Parental COVID-19 vaccine hesitancy: a cross-sectional survey in Italy

Abstract

Background
Understanding parents’ hesitancy against COVID-19 vaccination for their children may be useful.

Methods
A self-administered online survey was conducted among 394 parents with at least one child aged 12-18 years in Italy.

Results
The mean perceived risk that their child can be infected by the SARS-CoV-2, measured on a 10-point Likert-type scale, was 7.7 and it was higher if at least one parent/partner cohabitant have had COVID-19, in those who believed that COVID-19 is a serious illness, and in those who had not vaccinated their child. 82.1% respondents were willing to vaccinate their child and this was more likely among those who believed that this vaccine is useful and who did not need additional information. Only 12.4% were, according to the 5-item Parent Attitudes About Childhood Vaccines Survey (PACV-5) score, high-hesitant toward anti-COVID-19 vaccination. Respondents not graduated, those who did not believe that this vaccination was useful, those who did not get this vaccine, those who did not obtain information from physicians, and those who needed additional information were more likely to be high-hesitant.

Conclusions
Communication and public health interventions must be intensified to enhance the attitude and to help parents on deciding on COVID-19 vaccination of their children.

Full text

Full Terms & Conditions of access and use can be found at
https://www.tandfonline.com/action/journalInformation?journalCode=ierv20
Expert Review of Vaccines
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ierv20
Parental COVID-19 vaccine hesitancy: a cross-
sectional survey in Italy
Aida Bianco, Giorgia Della Polla, Silvia Angelillo, Concetta P Pelullo,
Francesca Licata & Italo F. Angelillo
To cite this article: Aida Bianco, Giorgia Della Polla, Silvia Angelillo, Concetta P Pelullo,
Francesca Licata & Italo F. Angelillo (2022) Parental COVID-19 vaccine hesitancy:
a cross-sectional survey in Italy, Expert Review of Vaccines, 21:4, 541-547, DOI:
10.1080/14760584.2022.2023013
To link to this article: https://doi.org/10.1080/14760584.2022.2023013
Published online: 02 Jan 2022.
Submit your article to this journal
Article views: 133
View related articles
View Crossmark data

ORIGINAL RESEARCH
Parental COVID-19 vaccine hesitancy: a cross-sectional survey in Italy
Aida Bianco
a
, Giorgia Della Polla
b
, Silvia Angelillo
a
, Concetta P Pelullo
c
, Francesca Licata
a
and Italo F. Angelillo
c
a
Department of Health Sciences, University of Catanzaro “Magna Græcia”, Catanzaro, Italy;
b
Health Direction, Teaching Hospital, University of
Campania “Luigi Vanvitelli”, Naples, Italy;
c
Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
ABSTRACT
Background: Understanding parents’ hesitancy against COVID-19 vaccination for their children is
useful.
Methods: A self-administered online survey was conducted among 394 parents with at least one child
aged 12–18 years in Italy.
Results: The mean perceived risk that their child can be infected by the SARS-CoV-2, measured on a 10-
point Likert-type scale, was 7.7 and it was higher if at least one parent/partner cohabitant have had
COVID-19, in those who believed that COVID-19 is a serious illness, and in those who had not
vaccinated their child. 82.1% respondents were willing to vaccinate their child and this was more likely
among those who believed that this vaccine is useful and who did not need additional information.
12.4% were, according to the 5-item Parent Attitudes About Childhood Vaccines Survey (PACV-5) score,
high-hesitant toward anti-COVID-19 vaccination. Respondents not graduated, those who did not
believe that this vaccination was useful, those who did not get this vaccine, those who did not obtain
information from physicians, and those who needed additional information were more likely to be high-
hesitant.
Conclusions: Communication and public health interventions must be intensified to enhance the
attitude and to help parents in deciding on COVID-19 vaccination of their children.
ARTICLE HISTORY
Received 3 September 2021
Accepted 21 December 2021
KEYWORDS
Children; Italy; COVID-19;
parents; vaccination; vaccine
hesitancy
1. Introduction
Public health measures in communities and settings where
people gather remain the foundation of the pandemic
response in order to prevent and reduce the spread of SARS-
CoV-2 infection. It is well-known that these universal preven-
tive measures included hand washing with soap and water,
wearing of face mask, social distancing, covering of the mouth
and nose when coughing, and avoiding touching of the face.
Moreover, in early December 2020 various vaccines, com-
monly recognized as one of the most successful and cost-
effective public health investments, have arrived and mass
vaccination programs have been introduced in several
countries.
In Italy, the widespread outbreak of the SARS-CoV-2 infec-
tion has determined more than 4.500.000 confirmed cases and
128.000 deaths, as of 25 August 2021 [1]. In Italy, the corona-
virus disease 2019 (COVID-19) vaccination campaign was initi-
ally launched at the end of December 2020 among healthcare
workers (HCWs) and residents of nursing homes, followed by
elderly people, essential service providers, and people with
chronic diseases. The Italian Medicines Agency (AIFA) subse-
quently recommended a COVID-19 vaccine for children age 12
and up via a notification issued on 31 May 2021 [2]. Because of
the impact of parents’ beliefs and attitudes on the decision
regarding the vaccine uptake of their children, this group is
the cornerstone of vaccination. However, while previous
studies have been conducted to examine willingness and
hesitancy in the context of COVID-19 vaccination among dif-
ferent groups of individuals in different localities [3–9], infor-
mation is lacking about the parental hesitancy regarding this
vaccination for their children [10–13]. Moreover, even less is
known about the hesitancy and motivations among this popu-
lation in Italy and, given the public health importance of
a broad uptake of COVID-19 vaccination to prevent the spread
of the disease, a better understanding of this topic is strongly
required. With this in mind, to bridge this knowledge gap the
present study was designed to determine the prevalence of
the hesitancy toward COVID-19 vaccination for children and to
identify the main determinants among a sample of parents in
Italy.
2. Materials and methods
2.1. Setting and participants
An anonymous survey was developed and administered using the
online platform Google Forms (Google Inc. Mountain View, CA,
USA) between April and May 2021 among a random sample of
parents with at least one child aged 12 to 18 years recruited from
five randomly selected middle public schools in the geographic
areas of Catanzaro and Salerno, southern part of Italy. Assuming
that 15% of the subjects in the population were highly hesitant
regarding the COVID-19 vaccine for their child, and an expected
CONTACT Italo F. Angelillo italof.angelillo@unicampania.it University of Campania ‘Luigi Vanvitelli’, Via Luciano Armanni, 5, 80138 Naples, Italy
EXPERT REVIEW OF VACCINES
2022, VOL. 21, NO. 4, 541–547
https://doi.org/10.1080/14760584.2022.2023013
© 2022 Informa UK Limited, trading as Taylor & Francis Group

