Parental intention on getting children COVID-19 vaccinations: Invariance evaluation across parenting roles and COVID-19-like symptoms experiences among Iranians during the pandemic period

ABSTRACT

Countries worldwide are facing challenges with increasing the COVID-19 vaccination rates for children. This study examined associations between perceived knowledge, coping appraisal, threat appraisal, adaptive response, maladaptive response, and intention, and possible variance across parents (mother or father) and COVID-19-like symptoms experiences regarding parental intentions to vaccinate their children. A total of 836 Iranian parents with children between the ages of 6 and 12 y completed measures assessing perceived knowledge, coping appraisals, threat appraisals, intentions, adaptive responses, and maladaptive responses. Multigroup structural equation modeling revealed that perceived knowledge was positively associated with both coping and threat appraisals, coping appraisals positively associated with adaptive responses, maladaptive responses, and intentions to vaccinate, threat appraisals positively associated with adaptive and maladaptive responses, and adaptive responses positively associated with intentions to vaccinate. The invariance evaluation revealed no differences across parents or COVID-19-like symptoms experiences in parental intentions to get their children vaccinated. The findings suggest that cogent information regarding childhood COVID-19 vaccination may boost parents’ knowledge influencing their appraisals, adaptive responses and intentions to vaccinate their children. Specifically, coping appraisals and adaptive responses appeared to be important mediators between knowledge and intentions to vaccinate. Furthermore, intentions to vaccinate children may not be strongly influenced by parental roles or COVID-19-like symptoms experiences. These findings may help multiple stakeholders promote COVID-19 vaccination rates among children, and countries should further examine ways of increasing rates based on their specific needs.

KEYWORDS:

• Measurement invariance
• COVID-19 vaccine
• children
• extended protection motivation theory
• parents
• fear of COVID-19

Introduction

Infections involving the SARS-CoV-2 coronavirus, a novel virus initially identified in 2019, may lead to the COVID-19 disease. Between 2020 and 2022, the SARS-CoV-2 virus was transmitted rapidly and resulted in the COVID-19 pandemic. Accordingly, the COVID-19 pandemic significantly changed lifestyles by altering social, personal, work routines and impacted mental and physical health directly and indirectly.^1–10 The infection rate of COVID-19 was very swift and its aftereffects were so devastating that it created significant reactions which prompted adjustment of lifestyles at that time. Specifically, the high infection rate of COVID-19 and its high mortality rate in the absence of effective treatments triggered fear of COVID-19.⁷ The high mortality rate, especially at the beginning of the COVID-19 pandemic, rallied health professionals and other experts to help find a cure. Fortunately, after much effort, diligence and dedication, different types of vaccines were produced to help stem stem SARS-CoV-2 infection and COVID-19 illness^11,12 after using several non-pharmacological interventions for the containment, mitigation, and suppression of COVID-19 (e.g., quarantines, lockdowns, physical distancing, mask-wearing, and regular washing of hands). However, the vaccination drive has not been as smooth as anticipated due to several factors such as COVID-19 mutations which challenge the vaccine’s impact at individual and population-based levels. The effectiveness of the vaccine amidst the virus’ recurrent mutations leading to new variants of the SARS-CoV-2 virus and recurrent COVID-19 infection waves may complicate people’s inclinications toward vaccination.^13,14 The extended Protection Motivation Theory (extended PMT),^15,16 a social cognitive theory for explaining people’s response toward perceived threats, is used in this study to examine reasons underlying parents’ intentions to vaccinate their children. In this study, the factors underlying the extended PMT are perceived knowledge, coping appraisals, threat appraisals, adaptive responses, maladaptive responses, and intentions (i.e., to vaccinate).^15,17

