key: cord-0845773-z5h6bi6m
authors: Rogers, Adam A.; Cook, Rachel E.; Button, Julie A.
title: Parent and Peer Norms are Unique Correlates of COVID-19 Vaccine Intentions in a Diverse Sample of US Adolescents
date: 2021-09-23
journal: J Adolesc Health
DOI: 10.1016/j.jadohealth.2021.09.012
sha: afb81951b33c0e0bb56f4441480157038592db30
doc_id: 845773
cord_uid: z5h6bi6m

PURPOSE: Recent studies have documented worrisome levels of hesitancy and resistance to the COVID-19 vaccine, including within the adolescent population. In this study, we examined attitudinal (perceived severity of COVID-19, vaccine-related concerns) and interpersonal (parent and peer norms) antecedents of adolescents’ intentions to receive the COVID-19 vaccine. METHODS: Participants were 916 adolescents (ages 12 – 17) from across the United States (47.3% male) representing diverse ethnic and socioeconomic backgrounds (26% African American, 22% Hispanic/Latinx; 35% White; 7% Asian American). They completed a survey on their experiences and attitudes surrounding COVID-19 and the COVID-19 vaccine. RESULTS: Parent and peer norms were distinct predictors of adolescent willingness to receive the vaccine. These norms were associated with vaccine intentions directly, as well as indirectly through adolescents’ beliefs about the vaccine’s safety, efficacy, and necessity. Parent norms in particular displayed large effect sizes and explained considerable variance in adolescents’ vaccine intentions. CONCLUSIONS: Parents and friends – who figure as adolescents’ most salient interpersonal relationships – are key leveraging points in promoting adolescents’ uptake of the COVID-19 vaccine. Norm interventions and family-based interventions may be successful in this regard.

Public scrutiny of the COVID-19 vaccine has resulted in 20 many obstacles to its uptake, and vaccine hesitancy is a reality for many adolescents. Parent and 21

peer vaccination norms explain unique and considerable variance in adolescents' intentions to 22

receive the COVID-19 vaccine. These relationships are leverage points for intervention. adolescents is critical to ensure their safety from the virus and slow its overall spread, 5 particularly in the midst of rapidly emerging and highly-infectious variants (e.g., Delta) 1 . 6 However, given the heightened public scrutiny of the COVID-19 vaccine, there are considerable 7 attitudinal and social apprehensions, and pediatricians may find vaccine hesitancy to be a 8 challenge to vaccine uptake in this population. Guided by the Health Belief Model 2 , this study 9 identified the unique attitudinal and interpersonal antecedents of adolescents' COVID- 19 10 vaccination intentions, including their direct and indirect pathways of association. 11

The Health Belief Model (HBM) 2 and supporting literature 3, 4 hold that the most proximal 13 determinants of an individual's uptake of a vaccine include (a) their perceived severity of and 14 susceptibility to the disease, alongside (b) their perceived benefits and/or risks of receiving the 15 vaccine. Adolescents report various perceptions and anxieties regarding the severity of COVID-16 19 and its impact on their lives, including worries about their health, changes in their peer 17 networks and family dynamics, increased economic difficulties for their parents, and academic 18 difficulties 6 . These perceived impacts might motivate greater vaccine uptake. However, a 19 significant portion of adolescents have also reported hesitancy or resistance to the COVID-19 20 promote more willingness to be vaccinated, whereas harboring concerns about the vaccine's 1 safety or necessity would undermine such motivations. 2

Although these attitudinal considerations are viewed as proximal determinants of vaccine 3 uptake, scholars have observed that vaccine-related attitudes and beliefs are socially derived 4 phenomena 3 , and that the adoption of medical innovations like vaccines must diffuse through 5 social systems 5 . Therefore, adolescents' attitudes toward COVID-19 and vaccination represent 6 shared interpersonal understandings that constitute "localized vaccine cultures 3 ", and these shape 7 the transmission of vaccine willingness as a social process. As such, social messaging about the 8 and severity of COVID-19, COVID-19-related anxiety, vaccine-related concerns, and  3 parent and peer norms were unique predictors of vaccination intentions. We also examined if 4 these processes were moderated by age, gender, and ethnic identity. Finally, because social 5 factors give rise to vaccine-related attitudes 3,4 , we examined whether vaccine-related concerns 6 mediated the relations between parent and friend vaccination norms and adolescents' intention to 7 be vaccinated. In all analyses, we controlled for adolescent age, gender identity, household 8 income, parent education, and race/ethnicity. 9

