key: cord-0875160-oye7272z
authors: Limbers, Christine A.; Thompson, Rachel
title: Maternal Attitudes and Intentions about the COVID-19 Vaccine for Children 5 to 11 Years
date: 2022-05-25
journal: J Pediatr Health Care
DOI: 10.1016/j.pedhc.2022.05.015
sha: b3c51caa98b76bd97d62e3c000d54d21b52c342e
doc_id: 875160
cord_uid: oye7272z

The current study assessed maternal attitudes and intention about the COVID-19 vaccine for children ages 5 to 11 years since the onset of the Delta variant and examined if the Delta variant changed maternal perceptions about COVID-19 vaccination and COVID-19 precautions for children. Participants were 821 mothers (mean age = 40.11 years; 84.3% White) from the United States who had at least one child ages 5 to 11 years old. They were recruited online and completed questionnaires on Qualtrics about their youngest child ages 5 to 11 years. The majority of mothers (n = 595; 72.6%) reported they were very likely to have their child vaccinated for COVID-19 once a vaccine is available for children. After controlling for maternal and child factors, maternal trust in the COVID-19 vaccine development and approval process (Odds Ratios = 35.07; p <0.001), trust in the child's physician (Odds Ratios = 1.65; p <0.01), and trust in the local public health department (Odds Ratios = 1.87; p <0.05) were associated with maternal likelihood of having one's child vaccinated for COVID-19. Our findings highlight that one strategy for increasing maternal intent to have one's child vaccinated for COVID-19 may be bolstering maternal trust in the COVID-19 development and approval process.

conducted one of the most comprehensive studies to date on parental perceptions and intentions about the COVID-19 vaccine for their children. In this study, 28% of parents of children ages 0 to 18 years in the U.S. reported they were very likely to have their child vaccinated for COVID-19 (Szilagyi et al., 2021) . Parents were most likely to report the intent to have their child vaccinated if their child was older and if they had obtained a bachelor's degree or higher, identified as Democrat, and had already received or expressed intent to receive the COVID-19 vaccine for themselves. Parents reported their child's physician was a highly trusted source for information about the COVID-19 vaccine (Szilagyi et al., 2021) .

While the study by Szilagyi et al. provides December 2021, has been diagnosed at higher rates and led to greater hospitalizations among children and adolescents in the U.S. than previous variants (American Academy of Pediatrics, 2021; (Siegel et al., 2021) .demy

The purpose of the current study was to assess maternal attitudes and intention about the COVID-19 vaccine for their children since the Delta variant onset. We also sought to examine if the Delta variant changed maternal perceptions about precautions for their children. Given that the COVID-19 vaccine was already authorized for emergency use in adolescents ages 12 years and older at the time of the study, we chose to specifically assess maternal attitudes and intentions about the COVID-19 vaccine in mothers of children ages 5 to 11 years as the COVID-19 vaccine had not yet been approved for emergency use in children in the U.S. in this age range.

Participants were a sample of 821 mothers of 1,785 children 17 years old or younger. In order to be eligible to participate in the study, participants had to indicate being a woman from the U.S. who was at least 18 years old and had at least one child 5-to-11 years old. Potential participants who were not literate in English were excluded from the study.

Participants were recruited between September 22, 2021 and October 11, 2021 through the social media platforms Facebook and Reddit. An advertisement that contained a link to the study was posted on group pages relevant to mothers and parenting. The link took potential participants to a Qualtrics survey where they responded to initial screening questions related to their gender, age, ages of their children, and country of residence. Potential participants who selected they were female, at least 18 years old, had at least one child 5 to 11 years old, and lived in the U.S. were presented with a short description of the study and consent form. Potential participants who wanted to proceed with the study were asked to provide their consent to participate through checking a box on the screen. Participants completed questionnaires online through Qualtrics. Mothers who had multiple children in the 5 to 11 year old age range were asked to complete the questions about their youngest child in that age range. The decision to ask about the youngest child in the 5 to 11 year old age range was based on the findings by Szilagyi et al. (2021) that parents of younger children were less likely to report the intent to have their child vaccinated. Financial compensation was not offered for participation in the study. The study procedures were approved by the Institutional Review Board at X University.

The questionnaires for this study were adapted from Szilagyi et al. (2021) . As noted previously, mothers who had multiple children 5 to 11 years old were asked to complete the questions about their youngest child in that age range.

