Barriers and facilitators of childhood COVID-19 vaccination among parents: A systematic review

Abstract

Background:

The acceptance of vaccination against COVID-19 among parents of young children plays a significant role in controlling the current pandemic. A wide range of factors that influence vaccine hesitancy in adults has been reported worldwide, but less attention has been given to COVID-19 vaccination among children. Vaccine hesitancy is considered a major challenge in achieving herd immunity, and it is more challenging among parents as they remain deeply concerned about their child’s health. In this context, a systematic review of the current literature is inevitable to assess vaccine hesitancy among parents of young children to ensure a successful ongoing vaccination program.

Method:

A systematic search of peer-reviewed English literature indexed in Google Scholar, PubMed, Embase, and Web of science was performed using developed keywords between 1 January 2020 and August 2022. This systematic review included only those studies that focused on parental concerns about COVID-19 vaccines in children up to 12 years without a diagnosis of COVID-19. Following PRISMA guidelines, a total of 108 studies were included. The quality appraisal of the study was performed by Newcastle–Ottawa Scale (NOS).

Results:

The results of 108 studies depict that vaccine hesitancy rates differed globally with a considerably large number of factors associated with it. The highest vaccine hesitancy rates among parents were reported in a study from the USA (86.1%) and two studies from Saudi Arabia (>85%) and Turkey (89.6%). Conversely, the lowest vaccine hesitancy rates ranging from 0.69 and 2% were found in two studies from South Africa and Switzerland, respectively. The largest study (n = 227,740) was conducted in Switzerland while the smallest sample size (n = 12) was represented by a study conducted in the USA. The most commonly reported barriers to childhood vaccination were mothers’ lower education level (N = 46/108, 43%), followed by financial instability (N = 19/108, 18%), low confidence in new vaccines (N = 13/108, 12%), and unmonitored social media platforms (N = 5/108, 4.6%). These factors were significantly associated with vaccine refusal among parents. However, the potential facilitators for vaccine uptake among respondents who intended to have their children vaccinated include higher education level (N = 12/108, 11%), followed by information obtained through healthcare professionals (N = 9/108, 8.3%) and strong confidence in preventive measures taken by the government (N = 5/81, 4.6%).

Conclusion:

This review underscores that parents around the globe are hesitant to vaccinate their kids against COVID-19. The spectrum of factors associated with vaccine hesitancy and uptake varies across the globe. There is a dire need to address vaccine hesitancy concerns regarding the efficacy and safety of approved vaccines. Local context is inevitable to take into account while developing programs to reduce vaccine hesitancy. There is a dire need to devise strategies to address vaccine hesitancy among parents through the identification of attributing factors.

Introduction

The COVID-19 pandemic resulted in serious disruptions in the healthcare system and economics across the globe. The SARS-CoV-2 infections ranged from 3 to 17 million daily worldwide from April 2020 to October 2021 (1, 2). This pandemic has considerable mortality reaching up to millions worldwide (3). As compared to adults, children present with mild flu-like symptoms but there is increasing evidence of complications, such as severe acute respiratory disorder and cardiac inflammation, due to the emergence of new variants (4–8). Tireless efforts have been undertaken to alleviate the disease spread and its impact nationwide. These include maintaining physical distances, wearing masks, limiting social contacts, and developing vaccines (9–13). Vaccines play a significant role in drastically reducing and completely eradicating vaccines preventable diseases (VPDs) (14). Initially, COVID-19 vaccines were prioritized for healthcare workers and high-risk groups, especially older people with multiple comorbidities (15, 16). However, the administration of vaccines in children is now considered inevitable owing to multisystem inflammatory syndrome reported in the children (3, 4).