Between 10 June and 24 June 2021, participants were recruited from a third-party 12 research service, Qualtrics, which retains a national database of research participants gathered 13 through various digital advertising channels (e.g., social media, search engines) and address-14 based sampling methods (e.g., mailing lists). A stratified random sample of adolescents was 15 drawn from this database, using national quotas for adolescent age, gender, parent income, and 16 U.S. geographic region (south, west, midwest, northeast). We oversampled ethnic minority 17 adolescents to ensure adequate statistical representation of ethnic groups. Participants had to be 18 between 12 and 17 years of age to participate. Just over 1,200 adolescents were contacted 19 through an online survey platform. A description of the study was provided, and adolescents and 20 their parent/caregiver were required to provide assent and consent (respectively). In total, 928 21 families consented, with 916 adolescents completing the questionnaire (response rate of 74.9%). 22

The survey asked about their experiences and attitudes surrounding COVID-19 and the COVID-23 

Adolescents reported their degree of concern about the 22 COVID-19 vaccines on eight items. These items reflected two themes identified in recent work 23 on adults' 11 and adolescents' 7 vaccination concerns: worry about safety and efficacy and doubts 1 about its necessity. All items were rated on a 5-point scale (1 = not at all true of me; 5 = very 2 true of me). An exploratory factor analysis was estimated (principal axis factoring) using an 3 oblique rotation (promax) to verify this dimensionality (items and factor loadings in Table S1 in 4 online supplemental material). We used an oblique rotation because we anticipated covariance 5 between these vaccine-related concerns. The safety and efficacy subscale included five items, 6 averaged (e.g., "I worry that there are negative side effects from the vaccine"). The necessity 7 subscale included three items, averaged (e.g., "I think COVID-19 is pretty mild, so I don't need a 8 vaccine). Higher scores on each reflected greater endorsement of said concern; αsafety = .83 ; 9 αnecessity = .82. 10

parents' and friends' receipt of the COVID-19 vaccines. They completed a single item indicating 12 descriptive friend norms, "How many of your close friends do you think will get a COVID- 19 13 vaccine?" (1 = none of them, 5 = almost all of them); and a single item assessing friend 14 injunctive norms, "How many of your friends believe that other people should get vaccinated for 15 COVID-19?" (1 = none of them, 5 = almost all of them). These items were highly correlated (r = 16

.78, p < .001) and averaged for an overall friend norms score, higher scores indicating greater 17 perceived support for vaccination among one's friends. 18

Parents' descriptive norms were assessed with one item for each parent, e.g., "Does your 19

[mother-/father-] figure plan on getting vaccinated for COVID-19?" (1 = no, 2 = maybe, 3 = 20 yes/already vaccinated). Injunctive norms were assessed with a single item, "Do your parents 21 generally believe that others should get vaccinated for COVID-19?" (1 = not at all, 5 = yes, very 22 much). These three items were highly correlated (rs ranging from .67 to .83, ps < .001), so were 23 combined for an overall parental norms score. Higher scores indicated greater perceived support 1 for the COVID-19 vaccine by one's parents. 2

Sociodemographics. Participants reported their age, gender identity (male, female, 3 transgender, non-binary), and racial-ethnic identity (African American, Asian American, 4

Hispanic/Latinx, White, American Indian or Alaska Native, Pacific Islander, Other, or 5

Mixed/Biracial). For analysis, gender identity was dummy coded for female (1 = female, 0 = 6 other) and non-binary identities (1 = non-binary, 0 = other), with male as the reference category. 7

Transgender adolescents were included with the gender category with which they identified. 8

Dummy codes were also created for ethnic identity, with white as the reference category: African 9

American, Hispanic/Latinx, Asian American, and Other (American Indian, Pacific Islander, 10

