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. Author manuscript; available in PMC: 2025 Dec 2.
Published in final edited form as: Vaccine. 2024 Oct 4;42(26):126389. doi: 10.1016/j.vaccine.2024.126389

Factors that Shape COVID-19 Pediatric Vaccine Decision-Making in Rural Agricultural Communities: A Qualitative Study

Kelley M Pascoe 1, Sonia Bishop 1,2, Xuehan Ci 1, Magaly Ramirez 1, Georgina Perez 2, Genoveva Ibarra 5, Lorenzo Garza 6, Sandra Linde 6, Miriana C Duran 1, Hwa Young Chae 1, Thomas Quigley 5,7, Laurie Hassell 2, Michelle M Garrison 1,3, Paul K Drain 4, Parth D Shah 5, Linda K Ko 1,2
PMCID: PMC11645238  NIHMSID: NIHMS2026331  PMID: 39368130

Abstract

While COVID-19 immunizations can improve outcomes from SARS-CoV-2, vaccine rates in the United States have been lowest among children under age 11 and among rural agricultural communities. This study examined factors influencing pediatric COVID-19 vaccine uptake among rural agricultural and predominantly Hispanic communities in Washington State. We conducted in-depth interviews with school district employees and students and held English and Spanish focus group discussions with parents, all of which were audio-recorded and transcribed. We used inductive coding with constant comparison approach to capture emergent themes. We identified five factors that influenced pediatric COVID-19 vaccine uptake in a rural community, including: 1) concerns and misinformation surrounding the new vaccine; 2) witnessing others’ vaccine and pandemic experiences; 3) participation in social activities; 4) politicization of and political climate surrounding the vaccine; and 5) health education surrounding the vaccines. To increase pediatric COVID-19 vaccine uptake in rural communities, school districts, students, and parents should receive accurate information and reassurance to dispel health concerns and misinformation, without politicization of the vaccine and fears surrounding vaccine regulations. Social networks can be leveraged to encourage vaccine uptake by sharing positive vaccination vignettes.

Keywords: pediatric vaccines, COVID-19, vaccine hesitancy, health education, intention, barriers, facilitators, agricultural, rural

1. Introduction

Rural and agricultural communities across the United States experienced higher rates of COVID-19 infection, hospitalization, and death compared to their urban counterparts (Dobis & McGranahan, 2021; Matthews et al., 2021; Tai et al., 2021). Morbidity and mortality rates were exacerbated by pre-existing rural–urban health disparities, including demographic factors (e.g., older populations), socioeconomic determinants of health (e.g., lower income), higher rates of chronic health conditions, and barriers to healthcare access (e.g., physician shortages, lower rates of health insurance)(Gong et al., 2019; Kaufman et al., 2020). Limited COVID-19 testing capacity, large essential workforces, inadequate employer benefits, and vaccine deserts further amplified rural and agricultural communities’ risk of COVID-19 spread and worse health outcomes (Callaghan et al., 2021; Dorn et al., 2020; Rader et al., 2022; Souch & Cossman, 2021). Non-Hispanic Black, non-Hispanic American Indian and Alaska Native, and Hispanic communities experienced higher rates of COVID-19 mortality and decreases in overall life expectancy (Cheng et al., 2020; Luck et al., 2022; Lundberg et al., 2022).

Vaccines are effective strategies to protect against COVID-19 (Lan et al., 2023). However, COVID-19 vaccine uptake, defined as the number of individuals who have been vaccinated, has been suboptimal among rural Hispanic children compared to their urban counterparts (Valier et al., 2023). Lower pediatric COVID-19 vaccine uptake in rural communities has been attributed to decreased access to healthcare (Saelee et al., 2022), lack of providers’ vaccine recommendation (Sparks et al., 2021), concerns about long-term vaccine side effects, conflicting media information, and lower community and family support for vaccination (Fisher et al., 2023; Fisher et al., 2022). Most studies, however, were quantitative studies with only one including qualitative data from parents and focused on rural populations (Fisher et al., 2023; Lacy et al., 2022). Qualitative research on rural Hispanic parents’ decision-making regarding pediatric COVID-19 vaccination is necessary to develop culturally appropriate interventions to increase pediatric vaccine uptake.

