Caregivers’ intentions to COVID-19 vaccination for their children in China: a cross-sectional survey

ABSTRACT

Chinese caregivers’ intentions to allow their children to be vaccinated against coronavirus disease 2019 (COVID-19) is unknown. We explored the intention rate of Chinese caregivers to allow their children to be vaccinated and examined potential influencing factors and underlying reasons for their unwillingness or hesitation. From November 30, 2020, to January 31, 2021, we conducted a cross-sectional survey of 3703 caregivers in six representative provinces in China. We assessed intention rates and correlates of caregivers’ intentions to vaccinate children against COVID-19, using descriptive analyses and a multiple logistic regression analysis, respectively. In the study sample, about 84.0% of caregivers intended to get their children vaccinated for COVID-19 if the vaccine was available. In particular, 92.2% of caregivers who were willing to be vaccinated themselves for COVID-19 intended to have their children vaccinated, yet among caregivers who were unwilling (or uncertain) whether to be vaccinated, only 41.1% intended to have their children vaccinated. Older age, lower education level, and perceived safety and effectiveness of the COVID-19 vaccine were associated with increased odds of caregivers intending to have their children vaccinated. Of the six provinces included in the study, residence in a province other than Hubei increased the likelihood that caregivers would choose not to have their children vaccinated. We found a relatively high vaccination rate (84.0%) among caregivers by using a cross-sectional sample in China. Concerted efforts are needed to address caregivers’ concerns about vaccine safety, especially among caregivers who do not intend to be vaccinated themselves.

Plain Language Summary

Recently, COVID-19 infection in children has increased. Although most countries have not approved the COVID-19 vaccine for children, it is likely that they will do so. There is a clear need to explore caregivers’ intentions and to understand potential hesitancy as means to inform vaccination policies. We found a relatively high caregivers’ intention rate to have their children vaccinated against COVID-19, and caregivers’ intentions to be vaccinated themselves was associated with their own decision to have their children vaccinated. In this study, older age, lower education level, belief that the COVID-19 vaccine was safe and effective, and residence in Hubei province were associated with increased odds of caregivers intending to have their children vaccinated. Policy makers should address caregivers’ concerns about vaccine safety and encourage caregivers themselves to get vaccinated before they decide to have their children vaccinated.

KEYWORDS:

• COVID-19 vaccines
• caregivers’ intentions
• child immunization
• vaccine hesitancy

Introduction

Globally, the coronavirus disease 2019 (COVID-19) pandemic has resulted in substantial morbidity and mortality and has placed a tremendous burden on health-care systems and on society. ^1–4 Although fewer children worldwide aged <18 years have been reported to be infected with the COVID-19 virus compared with adults, the trend toward child COVID-19 infection appears to be increasing.⁵ According to UNICEF, around 12 million COVID-19 cases have occurred in children and adolescents worldwide, 13% of the 91 million COVID-19 cases in 101 countries as of May 2021.⁶ In the United States, child COVID-19 cases have accounted for about 22% of new weekly cases (71,649 new child cases) between April 22 and 29, 2021.⁷ In China, one study reported that there were more than 2000 pediatric COVID-19 infection cases between January 16, 2020 and February 8, 2020.⁸ Most Children infected with COVID-19 have mild symptoms or even asymptomatic infection, yet in certain cases, children have become severely ill or even died due to COVID-19.^5,7,9 Most recently, the delta variant of COVID-19 was found to be more contagious for children. Therefore, it is imperative to better understand how to protect the vulnerable children from COVID-19 infection.

As there are currently no specific antiviral treatments for COVID-19, vaccine development is considered one of the most effective strategies to limit the spread of COVID-19.^{10, 11} Children are often the highest priority group for general vaccination (e.g., Bacille Calmette-Guerin vaccine, Diphtheria and tetanus toxoid with acellular pertussis vaccine);^{12, 13} however, due to the lack of evidence-based data from clinical trials, only a few countries just authorized the use of COVID-19 vaccine in children, such as U.S. and Canada.^14,15 China also just approved to offer COVID-19 vaccine to children aged 3 to 17 years old for emergency use on July 16, 2021; however, little is known about Chinese caregivers’ intentions to allow their children to be vaccinated against COVID-19.¹⁶ Thus, there is a clear need to investigate caregivers’ intention rate to better inform the vaccine uptake strategies for children to reduce infection and mortality.

