friends, and co-workers, especially those who were healthcare providers, addressed their concerns and facilitated their decision to have their child(ren) vaccinated. Participants reported they were discussing personal experiences of vaccination, experiences of COVID-19 illness, and related health behaviors with trusted sources while trying to decide whether to have their child(ren) vaccinated. Similarly, quantitative studies find that individuals who perceive vaccination to be the norm among those around them, or that those close to them want them to be vaccinated, are more likely to be vaccinated themselves (Willis et al., 2023c; Quinn et al., 2017). Our findings are also consistent with recent research that found family communication was the strongest predictor of intention to vaccinate, and talking with family and friends about whether to get the vaccine was among the top motivations for getting vaccinated for participants (Cunningham-Erves et al., 2023; Francis et al., 2022). Our findings provide new qualitative information as participants describe the process in their own words and highlight the importance of social norms and information sharing among family and friends in the vaccine decision-making process.

Participants discussed the influential impact of direct recommendations from healthcare providers and school administrators on addressing their hesitancy with having their child(ren) receive the COVID-19 vaccine. Participants recounted how strong recommendations from their healthcare providers and school officials helped to make them feel more comfortable with having their child(ren) vaccinated against COVID-19. These findings are consistent with recent quantitative literature documenting healthcare providers and school administrators as influential, trusted sources of COVID-19 vaccine information whose recommendations encouraged greater willingness to vaccinate among parents (Goldman et al., 2020; Rhodes et al., 2020; Scherer et al., 2021; Szilagyi et al., 2021). Furthermore, the study finding highlights the importance of all providers that administer vaccines including pediatric nurse practitioners, family nurse practitioners, and adult nurse practitioners who can provide strong recommendations that may encourage COVID-19 vaccination among the hesitant. The finding is also consistent with previous research documenting that parents want clear and timely vaccine information from sources they trust (Ames et al., 2017). Some participants said they did not receive a direct recommendation, especially from their healthcare provider. This finding is concerning but consistent with some studies that show only about half of parents received a recommendation from their healthcare provider regarding the COVID-19 vaccine (Willis et al., 2023b; Willis et al., 2024). Given that healthcare providers’ recommendations are important and may only happen half of the time, researchers and public health officials should focus on understanding why healthcare providers do not recommend the COVID-19 vaccine to their patients and test interventions to increase healthcare provider recommendations.

Within the practical issues domain of the IVM, participants described the accessibility of the COVID-19 vaccine as both a barrier and facilitator of vaccination. For some participants, it was very easy to access the COVID-19 vaccine once they had decided to get their child(ren) vaccinated. These participants described an easy process of accessing the vaccine from their established providers, pharmacists, or local health department units. Other participants encountered difficulties with accessing pediatric COVID-19 vaccines in their area or from their regular providers who offered other childhood immunizations. These findings support the research documenting that access to the COVID-19 vaccine plays an influential role in vaccine uptake, and removing barriers to vaccine access can facilitate the process of vaccination (McCabe et al., 2023; Swope et al., 2023).

Limitations and strengths

This study is not without limitations as the findings may be less generalizable because of the relatively small sample of 20 participants. However, the main objective of qualitative exploration is not generalizability but to document the emic perspective of participants. Our findings provide an in-depth, nuanced insider perspective of factors influencing vaccine hesitancy as well as facilitators of COVID-19 vaccination among hesitant adopter parents in their own words. The sample reported a higher level of educational attainment than may be representative of the larger state population with more than half of participants reporting an associate, bachelor’s, or graduate degree. The racial and ethnic diversity of the sample strengthens the study findings. Study findings provide important information that can inform future interventions to increase pediatric COVID-19 vaccine uptake among hesitant parents.

Conclusion

The study findings document the factors influencing hesitancy and the facilitators motivating COVID-19 vaccination among hesitant adopter parents. Our findings fill the gap in the literature by providing hesitant adopters’ lived experience, perspectives on vaccine hesitancy, and the influential factors that helped participants overcome their hesitancy and choose to vaccinate their child(ren) against COVID-19. Our study provides insight into the role of thoughts and feelings related to safety concerns and how the perceived risk of exposure influences vaccine hesitancy among parents. Study findings document how parents’ perceptions of the protection the vaccine offered against serious illness helped them overcome their hesitancy. In addition, our study documents the critical influence of social processes on helping hesitant adopter parents choose to vaccinate their child(ren) despite their hesitancy. Our study shows how critical the role of social norms and information sharing about the COVID-19 vaccine is to facilitating vaccination among hesitant adopter parents. Our findings highlight the important influence of direct recommendations from healthcare providers and school administrators to get the COVID-19 vaccine on the decision-making process of hesitant adopter parents. This finding has clinical implications for physicians and nurse practitioners administering the COVID-19 vaccine. Our findings suggest that providers should not assume hesitancy means vaccine refusal and that providers should engage hesitant parents and provide them with understandable information and answer questions they have to encourage vaccine uptake. Finally, the study findings underscore the need to discuss the attitude of vaccine hesitancy and the action of vaccination as separate but co-existing and interrelated domains. Study findings provide important insights that can inform future interventions to increase pediatric COVID-19 vaccine uptake among hesitant parents.

Funding acknowledgment:

This work is supported by the Community Engagement Alliance (CEAL) Against COVID-19 Disparities (NIH 10T2HL156812-01) and University of Arkansas for Medical Sciences Translational Research Institute funding awarded through the National Center for Advancing Translational Sciences of the National Institutes of Health (NIH) (UL1 TR003107). This work was also supported in part by the Arkansas Biosciences Institute, the major research component of the Arkansas Tobacco Settlement Proceeds Act of 2000. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders.

Footnotes

Ethical Statement

The Institutional Review Board at the University of Arkansas for Medical Sciences reviewed and approved all study materials and procedures (IRB#274483). Potential participants were identified from a larger quantitative sample of 2,201 adult Arkansans who were surveyed in October 2022 and agreed to be contacted for a follow-up interview. To be included in a qualitative interview, potential participants had to be adults ≥18 years old, had to report some level of COVID-19 vaccine hesitancy, and had to have had their eligible child(ren) vaccinated against COVID-19. One hundred and ten (110) met the inclusion criteria and were sent an email by study staff inviting them to participate in an interview. Twenty participants responded affirmatively to the email, completed the interview, and comprised the qualitative sample. The study staff reviewed the study information sheet with participants and answered any questions before the interview started. When the interview started, participants gave their verbal consent to participate, and they were provided with a $50 gift card upon completion of the interview in appreciation of their time.

Conflict of interest: The authors declared no conflicts of interest.

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