Owing to the emergence of new variants with rapid transmissibility, a high vaccination uptake is needed among general population including children to ensure the achievement of herd immunity (17). The current situation necessitates the administration of COVID-19 vaccines in children, but still, vaccine hesitancy has become a global challenge (18). Although the vaccine hesitancy varies across the globe and is terrifyingly high in many regions encompassing substantial proportion of world’s population, the vaccination rate is below the average number required for herd immunity and rates of vaccination intentions are declining especially among parents of young children despite recent advances (19). “Parental vaccine hesitancy is defined as the delay in the acceptance or refusal of vaccines from parents of children despite their availability” (20). As parents are decision makers related to their children’s vaccination, reluctance or refusal to vaccinate their kids may result in developing VPDs. In particular, the most important factor influencing the decision-making on COVID-19 childhood vaccination includes parents’ knowledge and attitude. Lower knowledge would ultimately result in decreased acceptance (21, 22). The predominant factors reported to play a key role in parental vaccine hesitancy include social, cognitive, and contextual factors (23).

The primary focus of health authorities is to ensure a prosperous campaign among children regarding COVID-19 vaccination. However, the major hindrance toward the prospective and approved COVID-19 vaccination among children is linked to parental vaccine hesitancy as parents are actual decision makers. Parents’ attitude toward COVID-19 vaccination varies widely across geographical regions. The literature shows wide variations in vaccination hesitancy rates and factors associated with vaccine acceptability and hesitancy among parents. There is a dire need to systematically collect the available evidence to draw a firm conclusion from this scenario. To the best of our knowledge, till date there is no systematic review (SR) synthesizing the diverse information into a composite document on parenteral hesitancy toward COVID-19 vaccination from different regions across the globe. In this context, this SR was aimed to (1) check parents’ hesitancy toward children vaccination against COVID-19 and (2) ascertain the barriers and facilitators of vaccine uptake. The findings of this review will aid to map and understand the parental concern about the childhood COVID-19 vaccine and will underscore the areas of action plans.

Methods

Ethics

Since all the data were obtained from publicly available evidence, this study was exempted from ethics approval.

Review design

The PRISMA guidelines were followed to perform a systematic literature search (24). The framework of the current review is divided into five stages: (1) Identification of the research question. (2) Identification of relevant studies. (3) Study selection. (4) Data extraction. (5) Quality assessment. (6) Reporting of findings.

Stage 1: Identifying research questions

This systematic review is guided by the following questions: (1) What is the prevalence parental vaccine hesitancy toward childhood COVID-19 vaccines? (2) What are the barriers of childhood COVID-19 vaccines uptake? (3) What are the facilitators of childhood COVID-19 vaccines uptake?

Stage 2: Identifying relevant studies (eligibility criteria)

Information sources and search strategy

Two review authors performed an independent systematic search in Google scholar, PubMed, Web of Science, and EMBASE databases between 1 January 2020 and 30 August 2022. The keywords used to identify the relevant studies were “2019-nCoV” or “SARS-CoV-2” or “COVID-19” or “Coronavirus Disease,” and “vaccine hesitancy” or “vaccine uptake” or “vaccine acceptance” or “vaccine reluctance” or “vaccination” or “vaccination rate” or “vaccination readiness” or “vaccine acceptance” and “parents” or “parenteral” or “childhood” or “pediatrics” or “children.”

Study selection

Eligible studies were selected according to research questions and Population–Concept–Context (PCC) framework proposed by Joanna Briggs Institute (JBI) as shown in Table 1. JBI reviews are aimed to provide unbiased and comprehensive synthesis of a large number of relevant studies. This systematic review included only those studies that focused on parental concerns about COVID-19 vaccines in children up to 12 years without a diagnosis of COVID-19. Studies in English language or English language translation were included due to the lack of financial and language resources although authors are in the view that English is not the universal language of science. The current review included a cross-sectional online survey, mixed methods, and observational studies. Gray literature and unpublished studies were not included. This review did not include letters, reports, documentaries, or editorials as these studies do not provide empirical evidence required to ascertain the answers to review questions.

Inclusion and exclusion criteria

All the studies containing data on parents’ vaccine hesitancy of children up to 12 years without a diagnosis of COVID-19 were included, as vaccine hesitancy has been more pronounced among parents of children with compromised health conditions. Therefore, articles containing data on children with compromised health conditions, for example, cancer and attention-deficit/hyperactivity disorder (ADHD), were also included. We excluded studies with data on teenagers and adolescents. Studies that do not include data on parental concern about the COVID-19 vaccine in children or that have data on childhood vaccine hesitancy in other immunization programs were excluded.