Table 1. Characteristics of the study sample

Variables	Total		Caregivers’ intentions to have their children vaccinated, yes			Caregivers’ intentions to be vaccinated themselves, yes
	N	Column %	N	Row %	p-Value	N	Row %	p-Value
Total	3703	100.0	3110	84.0		3107	83.9
Age group (years)					.004			.001
20–39	1255	33.9	1019	81.2		1079	86.0
40–59	1041	28.1	894	85.9		887	85.2
≥60	1407	38.0	1197	85.1		1141	81.1
Gender					.901			.275
Male	1590	42.9	1334	83.9		1322	83.1
Female	2113	57.1	1776	84.1		1785	84.5
Relationship to child(ren)					.321			.003
Mother	1278	34.5	1064	83.3		1101	86.2
Father	835	22.6	694	83.1		708	84.8
Grandparent	1590	42.9	1352	85.0		1298	81.6
Education level					<.001			.013
Middle school or below	1771	47.8	1523	86.0		1453	82.0
High school/technical college	1374	37.1	1148	83.6		1176	85.6
Bachelor degree or above	558	15.1	439	78.7		478	85.7
Living residence					.145			.810
Urban	2129	57.5	1772	83.2		1789	84.0
Rural	1574	42.5	1338	85.0		1318	83.7
Annual household income					.344			.503
<100,000 Yuan	2496	67.4	2109	84.5		2083	83.5
100,200,000 Yuan	888	24.0	741	83.4		756	85.1
≥200,000 Yuan	319	8.6	260	81.5		268	84.0
Province					<.001			<.001
Hubei	972	26.2	894	92.0		884	90.9
Chongqing	541	14.6	493	91.1		482	89.1
Gansu	776	21.0	578	74.5		586	75.5
Guangdong	542	14.6	444	81.9		447	82.5
Jilin	353	9.5	282	79.9		278	78.8
Zhejiang	519	14.0	419	80.7		430	82.9

Table 2. Perceptions of COVID-19 infection or vaccine

Variables	Total		Caregivers’ intentions to have their children vaccinated, yes			Caregivers’ intentions to be vaccinated themselves, yes
	N	Column %	N	Row %	p-Value	N	Row %	p-Value
Total	3703	100.0	3110	84.0		3107	83.9
Perceived risk of COVID-19 infection					<.001			<.001
High	1093	29.5	945	86.5		979	89.6
Fair/low	2610	70.5	2165	83.0		2128	81.5
Perceived severity of COVID-19 infection					.005			<.001
High	3057	82.6	2591	84.8		2633	86.1
Fair/low	646	17.4	519	80.3		474	73.4
Perceived safety of COVID-19 vaccines					<.001			<.001
Safe	2422	65.4	2185	90.2		2248	92.8
Not safe/not clear	1281	34.6	925	72.2		859	67.1
Perceived effectiveness of COVID-19 vaccines					<.001			<.001
Effective	2537	68.5	2287	90.1		2357	92.9
Not Effective/not clear	1166	31.5	823	70.6		750	64.3
Trust in governments’ information and suggestions of vaccination					<.001			<.001
Trust	3302	89.2	2867	86.8		2916	88.3
Fair/not trust	401	10.8	243	60.6		191	47.6
Trust in health workers’ information and suggestions of vaccination					<.001			<.001
Trust	3301	89.1	2862	86.7		2916	88.3
Fair/not trust	402	10.9	248	61.7		191	47.6

Table 3. Caregivers’ intentions to be vaccinated and to have their children vaccinated

		Caregivers’ intentions to have their children vaccinated
		Total		Yes		No/not sure
		N	Row %	N	Row %	N	Row %	p-Value
Caregivers’ intentions to be vaccinated themselves	Total	3703	100	3110	84.0	593	16.0	<.001
	Yes	3107	100	2865	92.2	242	7.8
	No/not sure	596	100	245	41.1	351	58.9

Table 4. Adjusted logistic regression of caregivers’ intentions to have their children vaccinated against COVID-19 (N = 3703)

