A socio-ecological perspective on parents' intentions to vaccinate their children against COVID-19

Parents' and Caregivers' Support for in-School COVID-19 Mitigation Strategies: A Socioecological Perspective

Informed by the social ecological model, which asserts that health behaviors and beliefs are the result of multiple levels of influence, we examined factors related to parents' support for in-school COVID-19 mitigation strategies. Using data from a survey of 567 parents/caregivers of public elementary and middle school students in eight Maryland counties, we employed regression models to examine relationships between parent-, child-, family-, school-, and community-level factors and acceptability of mitigation strategies. Acceptance of COVID-19 mitigation strategies was positively correlated with child- and family-level factors, including child racial identity (parents of Black children were more accepting than those of White children, odds ratio [OR]: 2.5, 95% confidence interval [CI] = [1.5, 4.1]), parent receipt of the COVID-19 vaccine (OR: 2.4, 95% CI = [1.5, 3.7]), and parent Democrat or Independent political affiliation (compared with Republican affiliation, OR: 4.2, 95% CI = [2.6, 6.7]; OR: 2.2, 95%CI = [1.3, 3.8], respectively). Acceptance was also positively associated with parents' perceptions of their school's mitigation approach, including higher school mitigation score, indicating more intensive mitigation policies (OR: 1.1, 95% CI = [1.0, 1.1]), better school communication about COVID-19 (OR: 1.7, 95% CI = [1.4, 1.9]) and better school capacity to address COVID-19 (OR: 1.9, 95% CI = [1.5, 2.4]). Community-level factors were not associated with acceptance. Child- and parent-level factors identified suggest potential groups for messaging regarding mitigation strategies. School-level factors may play an important role in parents' acceptance of in-school mitigation strategies. Schools' capacity to address public health threats may offer an underappreciated and modifiable setting for disseminating and reinforcing public health guidance.

Let's (not) talk about sexual health: How sexual communication apprehension with healthcare providers and peer communication influence intentions to protect sexual health

OBJECTIVE

This study examined how patients' clinical and peer interactions may affect their communication apprehension with healthcare providers, a major communication barrier to sexual health protective behaviors (SHPB).

METHODS

Between January 2022 and February 2023, we conducted an online survey with 310 participants recruited through snowball sampling. Using structural equation modeling (SEM), we explored relationships among patient-provider interactions, peer communication about sex, communication apprehension with providers, and SHPB intentions.

RESULTS

Significant predictors of SHPB intentions included lower communication apprehension and more peer communication. Communication apprehension was a significant mediator in paths from peer communication and three types of patient-provider communication to SHPB intentions.

CONCLUSIONS

Our study indicates the need to address communication barriers to increase patients' SHPB intentions. Active patient involvement and patient-centered communication may open up discussions about sex in the clinical setting. Peer interactions, informed by scientific guidance, may reduce patients' apprehension, leading to better health outcomes.

PRACTICE IMPLICATIONS

Communication interventions are needed to promote collaborative patient-provider environments and peer sexual communication. Active involvement and evidence-based discussions can help patients navigate difficult conversations (e.g., like sex), improving SHPB.

Physicians' perspectives on COVID-19 vaccinations for children: a qualitative exploration in Ontario, Canada

OBJECTIVES

Parents' decisions to vaccinate their children against COVID-19 are complex and often informed by discussions with primary care physicians. However, little is known about physicians' perspectives on COVID-19 vaccinations for children or their experiences counselling parents in their decision-making. We explored physicians' experiences providing COVID-19 vaccination recommendations to parents and their reflections on the contextual factors that shaped these experiences.

DESIGN

We conducted an interpretive qualitative study using in-depth interviews. We analyzed the data using reflexive thematic analysis and a socioecological framework.

SETTING

This study involved primary care practices associated with The Applied Research Group for Kids (TARGet Kids!) primary care research network in the Greater Toronto Area, Ontario, Canada.

PARTICIPANTS

Participants were 10 primary care physicians, including family physicians, paediatricians and paediatric subspecialists.

