Factors influencing COVID-19 vaccination intention among parents of children aged 5-11 years in South Korea: a cross-sectional study

Article information

Child Health Nurs Res. 2023;29(3):237-247

Publication date (electronic) : 2023 July 31

doi : https://doi.org/10.4094/chnr.2023.29.3.237

Jung Hwa Kang¹, Yunsoo Kim^,2

¹Graduate Student, Department of Nursing, Catholic Kwandong University College of Medicine, Gangneung, Korea

²Assistant Professor, Department of Nursing, Catholic Kwandong University College of Medicine, Gangneung, Korea

Corresponding author Yunsoo Kim Department of Nursing, Catholic Kwandong University College of Medicine, 24 Beomil-ro, 579 Beon-gil, Gangneung 25601, Korea TEL: +82-33-649-7614 FAX: +82-33-649-7620 E-MAIL: agneskim4320@gmail.com

This article was adapted from a thesis by Jung Hwa Kang in partial fulfillment of the requirements for the master's degree at Catholic Kwandong University.

Received 2023 June 19; Revised 2023 July 14; Accepted 2023 July 15.

Abstract

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) originated in China in December 2019 and then caused the coronavirus disease 2019 (COVID-19) pandemic [1]. According to the Korea Disease Control and Prevention Agency (KDCA), from the first case of COVID-19 in Korea on January 20, 2020 to June 5, 2023, the cumulative number of confirmed cases of COVID-19 was 31,789,625 and the cumulative number of deaths was 34,827. Children and adolescents aged 19 years or younger accounted for 7,099,665 (22.3%) of these confirmed cases, specifically 3,155,000 (9.9%) children aged 0-9 years and 3,944,665 (12.4%) adolescents aged 10-19 years [2].

South Korea initiated COVID-19 vaccinations for 12- to 17-year-old in October 2021 to curb infection rates in adolescents [3]. Initially, it was observed that children aged between 5 and 11 years tended to experience asymptomatic infections and a lower rate of severe cases when infected with COVID-19. However, with the emergence and predominance of the Omicron variant, the infection rate has risen substantially in the 5- to 11-year-old group, which was previously ineligible for vaccination. Moreover, serious consequences such as death and multisystem inflammatory syndrome in children have been reported among pediatric patients with severe COVID-19 [3]. Consequently, South Korea began administering COVID-19 vaccines to children aged 5-11 years on March 31, 2022 [4]. High-risk children with underlying medical conditions, such as pediatric diabetes, obesity, and chronic lung disease, are more likely than healthy children to become severely ill with COVID-19, so the KDCA has recommended aggressive vaccination. For healthy children, information about the effectiveness and safety of the vaccines was provided so that parents could make an autonomous decision about vaccination [4]. However, as of June 5, 2023, only 33,387 Korean children aged 5-11 years had received COVID-19 vaccination, representing a mere 1.1% of the demographic [5]. In contrast, in the United States, 32.9% of children aged 5-11 years had received their primary COVID-19 vaccination, with an additional 4.8% having also received a COVID-19 booster shot [6].

Vaccination is one of the most effective tools among many ways to prevent pandemics [7]. Vaccination against COVID -19 prevents both symptomatic and asymptomatic infections, reduces severity and hospitalization rates among people with COVID-19, and reduces mortality [8]. Children aged 5-11 years, who often gather in groups at daycare centers and elementary schools and who may be less consistent about personal hygiene, are highly susceptible to infectious diseases. Until reaching middle-school age, children typically rely on their parents for health management. As such, vaccinating 5- to 11-year-old against COVID-19 is expected to play a crucial role in decreasing the virus's incidence among this high-risk group. This strategy will also reduce the severity and mortality of COVID-19 in infected children. The Centers for Disease Control and Prevention reported that children in the United States aged 5-11 years who were not vaccinated against COVID-19 were 1.5 times more likely to be hospitalized than those who were vaccinated [9]. A second dose of the COVID -19 vaccine also prevented 84% of pediatric multisystem inflammatory syndrome infections in children aged 5 to 18 years in the United States [10]. However, most children ages 5-11 cannot make the decision to get a COVID-19 vaccine on their own. Parents play a pivotal role in their children's vaccination process, often being the most influential figures in executing such healthcare decisions [11]. Therefore, to understand the low COVID-19 vaccination rates among children aged 5-11 years, it is important to understand parental intentions to vaccinate their children against COVID-19.

