Abstract

1. Introduction

Over 33 million confirmed cases of coronavirus (COVID-19), including more than 1 million deaths, have been reported globally since the start of the COVID-19 pandemic to 29th September 2020 [1]. COVID-19 has spread to almost every country in the world, resulting in excess mortality and serious social and economic disruptions.

According to COVID-19 mortality figures, the UK is one of the worst affected countries in the world, with over 440,000 cases and 42,000 deaths reported as of 29th September 2020 [1], [2]. In efforts to slow the spread of COVID-19 in the UK, stringent restrictions on movement were enforced on 23rd March 2020, with the general public directed to only leave their homes to: shop for basic essentials, take one form of exercise per day, access medical care or help a vulnerable person, and to travel to and from work if absolutely necessary (where unable to work from home) [3]. People most at-risk from COVID-19 were asked to protect themselves by shielding from 23rd March 2020: staying at home at all times, for at least 12 weeks. In addition, schools were closed to all but vulnerable children and children of key workers [3].

Although restrictions to slow COVID-19 spread have eased in many countries, including the UK, day-to-day life globally remains distinctly marked by the COVID-19 pandemic, and measures to prevent COVID-19 spread [4]. A COVID-19 vaccine has been heralded as key to ending the pandemic and clinical trials to develop a COVID-19 vaccine are currently being conducted at an accelerated rate [5], [6]. To date, over 160 COVID-19 vaccine candidates are under development, with 26 in human trials [6]. In the UK, a Vaccine taskforce has been created to ‘drive forward, expedite and co-ordinate efforts to research and then produce a coronavirus vaccine and make sure one is made available to the public as quickly as possible’ [5]. On 20th July 2020, the UK government secured early access to 90 million doses of promising COVID-19 vaccines, ‘giving the UK the most likely chance of getting access to a safe and effective vaccine at the quickest speed’ [7].

In planning for the near-future availability of a COVID-19 vaccine, as well as focusing on how to deliver COVID-19 vaccine programmes and ensure equitable vaccine allocation globally [8], it is crucial to explore the acceptability of a COVID-19 vaccine to the public. The success of any COVID-19 vaccination programme will depend on public willingness to receive the vaccination.

In the UK, the Joint Committee on Vaccination and Immunisation (JCVI), have provisionally advised that if and when a COVID-19 vaccine becomes available the priority should be to vaccinate those at highest risk of COVID-19 exposure, transmission and severe COVID-19 disease [9]. The JCVI has communicated a preliminary list of priority groups to receive the vaccine that targets those most at risk of disease although it recognises that depending on future vaccine characteristics, it may be that vaccinating young and healthy members of the population will help to prevent COVID-19 transmission to high-risk groups and also reduce societal and economic disruption.

In recognition that a COVID-19 vaccine could be made eligible to the majority of the population, we conducted a multi-methods study to investigate the views of parents and guardians in England on the acceptability of a future COVID-19 vaccine, for themselves and their children.

2. Methods

We used a multi-methods approach – combining qualitative and quantitative methods – with the aim of gaining a more complete insight into the acceptability of a future COVID-19 vaccine. The study utilised a cross-sectional questionnaire survey and semi-structured interviews, to quantify the prevalence of different views on COVID-19 vaccine acceptability, and to explore reasons behind these views. The questions asked regarding COVID-19 vaccine acceptance were part of a larger study exploring parents’ and guardians’ views and perceptions towards childhood vaccinations and use of NHS general practice services for childhood vaccination during the COVID-19 pandemic

3. Cross-sectional survey

4. Findings

1252 parents and guardians completed the survey (see participant characteristics in Table 1). Most survey participants were female (95.0%; n = 1190), raising a child/children with a partner (97.0%; n = 1214), and identified as being White British, White Irish or White Other (94.1%; n = 1178). The age range of participants was 18–48 years (Mean = 32.95, SD = 4.565). Median household income was reported as £55,000-£64,999. Of the survey participants, 1049 (83.8%) left open-text responses to the open text survey questions.

