SARS-CoV-2 vaccine acceptance among caregivers of children younger than five years of age: A cross-sectional survey in Toronto

Background Despite severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine approval in Canada for children six months to five years old, vaccine acceptance for this age group remains low compared with other age groups. This study aimed to assess vaccine acceptance among caregivers of children younger than five years old and to identify factors associated with SARS-CoV-2 vaccine hesitancy in Toronto. Methods A multi-language self-administered survey was sent to caregivers of children attending 660 Toronto schools and two community health centres between April 5 to July 4, 2022. Data on socio-demographic characteristics, acceptance of routine childhood and influenza vaccines and current SARS-CoV-2 vaccine status for parents and older siblings were collected. Results A total of 253 caregivers of children younger than five years old answered the survey. Although 234 (94%) of the responding caregivers were fully vaccinated against SARS-CoV-2 and more than 90% had their children older than five years receiving one dose of the vaccine, only 148 (59%) had intentions to vaccinate their child younger than five years old. Conclusion These findings highlight the importance of interventions to increase vaccine confidence among caregivers of children aged younger than five years old.


Introduction
In Ontario, from January 15, 2020, to March 11, 2023, there have been 1,695 children younger than five years old hospitalized for coronavirus disease 2019 (COVID-19) and 23 deaths from COVID-19 (1).National data from Canada found that among children younger than 18 years old hospitalized because of COVID-19, the highest proportion of severe disease was in children aged 2-5 years old (2).On July 14, 2022, Health Canada first approved severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines for children six months to five years of age (3).However, the uptake of SARS-CoV-2 vaccines in this age group has been low in all provinces and remains below 10% in Canada, compared with 52% in the 5-11 years old age group and 83.9% in the 12-17 years old age group (4).Although vaccine uptake rates (which refer to the actual behaviour of getting a vaccine) are lower than reported rates of vaccine acceptance (which refer to the intent to receive a vaccine, or attitude), understanding the COVID-19 vaccine acceptance rates in caregivers of young children and their reasons for hesitancy would allow for the development of targeted interventions to increase confidence and uptake in this age group (5,6).This study addresses time-sensitive and urgent public health matters: 1) the assessment of vaccine acceptance (intent to receive a vaccine or to vaccinate) in caregivers of children younger than five years of age and 2) identification of factors associated with vaccine hesitancy (delay in acceptance or refusal of vaccines) in Ontario prior to the national approval of vaccines for this age group (6).

Methods
A multi-language self-administered cross-sectional survey was sent to caregivers of children and/or pre-school children at 660 public and private schools affiliated with the Hospital for Sick Children COVID-19 Testing Centre and two community health centres in Toronto.The survey was distributed from April 5 to July 4, 2022-immediately before the approval of the vaccine for children six months to five years of age.Caregivers who reported caring for children younger than five years old were asked about their intention to vaccinate their child(ren) against SARS-CoV-2 upon approval of the vaccine for this age group, and their reasons for being hesitant to accept COVID-19 vaccines.Caregivers were considered vaccine-acceptant when they intended (very likely/likely) to vaccinate their children against SARS-CoV-2 in the future, and vaccine-hesitant when had little or no intention (very unlikely/unlikely/unsure) to vaccinate their children in the future.The survey collected information on socio-demographic characteristics (including age, relationship to the child, education status, country of birth and ethnicity) and current vaccine status for caregivers and older siblings of the school-aged group.The questionnaire can be found in the Supplemental material.Data were analyzed using χ 2 or Fisher's exact tests and p-values of <0.05 were considered to be statistically significant.
Responses to the open-ended questions were coded and clustered using thematic analysis.