response rate of 50%, the study would require a sample size of 392
for estimating the expected proportion with a margin of error of
5% and a 95% confidence interval.
2.2. Procedures
The Ethics Committee of the Teaching Hospital of the
University of Campania ‘Luigi Vanvitelli’ approved the
study protocol. Once ethics approval was obtained, the
directors of the selected schools received a letter on the
objectives of the study and their collaboration was
requested. After their approval, the schools send to each
family an e-mail with an invitation letter regarding the
purposes and voluntary nature of the study, the proce-
dures, the duration of the electronic survey (estimated to
be less than 10 minutes), and a link in order to complete
the questionnaire by one of the parents. Reminders were
sent after two weeks, and the survey link was closed four
weeks after the distribution of invitations. Only one parent
per child was invited to complete the questionnaire on-line
via the link or via telephone for personal choice with
a research assistant who had previous experience in qua-
litative research. In the invitation letter and at the start of
the questionnaire, participants were assured regarding the
confidentiality of the responses by replacing names with
numbers and removing any identifying information from
the interview transcripts, that their participation was on
a voluntary basis, that all questions were compulsory and
respondents will not be able to move on before they have
answered, and that they could withdraw their participation
at any time. Respondents were asked for consent on the
opening page of the survey, where information about the
study and its aims were presented. By selection of a tick
box, parents provided the informed consent prior to start-
ing the questionnaire. Respondents did not receive any
type of award or credit for survey completion.
2.3. Instrument
A survey questionnaire was adapted specifically from previous
similar studies in the field conducted by some of us on other
populations [4,14]. The questionnaire was pretested on
a group of 20 non-selected parents for assessing content
validity, appropriateness, clarity, and question comprehensi-
bility. The results of the pretest were not included in the study.
The instrument was divided into the following three sections: 1)
socio-demographic and general characteristics of the respondent
(gender, age, marital status, occupation, educational level, number
of children in home, at least one parent/cohabitant partner having
been infected with SARS-CoV-2, having vaccinated the child
against COVID-19); 2) attitudes toward the COVID-19 infection
and vaccination (concern that the child could be infected by the
SARS-CoV-2, belief that COVID-19 is a serious illness, perceived
utility of COVID-19 vaccine) and behaviors. The attitudes were
measured with a 10-point Likert-type scales from 1 to 10, with
higher values corresponding to a stronger agreed with the state-
ments. Parents were also asked whether they had already received
the COVID-19 vaccine and if the answer was negative, it was asked
whether they were willing or unwilling to receive it. Parents were
also asked whether their child has been vaccinated and if the
answer was negative, whether they were willing for vaccination
and the reasons for willingness or unwillingness. Parental vaccine
hesitancy was assessed using the 5-item version of the validated
15-item Parent Attitudes About Childhood Vaccines Survey (PACV)
[15,16] that has been modified to investigate the COVID-19 vac-
cine hesitancy. Participants responded to PACV-5 items on
a 5-point Likert scale. All items are assigned a numeric score,
with non-hesitant responses receiving a score of 0, responses of
‘not sure’ and ‘I don’t know’ receiving a score of 1, and hesitant
responses receiving a score of 2. The score ranged from 0 to 10,
with higher scores indicating increased hesitance. Participants
were categorized as high-hesitant with a PACV-5 score 7–10,
moderate-hesitant with a score 5–6, and low-hesitant with
a score 0–4; and 3) their primary sources of information about
COVID-19 vaccination, and whether they had further need.
2.4. Statistical analysis
The data were managed and analyzed using the software
Stata version 15 [17]. Analysis was performed in three steps.
First, descriptive analyses were conducted to identify the dis-
tribution of the different variables of the study population.
Second, univariate analysis was conducted using chi-square
test and Student’s t-test, respectively, to examine the potential
association between the categorical and the continuous vari-
ables. Third, the variables which revealed a p-value less than or
equal to 0.25 in univariate analysis were included as predictor
variables into multivariate logistic and linear regression mod-
els in order to identify the association between independent
characteristics and the following outcomes of interest: belief
that COVID-19 is a serious illness (no = 0; yes = 1) (Model 1);
concern that their child can be infected by the SARS-CoV-2
(continuous) (Model 2); belief that the vaccine against COVID-
19 was useful for the prevention of the disease (continuous)
(Model 3); positive attitude toward willingness to vaccinate
against COVID-19 their child (no = 0; yes = 1) (Model 4); and
parents’ COVID-19 vaccine hesitancy (PACV-5 score ≤6 = 0;
PACV-5 score 7–10 = 1) (Model 5). The following explanatory
variables were tested in all Models: gender, age, marital status,
baccalaureate/graduate degree, HCW, other parent/partner
working in the healthcare sector, number of children in
home, at least one parent/cohabitant partner who have con-
tracted SARS-CoV-2, having received the COVID-19 vaccine,
having received information on COVID-19 vaccination from
physicians, and need of additional information on COVID-19
vaccination. The variable child immunized against COVID-19
was included in Model 2; the variable concern that their child
can be infected by the SARS-CoV-2 was included in Models 3
to 5; the variable parents who believed that the vaccination
was useful for the prevention of COVID-19 was included in
Models 4 and 5; and the variable parents who believed that
COVID-19 is a serious illness was included in Models 2, 4, and
5. To examine the contribution of each variable, Odds Ratios
(OR) and the 95% confidence intervals (CI) were calculated in
the multivariate logistic regression analysis, and standardized
regression coefficients (ß) in the linear regression analysis. All
analyses were based on two-sided p values, with statistical
significance defined as p equal to or less than 0.05.
542 A. BIANCO ET AL.