The COVID-19 vaccines primarily help with preventing hospitalizations, illness severity, and death. However, vaccination efforts faced challenges (e.g., refusal or hesitancy) worldwide.^18–20 A main challenge involved vaccine hesitancy (i.e., delay in acceptance or refusal to vaccinate despite the availability of vaccination services), first among the adult population and later among children due to several factors including misinformation or inadequate information.^18,21,22 That is, inadequate or false information regarding COVID-19 vaccines and their efficacies may have generated mistrust in the utility of the vaccines, especially among children. For instance, being “afraid of the side effects of vaccine,” “don’t think it can be reliable as it will be a new vaccine” and “COVID-19 infection is a biological weapon and the vaccine will serve those who produce this virus” are some of the reasons that have been reported to have influenced intentions to vaccinate.^23–28 However, with strong educational efforts by health experts and authorities, there was an increase in the quality of knowledge¹⁵ and consequently, COVID-19 vaccine uptake.²⁸ Previous studies have associated formal knowledge of COVID-19, adherence to COVID-19-related policies, and vaccination intentions.^15,28 A previous study also revealed that cogent information on COVID-19 vaccine helped increase parents’ intentions to vaccinate their children.^28,29 Therefore, parents’ perceived knowledge (i.e., information received from formal and/or informal sources) of COVID-19 vaccines may influence their coping and/or threat appraisals (e.g., assessment of the risk and severity of COVID-19, perceptions, efficacy, and/or adverse effects of the vaccines) which could then influence their responses—adaptive responses (i.e., precautionary actions toward stressful events for self-protection such as vaccinating or having positive thoughts about the vaccine) and/or maladaptive responses (i.e., negative thoughts or decisions that may hurt one’s own or others’ interests such as not vaccinating) – consequently influencing their intentions to vaccinate their children.^{15–17,23–27,29–30}

Parents’ intentions to vaccinate their children are complicated. For instance, a study reported that almost 90% of parents had COVID-19 vaccinations but only 42% intended to vaccinate their children.³¹ Reported factors that may help boost children’s vaccination rates include compulsory vaccination policy, information on vaccine safety and adverse effect rates and severities, and mothers’ or both parents’ involvement in decisions regarding children’s healthcare.^28,29,31,32 These views were supported by a recent review of parents’ acceptance rates of COVID-19 vaccination toward their children. Among 98 studies, worldwide estimation of parental acceptance to vaccinate their children (0–18 y) with the COVID-19 vaccine was 57%.³³ Furthermore, factors related to vaccination acceptance were “parents’ COVID-19 vaccine knowledge,” “trust in the COVID-19 vaccine,” and “facilitators in vaccination (e.g., low cost, good vaccine accessibility, and government incentive),” while mental health challenges (e.g., having worries and psychological distress) were linked to lower willingness to vaccinate.³³ Therefore, parents’ roles and their prior COVID-19 vaccination experiences may contribute to their intentions to vaccinate their children.

Global views on the COVID-19 vaccine and vaccination drive seem to align with those of Iranians. In a nationwide Iranian survey, 64.2%-69% of people intended to accept COVID-19 vaccination.^34,35 The percentage was higher for individuals with greater exposure to social norms supportive of COVID-19 vaccination and higher perceived benefits of COVID-19 vaccination.³⁴ However, vaccination intent was lower for individuals with greater COVID-19 vaccine safety concerns, older age and female sex. Concerns regarding unknown efficacy, lack of trust in vaccine companies, and contradictory recommendations from health authorities regarding vaccines, and working in the healthcare field were also linked to lower vaccination intent.^34–36 As the situation of the COVID-19 pandemic considerably worsened, there was the need to vaccinate children. Therefore, Iran initiated a free vaccination program for children between five and 12 y beginning in February 2022.³⁷ However, parents’ hesitancy for the COVID-19 vaccine seemed to extend to children, although most Iranian parents had received COVID-19 vaccinations (i.e., 82.8% of mothers and 84.3% of fathers were vaccinated with 2–3 doses).³⁸ According to the head of the infectious disease management center of the Ministry of Health in Iran, the coverage of corona vaccination among the age group of 5–11 y is not very acceptable (maximum 10% of the age group) compared to those aged 12–18 y (75% of the age group) and above 18 y.³⁸ It seems that Iranian parents had doubts about vaccination and fear of its possible adverse effects on children under 12 y old. Some of the most common beliefs for not vaccinating children were future adverse effects of the vaccines including undesirable effects on children’s growth and future fertility.³⁸ Therefore, the findings of this study could be important to health experts and authorities regarding how to convey to parents information about vaccinations, specifically for COVID-19 and possibly other infectious diseases. To understand the reasons underlying parents’ intention to vaccinate their children, this study examined (1) associations between variables (i.e., perceived knowledge, coping appraisals, threat appraisals, adaptive responses, maladaptive responses, and intentions), and (2) possible variance across parents (mother or father) and COVID-19-like symptoms experiences regarding intentions to vaccinate their children. It was hypothesized that there would be (1) significant associations between perceived knowledge, coping appraisals, threat appraisals, adaptive responses, maladaptive responses and intentions, and (2) invariance across mothers and fathers or COVID-19-like symptoms experiences regarding intentions to vaccinate their children.

