Characterization of parental intention to vaccinate elementary school aged children in the state of California

Abstract

In October 2021, Emergency Use Authorization of Coronavirus Disease 2019 (COVID-19) vaccines was granted for children aged 5–11. To ensure vaccine uptake in children upon approval, California will implement a state-wide executive order mandating COVID-19 vaccination for school children following full US FDA approval. This study uses survey data collected between November 6th, 2020 and December 14th, 2020 (n = 2091) to identify how sociodemographic characteristics and attitudes towards childhood vaccines among California parents were associated with their intentions to vaccinate their child against COVID-19. About one quarter (26 %) of surveyed California parents did not intend to vaccinate their child, suggesting skepticism towards the COVID-19 vaccine for children and the potential for pushback to a COVID-19 vaccine school-entry mandate. However, 17 % were unsure of their decision, suggesting the potential for public health messaging to make a positive impact on COVID-19 vaccine confidence and uptake. This study identifies characteristics of hesitant parents in California to prioritize for research and outreach. These data also provide a baseline for parental attitudes towards vaccinating children against COVID-19 in California, which will be useful for characterizing changes in attitudes towards childhood COVID-19 vaccination over time.

1. Introduction/Background

Via an executive order in California, vaccination for Coronavirus Disease 2019 (COVID-19) will be mandated for all children attending kindergarten through grade 12 (K-12) in public and private schools following full Food and Drug Administration (FDA) approval [1] An Emergency Use Authorization (EUA) was granted to Pfizer-BioNTech vaccine for children ages 5–11 on October 29, 2021; however, full FDA approval may not occur until January 2023, thereby postponing the statewide mandate [1], [2]. At the school district level, movements to mandate COVID-19 vaccination for children 12 and older by January 1, 2022 have been postponed in Los Angeles Unified School District due to potential disruptions to the learning of unvaccinated students [3]. However, legislation has been introduced at the state level that would add COVID-19 vaccination to the required vaccines needed to attend K-12 schools in California; passage of such legislation would bar parents from obtaining Personal Belief Exemptions (PBEs) for the childhood COVID-19 vaccine [3]. Some people oppose mandates due to concerns regarding the safety and necessity of vaccination, while others view mandates as important for reducing community transmission [4]. In this study, we use survey data to characterize California parents' intention to vaccinate their elementary school aged children (ages 5–11) against COVID-19, and to examine how parental vaccine intention varies by attitudes, beliefs, and sociodemographic characteristics.

2. Methods

2.1. Survey design

Between November 6th, 2020 and December 14th, 2020, a Qualtrics panel survey on childhood immunizations was administered to parents of elementary school aged children in California. The survey yielded 2091 responses, 51 of which were completed in Spanish. This report focuses on a subset of the survey pertaining to COVID-19 vaccines for children.

3. Survey content

Vaccine attitudes were assessed by asking respondents whether or not they agreed with various statements, with Likert scale response options of “strongly agree,” “agree,” “neither agree nor disagree,” “disagree,” and “strongly disagree”. We assessed respondents’ intention to vaccinate their children via their responses to the statement “I want my child to receive COVID-19 vaccination as soon as it is available to children.” We developed several validated scales to assess constructs that measure confidence in the child immunization schedule, perceived susceptibility to and severity of vaccine preventable diseases (VPDs), perceived vaccine safety and efficacy, and trust in public health authorities such as the Centers for Disease Control and Prevention (CDC), the FDA, and local health departments [5], [6] We also collected basic sociodemographic characteristics including parental race/ethnicity, income, age, education status, and region.

4. Data analyses

Using raking, survey data were weighted by race, ethnicity and income based on California’s most recent census data at the time (2019). Parental intention to vaccinate their child against COVID-19 (outcome of interest) among the surveyed population was split into three categories. Respondents answering “strongly agree” or “agree” were categorized as intending to vaccinate their children; respondents answering “neither agree nor disagree” were categorized as unsure; and respondents answering “disagree” or “strongly disagree” were categorized as not intending to vaccinate their children. Construct scales were dichotomized at the middle of the scale to create “high” and “low” categories, and Cronbach alpha values were calculated to assess scales’ internal reliability. Using weighted data, we applied multiple logistic regression to ascertain odds ratios (ORs) comparing parents’ intention to get their children vaccinated against COVID-19 by their sociodemographic characteristics, vaccine attitudes, and study constructs.

