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Original research
Parents’ acceptance attitudes towards the vaccination of children based on M-LSGDM approach in China: a cross-sectional study
  1. Linan Cheng1,2,
  2. Jianhui Kong3,
  3. Xiaofeng Xie4,
  4. Li Zhang5,
  5. Fengying Zhang2
  1. 1School of Nursing, Soochow University, Suzhou, Jiangsu, China
  2. 2West China Hospital/West China School of Nursing, Sichuan University, Chengdu, Sichuan, China
  3. 3Southwest Minzu University, Chengdu, Sichuan, China
  4. 4Innovation Center of Nursing Research, Nursing Key Laboratory of Sichuan Province, West China Hospital, Chengdu, Sichuan, China
  5. 5Chengdu Women's and Children's Central Hospital/School of Medicine, University of Electronic Science and Technology of China, Chengdu, Sichuan, China
  1. Correspondence to Dr Fengying Zhang; zhangfengying2020{at}163.com

Abstract

Objectives Ensuring that children receive timely vaccinations is paramount for preventing infectious diseases, and parental attitude plays a pivotal role in this process. This study addresses this gap in the existing literature by examining parental attitudes towards vaccinating their children.

Design A cross-sectional study.

Methods An online survey including parents’ sociodemographic characteristics, risk perception and attitudes towards child vaccination towards COVID-19 was conducted. The modified large-scale group decision-making approach for practicality and binary logistic regression was used to identify the predictors influencing parents’ decision-making.

Results Of the 1292 parents participated, 957 (74.1%) were willing to vaccinate their children, while 335 (25.9%) refused the vaccination. The study indicated that age, parental anxiety regarding child vaccination, concerns about the child’s susceptibility to the disease, opinions towards vaccination benefits versus disadvantages, place of residence, average family income and children’s health were significant predictors (p<0.05).

Conclusions While most parents supported childhood vaccination, some opposed it. Addressing persistent barriers is crucial to ensure widespread vaccination and child well-being.

  • health equity
  • health & safety
  • public health

Data availability statement

Data are available upon reasonable request.

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STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Big data have played a key role in building comprehensive and diverse datasets of parents’ acceptance attitude towards their children’s vaccination and influencing factors.

  • The modified large-scale group decision-making approach provides a predictive, dynamic and flexible framework for healthcare decision-making during public health events.

  • Binary logistic regression enhances analysis by identifying significant predictors, shedding light on parental attitudes towards children’s vaccination and informing strategies crucial for widespread vaccination coverage in public health.

  • The cross-sectional nature limits the ability to capture changes over time.

  • Self-report questionnaires’ potential bias highlights the need for longitudinal studies to comprehensively understand parental acceptance evolution over time and in response to various factors.

Introduction

COVID-19 vaccines received approval for public use in various countries worldwide in late 2020 and early 2021.1 Nevertheless, several studies have brought attention to the hesitancy surrounding COVID-19 vaccination among the general public.2 3 Vaccine hesitancy, labelled by the WHO as ‘one of the top ten threats to global health’, poses significant risks.3 It results in reduced herd immunity,4 increased disease-related mortality and morbidity rates, the emergence of new variants that can evade vaccine-induced immunity and outbreaks of infectious diseases.5–7 While research has explored factors hindering vaccine acceptance, the focus has primarily been on adults, neglecting the crucial role children play in contributing to herd immunity.8

Research has indicated that, during the pandemic, 60.1% of parents express an intention to vaccinate their children, while 22.9% refuse vaccination and an additional 25.8% remain unsure in the USA.9 With the global development and spread of infectious diseases, disability and mortality rates are increasing.9 10 The incidence of cases among children during the pandemic approached or even exceeded adult levels, potentially resulting in severe outcomes for children in Korea.11 Consequently, the matter of childhood vaccination demands heightened attention.

Understanding parents’ perspectives on vaccines affects children’s future health engagement consciousness and response.12 13 Vaccination is an expression of individual rights and responsibilities for children and parents. The benefits and risks of vaccines are central to parental decision-making. The higher risk and uncertainty associated with vaccinating children contribute to delays.13 14 However, children remain at risk of contracting infectious viruses and becoming sick during the pandemic, and being asymptomatic makes it easier to quietly spread the virus to others.15 16

In China, for children under the age of 18 years who do not have full civil capacity and need to be accompanied by their parents to be vaccinated against the virus, parents are key decision-makers regarding whether their children will receive vaccinations. It is important to measure parents’ attitudes towards vaccinating their children against the virus. Parents are required to learn about pandemic vaccination, the vaccination procedure, and the health status of their children in advance, sign an informed consent form for vaccination and complete the pandemic vaccination based on informed consent.