Participants were asked, "How likely are you to get your child vaccinated for COVID-19 once a vaccine is available for children?" Response options were very likely, somewhat likely, somewhat unlikely, very unlikely, and unsure. Participants were also asked, "If a vaccine against COVID-19 becomes available for children, do you plan to get your child vaccinated?" Response options were yes as soon as possible, yes but I want to wait and see, no but I want to wait and see, no I will not get a COVID-19 vaccine for my child, and not sure. Participants were asked, "If you have a child 12 years old or above, have they been vaccinated?" Response options were yes, no, and not applicable.

Vaccine hesitancy and access were assessed through an adapted version of the World Health Organization's Vaccine Hesitancy Scale (Kempe et al., 2020) . Participants were presented with the following statements: A COVID-19 vaccine might cause lasting health problems for my child, I am concerned about serious side effects of a COVID-19 vaccine for my child, A COVID-19 vaccine will not be around long enough to be sure it is safe for my child, I will do what my child's doctor or health care provider recommends about a COVID-19 vaccine, A COVID-19 vaccine will be beneficial to my child, Getting a COVID-19 vaccine for my child will be important for the health of others in my community, A COVID-19 vaccine for my child will be effective if approved by the FDA or CDC, Getting a COVID-19 vaccine is a good way to protect my child from COVID-19, A COVID-19 vaccine will be important for my child's health, Once approved, my family will have access to a COVID-19 vaccine for my child. Response options were strongly disagree, somewhat disagree, somewhat agree, and strongly agree.

Participants were asked, "How concerned are you about your child contracting COVID-19?"

Response options were not at all, somewhat, and very.

Participants were asked, "How likely are you to get the COVID-19 vaccine for yourself?"

Response options were I have already been vaccinated, very likely, somewhat likely, somewhat unlikely, and very unlikely.

Participants were asked, "Has your child received a flu vaccine in the past two influenza seasons (2019 to 2020, and 2020 to 2021)?" Response options were yes and no.

Participants were asked to rate how much they trust the following sources of information about the COVID-19 vaccine: your child's doctor, your child's school or school district, your local public health department, the CDC, the American Academy of Pediatrics, your close friends and family members, coworkers, classmates, or other acquaintances, and social media (e.g. Facebook, Instagram, Twitter). Response options were do not trust at all, trust somewhat, trust mostly, trust completely, and not applicable.

Participants were asked, "How much do you trust the process in general (not just for COVID-19) to develop safe vaccines for children?" and, "How much do you trust the governmental approval process to ensure a COVID-19 vaccine is safe for children?" Response options were fully trust, mostly trust, somewhat trust, and do not trust.

Participants were asked, "Has the Delta variant changed your opinions on vaccination for your child?" Response options were yes I am more likely now to vaccinate my child due to the Delta variant, yes I am less likely now to vaccinate my child due to the Delta variant, and no there has been no change. Participants were also asked, "Has the Delta variant changed your opinions on what precautions your child should take?" Response options were yes I have my child wear masks and social distance more now, yes I have my child wear masks and social distance less now, and no there has been no change.

Participants were asked, "Has your child's doctor or healthcare provider talked to you about the vaccine for your child?" Response options were yes they gave me information, yes they encouraged me to get it once my child is eligible, yes they expressed concerns about the vaccine, and no they have not discussed the vaccine with me.

Participants completed a demographic questionnaire that evaluated the following information: maternal age, number of children 17 years and younger, race (white, Black, Hispanic, Asian, Other), overall household annual income (less than $10,000, $10,000-$19,999, $20,000-$29,999, $30,000-$39,999, $40,000-$49,999, $50,000-$74,999, $75,000 -$99,999, $100,000-$150,000, More than $150,000), marital status (married, divorced, separated, widowed, other), highest level of education (high school degree, some college, college degree, master's degree, doctoral degree), state residing in, urban or rural city of residence, employment status, and political party identification (Democrat, Republican, Independent, Other, and I do not identify with a political party). Participants were also asked if any of their children or parents (grandparents to their children) residing in the home have a compromised immune system or are in another high-risk category and if anyone in their home had previously been diagnosed with COVID-19.

Descriptive statistics were computed to assess maternal intent to have child receive the COVID-19 vaccine, vaccine hesitancy and access, maternal likelihood of getting a COVID-19 vaccine, child influenza vaccination history, trusted sources of information on the COVID-19 vaccine, trust in vaccine development and approval process, school safety COVID-19 precautions, changes due to the Delta variant, and communication with healthcare provider.

Point-biserial correlations were used to assess the associations between the demographic and main study variables and maternal intent to have child receive the COVID-19 vaccine. For these analyses, maternal likelihood of having one's child vaccinated was coded as 1= very likely and 0 = somewhat likely, somewhat unlikely, very unlikely, and unsure. Point-biserial correlations were designated as small (.10-.29), medium (0.30-0.49), and large (>0.50).