43.3% of survey participants (n = 530) provided their details to be contacted for a follow-on interview. In total, 61 parents were contacted to participate. Of these 19 took part in interviews (18 women and one man), 39 did not respond to recruitment emails, two responded initially but did not follow through with an interview. The characteristics of interviewees are outlined in Table 2.

4.2. Survey open-text and interview findings: Main reasons for accepting the vaccine

Of the survey participants that stated they would definitely accept or were unsure but leaning towards accepting a COVID-19 vaccine for themselves (n = 1128), 897 gave an open-text reason (79.5%). Of the 1116 participants that stated they would definitely accept or were leaning towards accepting a COVID-19 vaccine for their child, 925 gave an open-text reason (82.9%).

Most interviewees said that they would definitely accept or were unsure but leaning towards accepting a COVID-19 vaccine for themselves (n = 18) and their children (n = 16) in their survey responses (see Table 2). Interestingly, one interviewee (#19) that was leaning towards accepting the vaccine at the time of completing the survey discussed that she was leaning towards refusing the vaccination (for herself and her child) at the time of interview.

The following reasons were given for COVID-19 vaccine acceptance for self and for child/children, in order of how often they were mentioned by survey participants and importance to interviewees (see Fig. 1 for the main reasons for accepting the vaccine).

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Fig. 1

Main reasons for accepting the vaccine.

4.2.1. To protect self and others

Of survey participants expressing positive intentions to vaccinate and leaving an open-text response, the most prevalent reason was to provide protection from COVID-19 to the person being vaccinated (for self: 42.4%, n = 380; for child: 42.5%, n = 393), followed by protecting other people (for self: 23.7%, n = 213; for child: 19.5%, n = 180), including family members (for self: 12.2%, n = 109; for child: 5.3%, n = 49). Participants also reported that they would vaccinate to protect someone known to them in a risk group for COVID-19 (for self: 8.2%, n = 74; for child: 3.1%, n = 29). 5.0% (n = 45) of survey participants specifically mentioned that they wanted to receive the vaccine to stay healthy to look after their child/children. Interviewees also corroborated these findings. They also highlighted that vaccinating would make them feel safer in visiting older family members.

‘…. for us, I definitely want that. I'd want us protected as a family. You know, my parents, his [partner’s] parents are ageing, so we'd be going to see them, and I don’t want to put them at risk. So, certainly, I think it's really important.’ (Interview #13)

Several survey participants cited that they would vaccinate as they were key workers (e.g. involved in health and social care, education and childcare, or the food sector) and in frequent contact with other people (6.7%; n = 60). Health and social care workers particularly noted a need to vaccinate to protect themselves and ‘at risk’ patients and clients.

4.2.2. Vaccination as a route to ‘returning to normal life’

For several interviewees, the availability of a vaccine was viewed as the only way of ending social-distancing measures and returning to normal life. Interviewees talked about lockdown as being financially unsustainable, and detrimental to physical and mental wellbeing and children’s educational and social development. Interviewees that were shielding during the pandemic were particularly keen to accept a future vaccine, with one parent who had looked into entering a COVID-19 vaccine trial saying they ‘would be first at the door’.

Survey participants also indicated that they would be vaccinated (3.7%; n = 33) and get their children vaccinated (2.6%; n = 24) as a means of stopping the need for social distancing and returning to normality.

‘…society can't go back to normal until most of us are immune. A vaccine is the quickest way to achieve that’ (Survey participant #346).

‘I believe in the importance of all recommended vaccinations for my child anyway and worry about her [participant’s daughter] contracting COVID-19. I also worry about her [participant’s daughter] losing out on normal experiences such as seeing relatives and friends, going to classes and preschool etc. if we cannot manage the pandemic.’ (Survey participant #857)

4.2.3. Trust and belief in the importance of vaccination

Survey participants indicated that they would receive the vaccine for themselves (5.1%; n = 46) or their child/children (7.0%; n = 65) if it was recommended by the government or healthcare workers. Survey participants cited their belief in the importance of vaccination as a reason to receive the vaccination themselves (3.9%; n = 35) or to vaccinate their children (5.4%; n = 50).