Stage 3: Selection of relevant studies (search strategy)

The key terms for search strategy were collaboratively identified by two investigators (M.R and N.B). The authors also kept in mind sensitivity and specificity. The search strategy was developed by investigators focusing on four major concepts: COVID-19 vaccine hesitancy, childhood COVID-19, vaccine hesitancy, parental concern about COVID-19 vaccine hesitancy, barriers and facilitators of COVID-19 vaccine uptake. To achieve a comprehensive set of citations, the authors truncated necessary keywords and included relevant subject heading for each concept. The strategies were modified to ensure appropriateness for each database. The adopted search strategies along with databases are described earlier.

Metadata were collected and uploaded by a research team from all identified records to Endnote, and subsequently, duplicates were removed. The review team used two-stage screening due to a large number of studies. The irrelevant articles were removed from the titles and abstracts, while the second stage comprised of reviewing full-text articles. Furthermore, irrelevant articles were removed from the study sample after reading each article. Data extraction was performed from the remaining articles with relevance to the study question. A total of 27 studies were included after the bibliographic screening. Two reviewers (MR and MHB) collectively searched the data, and disagreement was resolved by the third reviewer (Y.H.K). A summary of the study selection process has been given in the PRISMA flowchart (Figure 1).

FIGURE 1

Stage 4: Data extraction

Data extraction table was created in Microsoft word to ensure that the relevant information is systematically extracted in the table. Data from all relevant publications containing the following information were recorded: (1) Authors. (2) Publication year and duration of study. (3) Number of respondents. (4) Parental concern. (5) Vaccine hesitancy/vaccine acceptance percentages. (6) Barriers and facilitators of vaccine uptake (Table 2). Few modifications were also made to the data extraction tool according to the requirement after reviewing the first three articles. To achieve a comprehensive set of relevant data that was not included initially during the extraction process, further refinements were added. Data were charted by the first reviewer (M.R), and extraction was checked by the second reviewer (N.B).

Stage 5: Quality appraisal

The methodological quality of primary studies was appraised by Newcastle–Ottawa scale (NOS). The scale contains seven domains and uses a star system to appraise the studies. These domains include the following: (1) Selection (four subcategories; maximum four stars). (2) Comparability (one subcategory; maximum two stars). (3) Outcome (two subcategories; maximum three stars).

Stage 6: Collating, summarizing, and reporting the findings

This stage consisted of three major steps including numerical, tabular, and narrative summaries of the data. The current review collated and summarized the results systematically by adopting the framework recommended by Arksey and O’Malley (25). Therefore, the first step provided a descriptive numerical summary including the total number of articles searched, the total number of included studies, excluded studies, and reasons for exclusion. The second analytical step was aimed at answering the research questions through a tabular summary. The information included the author’s name, year of publication, study design, vaccine hesitancy/acceptance, and barriers/facilitators for uptake of vaccines. The third analytical step described similarities and differences in such a way in which parental concern and vaccine hesitancy have been defined within each country.

Results

Study selection

The literature review generated 3,750 records, and removing duplicates (n = 292) resulted in 958 studies. Of these, 286 articles were excluded due to the lack of topical relevance following abstract and title screening (Figure 1). A total of 820 articles were subjected to full-text screening. Of these, 686 articles were excluded for the following reasons: 412 articles focused on vaccination in adults and only mentioned childhood vaccination in conclusion, 170 articles were excluded due to repetition, 54 articles focused on other immunization programs with only future aspects of COVID-19 vaccination, and 54 records were published as editorials, letters, and commentaries. We included the oldest publication in the set-in case of duplication. In addition, 27 records were included that were not part of the original search results but were present in the bibliography of the selected studies. Finally, 108 relevant articles reporting the data either on vaccine hesitance or acceptance were identified for inclusion in this review (8, 26–46, 48, 51–135, 143). Some additional articles were also used during data synthesis as supportive evidence (47, 49, 50).