Method

Design

This study used a cross-sectional survey design to examine the aim of this study.

Target population, participants and procedure

The target population included parents in Qazvin, Iran, especially those with children. The study participants were parents of children 6–12 y old studying at primary schools in Qazvin, Iran. Six schools (n = 6) were randomly selected from the list of primary schools (n = 107) in Qazvin. After confirmation from the heads of schools, an online questionnaire and informed consent were sent to all parents of children in the randomly selected schools. Hence, all participants needed to complete the informed consent form before participating in the study. Only one parent from each child was considered a participant in the study. The online questionnaire and informed consent (i.e., using the Porsline platform) in the form of a link were sent via SMS to either one of the parents, and 836 (i.e., a response rate of 66.8%) consented and completed the questionnaire between September 2022 and November 2022. There was no pilot testing prior to this survey study. As part of the SMS, all parents were instructed to complete the questionnaire once and not to send or divulge the link containing the questionnaire to anyone. Also, we cross-checked the completed questionnaire (including their reported phone numbers) with the list of SMS numbers (i.e., phone numbers) of parents to ensure that there were no duplicates. The questionnaire included a demographic section and six different measures based on the extended PMT. Previous studies have used these extended PMT measures and they had been found to have acceptable psychometric properties.^7,16,17 Therefore, this study adapted the extended PMT measures and also analyzed and reported Cronbach’s alpha coefficients for each of the measures for this study as no piloting was done. The Cronbach’s alpha coefficient of the present study was 0.846 for perceived knowledge, 0.817 for intention, 0.792 for coping appraisal, 0.780 for threat appraisal, 0.817 for adaptive response, and 0.794 for maladaptive response. The ethics committee of Qazvin University of Medical Sciences approved the study procedure (IR.QUMS.REC.1401.150).

Measures

Demographic section

The demographic section solicited participants’ information on age, sex, educational levels (e.g., university, diploma), and COVID-19-like symptoms experiences regarding their children (i.e., if their children experienced any COVID-19 symptoms in the past).

Perceived knowledge

Perceived knowledge regarding the COVID-19 vaccination was assessed using a three-item scale with items rated on a five-point Likert-like scale (1 = strongly disagree to 5 = strongly agree). The item scores were summed to generate a total score with higher scores reflecting greater knowledge levels regarding COVID-19 vaccinations for children. A sample item is, “I feel well-informed about the COVID-19 vaccines available for children.”

Intentions

Intentions to receive the COVID-19 vaccination were assessed using a two-item scale with items rated on a five-point visual analogue scale (1 = strongly disagree; 5 = strongly agree). The items were summed to generate a total score with higher scores reflecting greater willingness for their children to receive vaccination. A sample item is, “I want to arrange for my children to receive a COVID-19 vaccination.”

Coping appraisals

Coping appraisals of the COVID-19 vaccination as a disease preventive strategy were assessed using a four-item scale with items rated on a five-point Likert-like scale (1 = strongly disagree to 5 = strongly agree). The item scores were summed to generate a total score with higher scores reflecting greater perceptions of vaccination as a protection strategy against COVID-19 in children. A sample item is, “Vaccination is an effective way to protect my child.”

Threat appraisals

Threat appraisals of strategies used to evaluate the risk of the COVID-19 pandemic were assessed using a seven-item scale (i.e., fear of COVID-19), with items rated on a five-point Likert-like scale (1 = strongly disagree to 5 = strongly agree). The items were summed to generate a total score, with higher scores reflecting greater perceived fear of COVID-19. A sample item is, “I am most afraid of coronavirus-19.”

Adaptive responses

Adaptive responses regarding positive thoughts related to COVID-19 vaccination were assessed using a three-item scale with items rated on a five-point Likert-like scale (1 = strongly disagree to 5 = strongly agree). The items were summed to generate a total score, with higher scores reflecting greater beliefs regarding the COVID-19 vaccination as a means for improving children’s well-being. A sample item is, “I am confident that the COVID-19 vaccine is safe and effective for children.”

Maladaptive responses

Maladaptive responses regarding negative thoughts related to COVID-19 vaccination were assessed using a three-item scale with items rated on a five-point Likert-like scale (1 = strongly disagree to 5 = strongly agree). The items were summed to generate a total score, with higher scores reflecting stronger beliefs regarding the COVID-19 vaccination as a form of potential harm to children’s health. A sample item is, “I believe that my child is not at risk of contracting COVID-19.”