Other, and Mixed/Biracial) ethnicities. They also reported their primary caregiver's highest level 11 of formal education (1 = no formal education, 2 = less than high school, 3 = high school/GED, 4 J o u r n a l P r e -p r o o f regression was favored for its practicality and straightforward interpretations. Missing data was 1 minimal (< 1% across all cases), so the default for listwise deletion was used. In Step 1 of the 2 model, we included socio-demographic variables, including age, gender identity, parent income, 3 mother's education, and racial-ethnic identity. In Step 2, we added COVID-19 impact, including 4 COVID-19 diagnosis, underlying health risks, school format, and income reduction. In Step 3, 5 we added COVID-19-related anxiety as an index of internalized threat of COVID-19. In step 4, 6

we added vaccine-related concerns, including concerns about the safety and efficacy of the 7 COVID-19 vaccine and doubts about its necessity. Finally, in Step 5, we included parent and 8 friend vaccination norms. We then examined whether parent and peer norms were moderated by 9 age, gender, or ethnic identity. Table 1 for sample characteristics; see Table S2 of online supplemental 19 material for vaccination intentions by sample characteristics). 20 Table 2 displays response proportions of vaccination intentions and means on the eight 22 vaccine concern items. At the time of data collection, approximately half the sample was either 23 vaccine-hesitant (responded "maybe"; 26.4%) or vaccine-resistant (responded "no"; 23.1%). The 1 most common concerns were regarding the vaccine's perceived safety. average levels of perceived friend and parent support for the vaccines (vaccination norms). They 4 also reported moderate levels of concern regarding the vaccines' safety and efficacy, low 5 concern about their necessity, and low COVID-related anxiety. Table 4 presents zero-order 6 correlations. Vaccination intentions were related to all continuous study variables in the expected 7 directions. 8

We then conducted sensitivity analysis comparing adolescents who intended versus did 9 not intend to get the COVID-19 vaccine (independent samples t-tests; see Table 3 ). Those who 10 intended to receive a COVID-19 vaccine (or who already received one) reported higher annual 11 household income, higher parent education, and more COVID-related anxiety than those who did 12 not intend to receive the vaccine, all with moderate effect sizes. They also reported fewer 13 concerns about the vaccines, with large effect sizes. Finally, they reported higher vaccination 14 norms among friends and parents, again with a large effect size. 15 Table 5 displays results of the regression analysis. In Step 1, age was positively 17 associated with vaccination intentions, indicating that older adolescents had a slightly greater 18 intention to be vaccinated than younger adolescents. Gender identity dummy codes were 19 unassociated with vaccination intentions, indicating similar levels of vaccine willingness among 20 boys, girls, and non-binary adolescents. Parent education and household income were also 21 positively associated with vaccination intention. Adolescents whose primary caregivers had more 22 education and who earned higher income had greater intentions to be vaccinated. The dummy 23 codes for Asian American and Latinx adolescents were significant and positive. Compared to 1 their white counterparts, Asian American and Latinx youth expressed greater willingness to be 2 vaccinated. The dummy codes for African American and "Other" (e.g., American Indian, Pacific We then tested whether relations between parent and friend norms and vaccine intentions 3 were moderated by age, gender identity, and ethnic identity. We included all two-way 4

interactions (e.g., parent norms-by-age, parent norms-by gender, parent norms-by-ethnicity 5 dummy codes; friend norms-by-age, friend norms by gender, friend norms by ethnicity dummy 6 codes). None of these were statistically significant (p values ranged from .135 to .993), and so 7 for brevity they are not displayed. 8

Finally, we examined evidence that vaccine-related concerns might mediate the 10 association between interpersonal norms and vaccination intentions. A path model was estimated 11 in which parent and friend norms predicted vaccine concerns for safety and efficacy, as well as 12 necessity, which in-turn predicted vaccination intentions. In the final models, parent norms were Discussion 20