5. Results

5.1. Study population

Unweighted and weighted sociodemographic characteristics of the respondents and their children are presented in Supplemental Table 1. The largest percentage of respondents were of Hispanic ethnicity (39 %), between 31 and 40 years old (48 %), with a total family income between $30,000 and $99,999 (40 %), and with some college education (49 %). Nearly all respondents (95 %) reported that their children were up to date on all childhood immunizations (Supplemental Table 1).

6. Characterizing Parents’ intention to vaccinate their children

Table 1 represents the distribution of responses to the survey questions comprising the scales. While over half (56 %) of parents of elementary school aged children wanted their child to be vaccinated against COVID-19 immediately upon vaccine availability, about one quarter (26 %) did not intend to vaccinate their child, and 17 % were still unsure. Despite 71 % of respondents agreeing that immunization requirements protect children, 39 % of respondents agreed that parents should be allowed to send unvaccinated children to school.

Table 1.

Scale development: vaccine attitude and study constructs, median (iqr) score estimates and measurements of internal consistency (cronbach alpha).

Questions and Scale Items	Weighted (%)					Median (IQR)	Cronbach Alpha
	Strongly Agree	Agree	Neither Agree nor Disagree	Disagree	Strongly Disagree
I want my child to receive COVID-19 vaccination as soon as it is available for children.	36.0	20.4	17.4	11.1	15.1
I would consider enrolling my child in a vaccine trial to receive COVID-19 vaccination.	18.3	16.9	16.2	17.9	30.8
Treatments are needed instead of vaccines to fight COVID-19.	22.5	24.3	31.6	13.4	8.2
It is better to be exposed to COVID-19 than to receive a vaccine.	16.8	13.9	22.0	17.6	29.7
Immunization requirements protect children from getting diseases from unimmunized children.	28.8	42.1	20.9	4.6	3.5
Parents should be allowed to send their children to school even if not vaccinated.	19.4	19.9	23.0	20.6	17.1
Trust in Public Health Authorities						57.1 (50.0–64.3)	0.93
They do everything they should to protect the health of the population.	33.4	35.8	21.1	6.5	3.3
They are partly responsible for the illegal drug problems in this country.	19.5	30.2	29.1	14.0	7.2
They recommend things for the public that aren’t helpful.	20.8	23.1	31.4	17.2	7.5
They use resources well.	22.0	34.9	30.6	8.9	3.7
They waste money on health problems.	16.8	19.2	32.8	20.7	10.6
They keep trying the same things to help the public, even when they don’t work very well.	18.1	28.4	34.3	12.1	7.0
They come up with new ideas to solve health problems.	22.9	35.7	29.5	7.1	4.8
They base recommendations on the best available science.	23.1	38.1	27.8	7.3	3.6
They accurately inform the public of both health risks and benefits of medicines.	24.6	35.0	26.9	9.1	4.5
They believe in what they recommend for the public.	22.3	39.0	26.3	8.1	4.3
They quickly help the public with health problems.	22.4	31.9	30.2	10.6	4.9
They are concerned about all people, without caring about who has more or less money.	20.8	32.4	26.3	11.9	8.7
They are more concerned about some racial and ethnic groups than other groups.	18.8	25.3	31.9	14.3	9.7
They ensure the public is protected against diseases.	22.6	34.3	29.4	8.2	5.4
Confidence in Child Immunization Schedule						43.8 (25.0, 62.5)	0.81
It is better for my child to develop immunity by getting sick than to get a shot.	17.5	20.8	25.7	18.1	18.0
It is better for children to get fewer shots at the same time.	21.4	31.8	31.4	9.4	6.1
Children get more shots than are good for them.	20.3	22.2	32.9	15.1	9.6
I am concerned that children’s immune systems could be weakened by too many immunizations.	25.3	26.0	21.3	17.6	9.7
	Very Likely	Likely	Somewhat Likely	Not Likely	Impossible
Perceived Susceptibility to Vaccine Preventable Diseases						75.0 (50.0, 87.5)	0.89
Imagine an unimmunized child in California: What is the likelihood that they will get the following illness or disease by the child turns 12 years old?
Whooping cough	32.0	27.2	24.5	13.9	2.4
Measles	26.8	29.7	23.3	17.4	2.8
Mumps	28.5	25.3	24.8	18.4	3.0
Influenza	38.5	28.5	19.5	10.8	2.7
Varicella	37.6	29.3	20.7	9.3	3.2
	Very Serious	Serious	Somewhat Serious	Not Very Serious	Not at all serious
Perceived Severity of Vaccine Preventable Diseases						75.0 (50.0, 100.0)	0.96
Please indicate how serious you think it would be for an 8-year-old child to develop the following illness or disease.
Whooping Cough	35.7	24.6	25.6	8.7	5.4
Measles	36.6	28.9	22.0	9.3	3.3
Mumps	36.7	28.4	21.4	9.1	4.5
Influenza	35.4	28.0	21.2	9.0	6.5
Varicella	35.1	28.1	211.1	8.8	6.8
	Very Effective	Effective	Somewhat Effective	Not Very Effective	Not at all Effective
Perceived Vaccine Efficacy						75.0 (60.0, 90.0)	0.88
Please indicate how effective you think vaccines are in preventing children from getting these childhood illnesses or diseases.
Whooping Cough	42.7	29.6	19.8	5.7	2.1
Measles	39.1	33.5	19.3	5.4	2.7
Mumps	41.0	32.8	18.5	5.9	1.8
Influenza	31.7	30.2	26.1	8.8	3.2
Varicella	41.2	30.9	19.8	5.5	2.6
	Very Safe	Safe	Somewhat Safe	Not Very Safe	Not at all Safe
Perceived Vaccine Safety						75.0 (50.0, 91.7)	0.92
Please indicate how safe you think these vaccines are for children.
Whooping Cough	36.7	32.7	22.3	4.6	3.8
MMR	30.9	38.0	21.1	6.3	3.8
Influenza	32.4	33.6	23.1	6.9	4.1
Varicella	33.2	36.6	21.2	5.8	3.2