Characteristics of studies

The current review is comprised of studies on COVID-19 acceptance/hesitancy from 27 countries. The dates of survey distribution ranged from January 2020 to August 2022. Stratified per country, the largest sample size (n = 227,740) was reported in a study conducted in Switzerland by Urrunaga-Pastor et al. (26), while the smallest sample size (n = 12) was present in a study conducted in the USA (27). The majority of the studies in this review were conducted in USA (n = 22), China (n = 16), and Saudi Arabia (n = 10) (Supplementary Table 1).

Prevalence of vaccine hesitancy

Vaccine hesitancy was presented in terms of percentage in all studies except two studies where vaccine hesitancy scores were estimated (28, 29). As per classification in the study, the highest vaccine hesitancy rates (>85%) among parents were reported in two studies conducted in Saudi Arabia and Turkey (30, 31). On the contrary, the lowest vaccine hesitancy rates (<4%) were found in two studies conducted in South Africa and Switzerland with 0.69 and 2%, respectively (32, 33) (Table 3).

Defining the problem of vaccine hesitancy

We distinguished three different approaches to vaccine hesitancy, namely, parental concerns (N = 108/108, 100%), vaccine safety (N = 60/108, 55%), and barriers (N = 70/108, 65%). Most of the studies focused on parental concern, and an increasing number of articles on this topic were published between 2020 and 2022 (Table 3).

Parental concerns

The contribution of parents toward vaccine hesitancy among children has been elucidated in many studies. Cognitive biases of parents have been attributed to decreasing trust in vaccination according to public health experts (31). The reason behind distrust was the risk associated with new vaccines in terms of adverse effects. The current review revealed that parents’ concerns about vaccine safety, side effects, and lack of evidence were significantly associated with vaccine hesitancy according to 62 (76%) studies conducted globally followed by psychological distress and adverse effects (N = 5/108, 4.6%). The reported reasons include cynicism about the efficacy and safety of vaccines and social media influence and a history of unknown allergies, respectively (34–38). Mothers were more hesitant to vaccinate their children in Turkey due to a lack of information about the effectiveness of vaccines and distrust of foreign vaccines (39) (Table 3).

Factors associated with vaccine hesitancy

The current review identified twenty-four barriers to COVID-19 vaccine uptake. It is inevitable to explore the reasons for vaccine hesitancy, reluctance, or outright refusal. The most commonly reported barriers include mothers’ lower education level (N = 46/108, 43%), followed by financial instability (N = 19/108, 16%), low confidence in new vaccines (N = 13/108, 12%) and unmonitored social media platforms (N = 5/108, 4.6%) were associated with vaccine refusal (8, 40–44). Low confidence in the new vaccine was reported in the USA and Saudi Arabia (N = 9/18, 60%) and financial instability was most commonly reported in China (N = 5/20, 25%) (Table 3).

Facilitators of vaccine uptake

Fifty-three studies investigated twenty-two facilitators of vaccine uptake. The significant facilitators for vaccine uptake among respondents who intended to have their children vaccinated include higher education level (N = 12/108, 11%) followed by information obtained through healthcare professionals (N = 9/108, 8.3%) and strong confidence in preventive measures taken by the government (N = 5/108, 4.6%) (40, 41, 45–47). Protecting the people around was another possible reason for the increased intention of vaccine uptake. Information obtained through healthcare workers was commonly reported determinant in the USA, while fear of COVID-19 was highly observed in China (Table 3).

Vaccine hesitancy/acceptance rates in children with comorbidities

Approximately 80% of parents in the USA showed willingness toward vaccination for their children with cancer due to the information obtained through oncologists, and the acceptance rate was quite higher than observed among parents with healthy children (48, 49). However, another study conducted in Taiwan highlighted the vaccine hesitancy among parents of children with ADHD owing to the regular use of medications for ADHD (50). In addition, parents of children with cancer and neurodevelopmental disorders were also unwilling to vaccinate their children against COVID-19 as revealed in studies conducted in USA and Bangladesh, respectively (51, 52) (Table 3).