Data analyses

Means and standard deviations and frequency and percentages were used to present descriptive aspects of the data. Pearson’s correlations were used to examine relationships between variables. Multigroup structural equation modeling (SEM) with the estimator of diagonally weighted least squares was used to assess whether the data fit with the proposed model (Figure 1). Four indices, comparative fit index (CFI), Tucker – Lewis index (TLI), root mean square error of approximation (RMSEA), and standardized root mean square residual (SRMR), were used to evaluate if the proposed model was supported. The fit indices CFI and TLI of greater than 0.900 were considered satisfactory while RMSEA and SRMR lower than 0.080 were considered satisfactory.³⁹ Invariance evaluation across parenting role and COVID-19-like symptoms experiences were examined using multigroup SEM. The Amos version 28 software was used to perform the SEM,⁴⁰ and SPSS 26.0 (IBM, Corp., NY: Armonk) was used for the remaining data analyses. The significance level was set at p < .050.

Figure 1. Structural equation model explaining parental intention on getting their children COVID-19 vaccinated based on the extended protection motivation theory. Coefficients are presented in standardized coefficients.

Results

Descriptive statistics

The descriptive statistics revealed that most participants (n = 836) were female (61.40%) with a mean age of 41.170 (SD = 3.690) years, as shown in Table 1. Many participants had a diploma-level education (362, 43.300%) and most of their children had prior COVID-19 infections (540, 64.600%).

Table 1. The demographic characteristics of the study participants.

	n(%)
Age (years)*	41.17 ± 3.69
Sex
Male	323 (38.6%)
Educational levels
University	188 (22.5%)
Diploma	362 (43.3%)
High school	203 (24.3%)
Primary and Secondary school	83 (9.9%)
COVID-19-like symptoms experiences among children
Yes	540 (64.6%)
No	296 (35.4%)

*Age was presented in Mean ± SD.

Reliability coefficients and factor loadings

The SEM’s descriptive statistics, reliability coefficients, and factor loadings for the measures used in the present study are shown in Table 2. The table indicates that all the measures had acceptable Cronbach’s alpha reliability coefficients, factor loadings, McDonald’s omega reliability coefficients and composite reliability.

Table 2. The reliability coefficients and factor loadings of the study’s measures and its items.

Construct	Measurement item	λ	α	CR	ω
Perceived knowledge			0.85	0.84	0.85
	I feel well-informed about the COVID-19 vaccines available for children	0.84
	I have a good understanding of the potential benefits and risks associated with COVID-19 vaccination for children	0.86
	The COVID-19 vaccine plays an important role in protecting our life	0.73
Intentions			0.82	0.82	NA
	I am willing to arrange for my children to take COVID-19 vaccination	0.90
	I want to arrange for my children to take COVID-19 vaccination	0.76
Coping appraisals			0.79	0.77	0.79
	Vaccination is an effective way to protect my child	0.74
	It is important that my child get the COVID-19 vaccination	0.81
	Getting the COVID-19 vaccination has positive influence on my child’s health	0.54
	I feel capable of managing any potential side effects my child may experience after getting vaccinated	0.60
Threat appraisals (Fear of COVID-19)			0.78	0.79	0.79
	I am most afraid of coronavirus-19	0.62
	It makes me uncomfortable to think about coronavirus-19	0.63
	My hands become clammy when I think about coronavirus-19	0.66
	I am afraid of losing my life because of coronavirus-19.	0.48
	When watching news and stories about coronavirus-19 on social media, I become nervous or anxious	0.78
	I cannot sleep because I’m worrying about getting coronavirus-19	0.62
	My heart races or palpitates when I think about getting coronavirus-19	0.29
Adaptive responses			0.82	0.81	0.82
	I am confident that the COVID-19 vaccine is safe and effective for children	0.83
	I am confident in my ability to handle any logistical challenges involved in taking my child for vaccination	0.74
	I think that receiving the vaccine will make a great contribution to my happiness and wellbeing in the future	0.71
Maladaptive responses			0.79	0.74	0.80
	The thought of taking my child for vaccination scares me and makes me anxious.	0.76
	I believe that my child is not at risk of contracting COVID-19.	0.64
	I am concerned about the potential discomfort or pain my child may experience during the vaccination process.	0.70

λ = Standardized factor loading from structural equation model; α = Cronbach’s alpha reliability coefficient; CR = Composite reliability; and ω = omega from structural equation model.