Table 2 displays stratified frequencies and ORs comparing parental intentions to vaccinate their children against COVID-19 by sociodemographic characteristics, vaccine attitudes, and scale constructs. White, non-Hispanic parents were the most likely to intend to vaccinate their child against COVID-19. Parents with higher (vs lower) trust in public health authorities had lower odds of being unsure (Odds Ratio: 0.31, 95 % Confidence Interval: 0.22–0.44) or not intending to vaccinate (OR: 0.15, 95 % CI: 0.11–0.20). Likewise, parents had lower odds of being unsure or not intending to vaccinate if they perceived higher (vs lower) vaccine safety (OR: 0.20, 95 % CI: 0.14–0.29; OR: 0.15, 95 % CI: 0.11–0.21) and efficacy (OR: 0.24, 95 % CI: 0.17–0.35; OR: 0.20, 95 % CI: 0.14–0.27), respectively. Parents also had lower odds of being unsure or not intending to vaccinate if they perceived higher (vs lower) susceptibility to VPDs (OR: 0.39, 95 % CI: 0.28–0.54; OR: 0.31, 95 % CI: 0.23–0.42) and VPD severity (OR: 0.58, 95 % CI: 0.42–0.81; OR: 0.64, 95 % CI: 0.48–0.84), respectively.

Table 2.

Parental intention to vaccinate child against COVID-19 by sociodemographic characteristics, vaccine attitudes, and study constructs (Weighted).