‘I trust that if vaccines are approved for general use and recommended by NHS, they are safe.’ (Survey participant #83)

A proportion of survey participants specifically reported trust in vaccinations, science or healthcare workers as a prompt to vaccinate their child/children (4.1%; n = 38) and themselves (2.7%; n = 24).

4.2.4. Less risk in vaccinating adults

Interviewees and survey participants discussed a greater willingness to ‘risk’ receiving the vaccination for themselves than for their children due to safety concerns. Survey participants also reported the perception that it was less risky to vaccinate adults than children (3.2%; n = 29) as the vaccine trials were conducted in adults.

‘I feel safer having the vaccine as an adult as trial would be based on adults’ (Survey participant #370)

4.3. Survey open-text and interview findings: main reasons for not accepting the vaccine

Of the participants that stated they would definitely reject or were unsure but leaning towards rejecting a COVID-19 vaccine for themselves (n = 124), 100 left an open-text reason (80.6%). Of the 136 participants that stated they would definitely reject or were leaning towards rejecting a COVID-19 vaccine for their child, 124 (91.2%) gave an open-text response. Three interviewees reported that they were unsure but leaning towards rejecting a COVID-19 vaccine for their child/children. One interviewee (#14) was leaning towards rejecting a COVID-19 vaccine both for themselves and their child (see Table 2).

The following reasons were given for COVID-19 vaccine rejection by survey participants and interviewees (see Fig. 2 for the main reasons for not accepting the vaccine).

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Fig. 2

Main reasons for not accepting the vaccine.

4.3.1. Vaccine safety and effectiveness concerns

The most common concerns expressed by survey participants about a COVID-19 vaccine were around vaccine safety (for self: 49.0%, n = 49; for child: 62.1%, n = 77) and effectiveness (for self: 11.0%, n = 11; for child: 8.1%, n = 10), which were largely prompted by the newness and rapid development of the vaccine (for self: 50.0%; n = 50; for child: 67.7%; n = 84), and the newness of COVID-19 (for self: 3.0%, n = 3; for child: 4.0%, n = 5). Participants were worried that the development process might be too rapid, not allowing enough time for adequate testing to confirm the vaccine’s short and long-term safety, and also vaccine effectiveness.

These concerns were echoed by interviewees who had reservations around how a vaccine developed in a fraction of the usual timeline for vaccine development could be confirmed as safe.

‘I'm very pro-vaccines in general, but my main concern was as long as it hasn't been rushed through. As long as we know it' safe and all the proper tests have been done, and, you know, when you sort of heard things in the news like well, it's been 18 years and they haven't developed a SARS vaccines, or whatever it was that was sort of banded around yesterday, it sort of makes you go, why is that? So, I think that if a vaccine was to come out like this one could do in a hurry it need to have associated information to how this has been able to happen so quickly.’ (Interviewee #19)

Some survey participants and interviewees wanted to ‘wait-and-see’ if the vaccination was safe before being vaccinated themselves, or getting their children vaccinated. One interviewee discussed preferring for her family to remain in lockdown for longer (i.e. living for a longer duration with the restrictions implemented on 23rd March 2020), to allow more time for vaccine development and safety testing. This interviewee acknowledged this situation as not a financially viable option for those unable to work from home.

4.3.2. Children less at risk of COVID-19

Some survey participants expressed a lack of benefit to vaccinating their children, citing that children are hardly affected, are at lower risk of severe COVID-19 infection than adults (19.4%, n = 24), and less likely to catch or transmit COVID-19 (3.2%, n = 4). Participants and interviewees discussed the decision to vaccinate their children in terms of balancing potential advantages and disadvantages. The perception that children are less at risk of COVID-19 was combined with safety concerns as a reason not to vaccinate.