RESULTS

Participants discussed elements at the individual level (their identity, role, and knowledge), the interpersonal level (their relationships with families, responsiveness to parents' concerns, and efforts to build trust) and structural level (contextual factors related to the evolving COVID-19 climate, health system pandemic response, and constraints on care delivery) that influenced their experiences providing recommendations to parents. Our findings illustrated that physicians' interactions with families were shaped by a confluence of their own perspectives, their responses to parents' perspectives, and the evolving landscape of the broader pandemic.

CONCLUSIONS

Our study underscores the social and relational nature of vaccination decision-making and highlights the multiple influences on primary care physicians' experiences providing COVID-19 vaccination recommendations to parents. Our findings offer suggestions for future COVID-19 vaccination programmes for children. Delivery of new COVID-19 vaccinations for children may be well suited within primary care offices, where trusting relationships are established, but physicians need support in staying knowledgeable about emerging information, communicating available evidence to parents to inform their decision-making and dedicating time for vaccination counselling.

Associations Between Social Networks and COVID-19 Vaccine Uptake in 4 Rural Alabama Counties: Survey Findings

OBJECTIVES

The COVID-19 pandemic demonstrated how vaccination decisions are influenced by misinformation, disinformation, and social pressures, leading to varied and inequitable uptake rates. In this study, we examined how COVID-19 vaccine messages received via social networks were associated with vaccine uptake in rural Alabama.

METHODS

From November 2021 through March 2022, we collected 700 responses to a telephone survey administered in 4 rural Alabama counties. We asked respondents to indicate whether certain social relationships (eg, family, businesses) tried to influence them to (1) obtain or (2) avoid a COVID-19 vaccine. We used χ2 tests, Kruskal-Wallis tests, Mantel-Haenszel χ2 tests, and Fisher exact tests to examine the associations between vaccination status and survey responses.

RESULTS

Respondents in majority-African American counties were significantly more likely than those in majority-White counties to have received ≥1 dose of COVID-19 vaccine (89.8% vs 72.3%; P < .001). Respondents who received ≥1 dose had a significantly higher mean age than those who had not (58.0 vs 39.0 years; P < .001). Respondents who were encouraged to get vaccinated by religious leaders were more likely to have received ≥1 dose (P = .001), and those who were encouraged to avoid vaccination by family (P = .007), friends (P = .02), coworkers (P = .003), and health care providers (P < .001) were less likely to have received ≥1 dose. Respondents with more interpersonal relationships that encouraged them to avoid vaccination were more likely to be unvaccinated (P < .001).

CONCLUSIONS

Interpersonal relationships and demographic characteristics appeared to be important in COVID-19 vaccine decision-making in rural Alabama. Further research needs to identify how to facilitate vaccine-positive interpersonal relationships, such as peer mentoring and trusted messenger interventions.

Utility of the Theory of Planned Behaviour for predicting parents' intentions to vaccinate their children against COVID-19

Vaccination is a crucial form of primary prevention, and it is important to understand the factors that influence parents' decisions to vaccinate their children. The current study examines the utility of the Theory of Planned Behaviour (TPB) and anticipated affect for explaining parents' intentions to vaccinate their children against COVID-19. Parents (N = 843) living in the United States completed an online survey. The TPB variables explained 65% of the variability in parents' intentions. In addition to all three of the TPB antecedents predicting vaccine intentions, both anticipated regret of not vaccinating and anticipated positive emotions of vaccinating were associated with parent intentions. Contrary to predictions, subjective norms were a stronger predictor of intentions when perceived behavioural control was lower compared to higher. These findings help further our understanding of parent-for-child vaccine decisions in the context of novel health threats and inform intervention efforts aimed at encouraging this behaviour.