Sociodemographic Characteristics	Total %	Intends to vaccinate (%)a			Unsure vs Yes	No vs Yes
		Yes	Unsure	No	OR (95 %CI)b	OR (95 %CI)b
	100	56	17	26
Relationship to Child
Mother	59	46	21	33	Ref	Ref
Father	41	70	12	18	0.38 (0.27–0.52)	0.36 (0.27–0.47)
Race/Ethnicity
White, non-Hispanic	37	72	10	18	Ref	Ref
Hispanic	39	45	23	32	3.72 (2.61–5.31)	2.83 (2.11–3.79)
Black, non-Hispanic	6	53	16	31	2.10 (1.02–4.33)	2.26 (1.31–3.92
Asian/Pacific Islander	15	53	22	25	3.02 (1.83–5.00)	1.87 (1.17–3.00)
Other	4	40	29	41	3.50 (1.69–7.24)	4.00 (2.27–7.06)
Age (years)
<30	27	52	19	29	Ref	Ref
31–40	47	56	16	27	0.80 (0.55–1.16)	0.88 (0.65–1.20)
>41	26	61	17	22	0.79 (0.52–1.18)	0.67 (0.46–0.97)
Total Family Income
<$30,000	20	45	22	33	Ref	Ref
$30,000–$99,999	42	52	19	29	0.76 (0.55–1.05)	0.75 (0.57–1.00)
>$100,000	38	71	12	17	0.34 (0.23–0.50)	0.32 (0.23–0.45)
Region of California
Greater Los Angeles Area	39	64	14	22	Ref	Ref
Greater Bay Area	18	55	19	26	1.59 (1.03–2.45)	1.42 (0.97–2.05)
Central California	16	48	22	30	2.09 (1.34–3.26)	1.81 (1.21–2.70)
Northern California	9	56	11	33	0.90 (0.48–1.69)	1.75 (1.08–2.84)
San Diego	10	60	19	20	1.45 (0.84–2.49)	0.99 (0.62–1.58)
Inland Empire	9	37	24	39	2.92 (1.73–4.94)	3.04 (1.95–4.76)
Education Status
High school graduate/GED certificate	28	45	21	34	Ref	Ref
Some college/college graduate	45	49	21	30	0.87 (0.60–1.25)	0.82 (0.59–1.12)
Post-graduate	27	80	8	11	0.21 (0.13–0.34)	0.19 (0.13–0.28)
Gender of Child
Female	39	51	21	28	Ref	Ref
Male	60	60	15	25	0.62 (0.46–0.84)	0.77 (0.59–1.00)
Other	1	46	15	39	0.78 (0.09–7.03)	1.58 (0.36–7.01)
School Grade
Kindergarten	18	53	19	27	Ref	Ref
First Grade	21	67	11	22	0.46 (0.27–0.77)	0.63 (0.41–0.97)
Second Grade	19	60	17	23	0.76 (0.47–1.24)	0.76 (0.49–1.17)
Third Grade +	42	50	20	30	1.08 (0.71–1.65)	1.15 (0.79–1.66)
I would consider enrolling my child in a vaccine trial to receive COVID-19 vaccination
No	65	35	25	40	Ref	Ref
Yes	35	94	4	3	0.06 (0.04–0.09)	0.02 (0.01–0.04)
Treatments are needed instead of vaccines to fight COVID-19
Yes	47	65	10	25	Ref	Ref
No	53	49	25	26	3.40 (2.42–4.78)	1.41 (1.08–1.83)
It is better to be exposed to COVID-19 than to receive a vaccine
Yes	31	78	6	17	Ref	Ref
No	69	47	24	29	7.70 (4.66–12.72)	2.94 (2.16–3.99)
Trust in Public Health Authorities
Low trust	31	30	22	48	Ref	Ref
High trust	69	68	15	16	0.31 (0.22–0.44)	0.15 (0.11–0.20)
Confidence in Child Immunization Schedule
Low confidence	68	58	16	26	Ref	Ref
High confidence	32	53	21	26	1.45 (1.06–1.97)	1.08 (0.82–1.43)
Perceived Susceptibility to Vaccine Preventable Diseases (VPDs)
Low susceptibility	29	39	22	39	Ref	Ref
High susceptibility	71	65	14	20	0.39 (0.28–0.54)	0.31 (0.23–0.42)
Perceived Severity of VPDs
Low severity	33	49	21	30	Ref	Ref
High severity	67	61	15	24	0.58 (0.42–0.81)	0.64 (0.48–0.84)
Perceived Vaccine Efficacy
Low efficacy	22	29	26	44	Ref	Ref
High efficacy	78	66	14	20	0.24 (0.17–0.35)	0.20 (0.14–0.27)
Perceived Vaccine Safety
Low safety	26	28	27	46	Ref	Ref
High safety	74	70	13	17	0.20 (0.14–0.29)	0.15 (0.11–0.21)