Studies show that understanding perceptions of vaccine uptake from multiple stakeholders provide a deeper assessment of concerns and needs around vaccine uptake (MacDonald et al., 2015). Parents and school employees are authoritative figures with direct or indirect influence on children’s health decisions. School employees, whom students spend significant time with, may serve as a trusted source of information (Szilagyi et al., 2021). Triangulating child, school employee, and parent perspectives, behaviors and experiences around vaccination provides an in-depth understanding of vaccine uptake that may aid the development of interventions targeting multiple constituents to address vaccine uptake in rural families. This paper examines factors that shape COVID-19 vaccine uptake among children within rural agricultural communities in Washington State with predominantly Hispanic/Latino (used interchangeably) populations.

2. Methods

2.1. Design Overview

Qualitative data around decision to vaccinate for COVID-19 were collected as part of a larger community–academic partnership and randomized control trial titled, “Reopening Schools Safely and Educating Youth (ROSSEY),” which examined the effectiveness of COVID-19 risk communication on school attendance among students attending elementary schools. We conducted semi-structured interviews with school employees (e.g., administrators, nurses, teachers), focus groups with parents, and semi-structured interviews with children to understand factors that influence COVID-19 vaccine uptake to inform messaging for ROSSEY risk communication intervention. Data were collected from May to August 2021. The study was approved April 22, 2021, by the University of Washington Institutional Review Board (STUDY00013064). School employees and parent participants received a $30 gift card, and child participants received a $15 gift card.

2.2. Setting

Research took place within four rural Yakima County agricultural communities in central Washington State. Yakima County residents are 50% Hispanic, considerably higher than that of Washington State (13%) (U.S. Census Bureau, 2017). Agriculture is the leading industry in Yakima County, representing 28% of all jobs (Meseck, 2022).

2.3. Community Engagement

We engaged an established Community Advisory Board (CAB) that met bimonthly throughout the study to provide local context during study design, review study materials to ensure cultural appropriateness, guide recruitment strategies, and offer insight and context in the interpretation and dissemination of findings to the community. The CAB is composed of representatives from Yakima Valley community organizations, county health department, community health centers, and school administration. The study included CAB members in all levels of research as co-investigators, project managers, and community health workers (CHWs) who collected data.

2.4. Participants

2.4.1. School Employee Key Informant Interviews

We used snowball purposive sampling (Palinkas et al., 2015) to ask key school employees to identify staff members familiar with school district COVID-19 risk mitigation strategies and an understanding of COVID-19’s impact in their community. An initial list of school employees was created for recruitment and augmented with CAB members’ suggestions. Trained CHWs contacted school employees via email and telephone for an interview. Once an interview was completed, we asked the school employee for names of other employees who may be interested in participating in the study. We conducted 19 school employee interviews, to gather detailed information on social, ethical, cultural, and behavioral concerns related to COVID-19 in the community, schools’ readiness to have students return to and maintain onsite learning, and interventions and implementation strategies that could help mitigate concerns. All interviews were conducted in English over a HIPAA-approved Zoom platform or by telephone, lasted 45–60 minutes and were audio-recorded and professionally transcribed. Informed consent was completed online using a secure REDCap database before the interview.

2.4.2. Parent Focus Groups and Children’s Semi-Structured Interviews

Parents who participated in the “Together We STRIDE (STRIDE)” (Ko et al., 2018) school-based study, had at least one child in grade K-8 and agreed to be contacted for future studies were sent invitation letters to participate in a focus group. Bilingual and bicultural (English and Spanish) CHWs contacted parents by phone to assess focus group participation interest. We conducted four focus groups (2 English, 2 Spanish) with a total of 26 parents (12 English, 14 Spanish), to better understand parent concerns around regular COVID-19 testing for their children, needs and concerns surrounding returning to onsite school learning, fears about children contracting COVID-19, and concerns regarding COVID-19 vaccine safety, acceptability and uptake. The focus group setting allowed for parents to interact, building upon each other’s discussion and identify social norms in the community around COVID-19 testing and vaccine uptake that may not have surfaced in one-on-one conversations. Focus groups lasted 60–90 minutes, were audio-recorded, and professionally translated and transcribed. Sessions were facilitated by a bilingual/bicultural moderator. Verbal informed consent was administered in the participants’ preferred language before the scheduled focus group.