Pearson’s correlations

The Pearson’s correlations between the key variables of the study are shown in Table 3. There were significant positive relationships between perceived knowledge, coping appraisals, threat appraisals, intention, adaptive responses, and maladaptive responses with the correlation coefficients ranging between 0.332 and 0.755 (p < .010).

Table 3. The correlations between key study variables.

	1	2	3	4	5	6	Mean	SD
1. Perceived Knowledge	1	0.531**	0.332**	0.529**	0.505**	0.508**	4.40	0.66
2. Coping appraisals	-	1	0.388**	0.722**	0.677**	0.696**	3.90	0.66
3. Threat appraisals	-	-	1	0.344**	0.354**	0.355**	25.59	4.74
4. Intentions	-	-	-	1	0.755**	0.659**	3.94	0.71
5. Adaptive responses	-	-	-	-	1	0.654**	4.03	0.64
6. Maladaptive responses	-	-	-	-	-	1	4.06	0.63

**= p < .010.

Associations between the extended PMT variables

The SEM results of the associations between the key variables used in this study are shown in Figure 1. Perceived knowledge was significantly and positively associated with coping appraisals (β = 0.681, p < .001) and threat appraisals (β = 0.411, p < .001). Coping appraisals were significantly and positively associated with adaptive responses (β = 0.820, p < .001), maladaptive responses (β = 0.884, p < .001), and intentions (β = 0.509, p < .001). Threat appraisals were significantly and positively associated with adaptive responses (β = 0.118, p < .001) and maladaptive responses (β = 0.091, p < .001). Lastly, adaptive responses were significantly and positively associated with intentions (β = 0.664, p < .001). In general, the SEM model showed a well-fitted model which is supported by the fit indices (CFI = 0.925; TLI = 0.913; RMSEA = 0.064; and SRMR = 0.066), except for the significant χ² (df) = 877,168 (198) test (p < .001).

Invariance evaluation

The findings on invariance evaluation across parents and COVID-19-like symptoms experiences through multigroup structural equation modeling are shown in Table 4. The fit indices for parenting roles and COVID-19-like symptoms experiences showed relatively good results. That is, the unconstrained indices for parenting role (mother or father) were χ² (df) = 2020.86 (594), CFI = 0.922, TLI = 0.909, and RMSEA = 0.038 and the unconstrained indices for COVID-19-like symptoms experiences were χ² (df) = 2066.36(594), CFI = 0.920, TLI = 0.906, and RMSEA = 0.039. Changes in CFI in the models obtained for measurement weights, structural weights, structural covariances, structural residuals and measurement residuals for both parenting roles and COVID-19-like symptoms experiences were less than 0.010. Furthermore, changes in TLI were similar to the CFI except that the measurement residuals of both parenting roles and COVID-19-like symptoms experiences were a bit above 0.010 (∆TLI = 0.014 and 0.017 for parenting roles and COVID-19-like symptoms experiences, respectively). In general, the fit indices improved as the models became more constrained, indicating that the data support measurement invariance across these variables. Therefore, there was no difference between parenting roles (mother or father) and COVID-19-like symptoms experiences.

Table 4. Invariance evaluation across parenting roles (mother or father) and COVID-19-like symptoms experiences through multigroup structural equation modeling.

	χ^2 (df)	∆χ^2 (∆df)	CFI	∆CFI	TLI	∆TLI	RMSEA
Parenting role
Unconstrained	2020.86 (594)	-	0.922	0	0.909	-	0.038
Measurement weights	2043.88(626)	23.03 (32)	0.922	0	0.914	0.005	0.037
Structural weights	2066.73 (646)	45.88 (52)	0.922	0	0.917	0.008	0.036
Structural covariances	2075.58 (648)	54.73 (54)	0.922	0	0.916	0.008	0.036
Structural residuals	2085.62 (658)	64.76 (64)	0.922	0	0.918	0.009	0.036
Measurement residuals	2126.06 (704)	105.21 (110)	0.922	0	0.923	0.014	0.036
COVID-19-like symptoms experiences
Unconstrained	2066.36(594)	-	0.920		0.906	-	0.039
Measurement weights	2086.04 (626)	19.68 (32)	0.920	0	0.912	0.006	0.037
Structural weights	2092.56 (646)	26.19 (52)	0.921	0.001	0.915	0.009	0.037
Structural covariances	2101.91 (648)	35.55 (54)	0.921	0.001	0.915	0.009	0.037
Structural residuals	2108.58 (658)	42.22 (64)	0.921	0.001	0.917	0.010	0.036
Measurement residuals	2135.94(704)	69.57 (110)	0.922	0.002	0.923	0.017	0.035

∆CFI <0.02, ∆RMSEA <0.02 indicates supported evaluation invariance.