The Social Ecology of Health Beliefs and Misinformation Framework: Examining the impact of misinformation on vaccine uptake through individual and sociological factors

BACKGROUND

Misinformation presents a critical concern for academic and public health discourse, particularly around vaccine response. Before the COVID-19 pandemic, vaccine hesitancy was responsible for decreased immunization uptake for vaccine-preventable diseases. Misinformation connected to the novel COVID-19 vaccine has further fueled vaccine hesitancy in Colorado and the United States. Our study brings together three different perspectives - physicians, public health professionals, and parents - to understand the impact of misinformation on vaccine uptake in Colorado. Our study proposes a framework for combining the Health Belief Model with the Socio-Ecological model to account for societal factors in healthcare decision making.

METHODS

Semi-structured interviews and focus groups with public health professionals, physicians, and parents (n = 31) were conducted in late spring and summer 2022. Data were coded inductively using thematic analysis. Identified themes were deductively categorized according to the Socio-Ecological Model and Health Belief Model.

RESULTS

Using a theoretical framework that combined the Health Belief Model and the Socio-Ecological Model, we identified seven factors that influenced vaccine hesitancy in Colorado. Intrapersonal factors included routine vaccine hesitancy connected to perceptions of severity and susceptibility, efficacy, and benefits and barriers to vaccine uptake; interpersonal factors included social networks; institutional factors included mass mediated platforms, portrayals of uncertainty, distrust in institutional sources of information, and political influences in vaccine decision making; and structural factors included economic barriers behind vaccine hesitancy.

CONCLUSIONS

Our study provides a unique, triangulated, post-positivist perspective on the role of misinformation in vaccine hesitancy in Colorado. The findings provide evidence that misinformation is an important barrier to vaccination uptake and can permeate multiple socio-ecological determinants/characteristics to influence vaccination behaviors including intrapersonal, interpersonal, institutional, and structural levels. We introduce the Social Ecology of Health Beliefs and Misinformation Framework to account for how misinformation may interrupt vaccine uptake.

A Review of the Data Supporting Use of COVID-19 Vaccinations in the Pediatric Population

OBJECTIVE

The objective of this study was to review the effectiveness and safety of COVID-19 vaccinations in the pediatric population.

DATA SOURCES

PubMed/Medline (September 2020 to December 2022), the Centers for Disease Control and Prevention, and Food and Drug Administration (FDA) websites.

STUDY SELECTION AND DATA EXTRACTION

Publications regarding the safety and efficacy of COVID-19 vaccinations in children were included.

DATA SYNTHESIS

Vaccines authorized for use in children include two monovalent mRNA vaccines (≥6 months old) and one monovalent protein subunit adjuvant vaccine (adolescents only). Omicron-specific mRNA bivalent boosters are authorized for children ≥6 months old. Studies after monovalent vaccine authorization illustrated efficacy in children >5 to 6 years of age, specifically decreased severe COVID-19 (including mortality) and multisystem inflammatory response syndrome occurrence (including during Omicron predominance). Available data for children <5 to 6 years suggests efficacy, although data are limited. Monovalent vaccine efficacy against Omicron infections may wane as early as 2 months, but protection against severe disease complications may last longer, and bivalent Omicron boosters are anticipated to increase effectiveness. Myocarditis/pericarditis is a safety concern associated with the COVID-19 vaccinations but occurs less frequently then COVID-19 complications and thus the benefit outweighs the risks.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Caregivers seek information from health care professionals regarding vaccine safety and efficacy. Pharmacists can use the objective information in this review to educate caregivers and effectively administer COVID-19 vaccines to patients.

CONCLUSIONS

There is sufficient and continually growing safety and efficacy data available to recommend COVID-19 vaccinations for children ≥6 months of age.

Socioecological Analysis of a Nursing Advocacy Skills-Building Activity

BACKGROUND

Advocacy is an expectation of the nursing profession. Nursing curricula should include opportunities for advocacy skills building at multiple levels of potential effect. Analyses of student performances during these advocacy exercises provide insight into how well students understand the multifactorial nature of most public health issues.

METHOD

A socioecological model was used to evaluate nursing students' advocacy responses to food-insecurity scenarios during a guided online discussion activity aimed at advocacy skills building.

