key: cord-0781859-mtad0xz0
authors: Baumann, Brigitte M.; Rodriguez, Robert M.; DeLaroche, Amy M.; Rayburn, David; Eucker, Stephanie A.; Nadeau, Nicole L.; Drago, Lisa A.; Cullen, Danielle; Meskill, Sarah Dennis; Bialeck, Suzanne; Gillman, Michael
title: Factors Associated with Parental Acceptance of COVID-19 Vaccination: A Multicenter Pediatric Emergency Department Cross-sectional Analysis
date: 2022-02-01
journal: Ann Emerg Med
DOI: 10.1016/j.annemergmed.2022.01.040
sha: 14d273a5a03fe219b477034cbd834670e1a4e72a
doc_id: 781859
cord_uid: mtad0xz0

Objective At a time when the COVID19 vaccine was approved for everyone > 12 years of age, we sought to identify characteristics and beliefs associated with COVID-19 vaccination acceptance. Methods We conducted a cross-sectional survey study of parents of children aged 3-16 years presenting to one of 9 emergency departments from June-August 2021 to assess parental acceptance of COVID-19 vaccines. Using multiple variable regression, we ascertained which factors were associated with parental and pediatric COVID-19 vaccination acceptance. Results Of 1491 parents approached, 1298 (87%) participated of which 50% of parents and 27% of their children > 12 years of age were vaccinated. Characteristics associated with parental COVID-19 vaccination were trust in scientists [adjusted odds ratio (aOR) 5.11, 95% confidence interval (CI) 3.65-7.15], recent influenza vaccination (aOR 2.66, 95% CI 1.98-3.58), college degree (aOR 1.97, 95% CI: 1.36-2.85), increasing parental age (aOR 1.80, 95% CI 1.45-2.22), friend/family member hospitalized with COVID-19 (aOR 1.34, 95% CI 1.05-1.72) and higher income (aOR 1.60, 95% CI 1.27-2.00). Characteristics associated with pediatric COVID-19 vaccination (≥ 12 years) or intended COVID-19 pediatric vaccination (children < 12 years) were parental trust in scientists (aOR 5.37, 95% CI 3.65-7.88), recent influenza vaccination (aOR 1.89, 95% CI 1.29-2.77), trust in the media (aOR 1.68, 95% CI 1.19-2.37), parental college degree (aOR 1.49, 95% CI: 1.01-2.20), and increasing parental age (aOR 1.26, 95% CI 1.01-1.57). Conclusions COVID-19 vaccination acceptance was low. Trust in scientists had the strongest association with parental COVID-19 vaccine acceptance for both parents and their children.

By October 1, 2021, the number of worldwide SARS-CoV-2 (COVID- 19) infections totaled 219 million cases, with nearly 4.6 million deaths. 1 With broad availability of COVID-19 vaccines for adults and older children, hope arose that the United States (US) could achieve sufficient level of immunizations to reach herd immunity. 2 . 3 Yet, vaccine hesitancy has hampered this public health goal. [4] [5] [6] Prior to its release, COVID-19 vaccine acceptance in the general population ranged from 56-75%. [7] [8] [9] [10] [11] This data was disappointingly prescient; as of October 2021, only 56% of the US population had been fully vaccinated for COVID- 19. 12 Importance While multiple investigators have documented vaccine hesitancy in adults, little data exists from pediatric populations. [13] [14] [15] Using an established national internet panel, Szilagyi et al found that less than half of parents are likely to have their child receive a COVID-19 vaccine. 10 Yet, telephone and internet-based surveys may miss disadvantaged and highly vulnerable populationsthose who may be at the greatest risk for morbidity and mortality and who would most benefit from COVID-19 vaccination. 6, 10, [16] [17] [18] [19] [20] Furthermore, by focusing only on vaccine hesitancy and not addressing vaccine acceptance, it is possible that important and modifiable factors that can lead to increased vaccine rates may be overlooked.

The emergency department (ED) serves ethnically and racially diverse populations, including many vulnerable patients with limited access to primary care. In J o u r n a l P r e -p r o o f this cross-sectional study conducted during real-time pediatric ED patient visits, we examined parents' and children's COVID-19 vaccine rates and likelihood of future vaccination in potentially medically underserved populations. Our primary goals were to identify parental characteristics and beliefs which may be associated with COVID-19 vaccine acceptance, both for themselves and for their children. By gathering data in EDs where many parents and children from at-risk minority groups seek pediatric care, we hoped to obtain a sample more broadly representative of vulnerable populations.

