Explore the attitudes of children and adolescent parents towards the vaccination of COVID-19 in China

Novel Coronavirus infections pose a serious threat to the health and safety of the public, with over 260 million COVID-19 cases and over 5.21 million deaths worldwide as of December 1, 2021 [1]. COVID-19 has been mostly seen in adults since the outbreak, and children consistently accounted for a small proportion of the total number of coronavirus disease cases in 2019, with pediatric cases accounting for only 2% of the 80,900 COVID-19 cases during the surge in China [2, 3]. Although the majority of pediatric cases of COVID-19 are asymptomatic or mild, with a good prognosis and low mortality, novel coronavirus infection of severe acute respiratory syndrome (SARS) has been reported in children of all age groups [2, 4]. In addition, the disease may progress to multisystem inflammatory syndrome (MTIS), a life-threatening complication of COVID-19 infection [5]. Results of MTIS include myocardial dysfunction, shock, and respiratory failure and require intensive care. Study indicated that 18.4 out of 100,000 children aged 0–4 years and 10.6 out of 100,000 children aged 5–17 years required hospitalization, of which one third required intensive care.

There has recently been increasing evidence that people who are fully vaccinated with the mRNAs (BNT162b2 or mrna-1273) are less likely to develop symptomatic infections and transmit SARS coronavirus 2 (novel coronavirus) to others than those who are not vaccinated [5, 6]. Vaccines tested in young adults over the age of 12 were reported to be safe and effective, including mRNA vaccines produced by Moderna and Pfizer-Biontech [7, 8]. In addition, phase I/II clinical trial results of two inactivated Chinese vaccines produced by Sinovac and Sinopharm showed that the vaccines were well tolerated, safe and could induce humoral reactivity in children and adolescents aged 3–17 years [9]. While vaccinating children and adolescents is seen as key to ending the epidemic, Vaccine Hesitancy (VH) -- the delayed acceptance or refusal of a vaccine despite its availability -- remains a barrier to full population vaccination [5, 10]. Alfieri et al.’s study showed that 33% of parents were hesitant to vaccinate their children against COVID-19 [11]. Separate data from the US showed that 33% of parents said it was very unlikely that their children would be vaccinated against COVID-19 and 12% said they were not sure [12].

As the incidence of asymptomatic carriers is getting higher and higher, the symptoms of patients with COVID-19 infection are getting lighter and lighter, children and adolescents are likely to become a silent source of infection and remain a threat, becoming an important source of sustained transmission [5, 13]. In order for vaccines to be effective in controlling the spread of COVID-19, it is estimated that 67% of the population needs to be vaccinated to achieve herd immunity [11, 14], and a comprehensive push to vaccinate adults, children and adolescents is an inevitable trend in controlling the spread of COVID-19. In addition, for children under the age of 18, such as parents’ behaviors and values tend to have a great impact on their children. This paper mainly explores parents’ attitudes towards COVID-19 vaccination and related influencing factors, so as to provide corresponding guidance for popularizing vaccination for children and adolescents.

This study contributed to a better understanding of parents’ attitudes towards their children’s COVID-19 vaccination. In this study, 74.38% would actively get vaccinated. Overall, Chinese parents have high willingness to vaccinate children and adolescents against COVID-19. In addition, the study found that 80.19% of parents said they would actively vaccinate their children against COVID-19, 3.37% refused to vaccinate their children, 4.95% said they would delay vaccination, and 11.49% were still hesitant. More and more evidences reveal that vaccination against COVID-19 is currently an important tool to reduce the burden of the COVID-19 epidemic. Rhodes et al. showed parents scored below the midpoint on the willingness to vaccinate their children (M = 3.55, SD = 2.13) [15]. Our research showed that nearly 15% of parents were still refusing to vaccinate their children or are hesitant to do so. Our findings are similar to the survey study from Turkey [16]. Therefore, it is necessary to conduct our questionnaire to encourage and publicize the importance of COVID-19 vaccination, so as to control the COVID-19 epidemic earlier in the world.