Parents who participated in a focus group were asked whether they were interested in their child being interviewed by a member of the research team. If a parent agreed, a research team member contacted the parent to obtain parental consent and child assent, and schedule an interview. We conducted 18 interviews by phone in English (child’s preferred language) to better understand in-depth children’s perspectives on needs and concerns around COVID-19 testing, COVID-19 preventative measures and onsite school learning, and fears around contracting COVID-19 and strategies to mitigate concerns. Child interviews lasted 30–45 minutes and were audio-recorded and professionally transcribed.

2.5. Instrumentation

The interview and focus group guides were designed to understand social, ethical, and behavioral needs for the return to and maintenance of in-person learning, including factors that influence decision to vaccinate children against COVID-19. Instrument development and data analysis were informed by Theory of Planned Behavior, Social Cognitive Theory and sociocontextual factors (Ajzen, 1985; Bandura, 1986; Burke et al., 2009; Pasick et al., 2009). Detailed information on instrument development including the primary focus of the semi-structured interviews and moderator guide is outlined in a prior publication (Ramirez et al., 2023). Moderator guides for the Spanish focus groups were translated from English to Spanish by a certified translator and reviewed by bilingual research team members for accuracy.

2.6. Data Analysis

Qualitative data from school employees, parents, and children were coded separately using Dedoose version 9.0.62 (Los Angeles, CA). An inductive, constant comparison approach was used to code the data (Miles et al., 2020). Five research team members coded the transcripts using inductive coding, followed by deductive coding using a priori codes based on the interview and focus group guides to ensure information from the questions was retained during coding. A detailed analysis of the data has been reported (Ramirez et al., 2023).

The current study triangulated codes pertaining to decision to vaccinate for COVID-19 across focus groups and interviews. Triangulation of qualitative methods enhanced the research team’s ability to identify areas of convergence and divergence across individual and social contexts (Lambert & Loiselle, 2008). Tentative themes across coded excerpts were identified by clustering codes with similar ideas (Miles et al., 2020). The interrelationship across and within themes was analyzed, resulting in a collection of candidate themes, which were refined to ensure excerpts within themes were coherent, and each theme was distinct from the others. Themes were validated by research team members from the community and CAB.

3. Results

3.1. Demographic Characteristics and Qualitative Themes

Participants were mostly female (children n=10, 56%; parents n=25, 96%; school employees n=12, 63%) and Hispanic (children n=18, 100%; parents n=22, 85%; school employees n=11, 58%). Most children were bilingual with English as the dominant language (n=11, 65%); parents were primarily Spanish speaking (n=11, 42%); and most school employees spoke English (n=17, 89%). Other demographic factors, including annual household income and parent education, were evenly distributed among participants (Table 1).

Table 1:

Socio-demographic Characteristics of the Participants

Characteristic Children N=18 Parents N=26 School Employee N=19
Age (years), mean (SD) 13 (1) 46 (7)
Gender1
 Male 8 (44%) 1 (4%) 5 (26%)
 Female 10 (56%) 25 (96%) 12 (63%)
Ethnicity
 Hispanic 18 (100%) 22 (85%) 11 (58%)
 Non-Hispanic 0 (0%) 4 (15%) 8 (42%)
Interview language
 Bilingual (Spanish dominant) 2 (11%) 3 (11%) 2 (11%)
 Bilingual (English dominant) 11 (61%) 7 (27%) 8 (42%)
 English only 5 (28%) 5 (19%) 9 (47%)
 Spanish only 0 (0%) 11 (42%) 0 (0%)
Grade
 6th 3 (15%)
 7th 5 (25%)
 8th 7 (35%)
 9th 5 (25%)
Annual household income
 Less than $15,000 2 (7%) 0 (0%)
 $15,000 – $35,000 10 (39%) 0 (0%)
 $35,000 – $50,000 6 (23%) 2 (11%)
 $50,000 – $75,000 3 (12%) 2 (11%)
 $75,000 or more 2 (8%) 10 (53%)
 Don’t know 3 (12%) 5 (26%)
Country of origin1
 United States 10 (39%) 15 (79%)
 Outside of the United States 16 (62%) 3 (16%)
Insurance status2
 Employer or individual health insurance 9 (35%) 19 (100%)
 Government health insurance 5 (19%) 0 (0%)
 Uninsured 12 (46%) 0 (0%)
 Prefer not to answer 1 (4%) 0 (0%)
Employment status
 Full time 13 (50%) 19 (100%)
 Part time 7 (27%) 0 (0%)
 Seasonal work 1 (4%) 0 (0%)
 Unemployed 4 (15%) 0 (0%)
 Prefer not to answer 1 (4%) 0 (0%)
Marital status
 Single/divorced 9 (35%) 3 (16%)
 Married/marriage-like relationship 17 (65%) 15 (79%)
 Prefer not to answer 0 (0%) 1 (5%)
Highest level of education
 Elementary school 5 (19%) 0 (0%)
 Some high school 6 (23%) 0 (0%)
 High school graduate or GED 4 (15%) 3 (16%)
 Some college 6 (23%) 4 (21%)
 College graduate 3 (12%) 4 (21%)
 Graduate school degree 2 (8%) 8 (42%)
Most common place of health care1
 Doctor’s/nurse office 6 (23%) 17 (90%)
 Clinic 18 (69%) 1 (5%)
 Hospital 1 (4%) 0 (0%)
 Traditional medicine 1 (4%) 0 (0%)
People per household, mean (SD) 6 (2) 3 (1)
Years in the United States, mean (SD) 33 (11)
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1

Missing value because participant(s) preferred not to provide an answer.

2

Participants could select multiple health insurance options.

We identified five factors that shaped decision to vaccinate children against COVID-19: 1) COVID-19 vaccine concerns and misinformation, 2) witnessing others’ COVID-19 vaccine and pandemic experiences, 3) participation in social activities, 4) politicization of and political climate surrounding the vaccine and 5) health education around COVID-19 vaccines.

3.2. Concerns and Misinformation Surrounding the COVID-19 Vaccine

Parents and school employees shared concerns pertaining to the relative newness of the COVID-19 vaccine, which lowered decisions to vaccinate children. Many were concerned about how quickly the vaccine was developed, sharing that it was “released in a short amount of time” and “rolled out too quickly.” A school employee shared parental hesitation about giving their children a relatively new vaccine, stating that they “didn’t want their kids being used for research.” Given vaccine novelty, participants also expressed uncertainty about vaccine effectiveness. One participant expressed concern around the duration of protection afforded by the vaccine:

I’ve heard lots of concern […] that it’s only effective for a short amount of time, so it’s just kind of a Band-Aid. (School Employee)

Some parents also expressed uncertainty about the need for vaccination after COVID-19 infection as the vaccine might be irrelevant due to natural immunity. For example, one parent expressed doubt about getting the vaccine after infection:

Like I already got COVID. Why get vaccinated? I already have my antibodies. (Parent)

Furthermore, the newness of the vaccine contributed to uncertainty around vaccine safety. Safety concerns were primarily about side effects, often in reference to children living with existing health conditions. For example, a parent shared that they would not vaccinate their children since “they both have asthma” and the parent “does not know what reaction they will have to the vaccine.” Similarly, a school employee shared that their child with asthma was afraid of the side effects:

I do have a son who has very bad asthma, so he refuses [to get the vaccine]. He thinks something’s going to happen, like it’s going to have a reverse effect. (School Employee)

Several parents also shared concerns around sterilization and infertility as side effects, that vaccinating their children for COVID-19 now would have adverse consequences on their future reproductive health. For example, one parent shared:

I guess the biggest thing preventing me [from vaccinating my child] is like others have mentioned, the possibility of sterility. That’s kind of scary. She’s young. She has her whole life ahead of her. I want to see how it [vaccine] plays out in the long term. (Parent)

Parents and school employees were also concerned that children might experience blood clots, hair loss, and tiredness after COVID-19 vaccination. Some of the children also shared concerns about blood clots and pain at the injection site. Conversely, other children who had been vaccinated shared positive experiences and minimal side effects. One child shared this sentiment:

They said you’re going to get real bad aching pains in the place you got the shot. I didn’t even really get much of that. It was tender, but there wasn’t much of an ache. (Child)

Concerns (including misinformation) about COVID-19 vaccine side effects spread primarily through social media platforms and word-of-mouth. Misinformation about the COVID-19 vaccine shared during interviews included: vaccines only contain air; the government uses vaccines to place chips, magnets, or tracking devices into people’s arms; vaccines turn people into “zombies”; vaccines cause fertility risks; and vaccines cause death. For example, one child shared:

On social media I’ve heard that it [COVID-19 vaccine] turns you like magnetized or whatever. But I don’t know. (Child)

While the child participant expressed uncertainty around the misinformation, others expressed the power of repeated misinformation to instill concerns. One parent shared this sentiment:

Many people say that they’re inserting a chip through the vaccine. Others say that after a short time, you’ll turn into a zombie. They say so many things to instill fear and doubt, you think maybe its true. (Parent)

While some participants expressed sincerely held concerns, others used language such as “rumors” and “myth(s)” indicating an awareness of misinformation, or a lack of evidence. For example, a school employee shared rumors they heard about the vaccine:

I guess a lot of it is hearsay. As you know, there’s a lot of […] rumors. Oh, you know if you take the shot, you become a zombie, you know, or if you do the shot, these are the symptoms that you might get. You might even die if you take the shot. So, there is still a lot of fear in the community in reference to that. (School Employee)

3.3. Witnessing Others’ Experiences with the COVID-19 Vaccine and Pandemic

Participants’ decision to get vaccinated or have their children vaccinated was influenced by the opinions and/or experiences of family members, friends and colleagues. Participants shared loved ones’ experiences about the vaccine itself and, more broadly, the pandemic (e.g., observing those around you die). Bearing witness to a friend or family member who had not experienced side effects from the COVID-19 vaccine eased participants’ side effect concerns. A parent stated:

I have a sister […] and both of her kids have been vaccinated. […] seeing that they are okay and knowing that there are no side effects and no long-term effects or short-term […] might help. (Parent)

Conversely, witnessing a friend or family member experience side effects after COVID-19 vaccination could deter participants from getting vaccinated. For example, a child participant shared their hesitation to get vaccinated stemmed from observing their sibling’s vaccination side effects:

My sister got it (vaccine) and she said she couldn’t move her hand or her arm […] so that’s just what I’m scared of, like not being able to move or getting really sick from it. (Child)

Some adult participants also shared their concern about vaccination because a close friend had passed away shortly after COVID-19 vaccination, reinforcing their concerns about vaccine side effects. It is important to note in both cases, participants shared the vaccine was not confirmed as the cause of death:

I’ve really had a friend pass away…[They] really didn’t say what was the cause of [death]…I know she had talked to me two days before she passed away [and] that she had gotten the second vaccine. (Parent)

Study participants were also influenced by the social consequences of vaccination. Witnessing a friend or family member experience adverse social consequences could deter participants from COVID-19 vaccination. A parent shared a family member’s experience of being bullied by coworkers after they found out she received the COVID-19 vaccine:

The place where my sister works, they bully her by saying, “If you’re vaccinated, you’re going to turn into a zombie, and I’m not going to get the vaccine, but you are.” They tell her all this bad stuff all day. (Parent)

Study participants were also influenced by others’ experience with COVID-19 infection. Friends and family members who had observed or experienced severe illness or death from COVID-19 infection encouraged participants to vaccinate their children. For example, one parent described how their parents in Mexico had witnessed the human costs of the COVID-19 pandemic in their country. Thus, their parents encouraged prevention behaviors, including vaccination. The parent stated:

People in Mexico have passed away due to COVID. They didn’t even allow them to say their goodbyes. They’re not even buried, they’re cremated. My parents called me, telling me to immunize my children, to take care of them, to not take them out all the time, to not take them to stores too much. (Parent)

3.4. Participation in Social Activities

Despite concerns about the COVID-19 vaccine, study participants across all groups shared the ability to return to social activities, or “normal life,” would motivate them to get vaccinated. For adult participants, a return to “normal life” equated to traveling and reuniting with family members:

Our health and the health of our family and friends [are motivators for decision to get vaccinated]. We have also stopped having family reunions for the same reason, because we can’t have too many people in the house. So, [getting the vaccine] to be able to get together again. (Parent)

Vaccination was perceived as a way to protect oneself, family members, and community during social activities. For one parent, these benefits outweighed potential side effects:

I would tell my kids, yeah, there are side effects when you get your vaccine. Yeah, your arm will hurt, or you will have a headache, little side effects. But I would encourage them to get it so they can protect themselves, protect our family, and protect the community too. (Parent)

Child participants also spoke of a return to “normal life,” of the ability to see friends and family, specifically grandparents. They also mentioned the ability to participate in sports again:

[Getting the vaccine] helps my family and it’s easier, so I can do sports and play basketball. (Child)

3.5. Politicization of and Political Climate Surrounding the COVID-19 Vaccine

Parents and school employees discussed the politicization of the COVID-19 vaccine relative to school vaccination requirements. Many referenced the difference between routine childhood immunizations, especially those required for school, and the novel COVID-19 vaccine. One school employee highlighted the role of divided and opposing vaccination messaging:

I think that [political messaging] is something that we did not face, let’s say, with H1N1 or any other vaccine. It was just a vaccine, right? In this case now, you definitely can see the divide of who is pushing the vaccine […] but then this push to not vaccinate is a new one that we have not had to deal with in the past. (School Employee)

Parents expressed similar sentiments in which the broader political climate became a new factor when considering childhood immunizations. Parents shared that before COVID-19, required immunizations were an expected and routine part of school enrollment. This established requirement largely encouraged vaccination. However, the divisive political nature of COVID-19 vaccination contributed to parental hesitation to vaccinate children. One parent explained the contrasting perspectives between the novel COVID-19 vaccine and routine immunizations:

When I signed my kids up for school and preschool, they asked me for their immunization cards. So, we regularly give our kids immunizations. Just because [COVID-19] was something new that affected the world so fast, I think that’s what makes it a little scary, right? And there’s a lot of politics involved. But, you know, the pneumonia shot didn’t really have a lot of politics, or like MMR or anything else. (Parent)

Despite the larger political environment and reluctance to vaccinate, some parents expressed willingness to comply with school vaccination policies. One parent, concerned about potential side effects, shared the influence of school immunization requirements:

I didn’t want them to give [the COVID-19 vaccine] to her, because I don’t know how she’s going to react, she’s still very young. But if it’s a requirement to return to school, then I’ll have to accept that they’re going to give it to her. (Parent)

Politics surrounding citizenship and immigration status also impacted vaccination decisions. Parents shared concerns that they might need to disclose their legal status when seeking COVID-19 testing or vaccination and that it could result in deportation. One parent shared their fear of potential deportation after vaccination:

Some of us don’t have our papers or any kind of legal status here, and they put fear in our community. Or if you get a vaccine, they’re going to ask you [about citizenship status] and if you don’t have that when you go, they can report it […] and you can be deported. That’s why a lot of people don’t get tested or get vaccinated. (Parent)

3.6. Health Education around COVID-19 Vaccines

Parents and school employees highlighted vaccine education/information as a factor that could promote the decision to vaccinate children, particularly in the Latino community. School employees stated vaccine development information could shape vaccine perceptions:

I think more education of what actually goes into making a vaccine and explaining how the vaccine works is needed. I think a lot of people don’t realize how vaccines work. Maybe more education […] really explain it in terms that people would understand. (School Employee)

Parents emphasized the importance of having access to educational information within the community as influential for intention to vaccinate:

Our community, from what I’ve heard, is doing a lot of the workshops […] making sure that everybody is being informed of the vaccines, getting tested. And so, I think having that access in our community has played a very important role in changing people’s mind in going towards the direction of being vaccinated. (Parent)

In addition to increasing knowledge around vaccines generally, parents suggested education/information could demystify COVID-19 misinformation about side effects. One parent stated how education that addressed infertility risk misinformation would be helpful:

I think if there were infographics or maybe a podcast or something I could listen to concerning fertility myths, I think that would be really helpful. (Parent)