χ² (df), chi-squared (degrees of freedom); CFI, comparative fit index; TLI, Tucker – Lewis index; RMSEA, root mean square error of approximation; ∆CFI, change in comparative fit index; ∆TLI, change in Tucker – Lewis index.

Discussion

The present study aimed to understand the reasons underlying Iranian parents’ intentions to vaccinate their children. Initial correlation analyses revealed that there were significant medium to large positive relationships between perceived knowledge, coping appraisals, threat appraisals, adaptive responses, maladaptive responses, and intentions to vaccinate which set the stage for a more stringent analysis (i.e., SEM). These positive relationships suggest that when one of the variables increases, the others may also increase. For instance, an increase in perceived knowledge of the COVID-19 vaccine may lead to an increase in appraisals (i.e., coping and/or threat). These relationships are similar to the findings of previous studies.^16,17,41 However, to investigate the rigor of these relationships, SEM was further used to examine relationships between variables.

The SEM findings indicated that perceived knowledge directly associated with coping and threat appraisals, suggesting that information on the COVID-19 vaccine should be clear and cogent for parents to appropriately appraise both coping mechanisms and perceived threats related to COVID-19 and related vaccinations. The appraisal mechanisms may then directly influence adaptive and maladaptive responses. Of note, the strength of associations between coping appraisal and both responses (i.e., adaptive and maladaptive responses) were numerically greater than those between threat appraisals and behavioral responses, suggesting the importance of coping appraisals in influencing adaptive and maladaptive responses. Also, only adaptive responses, compared to maladaptive responses, appeared to influence parents’ intentions to vaccinate their children. It is interesting to also note that coping (and not threat) appraisals may directly influence intentions to vaccinate, suggesting that cogent information may affect the appropriate use of coping strategies which may directly affect vaccination intentions. Therefore, it may be deduced that cogent information may directly provide valuable knowledge to parents which may then be used to appraise (i.e., coping and threat appraisals) the type of responses (i.e., adaptive or maladaptive) to use, although only adaptive responses may directly influence parents’ intention to vaccinate their children. While some previous studies have examined relationships between the extended PMT variables,^16,17 these studies have not investigated parents’ intentions to vaccinate their children. Additionally, other studies have generally examined associations between perceived knowledge (or information) and parents’ intentions to vaccinate their children,²⁸ and adaptive-maladaptive responses and parents’ intentions to vaccinate their children.³⁸

The invariance evaluation findings revealed that there was no difference across parenting roles (mother or father) or COVID-19-like symptoms experiences in parental intentions to vaccinate children. This suggests that regardless of whether the parent is a mother or father and regardless of their past experience with COVID-19 symptoms, intentions to vaccinate their children are similar. That is, an intention to vaccinate a child does not change based on the parent’s role (i.e., as a mother or father) or children’s COVID-19-like symptoms experiences. Hence, the model appears applicable across these variables. A possible reason for the invariance could be that parents (i.e., individually and/or as a couple) consider the child’s overall health (e.g., is the vaccine safe or necessary for the child) notwithstanding the role of the parent and previous COVID-19-like symptoms experiences. This is encouraging as health experts and health communicators may not have to prepare distinct information on vaccinations for mothers versus fathers or those with COVID-19-like symptoms experiences, even though some consider parental roles and COVID-19-like symptoms experiences as important factors in promoting COVID-19 vaccination.^28,29,31 That is, indirectly, the invariance evaluation findings do not support the prioritization of a parent or COVID-19-like symptoms experiences in disseminating vaccination information. The invariance evaluation findings, therefore, suggest further research into factors that may best promote COVID-19 vaccination programs.