Results
A total of 253 caregivers of children younger than five years old answered the survey.Although 234 (94%) of the responding caregivers had received at least two doses of COVID-19 vaccine and more than 90% had their children older than five years receiving at least one dose of the vaccine, only 148 (59%) intended to vaccinate their child(ren) younger than five years old.The level of COVID-19 vaccine acceptance differed among caregivers of different ethnic backgrounds, with lowest acceptance reported in Black (25%) and Middle Eastern (37.5%) (p=0.006).Other characteristics associated with differences in vaccine acceptance included caregiver's age (p=0.039,lowest in those over 40 years of age), education level (p=0.011,lowest in university graduates) and vaccination status (p<0.001,lowest in unvaccinated caregivers) (Table 1).Caregivers reported seeking information on COVID-19 vaccines primarily from public health resources (79%), government organizations (62%), social media (58%) and family doctors or paediatricians (45%).When comparing caregivers with different ethnic backgrounds, there were significant differences in the number of those seeking information from public health resources (p<0.001) and family doctors or paediatricians (p<0.001).Compared with caregivers with White background, all other ethnic backgrounds had lower reports of seeking information from public health resources (p<0.001) and family doctors or paediatricians (p<0.001).Additionally, seeking information from family doctors or paediatricians (p=0.029),public health resources (p<0.001),government organizations (p<0.001),professional groups (p=0.012) and social media (p=0.001)differed among caregivers with different levels of education.Caregivers with higher levels of education had higher reports of getting information from family doctors or paediatricians (except for those less than high school), public health resources, government organizations, professional groups and social media (except for a community college diploma) than those with lower levels of education (Table 2).Abbreviations: N/A, not applicable; SARS-COV-2, severe acute respiratory syndrome coronavirus 2 a For the question on current sources of information, there were two missing answers Abbreviation: SARS-COV-2, severe acute respiratory syndrome coronavirus 2 a Caregivers were considered vaccine-acceptant when they intended (very likely/likely) to vaccinate their children against SARS-CoV-2 in the future, and vaccine-hesitant when had little or no intention (very unlikely/unlikely/unsure) to vaccinate their children in the future b Caregivers were able to choose multiple responses for their ethnicity, the Indigenous ethnic group was classified as "mixed and other" due to small group size c Caregivers' country of birth income level was defined based on the World Bank classification 2021 (7) d Caregivers were able to choose multiple answers for the current source of information e Professional groups such as Canadian Medical Association, Canadian Nurses Association, etc.  1).

Conclusion
In this study, conducted prior to approval in Canada for COVID-19 vaccination in children between six months and five years of age, we found that caregivers' intent to vaccinate their child younger than five years old was low.Although vaccine acceptance and uptake may not necessarily be identical concepts, interestingly, the proportion of caregivers who were found to be acceptant of COVID-19 vaccines for their child was found to be much lower than the proportion of caregivers who reported to be vaccinated or who had an older child that was already vaccinated against COVID-19 (6).These findings highlight that targeted interventions are needed to support caregivers with education and opportunities for enhanced discussion supporting COVID-19 vaccination decisions for their young children, especially in groups that were found to have lower vaccine acceptance.Healthcare and public health professionals play a crucial role in fostering SARS-CoV-2 vaccine confidence in parents and relaying up-to-date and accurate information on the benefits and risks of vaccination to caregivers of young children.

Figure 1 :
Figure 1: Reasons for SARS-CoV-2 vaccine hesitancy in caregivers of children younger than five years of age a,b,c

Table 1 :
SARS-COV-2 vaccine acceptance among caregivers of children younger than five years of age

Table 2 :
Current sources of information on SARS-CoV-2 vaccines among caregivers of children younger than five years of age f Social media includes Twitter, Facebook, WhatsApp, WeChat, radio/television/newspapers or news websites g Social networks such as family, friends, neighbours or co-workers.Percentages were calculated based on the cases with complete data h Other sources reported in open-ended questions include scientific articles, workplaces, schools, statistics on government websites, World Health Organization and Centers for Disease Control and Prevention reports, and a friend (a virologist) Long-term side effects reported in open-ended questions include cardiovascular (11/64 or 17.2%; e.g.myocarditis, pericarditis, bleeding and other cardiovascular effects), neurological or developmental (6/64 or 9,4%; e.g.developmental or cognitive issues, stroke and aneurism and other neurological side effects), uncertain due to lack of data, evidence for and potential unspecified new side effects (20/64 or 31.3%),infertility (4/64 or 6.3%), inflammation and autoimmune disease (3/60 or 4.7%) and other long-term side effects (6/64 or 25.0%) b Immediate side effects include cardiovascular (11/36 or 30.6%; e.g.myocarditis/pericarditis, thrombosis and other cardiovascular effects), neurological (3/36 or 8.3%; e.g.stroke, Bell's palsy or other forms of paralysis and seizure), vaccine reactogenicity (7/36 or 19.4%; e.g.fever and pain), allergic reactions (2/36 or 5.6%); inflammation and autoimmune disease (2/36 or 5.6%) and other immediate side effects (11/36 or 31%) Abbreviations: COVID-19, coronavirus disease 2019; SARS-COV-2, severe acute respiratory syndrome coronavirus 2 a c Other reasons include vaccination being unnecessary (4/18 or 22.2%), lack of effectiveness (3/18 or 16.7%) and other reasons (5/18 or 27.8%; e.g.other specific concerns and other general and unspecified concerns)