The source of information was also deemed important to add credibility to the information shared. Participants specified medical providers as trusted individuals for sharing vaccine information and addressing vaccination concerns:

Ask your doctor for advice about getting the COVID vaccine or not. And get more information, not just one doctor, but asking different doctors what their opinion is, so you can feel more comfortable to make sure the vaccine is safe for your child if they have a health issue. (Parent)

4. Discussion

By examining perspectives among school employees, children, and parents in rural agricultural, largely Hispanic communities, we identified five factors that shape decisions to vaccinate children for COVID-19: concerns and misinformation surrounding the COVID-19 vaccine, witnessing others’ experience with the COVID-19 vaccine, politicization of and political climate surrounding the vaccine, participating in social activities, and health education around COVID-19 vaccines in general and more specifically to demystify misinformation. Three of the five factors – concerns and misinformation surrounding the COVID-19 vaccine, witnessing others’ experience with the COVID-19 vaccine, and participating in social activities – were mentioned by all three participant groups. The remaining two factors – politicization of and political climate surrounding the vaccine, and health education around COVID-19 vaccines – were only mentioned by school employees and parents.

Our results corroborate previous research on the influential role of vaccine safety concerns and misinformation on parents’ decisions to vaccinate their children (Khan et al., 2022; Ruggiero et al., 2021; Szilagyi et al., 2021). While all participant groups mentioned general side effects, such as pain or soreness at the injection site, they also mentioned concerns for side effects unique to the COVID-19 vaccine such as “blood clots,” given the well-publicized suspension of the AstraZeneca vaccine due to blood clots (Jordans, 2021; “Oxford Pauses,” 2021) and reports of myocarditis and pericarditis in the early stages of vaccine rollout (Silberner, 2021; Wise, 2021). Another noteworthy concern raised by our study participants was infertility. While this concern has been observed for HPV vaccines using narratives prying on historical trauma (Stern, 2011), the COVID-19 vaccine misinformation was further elevated by crafting it as scientific information (Abbasi, 2022). For example, rumors spread on social media that mRNA vaccine-induced antibodies against the SARS-CoV-2 spike protein, could attack a placenta protein called syncytin-1, causing infertility (Abbasi, 2022); infusing factual information such as syncytin-1 (a real human protein) may have increased the credibility of the false information.

The national political climate and politicization of the vaccine influenced parents’ decisions to vaccinate their children. Parents and school employees identified as a barrier needs to disclose immigration status and documentation to receive a vaccine. This concern may have been more prevalent among our study population as over half of parents reported being born outside the United States. While we did not ask for immigration status due to the sensitive nature of this question, parents mentioned that fear of deportation dissuaded their decision to vaccinate their children. Our findings corroborate other studies, which found immigration status (Cáceres et al., 2022) and lack of documentation (e.g., social security number) (Gehlbach et al., 2021) as barriers to vaccine uptake. Public health practitioners may need to be aware of concerns for disclosing immigration status and proactively work to reduce confusion in partnership with trusted community leaders or agencies during public health emergencies.

Our study also found that parents’ decision to vaccinate their children was influenced by their social environment. Encouragement from older family members was noted as motivating factors to vaccinate their children. On the other hand, parents’ social networks were not always supportive of the vaccine and their influence went both ways. Consistent with our findings, a prior literature review of pediatric vaccine hesitancy showed social networks influence on vaccine uptake through normalization or disapproval of vaccination (Smith et al., 2017).

While our participants were from rural, agricultural communities, our findings were similar to results from other Hispanic communities. False claims of vaccines were egregious (vaccine turning people into zombies) with strong political (government uses vaccines to place tracking devices into people’s arms) and immigration narratives (needs to disclose legal status prior to receiving the vaccine), creating fear among immigrant and migrant workers residing in the area. To combat misinformation and increase understanding around vaccine uptake, our participants suggested tailored, positive health promotion and educational campaigns. A recent systematic literature review and meta-analysis found 19% to 20% improvements in vaccine uptake after educational interventions (Siddiqui et al., 2022). Given the wide and the fast spread of misinformation on social media, partnerships with major internet search providers such as Google™ and social media companies may counteract misinformation through fact checking, content removal, down-ranking, and/or adding warning labels. Additionally, public health strategies may counter misinformation through personal vignettes of positive vaccine experiences (Osakwe et al., 2022) as well as educations through community leaders and educators. The two types of vignettes may help create synergy to proactively promote vaccine uptake while dispelling misinformation.