Strengths, limitations, and implications

This study has multiple strengths including a relatively large and diverse sample size which included individuals of different sexes and educational levels and with different COVID-19 infection experiences among their children. Thus, the sample may reflect an Iranian population of parents, suggesting that healthcare providers, health experts, and educators/communicators may use the findings to improve vaccine uptake among parents and their children. This study has limitations. First is the use of cross-sectional survey design. As data were collected at one time point, one cannot establish causality between variables. Therefore, readers should be cautious in interpreting the findings. Second, a convenience sampling method was used which may bias the representativeness of the sample, although the schools were randomly selected. Third, the data were collected using self-reports that are prone to biases. Fourth, preventive measures and COVID-19 vaccination procedures implemented in Iran may differ from those in other countries. Therefore, differences across jurisdictions should be considered when interpreting and applying the findings. Fifth, the current study reported only internal consistency statistics, in part as the measures used were from prior Iranian studies. The current findings regarding internal consistency in the setting of prior findings suggest the acceptability of these measures, which were developed within a theoretical framework (i.e., extended PMT). Nonetheless, future studies should more fully investigate the psychometric properties (e.g., content validity and structural validity) of the measures used in this study. Notwithstanding, the findings are considered within a theoretical framework and provide important information regarding parental vaccination intentions for their children. Regarding health implications, cogent information is important in setting in motion series of events that may influence parents’ intentions to vaccinate their children. Health experts and government health policymakers should endeavor to provide reliable and factual data to people. Also, coping appraisals (i.e., positive perceptions about vaccinations) and adaptive responses (i.e., positive thoughts about vaccinations) can be used as indicators of vaccination drives as they are essential intervening variables for intentions to vaccinate children. Therefore, the current findings should help health experts and government health policymakers with information relevant to improving COVID-19 vaccination among children.

Conclusions

Using the framework of the extended PMT, this study examined associations between variables related to parental intentions for children’s COVID-19 vaccination and invariance evaluation across parenting roles (mother or father) and COVID-19-like symptoms experiences. The SEM results showed that perceived knowledge positively influenced coping and threat appraisals. Coping appraisals then positively influenced adaptive responses, maladaptive responses, and intentions to vaccinate. On the other hand, threat appraisals only positively influenced adaptive and maladaptive responses. Finally, adaptive responses but not maladaptive responses positively influenced intentions to vaccinate. The invariance evaluation revealed similarity across parenting roles (mother or father) and COVID-19-like symptoms experiences in parental intentions to get their children vaccinated. Therefore, cogent information on COVID-19 vaccination among children may boost parents’ knowledge influencing their appraisals, adaptive responses and eventually their intentions to vaccinate their children. Furthermore, intentions to vaccinate children may not depend substantially on differences between parental roles or COVID-19-like symptoms experiences. It is recommended that different jurisdictions continue to examine different ways of boosting COVID-19 vaccination among children as different regions may employ different strategies in addressing the COVID-19 pandemic. Lastly, health experts may consider these findings to help increase COVID-19 vaccination efforts among children.

Author contributions

Conceptualization, D.K.A., C.Y.L. and A.H.P.; methodology, D.K.A., M.N.P., C.Y.L. and A.H.P.; software, A.H.P.; validation, D.K.A., M.N.P., C.Y.L. and A.H.P.; formal analysis, D.K.A., C.Y.L. and A.H.P.; investigation, Y.N.Y. and A.H.P.; resources, D.K.A., M.N.P., C.Y.L. and A.H.P.; data curation, A.H.P.; writing – original draft preparation, D.K.A. and A.H.P.; writing – review and editing, D.K.A., M.N.P., C.Y.L. and A.H.P.; visualization, C.Y.L. and A.H.P.; supervision, A.H.P.; project administration, A.H.P.; funding acquisition, A.H.P. All authors agree to be accountable for all aspects of the work.

Acknowledgments

We extend our appreciation to the parents who graciously participated in this study.

Disclosure statement

The authors report no conflicts of interest. Dr. Potenza discloses that he has consulted for and advised Game Day Data, Addiction PolicyForum, Baria-Tek, and Opiant Therapeutics; been involved in a patent application involving Novartis and Yale; received research support from the Mohegan Sun Casino, Children and Screens and the ConnecticutCouncil on Problem Gambling; consulted for or advised legal and gambling entities on issues related to impulse control, internet use and addictive behaviors; provided clinical care related to impulse control, internet use and addictive behaviors; performed grantreviews; edited journals/journal sections; given academic lectures in grand rounds, CME events and other clinical/scientific venues; and generated books or chapters for publishers of mental health texts.

Additional information

Funding

The work was supported by the Qazvin University of Medical Sciences.