Ajzen's theory of planned behavior (TPB), an extension of the theory of reasoned action, posits three determinants of behavioral intention: attitude toward the behavior, subjective norms, and perceived behavioral control [12]. Attitudes, subjective norms, and perceived behavioral control each influence each other and also affect the intention to act, and intention directly affects behavior. Previous research has demonstrated the utility of the TPB in predicting and elucidating specific health behaviors. Notably, the TPB has been used for studies investigating motivations and influencing factors in carrying out vaccinations, including those for human papillomavirus (HPV) and influenza [13,14]. Most studies using the TPB to understand COVID-19 vaccination intentions have focused primarily on adults [15,16]. Investigations into COVID-19 vaccinations for children have largely concentrated on discerning parents' intentions regarding vaccinating their children [17-20]. While previous studies have utilized the TPB to analyze parents' intentions to vaccinate their children against COVID-19 [18,19], these studies targeted parents with offspring younger than 18 and 13 years, respectively, and did not specifically focus on the age group of 5-11 years. Research has been conducted on factors influencing elementary school children's COVID-19 vaccination intentions based on the health belief model [20]. However, other studies [19,21] have found that the TPB is more suitable for predicting COVID-19 vaccination intention than the health belief model, and there is a need for a Korean study to identify, using the TPB, factors affecting parents' intention to vaccinate their children against COVID-19.

We have witnessed a compression of pandemic cycles in the 21st century, with sporadic outbreaks ranging from severe acute respiratory syndrome (SARS) in 2002, to influenza A (H1N1 virus) in 2009, Middle East respiratory syndrome coronavirus (MERS-CoV) in 2015, and most recently, COVID-19 in December 2019 [22]. It is crucial to understand the factors affecting parents' choices regarding COVID-19 vaccinations for their 5- to 11-year-old children. Thus, utilizing TPB as a framework, this study sought to identify the principal variables related to parents' intentions to have their 5- to 11-year-old children vaccinated against COVID-19. The goal was to pinpoint the factors that influence these parental decisions. In doing so, the study aimed to provide primary data to inform nursing practices and strategize responses, not only for COVID-19 but also for potential future pandemics.

METHODS

1. Study Design

This cross-sectional, descriptive research study used TPB to investigate factors influencing the intentions of parents to have their children aged 5-11 years vaccinated against COVID -19. Figure 1 shows the theoretical framework. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines [23].

Figure 1.

Framework for studying the factors that influence COVID-19 vaccination intention among parents of children aged 5–11 years.

RESULTS

1. Whether Parents Knew that Their Children Were Eligible to Have a COVID-19 Vaccine

There were 177 (59.4%) parents who were aware that their child was able to have a COVID-19 vaccine, compared to 121 (40.6%) who were unaware. Of the 177 parents who were aware that their child was eligible to receive a COVID-19 vaccine, internet and social network services constituted the most common media pathway through which they became aware of this information, with 130 (73.4%) responses to this multiple-choice question. When parents who knew their child was eligible for COVID-19 vaccination were asked in a multiple-response item why their child had not yet been vaccinated, 143 (80.8%) reported that the reason was concerns about side effects and adverse events (Table 1).

Table 1.

Whether Parents Knew that Their Children Were Eligible to Have a COVID-19 Vaccine (N=298)

2. Parents' Attitudes, Subjective Norms, and Perceived Behavioral Control about Having Their Children Vaccinated Against COVID-19

The itemized scores of parents' attitudes, subjective norms, perceived behavioral control, and intention to vaccinate their children against COVID-19 are shown in Table 2.

Table 2.

Parental Attitudes, Subjective Norms, Perceived Behavioral Control, and Intentions to Vaccinate Their Children Against COVID-19 by Items (N=298)

The mean score for parental attitudes toward having their child vaccinated against COVID-19 was 3.26 out of 7, and that for subjective norms was 3.31 out of 7. Parents' perceived behavioral control over their child's COVID-19 vaccination had a mean score of 3.19±1.25 out of 7, and the mean score for parents' intention to have their child vaccinated was 2.96 out of 7. These findings show that the participants' attitudes, subjective norms, perceived behavioral control, and intention to have their children vaccinated against COVID-19 were all lower than moderate.

3. Differences in Intention to Arrange COVID-19 Vaccination for Children According to Participants' General and COVID-19-related Characteristics

Table 3 shows the differences in vaccination intention for children according to participants' general and COVID-19-related characteristics.

Table 3.