From 06/07/2021 to 08/13/2021, we conducted this cross-sectional survey study of parents and guardians of ED patients aged 3-16 years during their visits to nine pediatric EDs in eight US cities (Miami, FL; New Orleans, LA; Boston, MA; Detroit MI; Durham, NC; Philadelphia, PA; Camden, NJ; and Houston, TX). Three pediatric EDs were located within general academic hospitals and the remaining six were in academic pediatric hospitals. The median annual visits to these EDs were 32,000 (range 9,300 to 87,000) for 2020a lower census compared to 2019 (median annual visits 50,000; range 14,800 to 119,000). We obtained Institutional Review Board (IRB) approval or exemptions from all sites. We followed the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines. 21 

Select survey items were adapted from an earlier investigation of adult ED patients. 22 Options for the likelihood of receiving the COVID-19 vaccine were modeled after earlier investigations. 10 New items, relevant to children and to the SARS-CoV-2 Delta surge, were developed by the investigators. This survey draft was refined with respect to item content, completeness of response options, cultural sensitivity, ease of administration, and length using feedback from a patient focus group at Cooper University Hospital containing 10 parents of children aged 3-16 years. Once the English version was finalized, a Spanish version was created using a professional medical J o u r n a l P r e -p r o o f translation service and underwent minor revision by three native Spanish speakers.

Both the English (n=10) and Spanish versions (n=16) were pilot tested to assess comprehension, ease of completion, and response consistency (Survey, Web Appendix 1). The final pilot testing was conducted at Cooper University Hospital, Camden, N.J. and St. Christopher's Hospital for Children, Philadelphia, PA, pediatric EDs.

Parents or guardians of children aged 3-16 years were eligible if they were 18 years or older and could understand English or Spanish. Parents of these age groups were selected because children aged 3-16 years at the time of the survey were likely to be attending secondary school in the fall. Only one parent per child was enrolled, and repeat enrollments were disallowed. Enrollment of parents of critically ill children was at the discretion of the treating physician. To capture non-English speaking parents, a Spanish survey was utilized by eight of the nine sites. Parents were instructed to respond to the survey items based on the child presenting to the ED at the time of enrollment. Information obtained about the presenting child and plans for that child's COVID-19 vaccination was obtained from the parent.

Enrollment time frames were staggered across sites, due to differing IRB approval dates. Initial enrollments began on June 7 and ended August 13, 2021, with most sites enrolling over 5-6 weeks. Limitations on research staffing led to convenience sampling at all sites, with sites enrolling parents in 4-6 hour blocks. At all sites, parents were enrolled throughout the week, from 8 AM -8 PM. Seven sites additionally enrolled parents up until midnight or overnight. We sequentially screened potential participants using ED triage boards. Dedicated research personnel approached parents of children aged 3-16 years after the family unit was placed in an examination room.

Research personnel described the study in layman's terms, provided parents with a study information sheet (English or Spanish) and obtained scripted verbal consent.

Research personnel read study items in English to parents and data were recorded on either hard copies or directly into the REDCap database. For Spanish-speaking parents, Spanish surveys were verbally administered by research personnel whenever possible.

Due to pandemic-based restrictions on non-essential staffing, one site distributed J o u r n a l P r e -p r o o f Spanish surveys directly to parents. Upon collection, these were reviewed to ensure completion of all items.

We included the following general categories of parent and child data in the survey: 1) Demographic data; 2) COVID-19 vaccination status as categorized (Box) and the COVID-19 vaccine for themselves or their child: 1) Vaccine acceptors = "likely" or "very likely" to get vaccinated and 2) Vaccine hesitant = "neither likely or unlikely", "unlikely" and "very unlikely" to be vaccinated. In determining reasons for COVID-19 vaccine hesitancy, both for themselves and their children, parents were further divided into two groups: 1) Ambivalent, "Neither likely or unlikely" and 2) "Unlikely" or "very unlikely" to be vaccinated against COVID-19.

To ascertain prior experience with COVID-19, we asked parents if they or their children were ever diagnosed or had a positive COVID-19 test and if they had any friends or family members who had ever been hospitalized with COVID-19. To gauge parental assessment of child infectivity, parents were asked to rate their agreement with the following statement: "Children infected with COVID-19 can infect others" on a scale of 0-10, with 0 reflecting no agreement and 10 reflecting complete agreement. For level of trust with information sources, parents were asked to rate their agreement with the following two statements: 1) "I trust the information from scientists about the safety of the COVID-19 vaccines", and 2) "I trust the information from the media (TV/news) about the safety of the COVID-19 vaccines" using the same 0-10 scale.