Variables	aOR	95%CI	p-Value
Caregivers’ intentions to be vaccinated themselves
No/not sure	1.00
Yes	11.75	9.11–15.14	<.001
Age group (years)
20–39	1.00
40–59	1.50	1.12–2.00	.006
≥60	1.70	1.12–2.58	.013
Gender
Male	1.00
Female	0.94	0.70–1.29	.710
Relationship to child(ren)
Mother	1.00
Father	1.09	0.73–1.64	.658
Grandparent	0.77	0.50–1.18	.231
Education level
Middle school or below	1.00
High school/technical college	0.66	0.49–0.88	.005
Bachelor degree or above	0.45	0.30–0.66	<.001
Living residence
Urban	1.00
Rural	1.12	0.87–1.43	.392
Annual household income
<100,000 Yuan	1.00
100,200,000 Yuan	0.87	0.66–1.15	.331
≥200,000 Yuan	0.90	0.57–1.40	.628
Perceived risk of COVID-19 infection
High	1.00
Fair/low	0.96	0.75–1.22	.717
Perceived severity of COVID-19 disease
High	1.00
Fair/low	1.30	0.96–1.76	.086
Perceived safety of COVID-19 vaccines
Not safe/not clear	1.00
Safe	1.59	1.14–2.21	.006
Perceived effectiveness of COVID-19 vaccines
Not Effective/not clear	1.00
Effective	1.45	1.04–2.02	.029
Trust in governments’ information and suggestions of vaccination
Fair/not trust	1.00
Trust	1.43	0.89–2.30	.138
Trust in health workers’ information and suggestions of vaccination
Fair/not trust	1.00
Trust	0.97	0.59–1.59	.904
Province
Hubei	1.00
Chongqing	0.95	0.65–1.41	.820
Gansu	0.25	0.18–0.35	<.001
Guangdong	0.51	0.35–0.73	<.001
Jilin	0.53	0.35–0.79	.002
Zhejiang	0.38	0.25–0.57	<.001

aOR: adjusted odds ratio; bold-faced: p < .05.

Table 5. The most common reasons for caregivers who do not intend to have their children vaccinated COVID-19

Reasons	N	Column %
The vaccine may not be safe	300	50.59
Waiting for someone else to be vaccinated first	110	18.55
The vaccine does not work	69	11.64
Low risk of infection	39	6.58
The vaccine is expensive	33	5.56
Inadequate supplies of vaccine or don’t know where to get vaccinated	22	2.53
Other reasons	20	2.19

In China, over 1.01 billion doses of the COVID-19 vaccine have been received by adults as of June 19, 2021.¹⁷ Children vaccination is very important for reaching COVID-19 herd immunity.^18,19 Caregivers play a key role on ensuring children vaccinated, and previous studies have shown large differences in caregivers’ intention to vaccinate with different vaccines.^20–22 Studies have reported that child vaccination has been disproportionately affected by the attitudes and behaviors of caregivers, including beliefs regarding vaccine safety and efficacy, and keeping children up to date on vaccinations, including the influenza vaccination.^21,23,24,25 Caregivers’ vaccine hesitancy may be a major barrier to vaccine uptake for children.^22,26,27  For example, only 40% of children aged 6 months to 17 years in the United States received the 2009 H1N1 vaccination because of high vaccine hesitancy of parents.^28,29 However, there is limited information about caregivers’ intention to have their children vaccinated specifically for COVID-19. More evidences are needed to prepare for COVID-19 vaccination of children.

This study aims to (1) explore caregivers’ COVID-19 vaccination intentions for themselves and their children, (2) determine the association of caregivers’ vaccination intentions and other correlates with vaccination intentions for their children, and (3) examine reasons of caregivers not intending to have their children vaccinated.