‘Any vaccine for covid-19 will have been produced in a huge hurry, possibly bypassing some of the normal processes and procedures that ensure safety. As small children have a very low risk of being seriously ill from the virus, I'm not sure I would risk it. I would encourage my mum, who is 70 with underlying health conditions, to take it though as the risk /reward is different.’ (Survey participant #1095)

Several survey participants indicated that they would be more likely to get their child/children vaccinated if this was beneficial in reducing COVID-19 spread to older people and clinical risk groups.

4.3.3. Low perception of risk

Some survey participants indicated not needing the vaccine as they (16.0%, n = 16) and their child/children (3.2%, n = 4) were ‘fit and healthy’ and not in an at-risk group. 2% of participants (n = 2) indicated that it was better to prioritise ‘at-risk’ groups for vaccination.

4.3.4. Already had COVID-19

A small number of survey participants indicated that they would not accept a COVID-19 vaccine for themselves or their child/children as they (6.0%, n = 6) or their child (3.2%, n = 4) had already had COVID-19.

4.3.5. Need for transparency to make an informed vaccine decision

To be able to make an informed choice about vaccination, parents expressed a need for transparent information on vaccine development, vaccine efficacy and vaccine safety. A lack of vaccine information at present was given as a reason not to accept the vaccine for a minority of survey participants for their children (4.8%, n = 6) and for themselves (1.0%, n = 1). One interviewee also discussed that the information should come from trusted sources such as healthcare professionals, the NHS and Public Health England.

‘…if the NHS is telling you something you’re more likely to believe it, whereas if it’s a politician, you know, you’ve got much more incentive to think, “Well, are they telling the truth?” (Interviewee #17)

4.3.6. Lack of trust

A small number of survey participants stated a lack of trust in vaccinations, science or the medical profession as a reason to not accept a vaccine (for self: 4.0%, n = 4; for child: 1.6%, n = 2).

5. Discussion

In this multi-methods study, the majority of parents and guardians reported they would definitely accept or were unsure but leaning towards accepting a COVID-19 vaccine for themselves and their child/children.

Attitudes towards a COVID-19 vaccine appear more positive in our study (in terms of the proportion of participants reporting they would definitely accept or were leaning towards accepting vaccination) than those reported in surveys conducted with adults in France, Germany, Italy, Portugal, the Netherlands and the US [11], [12], [13], and comparable to reports from Denmark and Australia [12], [14]. However, this could be due to differences in the questions asked; highlighting the need for cross-country surveys and consistency in the wording of questions. These surveys indicate that the difference in vaccination acceptance ranges greatly between countries, from around 62% in France to 80% in Denmark and the UK [12], and are reflective of trust in vaccines and health systems more broadly, and in governments. More positive attitudes towards COVID-19 vaccination in our study appear to reflect the high level of parent trust in vaccines in the UK, and trust in the NHS.

The main reasons, or ‘pros’ for vaccinating, were to protect the individual being vaccinated against COVID-19, followed by protecting others from the disease. Uncertainties around vaccine safety, effectiveness, and the benefit of vaccinating children were the most prevalent reasons given for COVID-19 vaccine refusal. Safety and effectiveness concerns were prompted by fears that the accelerated vaccine development process, considered politically motivated, could result in cutting corners. Comparably, previous research also suggests that people consider older vaccines safer than newer ones [15], [16], and highlights the importance of transparency in communicating about the vaccine development process and of vaccination safety testing.

When a COVID-19 vaccine is launched, should any safety signals or safety concerns arise, it will be key for government and public health officials to reassure the public with transparency, action, accountability and timeliness in order to avoid any detrimental impact of the new vaccine on the current national immunisation programme. The dengue vaccine controversy in the Philippines highlights how safety concerns around a newly launched vaccine, Dengvaxia, can derail a successful national immunisation programme leading to drops in childhood vaccine uptake, and even spill over to other health care treatments [17]. A number of safety scares have also derailed vaccine programmes in the past, including safety concerns around the HPV vaccine in Japan which spread globally [18].