There is growing evidence that genetic and viral vector COVID-19 vaccines prevent not only severe disease but also asymptomatic infection [17]. And a study from the United Kingdom found that adults infected 3 weeks after receiving a dose of Pfizer-Biotech or Astrazeneca vaccine were 38 to 49% less likely to pass the virus on to their family contacts than unvaccinated individuals [18]. However, trust in vaccines is still a significant factor influencing vaccination willingness. The main reasons cited by the study for parents’ reluctance to vaccinate their children against COVID-19 included a lack of adequate scientific research (84.8%), concerns about safety and side effects (76.9%), and potential inefficacy of the vaccine due to mutations (36.7%)5. Our research suggests that parents believe the COVID-19 vaccine has no side effects, and that children are more likely to be vaccinated (OR = 1.51; 95% CI 1.42–1.73, p < 0.001). Therefore, access to more positive information about the safety and effectiveness of adolescent COVID-19 vaccines, as well as school COVID-19 vaccination requirements, are the most frequently reported factors that increase the willingness of parents and adolescents to be vaccinated [19, 20]. In addition, Marquez et al. found that 39.2% of parents refused to vaccinate their children against COVID-19, while 27.8% agreed that they would allow their children to be vaccinated against COVID-19 if their doctor recommended it20. Health workers’ advocacy of COVID-19 vaccines is one of the most important sources of reliable vaccine information for the public. Increased clear public communication about the benefits and safety of COVID-19 vaccines for children and adolescents, especially by healthcare professionals, will help increase parents’ confidence in COVID-19 vaccines and their willingness to vaccinate their children against COVID-19. Our result showed their children were more likely to be vaccinated when parents were vaccinated against COVID-19. It’s very critical to educate clear information and transparent communication from public health, governments and leaders about the safety of childhood COVID-19 vaccines [12, 21].

We analyzed the factors that may influence children’s willingness to be vaccinated against COVID-19 and found that gender, age, place of residence, number of children in the household, gender of children, whether it’s a single parent family and whether there is a doctor in the household had no significant influences on the willingness of children and adolescents to be vaccinated against COVID-19. Children who did not get sick were more likely to get vaccinated than those who had other illnesses in the last 3 months. Different from the previous studies, which showed that younger adolescents were more likely to receive COVID-19 vaccination than older adolescents [22], while our study found that older children (13–17 years old) were more likely to be vaccinated against COVID-19. This may be due to China’s implementation of the COVID-19 vaccination program by age, which partially affected the results of the study. Lack of knowledge about COVID-19 and vaccines may increase misunderstandings about COVID-19 vaccines, thereby reduce the willingness of parents to vaccinate children and adolescents.

Parents do have significant effects on their children. On the one hand, studies have found that children and adolescents are less likely to get vaccinated when their parents show signs of rejection, delay, and hesitation. Children were more likely to be vaccinated if their parents felt there were no side effects; and when their parents have been vaccinated against COVID-19, children are more likely to be vaccinated. Our study suggests that parents play a non-negligible and even decisive role in the vaccination of children and adolescents against COVID-19. Parents’ attitudes towards vaccination and their views on vaccines will affect their children’s vaccination willingness. On the other hand, research from Italy shows the lower the education level of the parents, the greater the harm they think the COVID vaccine will do to their children [23]. Our result showed children of parents with graduate education or above were more likely to be vaccinated too. Therefore, it is necessary to raise parents’ awareness of the effectiveness and safety of the vaccine, so as to increase the COVID-19 vaccination rate in children and adolescents.

There did exist some shortcomings in our study. Firstly, we adopted the form of online questionnaire, which was mainly written by parents and indirectly investigated the vaccination intention of children and adolescents. There may be some errors in the data and relevant information to a certain extent. Secondly, the sample size of Hong Kong, Macao and Taiwan was too small,so it’s very necessary to gather more different regions to participate the survey.

In general, Chinese children and adolescents have high desires to be vaccinated against COVID-19, and most parents have positive attitudes towards their children’s vaccination. However, many people still hesitate or even refuse to be vaccinated. From the study, we find that parents’ COVID-19 vaccine behaviors, education backgrounds, attitudes towards children’s vaccination, children’s age, recent illness and other factors have certain impacts on children and adolescents’ willingness to vaccinate against COVID-19.