Methods

Study design, data collection, and study sample

We designed a questionnaire with reference to previous relevant studies and through expert consultation to assess participants’ willingness to vaccinate and vaccine hesitation.^4,30,31 This questionnaire was modified by expert Delphi consultation and could be used to evaluate the complacency, confidence, and convenience of responders to vaccine hesitation proposed by SAGE.³² A cross-sectional face-to-face survey was conducted in six provinces in China by the Chinese Center for Disease Control and Prevention and Peking University from November 17, 2020, to January 28, 2021, right after COVID-19 vaccines were approved for conditional use in China. In order to improve the representativeness of the sample, six provinces were selected in eastern (Guangdong and Zhejiang province), central (Hubei and Jilin province), and western (Gansu and Chongqing) regions. Multistage sampling was used to select two cities from each province, two counties/districts from each city, and five communities/villages from each county/district. Considering the severity of the actual epidemic situation of the COVID-19 pandemic, Hubei province was over sampled with four cities. In total, the sample involved 28 counties with 140 communities/villages from six provinces in China. In each of the sample’s communities/villages, adults ≥18 years old in a household were randomly selected for the survey with the help of community staff, and interviewees were surveyed face-to-face using a uniform anonymous questionnaire after obtaining informed consent from the participants. This study was approved by the Peking University Institutional Review Board (IRB00001052-20011).

In this study, we focused on a subsample of caregivers defined as (1) adults aged ≥ 18 years who were (2) living in a family with at least one child under the age of 18 and were (3) the parent or grandparent of child(ren) under the age of 18. A total of 7259 participants were surveyed, and among them, 3452 participants who were not caregivers and 104 caregivers (not parents or grandparents) were excluded because they could not make a vaccination decision for the children. Finally, the sample size of caregivers for this analysis was 3703.

Study variables

The primary outcome of this study was caregivers’ intentions regarding COVID-19 vaccination for their children, measured in relation to the following question: “Do you intend to have your children vaccinated against COVID-19 if a vaccine is available?” (The COVID-19 vaccine was not available for children in China when the study was conducted.) Three options were offered to participants (intend, do not intend, unsure), and we categorized them into two groups: “yes (intended)” and “no/not sure (did not intend/were unsure).”

Caregiver’s intentions regarding COVID-19 vaccination for themselves were measured with a single question: “Do you intend to have a COVID-19 vaccination if it is approved?” Similar to the above intentions for their children, the answers were grouped into “yes” and “no/not sure.”

Perception variables for COVID-19 infection and vaccination included the following: (1) perceived risk of COVID infection: “How do you feel about your risk of COVID-19 infection?” (high, fair/low); (2) perceived severity of COVID-19 infection: “How severe do you think the COVID-19 infection is?” (high, fair/low); (3) perceived safety of COVID-19 vaccines: “What do you think about the safety of COVID-19 vaccines?” (safe, not safe/not clear); (4) perceived effectiveness of COVID-19 vaccines “What do you think about the effectiveness of COVID-19 vaccines?” (effective, not effective/not clear); (5) trust in health workers to provide information and suggestions regarding vaccination: “Do you trust vaccine-related information and advice from health workers?” (trust, fair/do not trust); (6) trust in governments to provide information and suggestions regarding vaccination: “Do you trust vaccine-related information and advice from the government?” (trust, fair/do not trust).

Reasons for not intending to have their children vaccinated against COVID-19 were measured by a single-choice question: “What is the primary reason you do not intend to have your children vaccinated against COVID-19?”(the vaccine may not safe, will wait for someone else to be vaccinated first, the vaccine does not work, low risk of infection, the vaccine is expensive, inadequate supplies of vaccine or don’t know where to get vaccinated, other).

Sociodemographics included the caregivers’ age (20-39, 40-59, and ≥60 years old), gender (male and female), relationship with children (father, mother, and grandparent), education level (junior middle school or below, high school and technical school, and bachelor’s degree or above), location (urban and rural), family annual income (<100,000 Yuan, 100,000-200,000 Yuan, and > 200,000 Yuan), and province (Hubei, Chongqing, Gansu, Guangdong, Jilin, and Zhejiang).

Statistical analysis

First, descriptive statistics were conducted to describe the characteristics of the study sample, and we examined the proportions of caregivers’ intentions regarding COVID-19 vaccination for their children and themselves, stratified by sociodemographic and perception characteristics. Second, the proportions of caregivers’ intentions regarding COVID-19 vaccination for their children, stratified by intentions for themselves, were calculated. In the above analyses, chi-square tests were used to examine significance. Third, a multiple logistic regression model was performed to estimate the association of caregiver’s intentions regarding COVID-19 vaccination for themselves and other factors with caregiver’s intentions for their children. The p-value < 0.05 was considered statistically significant. Finally, the distribution of the primary reason for not intending to have their children receive a COVID-19 vaccination was also reported. All data were analyzed using Stata 16.0 (Stata Corp, College Station, TX).