RESULTS

Student recommendations were categorized as individual, interpersonal, organizational, community, and policy interventions, with subcategories at each socioecological level.

CONCLUSION

Recommendations are given for future educational research specific to advocacy skills building. Implications for nursing education at each socioecological level also are discussed. [J Nurs Educ. 2023;62(9):509-515.].

A Qualitative Analysis of Social-Ecological Factors Shaping Childhood Immunisation Hesitancy and Delay in the Eastern Province of Saudi Arabia

(1) Background: Immunisation is a crucial and effective method for preventing infectious diseases, with its success dependent on high immunisation rates to protect under-immunised individuals and promote herd immunity. This qualitative descriptive study is part of a larger explanatory sequential mixed method design that aims to explore factors influencing parents' decision making to complete childhood immunisation in the Eastern Province of Saudi Arabia, a country experiencing disparities in immunisation coverage across its population. (2) Methods: The sample consisted of a subset of participants from the initial quantitative phase, which included a survey on the immunisation attitudes of parents living in Qatif. This initial phase included n = 350 participants, who were over 18, had access to one of the 27 Primary Health Care (PHC) Centres in Qatif, and had a child under 24 months. This paper presents the qualitative-descriptive phase, which used a qualitative survey to gain open-ended responses from parents (n = 20) and analysed using thematic analysis. (3) Results: Participants identified certain vaccines, particularly MMR, as influencing their immunisation practices. Specific factors identified as deterring parents from immunising their children included fear of autism and other developmental delays, concerns about risks and side effects, mistrust in vaccine efficacy, and discouraging information from the media. Parents' immunisation decisions were evidently affected by policy compliance, family and friends, and social networking sites. These factors are explained through the socio-ecological model. Moreover, the COVID-19 pandemic influenced parents' decisions on vaccine completion in terms of perceived barriers, perceived benefits, and perceived trust. (4) Conclusions: By examining the social-ecological factors shaping parents' decisions to immunise their children in the Eastern Province of Saudi Arabia, this research contributes to the literature and informs the Saudi National Childhood Immunisation Programme about factors contributing to childhood immunisation hesitancy, helping to address a critical healthcare issue.

Perceived Role of the School Nurse in Providing Pertinent COVID-19 Information to the School Community: Experiences of Public Health Graduate Students With School-Aged Children

The COVID-19 pandemic has been a major disruptor to school systems across the United States since March 2020. As a result, school nurses have had to adapt to these uncertain times. Previous research has demonstrated the impact of school nurses on student health; however, less is known about their role in educating the broader school community about COVID-19 prevention. In Spring 2022, four focus groups were conducted with public health graduate students with school-aged children, to assess perceptions of COVID-19 and public health emergency preparedness communication. MAXQDA was used for thematic analysis. School nurses were viewed as a credible source of COVID-19 information, especially for those who do not have access to healthcare services. While the primary role of school nurses is to provide health services to students, they also have the capacity to provide the community with vital public health emergency preparedness information.

Facilitators and Barriers to Implementing COVID-19 Prevention Strategies in K-12 Public Schools

To meet the educational needs of students, most schools in the United States (U.S.) reopened for in-person instruction during the 2021-2022 school year implementing a wide range of COVID-19 prevention strategies (e.g., mask requirements). To date, there have been limited studies examining facilitators and barriers to implementing each of the recommended COVID-19 prevention strategies in schools. Twenty-one semistructured interviews were conducted with public school staff from across the U.S. responsible for overseeing prevention strategy implementation. MAXQDA was used for thematic analysis. Findings identified key facilitators including utilizing Centers for Disease Control and Prevention guidance and district policies to guide decision-making at the school level, possessing financial resources to purchase supplies, identifying key staff for implementation, and having school health services infrastructure in place. Key barriers included staff shortages, limited resources, and community opposition. Findings from this study provide important insight into how schools can prepare for future public health emergencies.

COVID-19 Vaccine Uptake in Immigrant, Refugee, and Nonimmigrant Children and Adolescents in Ontario, Canada

Importance

COVID-19 vaccinations are recommended for minors. Surveys indicate lower vaccine acceptance by some immigrant and refugee groups.