A limitation of this study is that while questions for parent focus groups and school employee interviews covered COVID-19 vaccine questions without specifying a pediatric age group, the perspective of children is from ages 10–14, as they were identified by their parents to be interviewed by the study team. Additionally, parents focus groups included migrant workers; however, we did not collect information on migrant or immigration status as these questions are deemed sensitive by the participants. Despite limitations, this study is the first to our knowledge, to used qualitative data to understand pediatric COVID-19 vaccination decisions from three different group (parents, children, and school employees). This triangulation of perspectives provides important and nuanced insights on influential factors for all involved in pediatric vaccination decision-making to develop effective holistic interventions to improve vaccinations.

5. Conclusion/Implications

Understanding the perspectives of school employees, parents, and children around decisions to vaccinate against COVID-19 is critical to increase pediatric vaccine uptake. Our results suggest misinformation and vaccine safety concerns were key factors and often deterrents in parents’ decisions to vaccinate their children. Our findings also highlight the influence of social networks, especially the experiences and opinions of family, in parents’ vaccine decision-making. Finally, our results show uncertainty around needing to disclose immigration status or provide documentation when getting vaccinated were deterrents due to the fear of deportation. Although specific to COVID-19 vaccines, these key factors shed light on broader sentiments towards pediatric vaccination, which can inform future routine vaccination messaging campaigns, mass vaccinations in the event of future large scale public health events, and routine vaccination interventions beyond the COVID-19 pandemic. Leveraging positive vaccine experiences of family and friends alongside tailored health education delivered by trusted individuals can help reduce misinformation and vaccine concerns and thus promote decisions to vaccinate children in rural agricultural communities, thereby reducing preventable disease-related morbidity and mortality.

Highlights.

  1. Misinformation and politicization of COVID-19 vaccine were barriers to rural pediatric uptake.

  2. Sharing positive vaccine experiences can encourage pediatric vaccine uptake.

  3. Uncertainty around disclosing immigration status was a deterrent due to the fear of deportation.

Acknowledgements:

The authors would like to acknowledge the invaluable contributions from community members of the Yakima Valley, sharing their time and lived experiences about COVID-19 vaccination concerns in their community. The Community Advisory Board and community investigators were integral in development of the funding application, development of culturally and linguistically appropriate participant-facing materials, and providing overall guidance on the study protocol. We would also like to acknowledge the contributions of the Center for Community Health Promotion and the Office of Community Outreach and Engagement at Fred Hutchinson Cancer Center. Mr. Luis Aceves and Ms. Jenny Wool assisted with the data analysis.

Funding:

This publication was supported by the National Institutes of Health under Award Number 1OT2HD107544–01. This research was also supported by the Office of Community Outreach & Engagement of the Fred Hutch/University of Washington/Seattle Children’s Cancer Consortium (P30 CA015704) and the Institute of Translational Health Sciences at the University of Washington (UL1 TR002319). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Role of Funder/Sponsor:

The National Institutes of Health had no role in the design and conduct of the study.

Abbreviations:

COVID-19

Coronavirus Disease 2019

RADx-UP

Rapid Acceleration of Diagnostics Underserved Populations

ROSSEY

ReOpening Schools Safely and Educating Youth

CHWs

Community Health Workers

STRIDE

Strategizing Together Relevant Interventions for Diet and Exercise

HIPAA

Health Insurance Portability and Accountability Act

Footnotes

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Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT04859699 https://clinicaltrials.gov/ct2/show/NCT04859699

Institutional Review Board Statement: The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of the University of Washington (protocol code STUDY00013064 approved April 22, 2021).

Informed Consent Statement: Informed consent was obtained from all adult subjects involved in the study. Informed parental consent and child assent were obtained from all child subjects involved in this study.

Conflicts of Interest: The authors declare no conflict of interest.

Data Availability Statement:

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding author.

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