Results

Characteristics of the study sample (Table 1)

Overall, the majority of caregivers (n=3703) were aged 18-59 years old (62.0%), female (57.1%), parents (57.1%), had a high school education or above (52.2%), lived in an urban area (57.5%), and had <100,000 Yuan annual household income (67.4%). Approximately 84.0% of caregivers intended to have their children vaccinated if child vaccination was approved, and 83.9% of caregivers themselves intended to get vaccinated. The proportions of caregivers’ intention to have their children vaccinated showed the differences across age groups, different education level and provinces, respectively.

Perceptions of COVID-19 infection or vaccine (Table 2)

Among the caregivers, 89.2% trusted governments to provide accurate information and suggestions regarding vaccination, 89.1% trusted health workers to provide accurate information and suggestions regarding vaccination, 82.6% considered COVID-19 infection to be very serious, 70.5% considered themselves at low risk of COVID-19 infection, 68.5% considered the COVID-19 vaccine effective, and 65.4% considered the COVID-19 vaccine safe. Chi-square tests indicated that there were significant differences between perceptions of COVID-19 infection or vaccine and caregivers’ intentions to have their children vaccinated.

Caregivers’ intentions to have themselves and their children vaccinated (Table 3)

Among caregivers who themselves intended to be vaccinated, 92.2% intended to have their children vaccinated COVID-19, and among caregivers who themselves did not intend to be vaccinated, 41.1% intended to have their children vaccinated COVID-19 (p<0.001).

Correlates of caregivers’ intentions to have their children vaccinated (Table 4)

The multiple logistic regression analysis shows that caregivers who themselves intended to be vaccinated against COVID-19 were more likely to have their children vaccinated (adjusted Odds Ratio [aOR] 11.75, 95% confidence interval [CI] 9.11-15.14, p < 0.001), after controlling for sociodemographics and perceptions of infection and the COVID-19 vaccine. In the total sample, older age, lower education, and belief that the COVID-19 vaccine was safe and effective were associated with higher odds of caregivers intending to have their children vaccinated. Residence in a province other than Hubei (Gansu, Guangdong, Jilin, or Zhejiang) hindered the likelihood that caregivers will have their children vaccinated.

Reasons for not intending to have children vaccinated (Table 5)

More than half of caregivers (50.59%) reported that the safety of the COVID-19 vaccine was the main reason they did not intend to have their children vaccinated, and that waiting for others to be vaccinated first (18.55%) was the second reason. Another important reason that caregivers gave for not intending to have their children vaccinated was the belief that the COVID-19 vaccine does not work (11.64%).

Discussion

At present, both in China and globally, adults have been encouraged to get vaccinated against COVID-19, and clinical trials of the vaccine for children are being conducted. Improving the COVID-19 vaccination rate among both adults and children is necessary to reaching herd immunity. Our study has three key findings. First, we found that caregivers in China had a relatively high intention to have their children vaccinated against COVID-19. Second, caregivers’ intentions for their children be vaccinated against COVID-19 were highly associated with their own intentions to be vaccinated. Finally, the most important reason that caregivers were reluctant to vaccinate their children against COVID-19 was concern about the safety. These findings provide valuable information for China and for other countries to successfully promote COVID-19 vaccination in children.

Our findings indicated that 84.0% of Chinese caregivers intended to have their children vaccinated. Chinese caregivers in this study appears to be more willing to have their children vaccinated than were caregivers in other international studies. In a cross-sectional survey conducted in the United States, Canada, Israel, Japan, Spain, and Switzerland, approximately 65.2% of parents expressed the intention to have their children vaccinated against COVID-19,²⁵ and 48.2% of parents or guardians in a multimethod study in England clearly expressed their intentions to have their children receive a COVID-19 vaccine.^32,33 The higher intentions of caregivers in China to have their children vaccinated against COVID-19 may be because vaccination rates for diseases other than COVID-19 in China were higher than in the rest of the world. For example, childhood vaccination rates for Bacillus Calmette Guerin (BCG) and measles-containing vaccines (MCV), included in China’s free national immunization program, reached more than 99% of children.³⁴ Therefore, if the government promotes COVID-19 vaccination among children, caregivers may be more likely to accept it as they do other free vaccinations.