Establishing immunity barriers and achieving herd immunity through vaccination are important goals for epidemic prevention and control in children and can reduce or even block the spread of diseases. A survey showed that among adolescents aged 12–17 years, hospitalisation rates were approximately 10-fold higher in unvaccinated adolescents than in fully vaccinated adolescents, indicating that vaccines were highly effective at preventing serious pandemic illness in the USA.17 Studies have verified that vaccination is highly effective in preventing pandemic-associated hospitalisations in adolescents.17–19 It is imperative for minors to be vaccinated as the rate of adult vaccination continues to climb and the virus continues to mutate. Therefore, the vaccination of children against the virus has been a major concern.

Parents’ perceptions of pandemic vaccinations for their children are worth exploring. Some studies report that the main predictors of parents’ intention to vaccinate their children are fathers, older parental age, higher income, higher risk perception and positive attitudes towards vaccination.19 20 However, the predictors that influence parents to accept the vaccine for their children remain unclear in China. Hence, it is crucial to investigate parental acceptance of child vaccination, given the complexities of decision-making and epidemic uncertainties.

Various decision-making methods have provided insights for the study,21–24 such as multicriteria decision-making, Pythagorean fuzzy rough CRITIC-REGIME methodology and large-scale group decision-making (LSGDM) approach. The LSGDM approach is suitable for addressing complex decision-making problems, particularly in the context of emergency decision-making.25 LSGDM refers to the process in which a large number of decision-making members participate, express preferences for alternative solutions according to the information provided and aggregate the preferences of many members into large group preferences according to specific rules to obtain a ranking of solutions or select the required solutions from a large number of alternative solutions.24 25 LSGDM is complex for decision-making members, decision problems, the decision basis, the decision index system, the decision environment and decision information.26 27 The complexity of LSGDM means that there will inevitably be more uncertainty in the decision-making process, which we call risk.28 The risk sources of LSGDM include not only objective factors such as insufficient information and highly dynamic, imperfect decision-making mechanisms but also a large number of subjective factors, such as the decision-making subjects’ personal experience, knowledge level, personal habits and judgement ability. In view of the uncertainty of epidemics and infectious diseases, parents and family members are the final decision-makers for children, and their decision-making includes both external and internal factors. Therefore, we used a modified LSGDM (M-LSGDM) approach.

The M-LSGDM approach in the study has the following characteristics: (1) the decision-making participants are all parent; (2) the setting of the decision is the context in which children need to be vaccinated during the outbreak; (3) decision-making factors include both external and internal factors and (4) the result of the decision is complex and uncertain. It is of great practical significance to introduce decision-making risks into the M-LSGDM approach. Therefore, this study aimed to explore parental acceptance attitudes towards the vaccination of children during the pandemic and to predict the influencing factors based on the M-LSGDM approach. It is crucial for contributing to global discussions on effective vaccination strategies and public health communication.

Methods

Study design

This study employed a cross-sectional design. The Strengthening the Reporting of Observational Studies in Epidemiology cross-sectional reporting guidelines were used.29 Participants voluntarily and anonymously participated and were presented two questions at the beginning of the questionnaire survey: whether individuals agreed to participate in the anonymous survey and whether individuals agreed to take the survey as part of an academic study. Only the respondents who agreed to participate were included in the final analysis to ensure that informed consent was obtained. All the collected data remained confidential and were used only for this study.

Data collection

Data were collected between June and August 2022 using a Sojump online survey (Questionnaire Star survey website) on the largest online survey platform in China, Wen Juan Xing (Changsha Ranxing Information Technology, Hunan, China), which provides online questionnaire design and survey functions. This platform is used to confirm personal information, allowing authentic, diverse and representative samples. We used a self-selection online survey with a non-probability sampling method to recruit participants through social network links.30 The target population in the present study was adults aged 20 years or older living in mainland China.

Quality control

Before the survey, 30 participants were selected for a preliminary investigation to assess the completion time, wording and clarity of the questionnaire. The questionnaire was then modified accordingly. During the investigation, an author supervised the completion of the questionnaires and collected adjustment recommendations. After the investigation, we strictly screened the data to ensure accuracy.