Binary logistic regression analysis was used to examine the associations between maternal intent to have one's child receive the COVID-19 vaccine, maternal and child factors, and maternal trust in information sources. Maternal (i.e., age, number of children, annual household income, marital status, highest level of educational attainment, political party identification, employment status, urban vs. rural area, COVID-19 vaccination status) and child (i.e., child influenza vaccination history) factors associated with maternal intent to have one's child receive the COVID-19 vaccine in the point-biserial correlation analyses were entered into block 1. Maternal trust in COVID-19 vaccine development and approval process and all of the information sources except close friends and family members, coworkers, classmates, or other acquaintances, which was not associated with maternal intent to have one's child receive the COVID-19 vaccine in the point-biserial analysis, were entered into block 2.

All statistical analyses were performed in SPSS Version 26 and a p value of less than .05 was considered statistically significant.

A total of 1,022 individuals were administered the initial screening questions. Of these individuals, 147 were not eligible to participate in the study because they reported their gender as male, they were not 18 years or older, did not have at least one child between the ages of 5 and 11 years, or they did not live in the U.S. 54 individuals started the questionnaires but did not finish. Thus, the final sample was comprised of 821 mothers.

For mothers, number of children ages 17 years or younger ranged from 1 child to 11 children with a mean of 2.18 children (SD= .96). The target children ages 5 to 11 years mothers responded to questions about were 421 (51.3%) boys and 388 (47.3%) girls; the mean age of these children was 6.92 years (SD = 1.84). The mean age of mothers in the sample was 40.11 years (SD= 5.49; Range = 22-65 years). With regard to race, 692 (84.3%) mothers identified as White, 53 (6.5%) as Hispanic, 30 (3.7%) as Asian, 12 (1.5%) as Black, and 31 (3.8%) as Other.

Mothers were from all 50 states across the U.S., with Texas (n = 130; 15.8%), California (n = 104; 12.7%), Oklahoma (n = 65; 7.9%), and Illinois (n = 65; 7.9%) being the most represented states. The majority of mothers reported living in an urban area (n = 644; 78.4%). In terms of educational attainment, 22 (2.7%) mothers had earned a high school degree, 107 (13%) had attended some college, 271 (33%) held a college degree, 278 (33.9%) held a master's degree, and 141 (17.1%) held a doctoral degree. Most mothers reported being married (n = 728; 88.7%).

With regard to political party identification, mothers reported being Democrat (n = 502; 61.1%), Republican (n = 77; 9.4%), Independent (n = 77; 9.4%), and other or not identifying with a political party (n = 160; 19.5%).

The majority of mothers (n = 595; 72.6%) reported they were very likely to have their child vaccinated for COVID-19 once a vaccine is available for children; 55 (6.7%) mothers indicated being somewhat likely, 130 (15.8%) indicated being very unlikely, 21 (2.6%) indicated being somewhat unlikely, and 19 (2.3%) indicated being unsure. Similarly, 571 (69.5%) mothers indicated planning to have their child vaccinated as soon as possible if a vaccine against COVID-19 becomes available for children; 80 (9.7%) mothers reported yes, but I want to wait and see, 112 (13.6%) mothers reported no, I will not get a COVID-19 vaccine for my child, 35 (4.3%) mothers reported no, but I want to wait and see, and 23 (2.8%) mothers reported not sure.

Among mothers who reported they were likely to have their child 5 to 11 years old vaccinated, 471 (72.9%) reported wanting to do so to keep their child from getting sick with COVID-19.

Among mothers who indicated they were likely to get their child vaccinated, 314 (48.5%) indicated they still perceived a risk in the vaccine. Among mothers who reported they were unlikely to have their child 5 to 11 years old vaccinated, 69 (41.6%) indicated the vaccine has not been studied for long enough and 67 (40.4%) indicated concerns about the possibility of lasting health problems due to the vaccine. Of the 188 mothers who had at least one child 12 years and older, 131 (69.7%) indicated their child had already been vaccinated. 

Most mothers reported already getting the COVID-19 vaccine (n = 726; 88.4%) or being somewhat likely to receive it (n = 7; 0.9%).

The majority of mothers (n = 624; 76%) reported their child received a flu vaccine in the past two influenza seasons (2019 to 2020, and 2020 to 2021). 35.6%), and social media (n = 9; 1.1%).

In response to, "How much do you trust the process in general (not just for to develop safe vaccines for children?" mothers indicated fully trust (n = 389; 47.4%), mostly trust (n = 293; 35.7%), somewhat trust (n = 89; 10.8%), and do not trust (n = 43; 5.2%). With regard to how much mothers trust the governmental approval process to ensure a COVID-19 vaccine is safe for children, 316 (38.5%) fully trust, 281 (34.2%) mostly trust, 87 (10.6%) somewhat trust, and 129 (15.7%) do not trust.