Quality appraisal of studies

All the studies were subjected to NOS for quality appraisal. Overall, the majority of studies have a medium quality with an average of around six stars (range = 3–9 stars). Seven studies received three stars, thirteen studies received four stars, sixteen received five stars, twenty-eight studies received six stars, twenty-seven received seven stars, sixteen studies received eight stars, and only three studies received nine stars. Table 4 indicates the results of quality assessment of primary studies included in this review.

Discussion

Vaccine hesitancy is a global challenge that causes serious health consequences due to relaying of vaccine-preventable infectious diseases (135). Despite the development of safe and effective vaccines, trends in COVID-19 vaccine acceptance decreased between January 2020 and August 2022 as a result of an array of various factors (136). There is a scarcity of systematic review in the literature on childhood COVID-19 vaccine hesitancy among parents although a plethora of studies exists on COVID-19 vaccine hesitancy. In this context, this study is the first of its kind systematically evaluating both the acceptance and hesitancy of the childhood COVID-19 vaccine among parents.

Vaccine hesitancy (VH) has been reported across countries among parents and healthcare professionals (135). Lower vaccine acceptance among children has been observed as a result of parents’ perceptions that children are at lower risk of COVID-19. Although lower COVID-19 mortality rates have been reported in children, they still account for a significant proportion of COVID-19 cases. Children are 2.5 times more likely to be infected with Delta variant according to recent estimates from the UK (137). It has also been reported in Taiwan that approximately 50% of children retain symptoms even after 6 months of infection. Therefore, COVID-19 vaccine hesitancy plays a significant role in the current pandemic by casting a negative impact on socio-economic status and health.

Vaccine hesitancy may hinder the progress of childhood vaccination programs which in turn results in the increasing prevalence of vaccine-preventable diseases (VPDs). VH influenced the parent’s intention in vaccinating their children. Overcoming this challenge to increase vaccine uptake is inevitable during the COVID-19 pandemic. Thus, an estimate of vaccine hesitancy rates can be helpful for effective intervention and planning inevitably to increase awareness among people regarding the safety and efficacy of vaccines which in turn would help to control the negative influence of the current pandemic by reducing viral spread (138, 139).

The current review represents a large variability in vaccine hesitancy rates globally. The overall vaccine hesitancy rate (>85%) was very high in Saudi Arabia. This finding is close (but not similar) to the findings of studies conducted in Turkey but different from the conclusions of studies performed in China, Brazil, Switzerland, and Zambia where (>85%) vaccine acceptance rates were reported.

The determinants of vaccination hesitancy have been extensively analyzed in this review. Age and gender were effective predictors of sociodemographic factors. All the included studies revealed that younger parents were less likely to vaccinate their children as compared to older parents. The reason may be that younger parents could not judge the pros and cons of vaccines as effectively and accurately as older parents can (45). Several included studies showed that mothers were more hesitant toward vaccination of their children against COVID-19, which was consistent with vaccine intention for other diseases (32, 53, 108, 140). It may be because women are less engaged in riskier behavior as compared to men concerning psychological aspects. In addition, mothers with higher education levels are more concerned about health-related illnesses in daily life (68). However, contradictory results were reported regarding the association between vaccination intention and higher education level. Higher education provides parents with sufficient knowledge about disease and vaccines which play a significant role in effective decision-making regarding vaccination against COVID-19 (8). Economic factors should be taken into account while promoting vaccination. Financial instability was observed to be a negative factor related to vaccination intention most commonly reported in China. Furthermore, parents’ concerns relating to vaccine safety, efficacy, the novelty of vaccines, and adverse effects also contributed to high rates of vaccine hesitancy (141, 142). Another pertinent point is that social media platforms are considered more biased toward conspiratorial and misleading information about COVID-19. Falsehood was more widely shared by interconnected clusters of vaccine opponents globally through social media or web sources. Therefore, those who relied on information obtained through these unmonitored sources were reluctant toward vaccination (8, 46, 71).