Our primary outcomes were COVID-19 vaccination status of the parent and vaccination status of the child. For adults and children ≥ 12 years, vaccination status was defined as vaccinated versus unvaccinated. For our pediatric multivariable J o u r n a l P r e -p r o o f regression model, children aged < 12 years were placed in the "vaccinated" category if the parent reported themselves as being "very likely" to vaccinate this child once a COVID-19 vaccine is available for this age group (Box).

Participant characteristics were summarized as frequencies and percentages with corresponding 95% confidence intervals (CIs). We excluded non-responses to individual questions in proportion denominators. Nonparametric data is presented as medians with interquartile ranges (IQR). Median level of agreement with three statements (child infectivity, trust in scientists, and trust in media) were compared among three groups: 1) Vaccinated parents, 2) Vaccine acceptors, and 3) Vaccine hesitant, using Kruskal-Wallace testing.

We identified variables a priori which we believed would be associated with receipt of COVID-19 vaccination based on the literature. 23 The second logistic regression model explored the association between child COVID-19 vaccination, defined as vaccination of children ≥12 years or parental response being "very likely" to vaccinate children <12 years once a vaccine is available, and the following parental characteristics: sex, age, race, ethnicity, COVID-19 vaccination status, annual income, and education level. We also included child influenza vaccination within two years, any chronic medical condition in the child, parental J o u r n a l P r e -p r o o f agreement with the belief that children can infect others, and levels of trust in scientists and the media. Parental vaccination was not included in the pediatric model because we believed this factor to be highly associated with parental trust in scientists. By including two variables that are highly correlated with one another, the effect of each on the regression model becomes less precise. To avoid this potential for collinearity, we included only parental trust in scientists in our pediatric regression model.

Adjusted odds ratios (OR) are reported with 95% CIs. In our a priori sample size calculation, assuming a small effect size (0.02), inclusion of 11 predictor variables, a power level of 0.9, and an α of 0.05, we determined that we would need to enroll 1,071 parents. To assess potential differences in variables associated with prior COVID-19 vaccination status (children ≥ 12 years) and parental report of being "very likely" to pursue COVID-19 vaccination in children < 12 years, we conducted two sensitivity analyses, analyzing these two groups separately. Study data were collected and managed using REDCap electronic data capture tools hosted at Cooper University Hospital. 26 We used IBM SPSS Statistics version 27.0 (IBM Corp., Armonk, N.Y.) to conduct the analyses.

Of 2589 parents who were screened for inclusion, 1491 met inclusion/exclusion criteria. Of these 1491 parents, 1298 (87%) agreed to participate, 173 (12%) refused, 12 (1%) were excluded due to medical care interrupting enrollment, and 8 (<1%) had a language barrier. Most participants were women (83%)and the median age (IQR) of parents was 36 (31) (32) (33) (34) (35) (36) (37) (38) (39) (40) (41) (42) years. The predominant minority groups were African American/Black (41%) and Hispanic/Latinx (25%). Nearly one third of parents (31%) reported an annual income under $25,000.

Of the children who presented to the ED, 663 (52%) were male, and the median age (Table 1) .

Half of the parents were either fully vaccinated against SARS-CoV-2, 579 (45%), or had received one dose of their vaccination series, 67 (5%). Of the 650 (50%) unvaccinated parents, 184 (28%) were vaccine acceptors, while 238 (37%) were "very unlikely" to be vaccinated. In children ≥ 12 years, 112 (27%) were already vaccinated. In children < 12 years, two children were already vaccinated, and 242 (28%) of parents stated they were "very likely" to have their child vaccinated. Vaccine hesitancy and other parental and child characteristics are reported in Table 1 .

The greatest differences in vaccination rates based on demographic characteristics were among parents aged 18-34 years (37%, 95% CI 33-41) versus those aged ≥ 45 years (74%, 95% CI 68-80) and Black (39%, 95% CI 42-51%) versus non-Black parents (58%, 95% CI 54-61%). With respect to socioeconomic characteristics, the greatest disparities in vaccinations rates were in parents with an annual income <$25,000 (35%, 95% CI 30-40%) versus those earning ≥$75,000 (75%, 95% CI 70-80%) and those with an education level ≤ high school graduate (36%, 95% CI 32-40%) versus parents who received a college degree (72%, 95% CI 68-77%) ( Table 2) .