Participants

A total of 1292 respondents participated in the survey via a questionnaire survey website. However, 100 out of 1392 (7.2%) questionnaires were removed from the sample based on the following exclusion criteria: (1) the surveys were incomplete, (2) the questionnaires were completed by non-adults under 20 years of age, (3) the respondents did not consent to the first two questions and (4) the same response options were chosen consistently. Ultimately, 1292 eligible surveys were analysed.

Instruments

The survey included questions to assess the participants’ demographic characteristics (eg, age, gender, ethnicity, residence, professional background, who generally decides the child’s non-planned immunisation, acceptance attitudes towards children’s vaccination and reasons), risk perception, children’s health, plans to vaccinate their children and relevant factors related to vaccination.

The Risk Perception Scale was developed and validated by Ju et al.31 Based on a systematic review of existing risk perception assessment tools, this study combined cognitive-empirical self-theory and the common sense model in risk perception theory to establish a nine-item scale with three factors (emotional perception, cognitive judgement and psychological representation of unusual severity). Higher scores indicated greater risk perception.2 32 Some items were scored in reverse. The scale had adequate internal consistency, good content validity, appropriate convergent and discriminant validity, and construct validity, with a Cronbach’s alpha coefficient of 0.87. Based on this scale, a two-item coping dimension was added. The overall score ranged from 11 to 54 points. In addition, some of the responses were modified and simplified. In this study, Cronbach’s α coefficient was 0.873.

Statistical analysis

The primary outcome of the survey was acceptance attitudes towards child vaccination. Respondents who chose ‘yes’ were classified into the acceptance group, while those who chose ‘no’ were assigned to the refusal group.

Descriptive statistics were used to describe sociodemographic characteristics and risk perceptions. Binary logistic regression was then performed among the acceptance and refusal groups to identify the influencing factors, and ORs, SEs and 95% CIs were calculated. All data were analysed using IBM SPSS software (V.25.0).

Results

Study sample characteristics

The participants had a mean age of 37.80 years (SD=6.74; range=20–68). The mean risk perception score was 30.03 (SD=6.50; range=11–52). A total of 74.1% of respondents reported that they hoped to have their child vaccinated against the pandemic (n=957), while 335 (25.9%) refused vaccination. Regarding attitudes towards the vaccination of their children, 64.2% (n=830) reported that the benefits outweighed the disadvantages. Additional information is provided in tables 1 and 2.

Table 1

The basic characteristics among 1292 respondents

Table 2

Parents’ acceptance attitude towards vaccination of children

Predictive factors of vaccination acceptance attitudes for children

Sociodemographic characteristics, risk perception, attitudes towards children’s vaccination and concerns about vaccination were included in the regression, with the vaccine refusal group serving as the reference group (X2=777.569, p=0.000), see table 3.

Table 3

Factors influencing acceptance attitude towards vaccination of children

Age (OR=1.065, 95% CI: 1.030 to 1.102), anxiety about whether to vaccinate children (OR=2.480, 95% CI: 1.542 to 3.991), concerns about children getting the virus (OR=0.504, 95% CI: 0.293 to 0.866), opinions towards child vaccination (benefits>disadvantages vs benefits=disadvantages, OR=6.813, 95% CI: 3.892 to 11.927; benefits<disadvantages vs benefits=disadvantages, OR=0.133, 95% CI: 0.077 to 0.229), place of residence (big city vs county or rural, OR=2.789, 95% CI: 1.607 to 4.840), average family income (¥≤5000 vs >20 000, OR=1.759, 95% CI: 1.017 to 3.041, 8001–10 000 vs >20 000, OR=1.807, 95% CI: 1.050 to 3.108) and children’s health (relatively good vs relatively poor, OR=2.180, 95% CI: 1.149 to 4.319) were predictive factors of parents' acceptance of child vaccination.

Discussion

The present study explored parental vaccination acceptance for their children and investigated its predictors. A total of 74.1% of participants expressed willingness to vaccinate their children, while 25.9% refused vaccination. Binary logistic regression showed that age, anxiety about whether to vaccinate children, concerns about children getting the virus, opinions towards children’s vaccination, place of residence, average family income (¥) and children’s health were significant factors that influenced vaccination acceptance attitudes. Understanding the identified predictors empowers healthcare practitioners and policymakers to implement tailored communication strategies and targeted interventions, foster informed decision-making, thereby increasing vaccination rates and enhancing public health.