Factors influencing caregivers’ intentions to vaccinate children are complex, and the same is true for the COVID-19 vaccine.^13,35 In this study, we explored many factors that promote or encourage caregivers to have their children vaccinated. We found that caregivers’ intentions to be vaccinated themselves was highly associated with their intentions to have their children vaccinated, which was also consistent with previous studies in other countries.³³ Currently, China are adopting two major approaches to improve the uptake of COVID-19 vaccine among adults: centralized vaccination and outpatient vaccination. Over 1 billion doses have been administered by July, 2021 in China.¹⁷ COVID-19 vaccine is free in China as of December 31, 2020, thus there is no longer an economic barrier for vaccination.³⁶ Free vaccine, convenient service, and social mobilization may contribute to this achievement. Therefore, if the COVID-19 vaccines were approved in children, it is necessary to continue current approaches for adults to increase the uptake, most importantly target on caregivers’ intention by considering the specific needs or concerns from both caregivers and their children.

We found that caregivers’ hesitation or uncertainty about having their children vaccinated against COVID-19 was due mainly to concerns about safety and efficacy. More than 62% of parents who do not intend to have their children vaccinated COVID-19 concerned about the safety or effectiveness of COVID-19 vaccine (i.e., 50.6% believed that the vaccine might not safe and 11.6% believed that the vaccine did not work), and 18.6% of caregivers wanted to wait for others to be vaccinated. Previous studies have also shown that doubts about the safety of vaccines hindered caregivers’ decisions to have their children receive routinely administered vaccines.²² COVID-19 is an emerging infectious disease, and the time to develop and market a vaccine is short. Caregivers’ concerns about COVID-19 vaccine were justified.^37,38 Parents generally believe that older vaccines are safer than new vaccines because they have been tested in longer clinical trials and in many different markets.³⁹ The government should inform caregivers of the advantages and risks of COVID-19 vaccination, speed up research and trials, and improve caregivers’ trust in government information. Young and highly educated caregivers seem to be more hesitant to have their children vaccinated against COVID-19. Giving these young parents more information about scientific trial processes and data rather than just providing trial results may improve their confidence in the safety and efficacy of the vaccine. Caregivers stated that they had multiple channels to obtain information about vaccination. Platforms such as Weibo and Tik Tok could be used provide vaccine information, in addition to relevant publicity on official platforms.^40–42

Limitations

Our study has several limitations. First, this study was a cross-sectional survey and did not allow for a good inference of the causal relationship between influencing factors. Furthermore, this study was conducted before the upcoming large-scale distribution of the COVID-19 vaccine in China, and reflects caregivers’ intentions to be vaccinated themselves and have their children vaccinated only at the time of the survey. Second, the indicators used in this study to investigate caregivers’ perceptions of the safety and efficacy of the COVID-19 vaccine were general and did not assume specific vaccine attributes (e.g., efficacy rate of COVID-19 vaccine, incidence of adverse reactions, etc.). Third, while caregivers’ intentions to be vaccinated themselves was included as a control variable in the regression analysis, there were still some influencing factors that were not sufficiently considered in the questionnaire design (e.g., questions that were not limited to individuals’ knowledge, attitudes, and beliefs). Fourth, this study lacked open-ended questions when investigating caregivers’ hesitation or uncertainty to have their children receive the COVID-19 vaccine, and may have overlooked some reasons for this. Finally, due to the changing circumstances of the epidemic, the actual vaccination situation may change regarding when COVID-19 vaccine will become available for children in China.

Conclusion

In China, about 84.0% of caregivers in the studied sample intended to get their children vaccinated for COVID-19 if the vaccine was available. Caregiver’s age, view of the safety and efficacy of the COVID-19 vaccine, view of regional epidemic severity, and education were associated with the intention to get their children vaccinated for COVID-19. The most important reason hindering caregivers allowing their children to receive the COVID-19 vaccine was the concern about vaccine safety. Policy makers should address caregivers’ concerns about vaccine safety through enhanced scientific advocacy and encourage caregivers to get vaccinated before having their children vaccinated.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2021.1985355

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.