Comparison of Parents' Intentions to Vaccinate Their Children against COVID-19 by General and COVID-19-Related Characteristics (N=298)

Vaccination intention showed a significant difference according to participants' educational level, with those holding a high-school diploma or lower more likely to express intent (4.02±1.66 points) (F=7.60, p=.001). Employed participants (3.15±1.58 points) were significantly more likely to intend to vaccinate their children than unemployed participants (2.40± 1.82 points) (t=3.13, p=.002). A significant difference in intent was also found according to monthly income (F=4.18, p=.003). However, there was no significant difference according to participants' age, sex, religion, or number of children. A stronger intent to vaccinate children was significantly associated with having received only one COVID-19 vaccine (F=5.29, p=.006), not experiencing side effects post-vaccination (t=-4.33, p<.001), having no prior COVID-19 infection (t=-3.95, p< .001), and being unaware of the availability of COVID-19 vaccines for children (t=-7.24, p<.001). Participants whose children had not been infected with COVID-19 had a significantly stronger intent to vaccinate their children (3.26±1.72 points) than those whose children had been infected (2.38±1.41 points).

4. Factors Influencing the Intention of Participants to Arrange COVID-19 Vaccination for Their Children

Table 4 shows the results of the hierarchical regression analysis to identify the factors influencing participants' intentions to arrange COVID-19 vaccination for their children.

Table 4.

Factors Influencing COVID-19 Vaccination Intention among Parents

Among the general characteristics of the participants, significant differences in vaccination intention were found according to educational background and monthly income. The COVID-19-related characteristics that showed significant associations were the number of COVID-19 vaccinations, the presence or absence of side effects, presence or absence of a confirmed infection, the presence or absence of a confirmed infection in children, and awareness that children can be vaccinated against COVID-19. Hierarchical regression analysis was performed with those variables included as independent variables and vaccination intention as the dependent variable. Nominal variables such as educational level, monthly income, number of vaccinations, side effects, the presence of a confirmed infection in children, and awareness of whether children could receive COVID-19 vaccination were treated as dummy variables and analyzed.

Before conducting the regression analysis to identify factors influencing vaccination intention, the tolerance limits and variance inflation factor (VIF) were reviewed to confirm the absence of multicollinearity. The tolerance limits ranged from 0.25 to 0.98 (i.e., within the recommended range from 0.1 to 1.0), and the VIF ranged from 1.02 to 3.97 (i.e., not exceeding 10), so there was no problem with multicollinearity. The Durbin-Watson test value was 1.84 (i.e., close to 2), indicating that there was no problem with autocorrelation.

In model Ⅰ, the general and COVID-19-related variables were included as control variables as factors potentially influencing vaccination intention. Model I showed an explanatory power of 31%. In model II, variables of the theory of deliberate action, such as attitude, subjective norm, and perceived behavioral control, were added to model I, and the regression analysis showed significant results for perceived behavioral control (β=.40, p<.001), attitude (β=.37, p<.001), and subjective norms (β=.20, p<.001). A significant result was also found for unawareness that children could be vaccinated against COVID-19 (β=.07, p=.016). Model Ⅱ had a 58% increase in explanatory power over model I; thus, overall the model had 89% explanatory power (F=144.87, p<.001).

DISCUSSION

This study aimed to identify the factors influencing parents' intentions to vaccinate their children aged 5-11 years against COVID-19 through a TPB-based analysis. The goal was to provide primary data to improve the pediatric COVID-19 vaccination rate.

The study found that parents' attitudes, subjective norms, and perceived behavioral control towards their children's COVID-19 vaccination were significantly influential factors. These factors accounted for 89% of the explained variance in vaccination intention. These results are consistent with the study of Zhang et al. [18], which found that parental attitudes, subjective norms, and perceived behavioral control affected children's COVID-19 vaccination intentions. Similarly, Li et al. [19] showed that attitudes and subjective norms had significant effect on vaccination intentions, with an explanatory power of 73.9%. The findings of Zhou et al. [26] are also partially consistent with the current study.

In this study, perceived behavioral control had the strongest influence on parental vaccination intention. A study by Zhou et al. [26] also reported that perceived behavioral control, rather than attitudes, had a higher effect on parents' intention to vaccinate their children. However, the study participants scored below the midpoint (3.19 out of 7 points) on perceived behavioral control, which indicates the perceived ease or difficulty of vaccination. To improve this, it would be necessary to address difficulties that parents may encounter when planning to vaccinate their children against COVID-19. Simplifying the vaccination scheduling procedure, improving access to vaccines, and preparing parental leave systems nationally could contribute to this effort. However, this study did not identify the actual factors that affected parents' perceived behavioral control for having their children vaccinated against COVID-19. Therefore, follow-up studies are needed in the future.

The study found that participants' attitudes towards COVID -19 vaccination were the second most influential factor on vaccination intention. A previous study [19] has identified parental attitudes toward having their children vaccinated against COVID-19 as the most significant factor affecting parents' intentions to have their children vaccinated against COVID-19. However, the attitude score was also lower than the midpoint(3.26 out of 7 points), indicating the need for ongoing education on the scientifically proven benefits of COVID-19 vaccination.