The significant majority expressing willingness to vaccinate indicates widespread acceptance of the importance and efficacy of vaccination in disease prevention. Factors contributing to this positive inclination include trust in medical authorities, the perception of risk and personal experiences with successful vaccination outcomes. In contrast, the noteworthy minority declining vaccination rate may be influenced by factors such as vaccine hesitancy, lack of trust in the healthcare system or the dissemination of misinformation within specific communities.

The question of whether children should receive a pandemic vaccine remains a constant concern for parents. It is important to identify other barriers to or facilitators of parental decisions to accept vaccination. Previous studies have shown that risk perception is an important predictor of vaccination acceptance as those who perceive a high or very high risk of infection are more likely to be vaccinated as soon as possible instead of delaying it.11 33 34 The mean risk perception score was moderate. Advances and developments in medicine give people a great sense of security.35 This is especially due to the successful experience of previous studies in combating viral threats and the belief in vaccine effectiveness in accepting immediate vaccination.36 Understanding risk perception aids healthcare professionals and policymakers to precisely address public attitudes towards vaccination, boosting vaccination rates and enhancing public health. This comprehension allows practitioners to tailor focused communications and interventions to promote acceptance. This guides promotional and educational efforts by providing scientific evidence to boost public confidence in vaccines. Policymakers can adjust their policies to meet diverse needs based on varying risk perceptions.

Our findings are valuable for designing effective vaccination strategies and programmes for people experiencing vaccine hesitancy. Previous studies have shown the importance of the environment and organisation in the prevention and control of infectious diseases.36 However, we found that concerns about the lack of community support and effective treatment for epidemics were not predictors of acceptance of vaccination for children. Given the nationwide collective effort in epidemic prevention, protective measures implemented by communities and organisations cover everyone.7–10 Consequently, these factors did not emerge as predictive indicators for parents’ decisions regarding vaccine acceptance or refusal in this study. Nevertheless, we also affirmed the beneficial influence of environmental and organisational factors in the realm of large-group risk decision-making, viewed from a reverse perspective. These findings support the link between risk perception and vaccine acceptance.

Age was also an important predictor variable: older parents were more likely to make the fastest decision to receive a vaccine. Children are vaccinated multiple times during their lifetime, and these successful experiences provide confidence in vaccinations for fighting the pandemic. In addition, older parents have confidence in their own life experiences, allowing them to make decisions and respond quickly in the face of crises. Therefore, previous successful experiences were a major factor in the M-LSGDM approach in this study. Hence, age serves as an indicator of parental vaccination knowledge and life experience. Health policymakers should consider this when implementing tailored education and intervention measures in policymaking that align with demographic characteristics.

Knowledge, safety and efficacy of vaccination are also primary concerns for parents.9 10 The more parents know about vaccination, the more likely they are to accept it. The more parents worried that their children would contract the virus, the more likely they were to refuse the vaccine in the study, which was related to their insufficient knowledge of the pandemic and vaccines. Parents who believed that the benefits of vaccination outweighed its disadvantages were more likely to accept the vaccination as early as possible. Conversely, when parents perceived that the disadvantages outweighed the benefits of vaccination, they showed greater resistance to vaccinating their children. Furthermore, the more confused or unclear the parents were, the more certain they were about vaccinating their children based on other factors. In the context of large-group risky decision-making, the instability of decision-making members’ psychological behaviour can be regarded as uncertainty in the decision-making process. As a result, the uncertainty of decision-making members’ opinions is an important factor that ultimately affects the consistency of the M-LSGDM approach.14 37 Therefore, ‘I feel anxious about whether to vaccinate my child’ is a positive predictive variable.

Parents who live permanently in large cities are more likely to accept pandemic vaccinations than those living in counties or rural areas. This is one of the geographical risk factors based on the M-LSGDM approach used in this study. Permanent residents in large cities have many people with high mobility and risk. Therefore, these are areas where the country and its communities pay primary attention to prevention and management. In contrast, counties and rural areas have an advantage because of the safety of their geographical locations. In the event of a pandemic outbreak, it is more likely that children will not be vaccinated, given the uncertainty about the safety of the vaccine.10 Geographical variation in vaccine acceptance necessitates targeted policy measures considering specific regional needs.