The majority of mothers reported the Delta variant has not changed their intention on vaccination for their child (n = 609; 74.2%); 192 (23.4%) mothers reported that due to the Delta variant they are now more likely to vaccinate their child and 12 (1.5%) mothers reported that due to the Delta variant they are now less likely to vaccinate their child. 354 (43.1%) mothers reported due to the Delta variant they now have their child wear masks and social distance more, and 453 (55.2%) mothers indicated that as a result of the Delta variant they have not changed COVID-19 precautions they take for their child.

Most mothers (n = 498; 60.7%) reported that their child's physician or healthcare provider had not talked to them about the COVID-19 vaccine for their child; 292 (35.6%) mothers indicated their child's physician or healthcare provider had talked to them or shared information with them about the COVID-19 vaccine for their child. Table 1 provides the point-biserial correlations between the demographic variables and maternal likelihood of having one's child vaccinated for COVID-19. All of these correlations were in the small range except Democratic political party identification which was in the large range (r pb = 0.55; p < 0.001). Table 4 includes the odds ratios and 95% confidence intervals for the full model for which the primary outcome variable was maternal likelihood of having one's child vaccinated Nearly 3 out of 4 mothers in our sample reported being very likely to have their child vaccinated for COVID-19 once a vaccine is available and most mothers indicated planning to have their child vaccinated as soon as possible once a COVID-19 vaccine becomes available for their child.

Despite a large percentage of mothers reporting intent to have their child ages 5 to 11 years vaccinated for COVID-19, nearly half of mothers who indicated they were likely to get their child vaccinated reported they still perceived a risk in the vaccine. Mothers who reported they were unlikely to have their child 5 to 11 years old vaccinated were more likely to report concerns about the vaccine not being studied for long enough and the possibility of side effects and lasting health problems in their child due to the vaccine. Consistent with these findings, maternal trust in the COVID-19 vaccine development and approval process was the strongest predictor of maternal intent to have one's child vaccinated after controlling for child and maternal factors.

Taken as a whole, our findings highlight that one key strategy for increasing maternal intent to have one's child vaccinated for COVID-19 may be bolstering trust in the COVID-19 development and approval process. Trust may be fostered among mothers of children ages 5 to 11 years in numerous ways including targeted public health campaigns that aim to educate parents about the vaccine development and approval process.

While the majority of mothers indicated the Delta variant had not changed their intention on vaccination for their child ages 5 to 11 years, a little less than half of mothers in our sample did report that due to the Delta variant they now have their child wear masks and social distance more. Similar to the findings of Szilagyi et al. (2021) , mothers in our sample reported the child's physician as being the most trusted source of information about the COVID-19 vaccine for children. As such, one important method for bolstering trust in the COVID-19 development and approval process may be through encouraging pediatricians and family physicians to provide parents with information about the child COVID-19 vaccine, including an overview of the development and approval process and the potential benefits of their child receiving the vaccine.

The majority of mothers in our sample reported that their child's physician or healthcare provider had not talked to them about the COVID-19 vaccine for their child.

In our study, both trust in the child's physician and the local public health department were associated with maternal likelihood of having one's child vaccinated for COVID-19 after controlling for maternal and child factors. As such, local public health departments may also play a critical role in educating parents of children ages 5 to 11 years about the COVID-19 development and approval process and potential benefits of the COVID-19 vaccine. Local public health departments also can help families identify places administering the COVID-19 vaccine to children in their area. Most mothers in our sample reported their child would have access to a COVID-19 vaccine once approved.