Objective

To identify characteristics in immigrant, refugee, and nonimmigrant minors associated with vaccination.

Design, Setting, and Participants

This retrospective cohort study used linked, population-based demographic and health care data from Ontario, Canada, including all children aged 4 to 17 years registered for universal health insurance on January 1, 2021, across 2 distinct campaigns: for adolescents (ages 12-17 years), starting May 23, 2021, and for children (ages 5-11 years), starting November 25, 2021, through April 24, 2022. Data were analyzed from May 9 to August 2, 2022.

Exposures

Immigrant or refugee status and immigration characteristics (recency, category, region of origin, and generation).

Main Outcomes and Measures

Outcomes of interest were crude rates of COVID-19 vaccination (defined as ≥1 vaccination for children and ≥2 vaccinations for adolescents) and adjusted odds ratios (aORs) with 95% CIs for vaccination, adjusted for clinical, sociodemographic, and health system factors.

Results

The total cohort included 2.2 million children and adolescents, with 1 098 749 children (mean [SD] age, 7.06 [2.00] years; 563 388 [51.3%] males) and 1 142 429 adolescents (mean [SD] age, 14.00 [1.99] years; 586 617 [51.3%] males). Among children, 53 090 (4.8%) were first-generation and 256 886 (23.4%) were second-generation immigrants or refugees; among adolescents, 104 975 (9.2%) were first-generation and 221 981 (19.4%) were second-generation immigrants or refugees, most being economic or family-class immigrants. Immigrants, particularly refugees, were more likely to live in neighborhoods with highest material deprivation (first-generation immigrants: 18.6% of children and 20.2% of adolescents; first-generation refugees: 46.4% of children and 46.3% of adolescents; nonimmigrants: 18.5% of children and 17.2% of adolescents) and COVID-19 risk (first-generation immigrants; 20.0% of children and 20.5% of adolescents; first-generation refugees: 9.4% of children and 12.6% of adolescents; nonimmigrants: 6.9% of children and 6.8% of adolescents). Vaccination rates (53.1% in children and 79.2% in adolescents) were negatively associated with material deprivation. In both age groups, odds for vaccination were higher in immigrants (children: aOR, 1.30; 95% CI, 1.27-1.33; adolescents: aOR, 1.10; 95% CI, 1.08-1.12) but lower in refugees (children: aOR, 0.34; 95% CI, 0.33-0.36; adolescents: aOR, 0.88; 95% CI, 0.84-0.91) compared with nonimmigrants. In immigrant- and refugee-only models stratified by generation, region of origin was associated with uptake, compared with the overall rate, with the lowest odds observed in immigrants and refugees from Eastern Europe (children: aOR, 0.40; 95% CI, 0.35-0.46; adolescents: aOR, 0.41; 95% CI, 0.38-0.43) and Central Africa (children: aOR, 0.24; 95% CI, 0.16-0.35; adolescents: aOR, 0.51,CI: 0.45-0.59) and the highest odds observed in immigrants and refugees from Southeast Asia (children: aOR, 2.68; 95% CI, 2.47-2.92; adolescents aOR, 4.42; 95% CI, 4.10-4.77). Adjusted odds of vaccination among immigrants and refugees from regions with lowest vaccine coverage were similar across generations.

Conclusions and Relevance

In this cohort study using a population-based sample in Canada, nonrefugee immigrants had higher vaccine coverage than nonimmigrants. Substantial heterogeneity by region of origin and lower vaccination coverage in refugees persisted across generations. These findings suggest that vaccine campaigns need precision public health approaches targeting specific barriers in identified, undervaccinated subgroups.