Subjective norms were the third most influential among the factors examined. No previous studies identified subjective norms as affecting the intention to receive the COVID-19 vaccine. In a previous study that investigated the intention of mothers with boys in elementary school to arrange HPV vaccination for their children, it was observed that vaccination intention was affected by the parents' subjective norms regarding vaccination [27], which is consistent with the results of this study. However, the subjective norm score of the current study's participants was 3.31 out of 7 points, lower than the midpoint. To raise subjective norms, ongoing support from family members and society for COVID-19 vaccination is needed. Therefore, accurate information on the importance of pediatric COVID-19 vaccination needs to be disseminated to foster a supportive social atmosphere.

Notably, the intent of the participants to vaccinate their children against COVID-19 was lower than the midpoint (2.96 out of 7 points). Parents have a stronger influence on their children's vaccination status than anyone else in their children's lives, and it is important to understand their intentions to have their children vaccinated against COVID-19. Several previous studies [19,28] have also found that parents' intentions to vaccinate their children against COVID-19 were low. A study in Hong Kong [19] found that parents' intention to vaccinate their children against COVID-19 was 1.55 out of 5, and in the United States, 40.6% of parents with children aged 5-11 years refused to vaccinate their children against COVID-19 [28]. In the present study, of the 177 parents who knew their child was available for a COVID-19 vaccine, 80.8% responded (to a multiple-response item) that they did not vaccinate their child because of adverse events and side effects. In previous studies, a high percentage of parents expressed similar concerns as a primary reason for their low intent to vaccinate their children [29,30].

Parents need to be provided with accurate information about the risks and side effects of COVID-19 vaccination, which is why it is important to communicate scientific and systematic information about COVID-19 vaccines. However, information about COVID-19 can be distorted or biased depending on the method of communication and the type of media used. Interestingly, parents who were aware that children could be vaccinated against COVID-19 had a significantly lower intention to vaccinate, possibly due to inadequate or one-sided information about vaccination campaigns [30,31]. The study also found that awareness of the availability of COVID-19 vaccines for children affected parents' intentions to have their children vaccinated against COVID-19. Parents who were aware of the availability of COVID-19 vaccines for children had lower intentions to have their children vaccinated than those who were not (Table 1). This could have resulted from improperly executed campaigns to encourage COVID-19 vaccination. One-way information and messaging about the COVID-19 vaccine can often create fear or resistance in recipients [30]. In a previous study [30], the intention to have their child vaccinated against COVID-19 was 5.88 out of 10 for parents who received information about COVID-19 vaccines from the internet, compared to 6.21 out of 10 for parents who obtained information about COVID-19 vaccines from non-internet sources. In this study, when asked to provide multiple responses to the media of awareness of the availability of COVID-19 vaccines for children, 74.6% of parents reported that they obtained information about COVID -19 vaccines from the internet and social network services (Table 1). Parents may have been exposed to biased information about COVID-19 vaccines, resulting in lower intentions to have their children vaccinated against COVID-19. Therefore, it is crucial to maintain a reliable single communication system for accurate information delivery and to educate parents to be cautious of unverified information about COVID-19 vaccination on the internet or social media [32].

On May 5, 2023, about 3 years and 4 months after the COVID-19 pandemic was declared, the WHO declared COVID -19 an endemic disease [33]. However, endemicity does not mean the end of SARS-CoV-2, and since it can recur annually like the flu, COVID-19 quarantines and the response of the healthcare system will continue. Based on the factors that this study has identified which affect parents' intentions to vaccinate their children against COVID-19, systematic education about the safety and long-term effects of vaccines should be delivered through a reliable communication system. Such efforts may extend to other types of vaccination and contribute to overcoming future pandemics.

Finally, the sample population of this study may not be fully representative, since its research participants were recruited through online cafes. The results may reflect online communities' group tendencies. Furthermore, due to the limitations of online surveys, there was no way to verify that the respondents actually belonged to the intended study population. Hence, the findings may not be generalizable and should be interpreted with caution.

CONCLUSION

This study used the TPB to analyze the survey responses of 298 parents of children aged 5-11 years across South Korea to identify the factors influencing their vaccination intention regarding COVID-19.

In this study, the COVID-19 vaccination intention of parents of children aged 5-11 years old was investigated using the TPB, and the factors significantly affecting vaccination intention were identified. In the future, to clarify these factors, it is necessary to conduct more research on parents' vaccination intention regarding illnesses other than COVID-19 that affect children. In addition, parents should be provided with a variety of educational opportunities about the vaccines available for their children, and public outreach should be conducted to ensure that accurate information is communicated. In light of parents' significant concerns about vaccine side effects, it is important to continue to provide accurate information about vaccination by establishing a trusted communication system.

Article information Continued