Prior influenza vaccination status of parents was also associated with current COVID-19 vaccination, with those being vaccinated for influenza in the past two years being more likely to be vaccinated against COVID-19 (63%) compared to those who had not recently received an influenza vaccination (29%). Having a friend or family member hospitalized due to COVID-19 was also associated with increased parental COVID-19 vaccination rates. The greatest effect on COVID-19 vaccination status was in parents who had multiple friends/family members hospitalized due to COVID-19 (Table   2 ).

In our Kruskal-Wallace analysis, parents vaccinated against COVID-19 reported a higher median level of agreement with the statement "Children infected with COVID-19 can infect others" compared to vaccine hesitant parents. Vaccinated parents also reported a higher level of trust in the information from scientists about the safety of COVID-19 vaccines when compared to vaccine hesitant parents. Median agreement with trusting the media about the safety of COVID-19 vaccines was low in all groups, but still differed between vaccinated versus vaccine hesitant parents ( Table 2) .

Tables 3 and 4 present the reasons parents gave for their hesitancy in accepting the COVID-19 vaccine for themselves and for their children. For both, the most common reasons were concern about the long-term effects/safety of the vaccine, a desire to see what happens to vaccinated adults/children before considering it, and concerns about the short-term effects/safety of the vaccine. Two items, not believing that the vaccine will work and religious beliefs, ranked higher in parents who were "unlikely" or "very unlikely" to accept the vaccine for either themselves or their children when compared to those who reported themselves as being ambivalent.

Characteristics most highly associated with adult COVID-19 vaccination included a high degree of trust in scientists, receipt of influenza vaccination in the past 2 years, and attainment of a college degree (Table 5) . Characteristics independently associated with COVID-19 vaccination in children or rated by parents as "very likely" to accept vaccination in children aged < 12 years are found in Table 6 . The characteristic most highly associated with pediatric COVID-19 vaccination was parental high level of trust in scientists about the safety of the vaccine (OR 5.37, 95% CI 3.65-7.88).

Characteristics associated with pediatric COVID-19 vaccination was further examined based on eligibility for the vaccine. In children ≥ 12 years (vaccine eligible), COVID-19 vaccination was most highly associated with a parental belief (rated ≥7) that J o u r n a l P r e -p r o o f children infected with COVID-19 can infect others (OR 4.12, 95% CI 1. 17-14.48 ). In children < 12 years, this belief was not associated with a parental report of being "very likely" to vaccinate their child. Rather, a high level of parental trust in the information from scientists was mostly highly associated with a parental report of being "very likely" to pursue COVID-19 vaccination in their child (OR 7.79, 95% CI 4.74 -12.75) (Web Appendix 2).

As with all survey studies, our results may have been biased by refusals to participate, recall bias, and social desirability in self-reported behaviors. Those who refused participation may have been less interested or even against COVID-19 vaccination, and thus, less likely to engage with research staff. We attempted to mitigate this and response bias by using scripted recruitment and neutrally worded descriptions and study items in our survey. Our results pertaining to adults may not be representative of the general US adult population, since we only enrolled parents of children aged 3-16 years presenting to an ED. As such, most of our study participants were mothers, so we may not have had sufficient men in our sample to demonstrate differences in vaccine acceptance between the two sexes. Additionally, since all sites were urban, pediatric EDs, affiliated with academic centers, our findings may not accurately reflect parental perceptions or vaccine receptiveness prevalent in more rural settings. Our inclusion of children not yet eligible for vaccination in our multivariable analyses may have resulted in reporting bias. We hoped to mitigate this effect by only including children parents deemed "very likely" to be vaccinated, as opposed to including all vaccine acceptors, and by performing our sensitivity analyses. Finally, we enrolled during the summer 2021 period of the Delta variant surge, just prior to the return to school. As such, parental responses may have been influenced by news and personal events surrounding the surge and may not truly reflect their long-term views.

Nevertheless, we believe our use of pediatric EDs for in-person enrollment was an improvement over random telephone or internet-based survey methods commonly found in the extant literature. 10, 15, [27] [28] [29] [30] [31] [32] Given that most of our sites are in inner cities J o u r n a l P r e -p r o o f and/or serve as referral sites for outlying rural areas, this likely contributed towards our findings' generalizability.