There were some limitations to our study. Data were collected via the social media platforms Facebook and Reddit. While groups pertaining to parenting were targeted, it is likely that mothers with strong beliefs about the COVID-19 vaccine or who were more decided on whether they would have their child vaccinated were more likely to participate in the study. Our sample was comprised of a disproportionate percentage of educated, Democratic, and White mothers. As such, our findings may not generalize to the U.S. population of mothers ages 5 to 11 years as a whole, especially more conservative, less educated, and racially diverse U.S.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 0.12** Urban vs. Rural Area 0.11** Note: *** p < .001; ** p < .01; * p < .05; Maternal likelihood of having child vaccinated coded as 1= very likely and 0 = somewhat likely, somewhat unlikely, very unlikely, and unsure; Target child gender coded as 1 = girl and 0 = boy; Race coded as 1 = White and 0 = non-White; Annual household income coded as 0 = less than $10,000, 1 = $10, 000-$19,999, 2 = $20,000-$29,999, 3 = $30,000-$39,999, 4 = $40,000-$49,999, 5 = $50,000-$74,999, 6 = $75,000 -$99,999 , 7 = $100,000-$150,000, and 8 = More than $150,000; Marital status coded as 1 = married and 0 = separated, divorced, widowed, other; Highest level of education coded as 0 = high school degree, 1 = some college, 2 = 4-year college degree, 3 = Master's degree, and 4 = doctoral degree; Having someone in the home with compromised immune system or in high-risk category coded as 1 = yes and 0 = no; Someone in home previously diagnosed with COVID-19 coded as 1 = yes and 0 = no; Political identification coded as 1 = Democrat and 0 = Republican, other, Independent, do not identify with a political party; Employment status coded as 1 = yes employed full-time outside home and 0 = no not employed outside home full-time; Urban vs. rural area coded as 1 = urban and 0 = rural. Note: *** p < .001; ** p < .01; * p < .05; Maternal likelihood of having child vaccinated coded as 1= very likely and 0 = somewhat likely, somewhat unlikely, very unlikely, and unsure; Vaccine hesitancy and access variables coded as 0 = strongly disagree, 1 = somewhat disagree, 2 = somewhat agree, and 3 = strongly agree. Trusted Source Social Media 0.13*** Note: *** p < .001; ** p < .01; * p < .05; Maternal likelihood of having child vaccinated coded as 1= very likely and 0 = somewhat likely, somewhat unlikely, very unlikely, and unsure; Mother COVID-19 vaccination status coded as 1= already vaccinated and 0 = not vaccinated; Child influenza vaccination history coded as 1 = yes received a flu vaccine in the past two influenza seasons and 0 = did not receive a flu vaccine in the past two influenza seasons; Current school format coded as 1 = in-person learning with masks required and 0 = in-person learning without masks required; Trust in COVID-19 vaccine development and approval process coded as 1 = completely trust or mostly trust and 0 = somewhat trust and do not trust; Concerned about my child getting COVID-19 coded as 0 = not at all, 1 = somewhat, and 2 = Communication with healthcare provider coded as 1 = yes they gave me information, yes they encouraged me to get it once my child is eligible, and yes they expressed concerns about the vaccine and 0 = no they have not discussed the vaccine with me; Has the Delta variant changed your opinions on vaccination for your child coded as 1 = yes I am more likely now to vaccinate my child due to the Delta variant and yes I am less likely now to vaccinate my child due to the Delta variant and 0 = no there has been no change; Trusted sources coded as 0 = do not trust, 1 = somewhat trust, 2 = mostly trust, and 3 = fully trust. Note: *** p < .001; ** p < .01; * p < .05; Maternal likelihood of having child vaccinated coded as 1= very likely and 0 = somewhat likely, somewhat unlikely, very unlikely, and unsure; Annual household income coded as 0 = less than $10,000, 1 = $10,000-$19,999, 2 = $20,000-$29,999, 3 = $30,000-$39,999, 4 = $40,000-$49,999, 5 = $50,000-$74,999, 6 = $75,000 -$99,999, 7 = $100,000-$150,000, and 8 = More than $150,000; Marital status coded as 1 = married and 0 = separated, divorced, widowed, other; Highest level of education coded as 0 = high school degree, 1 = some college, 2 = 4-year college degree, 3 = Master's degree, and 4 = doctoral degree; Political identification coded as 1 = Democrat and 0 = Republican, other, Independent, do not identify with a political party; Employment status coded as 1 = yes employed full-time outside home and 0 = no not employed outside home full-time; Urban vs. rural area coded as 1 = urban and 0 = rural; Mother COVID-19 vaccination status coded as 1= already vaccinated and 0 = not vaccinated; Child influenza vaccination history coded as 1 = yes received a flu vaccine in the past two influenza seasons and 0 = did not receive a flu vaccine in the past two influenza seasons; Trust in COVID-19 vaccine development and approval process coded as 1 = completely trust or mostly trust and 0 = somewhat trust and do not trust; Trusted sources coded as 0 = do not trust, 1 = somewhat trust, 2 = mostly trust, and 3 = fully trust. 

Children and COVID-19: State Data

Parental Hesitancy About Routine Childhood and Influenza Vaccinations: A National Survey

Trends in COVID-19 Cases, Emergency Department Visits, and Hospital Admissions Among Children and Adolescents Aged 0-17 Years -United States

Parents' Intentions and Perceptions About COVID-19 Vaccination for Their Children: Results From a National Survey

No conflicts of interest declared.