Other surveys have identified that views on COVID-19 vaccine acceptance are influenced by vaccine efficacy and perceptions of disease risk. In a cross-sectional survey conducted in Indonesia, Harapan et al [19] found that 93.3% of participants would receive a COVID-19 vaccine that was 95% effective but only 67.0% of participants would accept a 50% effective vaccine. The authors also found that acceptance was higher amongst participants that considered themselves at greater risk of COVID-19 infection.

In our study, lower levels of vaccine acceptance for children were discussed by parents in terms of children being at lower-risk of COVID-19. Evidence suggests that children have lower susceptibility to COVID-19 [20], very few children develop severe COVID-19 (even if they are in a clinical risk group), and their role in the transmission of COVID-19 is unclear [21]. Similarly with influenza vaccination, parents and guardians in our study more often considered the perceived benefits to their child, rather than societal benefits, as a reason to vaccinate their children [22].

6. Strengths and limitations

The quality of the study was enhanced through the use of a multi-methods approach in which interview and open-text responses were used to develop insight into factors underpinning quantitative responses. Our study took place at the height of the COVID-19 pandemic in England and a survey repeated now that we are ‘past the peak’ of COVID-19 cases and deaths and lockdown has been eased may yield different responses. This has already been indicated in the second wave of a large European survey looking at COVID-19 vaccine attitudes [28]. This highlights the need for longitudinal studies to measure the acceptability of a COVID-19 vaccine at different intervals.

Our recruitment strategy achieved a high number of responses (n = 1252). Although largely representative geographically, our sample lacked representability in terms of household income and ethnicity. For example, in relation to ethnicity, according to the 2011 census 85% of the population in England was White. 94% of our survey participants self-reported as White [29]. Our recording of household income is not directly comparable to UK data from the Office for National Statistics (ONS), as we did not specify if the income value provided by survey participants should be pre or post-tax and benefits, or take into account the number of household occupants. We also captured data for income in banded forms, rather than asking for exact amounts. However, our sample appears to have a much higher median household income (£55,000-£64,999) than the median household income for the UK (£29,600) [30]. This meant that although our sample size was large enough to identify ethnicity and income as determinants of vaccine acceptance, it was not possible to explore differences in vaccination views by these variables when looking at open-text responses.

7. Conclusion

The success of COVID-19 vaccination programmes will rely heavily on public willingness to accept the vaccine. The main concerns raised by parents in our study were around the safety and effectiveness of a ‘rushed’ and new COVID-19 vaccine. To alleviate these concerns, there needs to be clear communication and transparency as to how COVID-19 vaccines are developed and tested, and safety and efficacy information.

Opening up a conversation with members of the public at an early stage is key to understanding factors that may affect vaccine acceptability, and developing approaches to allay any concerns. This must happen in parallel with efforts to develop a COVID-19 vaccine.

Importantly, efforts must be made to understand and address factors that may affect COVID-19 vaccine uptake in Black, Asian and ethnic minority groups and lower-income households who are disproportionately affected by COVID-19.

8. Author’s contributions

SB, RC, SM-J and PP initiated and designed the study. SB led the survey and interview recruitment. SB and PP conducted the interviews. RC led the design of the survey. RC performed the statistical analysis, with the support of JW. PP performed the analysis of open-text survey responses. SB performed the qualitative interview analysis and prepared the first draft of the manuscript. All authors were involved in the interpretation of findings. All authors participated in manuscript preparation and approved the final manuscript.

Data availability

The full dataset will be made available to bona fide researchers upon request and agreement by the study team. Further information on the data and access conditions can be found through the LSHTM Data Compass at: https://doi.org/10.17037/DATA.00001862.

Ethical approval

Ethical approval for this study was granted by the London School of Hygiene & Tropical Medicine Observational Research Ethics Committee (Reference: 21879).

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Acknowledgements

References