To assess parental COVID-19 vaccine hesitancy in a diverse, potentially vulnerable population, we conducted this cross-sectional study in a true, safety net health care setting. Two thirds of our participants were Black or Hispanic and nearly a third had an income of < $25,000. We had the following principal findings Our parental vaccination rate of 50% (at least one dose of vaccine) was slightly less than US vaccination rates of 52-58%, documented for early Juneearly August, 2021. 12 We believe this discrepancy is mainly due to our high percentage of African American participants, the majority of whom were not vaccinated. Concerns about the long-term effects and safety of the COVID-19 vaccine were listed the most frequently by vaccine hesitant parents. When we examined reasons why parents and their children were not vaccinated, the factor with the greatest discrepancy between parents who were ambivalent compared to those who were unlikely to vaccinate was not believing the COVID-19 vaccine will work. To address these misconceptions, some have called for public education campaigns directed at populations with low vaccine rates. Yet, in isolation, these efforts may not suffice. [33] [34] [35] Belief in whether the vaccine will work may be grounded in trust in the scientific community, a factor we found to be highly Other than the two who were already vaccinated, only 28% of parents were "very likely"

to have their children vaccinated once eligible and 56% were vaccine hesitant. Vaccine acceptance in our sample was lower than in prior, international studies where 60-65% of parents reported an intention to vaccinate their children. 25, [37] [38] [39] Our multivariable logistic regression findings differed from prior studies with respect to factors and characteristics associated with COVID-19 vaccination in adults. In our analysis, sex, race, and ethnicity were no longer associated with vaccination due to the inclusion of our "trust" variables. For parents, vaccine acceptance was most highly associated with trust in scientists about vaccine safety. Many early studies examined demographics and prior vaccination status but not perceptions or beliefs. Like these earlier studies, we also demonstrated that recent influenza vaccination, increasing parental age, increasing annual income levels, as well as receipt of a college degree are associated with COVID-19 vaccination in adults. 15, 25, [29] [30] [31] With respect to characteristics associated with vaccination of children (or high [41] [42] [43] Consistent messaging by public officials, including physicians, where personal actions mirror official policies (mask-wearing, acceptance of vaccination, and compliance with social distancing policies), must also occur to gain and maintain trust from the community. Finally, input and support from other community leaders, such as clergy, business leaders and community activists should also be considered, as these individuals have already established a level of trust that may be difficult to achieve by outsiders in a timely manner during a pandemic. The above, when coupled with efforts to make vaccination accessible and affordable to targeted populations, including EDbased COVID-19 vaccination, should help increase public trust and acceptance of COVID-19 vaccines. 22, [40] [41] [42] [43] In summary, we demonstrated that COVID-19 vaccine acceptance remains Adult or child ≥ 12 years of age who has received a full vaccination series or at least 1 dose of a COVID-19 vaccine Unvaccinated: Adult or child who has not received any COVID-19 vaccine

Vaccine acceptor: Adult who reports that they are "likely" or "very likely" to get a COVID-19 vaccine for themselves or their child Vaccine hesitant:

Adult who reports being "Neither likely or unlikely", "unlikely" or "very unlikely" of receiving any COVID-19 vaccine for either themselves or their child Ambivalent: Selection of "Neither likely or unlikely" with respect to receipt of a COVID-19 vaccine for either adults or children IQR, interquartile range, SCD, Sickle Cell Disease; G6PD, Glucose-6-phosphate-dehydrogenase deficiency a Vaccinated is defined as being fully immunized or receiving 1 of 2 injections of a 2 series vaccine 

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Children infected with COVID-19 can infect others. c 10 (9-10) (0-10) 10 (10-10) 10 (8.75-10) 10 (7-10) I trust the information from scientists about the safety of the COVID-19 vaccines. c 6 (4-10) (0-10) 9 (6-10) 6 (4-10) 4 (1-5) I trust the information from the media (TV/news) about the safety of the COVID-19 vaccines. c 4 (0-6) (0-10) 5 (3-8) 5 (2-7) 2 (0-5) a Not vaccinated; but likely or very likely to get immunized b Neither likely or unlikely; unlikely or very unlikely to get vaccinated c Kruskall-Wallace testing resulted in significant differences for all three items, infectivity, trust in scientists and trust in the media (p < .0001)