Adolescents are now a focus in the COVID-19 vaccination effort, but little is known 21 about the antecedents of their intentions to be vaccinated. We examined attitudinal and 22

interpersonal antecedents of adolescents' intentions to receive a COVID-19 vaccine, including 23 the direct and indirect pathways characterizing these associations. Specifically, we examined the 1 impact and perceived threat of the pandemic, concerns about the vaccine's safety and necessity, 2 and parent and peer norms surrounding the vaccine. 3 We were somewhat surprised that adolescents who were more adversely impacted by 4 COVID-19, such as those who were continuing to attend online classes, or whose families saw 5 reduced income, were not more willing to receive the vaccine than their less-impacted 6 counterparts. Although one may reasonably surmise that more impacted youth might favor 7 vaccination, our data indicated that the more important factor was their subjective and 8

internalized degree of anxiety about COVID-19. Despite low mean levels of COVID-19 anxiety, 9

it remained a unique predictor of adolescents' vaccine willingness. These findings might suggest 10 that efforts to promote the vaccination are unlikely to prove successful if they primarily 11 emphasize a return to normalcy (e.g., more in-person socialization). Even after considering indirect effects through vaccine-related concerns, parent and peer 22 norms still explained substantial variance as a direct effect of their own. Many adolescent health 23 behaviors are shaped by similar social processes 9 , and so the perceived behavior of others 1 surrounding the COVID-19 vaccine represents a key mechanism through which COVID- 19 2 vaccine adoption might diffuse through adolescent networks. Importantly, we found that these 3 processes were not moderated by adolescents' age, gender, or ethnic identity. The pandemic has 4 disproportionately affected youth from various demographics (particularly youth of color) 13 , so 5 while some pathways to vaccination will likely differ for youth from diverse backgrounds, our 6 findings indicate that the effectiveness of interpersonal norms cuts across the adolescent 7 population with relative uniformity. This makes sense as needs for relatedness and social 8 belonging are universal 14 . As such, this finding underscores the practicality and potential efficacy 9 of norm-based interventions on adolescent vaccine uptake. Although there are existing 10 interventions to increase adolescents' adoption of other vaccines (e.g., HPV, influenza, 11

MenACWY), the unique scrutiny around the COVID-19 vaccines likely warrants unique 12 intervention strategies. 13

Finally, we note that the effect size of parent norms was large. While peers are often seen 14 as a predominant influence in adolescence 15 , most adolescents still trust parents more than any 15 other source when it comes to large and significant life decisions 16 . Furthermore, age of consent 16 for vaccines varies from state to state, and so parents are sometimes the final say in their child's 17 vaccination. Implied is that the success of adolescent vaccination efforts will hinge largely on the 18 attitudes and behaviors of parents, a pattern that bears out in studies on various other vaccines 19 (e.g., STI, influenza, HPV) 17, 18, 19 . Efforts to promote vaccination among youth must consider 20 this family context and find ways to address parental concerns and persuade parents themselves 21 to be vaccinated. 22

The data were cross-sectional. Although results mapped onto theory and extant literature 1 in the expected ways 3 , longitudinal data are needed to verify hypothesized directions, particularly 2 in the mediation models. Furthermore, the situation with COVID-19 has proven to evolve 3 rapidly. While our findings might be useful for pediatricians and other practitioners, research 4

should continue tracking these processes as they unfold over the coming months. For example, 5 full FDA approval of the COVID-19 vaccines might change safety and efficacy perceptions, and 6 norms may shift in response. 7

The COVID-19 vaccines are vital for protecting adolescents from the virus, and may 9 require regular and repeated administration (e.g., booster shots) in the coming months and years. 10

Our study shows that parents' and friends' COVID-19 vaccination norms are likely to be 11 uniquely influential over adolescents' willingness to get vaccinated themselves. Adolescents ' 12 perceived social norms may also operate in part by generating specific concerns about the 13 vaccine. Norm-based interventions may prove successful in promoting higher vaccination rates 14 in this population. 15 Note. Vaccine concern items were scored on a 5-point rating scale (1 = not at all true of me; 5 = very true of me).

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Concern: Safety -.47*** -.47*** -.41***

Concern: Necessity -.49*** -.49 *** -.38*** .52***

COVID Anxiety .22*** .23*** .14** .11** -.09**