^aVaccine intention is represented by responses to the Likert scale statement “I want my child to receive COVID-19 vaccination as soon as it is available for children”, with “Strongly Agree” and “Agree” collapsing to Yes, “Neither Agree nor Disagree” to Unsure, and “Disagree” and “Strongly Disagree” to No. OR = Odds Ratio; 95 %CI = 95 % Confidence Interval.

7. Discussion

As of December 14th, 2020, about one quarter (26 %) of surveyed California parents did not intend to vaccinate their child, suggesting skepticism towards the COVID-19 vaccine for children and the potential for pushback to a COVID-19 vaccine school-entry mandate. However, 17 % were unsure of their decision, suggesting the potential for public health messaging to make a positive impact on COVID-19 vaccine confidence and uptake.

These data are similar to a national poll from November 15th, 2021, indicating that 46 % of adults believed the COVID-19 vaccine safe for children 5–17, and 47 % were confident in its efficacy for this age group [7]. With the public less confident in the COVID-19 vaccine than common childhood vaccines, implementing and enforcing vaccine mandates could cause discord between parents, public health authorities, and the government.

To aid in compliance and strengthen COVID-19 vaccine confidence and trust in public health authorities, vaccine perception must be improved among hesitant groups. However, the COVID-19 vaccine landscape is dynamic and strategies to increase vaccination must adapt to the current circumstances. Hospitalization rates are 3 times higher for non-Hispanic Black and Hispanic children compared to non-Hispanic white children, though parents of these minority children have lower intent to vaccinate their children against COVID-19 in our survey.⁸ Dissemination of reliable information from personal health care providers, local health departments, and community-based organizations is crucial to increase trust and confidence among parents.

This study has several limitations. The data collected are not necessarily generalizable to all California parents due to the potential for selection and response biases. However, survey weighting and anonymous responses should reduce these biases. Our main outcome measure is not a direct measure of intention, as it does not account for issues of accessibility; however, we felt it could be used as a close proxy. We noticed one unexpected result in our data: those confident in the child immunization schedule had higher odds of being unsure. However, confidence in the child immunization schedule was not associated with not intending to vaccinate, and no other counterintuitive associations were found.

Before the implementation of public and private school COVID-19 vaccine mandates in California, public perception and confidence in the vaccine must improve to maintain positive relationships between California parents and public health authorities. This study can contribute to this goal by identifying characteristics of hesitant parents in California to prioritize for research and outreach. These data also provide a baseline for parental attitudes towards vaccinating children against COVID-19 in California, which will be useful for characterizing changes in attitudes towards childhood COVID-19 vaccination over time.

Declaration of Competing Interest

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Nicola Klein reports financial support was provided by National Institutes of Health. Nicola Klein reports a relationship with Pfizer Inc that includes: funding grants. Nicola Klein reports a relationship with Merck Sharp & Dohme UK Ltd that includes: funding grants. Nicola Klein reports a relationship with GlaxoSmithKline USA that includes: funding grants. Nicola Klein reports a relationship with Sanofi Pasteur Inc that includes: funding grants. Nicola Klein reports a relationship with Protein Sciences Corp that includes: funding grants.

Appendix A. Supplementary material

The following are the Supplementary data to this article:

Data availability

The authors do not have permission to share data.