Also, the finding related to knowledge and acceptance among different groups of the population should not be underestimated. Parents with fear of contracting COVID-19 were in favor of COVID-19 vaccine uptake as reported in studies conducted in China and Malaysia (28, 94). These findings are in line with available literature demonstrating parents’ willingness toward vaccination due to fear of being infected with COVID-19 (143). A higher level of knowledge associated with a higher education level of the female gender was significantly associated with increased vaccine uptake most commonly observed in Saudi Arabia, Switzerland, and Brazil (40, 41, 142). These findings are consistent with another study conducted in Italy evaluating knowledge related to COVID-19 pandemic (144). Place of residence may also affect the awareness of COVID-19. Residents of urban areas are more inclined to the uptake of COVID-19 vaccine as reported in a study conducted in China (59). These findings are in line with a previously published study highlighting the importance of institutionalization in raising awareness of COVID-19 (144).

The current review provides a high level of evidence regarding vaccine hesitancy among parents by synthesizing a variety of research published till date. In addition, it includes wider scope of studies and also inspects the relationship of sociodemographic factors with vaccine hesitancy. Our study emphasizes that sharing of non-factual data should be avoided through social media and the provision of accurate scientific information should be encouraged. People should be informed correctly regarding the efficacy and safety of vaccines through health authorities to develop trust and confidence in new vaccines. However, data obtained through this review will facilitate the scientists and other healthcare authorities to further promote COVID-19 vaccination in children.

The adoption of a systematic review methodology provides an overview of COVID-19 vaccine hesitancy globally. This review provides deep insight into childhood COVID-19 vaccine hesitancy as the data are not assembled in the form of a systematic review, particularly on parents’ concern about childhood COVID-19 vaccination. Robust estimates of factors are provided in this study through simultaneous investigations of multitudes of relevant variables. Moreover, this review has also identified various predictors of vaccine hesitancy. Quality appraisal of included studies revealed that 88 studies have obtained five and more than five stars and only 20 studies scored less than five stars. However, the findings of this review should be estimated in light of certain limitations. Our review is limited to the studies published only in English language. In addition, our review is comprised of cross-sectional studies, and these studies are usually unable to develop causation as they collect data in a short span. Selection bias could not be ruled out either, because several surveys were conducted in vaccination clinics, emergency departments, or other medical settings. The current review did not comprise of meta-analysis due to the wide variation in methodologies of the primary studies. This review does not provide a comparison between adult and childhood vaccine hesitancy rates across the world. The current review included only those studies that encompass vaccine hesitancy rates among parents of young children and exclude adolescent. Another pertinent point is that we solely focused on scholarly articles and excluded gray literature. There was heterogeneity both in terms of the specific questions asked of participants as well as the provenance of those questions in theory or from standardized questionnaire sets. The use of variable questionnaires may under- or over-estimate the VH. Despite these limitations, this is the first review offering a picture of COVID-19 vaccine hesitancy among parents of young children and provides greater insight into parenteral behaviors toward childhood COVID-19 vaccine. Moreover, the current review was not only confined to parental vaccine hesitancy rates but also evaluated vaccine acceptance patterns. With regard to barriers and facilitators, few data are reported in the previously published scientific literature regarding this age group. The current review will help health authorities that are primarily engaged in childhood immunization to attain herd immunity against COVID-19.

Conclusion

Large variability in COVID-19 vaccine hesitancy was reported across the world. Vaccine safety was considered the most important factor of childhood COVID-19 vaccine hesitancy. In addition, a diverse range of factors influences parents’ beliefs on COVID-19 vaccination. A sizeable number of studies reported COVID-19 vaccine hesitancy rates up to 60%. Uncertainty regarding long-term adverse effects, the novelty of vaccines, non-reliable information obtained through social media, and financial instability were the major challenges faced during the implementation of the COVID-19 vaccination program for children. The worldwide prevalence of COVID-19 necessitates the collaborative efforts of government, media sources, and healthcare authorities. Nevertheless, advocating the safety and efficacy of vaccines through trusted sources might help in developing trust among parents and the general public.

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