Factors impacting parental uptake of COVID-19 vaccination for U.S. Children ages 5-17

COVID-19 vaccination of U.S. children lags behind adult vaccination, but remains critical in mitigating the pandemic. Using a subset of a nationally representative survey, this study examined factors contributing to parental uptake of COVID-19 vaccine for children ages 12-17 and 5-11, stratified by parental COVID-19 vaccination status. Among vaccinated parents, uptake was higher for 12-17-year-olds (78.6%) than 5-11-year-olds (50.7%); only two unvaccinated parents vaccinated their children. Child influenza vaccination was predictive of uptake for both age groups, while side effect concerns remained significant only for younger children. Although parents were more likely to involve adolescents in vaccine decision-making than younger children, this was not predictive of vaccine uptake. These results highlight the importance of addressing the unique and shared concerns parents have regarding COVID-19 vaccination for children of varying ages. Future work should further explore adolescent/child perspectives of involvement in COVID-19 vaccination decision-making to support developmentally appropriate involvement.

Parents' perspectives on SARS-CoV-2 vaccinations for children: a qualitative analysis

BACKGROUND

Uptake of the SARS-CoV-2 vaccine for children aged 5-11 years has been lower than anticipated in Canada. Although research has explored parental intentions toward SARS-CoV-2 vaccination for children, parental decisions regarding vaccinations have not been studied in-depth. We sought to explore reasons why parents chose to vaccinate or not vaccinate their children against SARS-CoV-2 to better understand their decisions.

METHODS

We conducted a qualitative study involving in-depth individual interviews with a purposive sample of parents in the Greater Toronto Area, Ontario, Canada. We conducted interviews via telephone or video call from February to April 2022 and analyzed the data using reflexive thematic analysis.

RESULTS

We interviewed 20 parents. We found that parental attitudes toward SARS-CoV-2 vaccinations for their children represented a complex continuum of concern. We identified 4 cross-cutting themes: the newness of SARS-CoV-2 vaccines and the evidence supporting their use; the perceived politicization of guidance for SARS-CoV-2 vaccination; the social pressure surrounding SARS-CoV-2 vaccinations; and the weighing of individual versus collective benefits of vaccination. Parents found making a decision about vaccinating their child challenging and expressed difficulty sourcing and evaluating evidence, determining the trustworthiness of guidance, and balancing their own conceptions of health care decisions with societal expectations and political messaging.

INTERPRETATION

Parents' experiences making decisions regarding SARS-CoV-2 vaccination for their children were complex, even for those who were supportive of SARS-CoV-2 vaccinations. These findings provide some explanation for the current patterns of uptake of SARS-CoV-2 vaccination among children in Canada; health care providers and public health authorities can consider these insights when planning future vaccine rollouts.

Application of behavioral change theory and models on COVID-19 preventive behaviors, worldwide: A systematic review

Objective:

This systematic review aimed to assess the global application of behavioral change theory and models on COVID-19 preventive behaviors.

Methods:

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses procedure. Databases such as PubMed/MIDLINE, Web of Science, Scopus, EMB ASE, World Health Organization libraries, and Google Scholar were used to search all published articles in the area of application of behavioral change theory and model on COVID-19 preventive behavior until October 1, 2022. Studies published in another language other than English were excluded. Two independent reviewers did the article selection and quality check. A third reviewer asked if any disagreement were found.

Result:

Seventeen thousand four hundred thirty-six total articles were retrieved from all sources after the removal of duplicated articles and those not evaluating the outcome of interest were excluded. Finally, 82 articles done using behavioral change theory and model on COVID-19 preventive behaviors were included. The health belief model (HBM) and theory of planned behavior (TPB) were most commonly used in COVID-19 preventive behaviors. The constructs of most behavioral theories and models were significantly associated with COVID-19 preventive behaviors such as hand washing, face mask use, vaccine uptake, social isolation, self-quarantine, social distance, and use of sanitizers.

Conclusion:

This systematic review summarizes comprehensive evidence on the application of behavioral change theory and model on COVID-19 preventive behaviors globally. A total of seven behavioral change theories and models were included. The HBM and TPBs were most commonly used for COVID-19 preventive behaviors. Therefore, the application of behavioral change theory and models is recommended for developing behavioral change interventional strategies.