The average family income was also an important predictor. Parents with a lower average family income (¥) were more likely to accept vaccinations. This is related to the economic level of the family and the physical health of the children. In this study, parents whose children were in relatively poor health were more willing to accept vaccines than those whose children were in relatively good health because the pandemic led to a worse state of children’s health, increasing the burden on the family and the consumption of medical and health resources.9 This point was confirmed in this study. Children over 7 years of age and those under 6 years of age have different vaccination requirements. However, the age of the children in this study was not statistically significant. Parents’ acceptance attitudes towards the vaccination of their children are affected by a variety of factors, including the individual, child, environment and organisation. Therefore, different intervention measures should be taken according to the parents’ different characteristics. Although the child’s age was not a significant factor, practitioners should employ age-appropriate vaccination communication and tailor efforts to meet the unique age group requirements for increased understanding and acceptance among parents. Policymakers should explore financial incentives for lower-income families, ensure equitable access and recognise the pandemic’s economic burden, as support measures such as affordable healthcare and childcare services can enhance overall vaccine acceptance.

Implications

The complexity of decision-making, highlighted by the M-LSGDM approach, emphasises the need for collaborative efforts. Healthcare practitioners, community leaders and policymakers should collaborate to develop comprehensive vaccination strategies, fostering a supportive environment for vaccination through partnerships with community organisations, such as providing transparent information, creating supportive networks and offering counselling services. These implications offer a roadmap for healthcare practitioners and policymakers to design effective strategies addressing nuanced factors in parents’ acceptance attitudes towards child vaccination during a pandemic. A proactive approach involving continuous monitoring and updating of intervention strategies is essential. The dynamic nature of public attitudes during a pandemic necessitates an adaptive healthcare policy framework to address evolving concerns and maintain high vaccination rates. Incorporating these insights into healthcare policies and practices can promote widespread vaccination and contribute to the well-being of children and communities.

Limitations

This study had several limitations. First, we conducted an online survey via social networks to reach a wide research population in a short time during the COVID-19 crisis due to social distancing. However, this type of online self-response method may only target certain sociodemographic groups. To address this problem, we enrolled a large sample and used a random sampling method to stratify respondents according to their demographic characteristics to increase the diversity and representativeness of the sample. Second, self-report questionnaires may not truly reflect the thoughts of participants because of flaws in the method of data collection; however, this limitation may not have negatively influenced the results. Further studies are needed to investigate the acceptance of vaccination during different periods of the pandemic and to assess the perception of vaccine efficiency and safety after the vaccine was made available to the public.

Conclusions

This study explored parental acceptance of vaccination among children and investigated its predictors. With 74.1% of parents expressing willingness to vaccinate their children, this signifies a positive trend and underscores the widespread acceptance of childhood vaccinations. However, the presence of a substantial minority (25.9%) who refused the vaccination highlights the enduring challenges of achieving comprehensive vaccination coverage.

Our study identified key predictors influencing parental decision-making, including age, parental anxiety, concerns about the child’s susceptibility to the pandemic and opinions on vaccination benefits, residence, income and children’s health. Collectively, these factors contribute to the complex landscape of parental attitudes towards child vaccination.

The introduction of the M-LSGDM approach serves as a noteworthy contribution by offering a predictive, dynamic and flexible framework for healthcare decision-making during public health events. This methodological innovation can guide future research and interventions by providing a comprehensive understanding of the multifaceted factors involved in parental decision-making.

Addressing the identified predictors and leveraging the M-LSGDM approach can enhance healthcare practitioners’ and policymakers’ abilities to develop targeted interventions and communication strategies, which are crucial for fostering the widespread acceptance of childhood vaccination, ensuring child well-being, preparing for potential future epidemics. This study underscores the importance of ongoing research and dynamic frameworks to adapt to the evolving landscape of public health challenges.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants. The West China Hospital of Sichuan University Biomedical Research Ethics Committee approved the study (ethics number: 2021-992). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

The authors wish to thank all the school administrators, community workers and volunteers for implementing the study.

References

Footnotes

  • Contributors LC and JK contributed to the study conception. LC,LZand FZ led the study design and supervised data collection and analysis. FZ also acted as guarantor for this study. XX and LZ did the final analysis and interpretation.LCand FZ wrote the first draft of the manuscript.JK.XX and LZ wrote the review and editing.All authors contributed to the manuscript. All authors approved the final draft.

  • Funding This study was supported by the National Natural Science Foundation of China (71871147) and the Science and Technology Department of Sichuan Province Project (2021YJ0013 and 2023JDGD0035).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.