3. Results
3.1. Characteristics of the respondents
Of the 800 parents contacted, 394 participants were inter-
viewed yielding a response rate of 49.3%. The socio-
demographic and key characteristics of the sample are
shown in Table 1. The majority were females (86.8%), the
mean age was 47.1 years, 89.8% were married or cohabited
with a partner, one-third had university qualifications, the
vast majority had at least another child in home (90.6%),
only 5.8% have been infected with SARS-CoV-2, and 65%
have been vaccinated against COVID-19.
3.2. Attitude toward COVID-19
Based on the attitude items assessed, 84.8% of respon-
dents agreed or strongly agreed that COVID-19 was
a severe disease. Those with the other parent/partner not
working in the healthcare sector, those who had received
the COVID-19 vaccine, and those who had received infor-
mation about vaccination against COVID-19 from physi-
cians were more likely to believe that COVID-19 is
a serious illness (Model 1 in Table 2).
° p< 0.001; °° p< 0.01; °°° p< 0.05
The perceived risk to parents that their child can be
infected by the SARS-CoV-2 resulted with a mean total value
of 7.7. The linear regression model showed that this perceived
risk was higher in those with at least one parent/cohabitant
partner who have contracted SARS-CoV-2, in those who
believed that COVID-19 is a serious illness, and in those who
had not vaccinated against COVID-19 their child (Model 2 in
Table 2). The belief that the vaccine against COVID-19 was
useful for the prevention of the disease resulted with a mean
total value of 8.7. Being married/cohabitant, having no more
than one other child in the home, those who had been
vaccinated against COVID-19, and those who had received
information about vaccination against COVID-19 from physi-
cians were more likely to believe that the vaccine against
COVID-19 is useful (Model 3 in Table 2).
Only 11.2% had their children vaccinated against COVID-19
and among parents of unvaccinated adolescents, 82.1% were
willing to vaccinate their child. Those who believed that the
vaccine is useful and those who did not need additional
information about this vaccination were more likely to express
the willingness to vaccinate their child against COVID-19
(Model 4 in Table 2). Parents reported that the three most
important factors for willingness to vaccinate their child were
confidence in this vaccine (29.3%), having their child’s doctor
who recommended the vaccine (28.9%), and that the COVID-
19 was a severe disease (22.6%). Among respondents who
were unwilling to vaccinate their child, the major cited reason
was the confidence that the COVID-19 vaccine was
unsafe (55.4%).
3.3. COVID-19 vaccine hesitancy
A total of 12.4% parents were classified as high-hesitant
toward anti-COVID-19 vaccination with a total PACV-5
score ≥7, 32% as moderate-hesitant scoring between 5
and 6, and 55.6% as low-hesitant scoring ≤ 4. The distribu-
tion of the responses for each item on the PACV-5 is
presented in Table 3.
More than half (51.3%) of the parents agreed or were
not sure that a child received too many shots and more
than three-quarters stated that it is better for children to
receive fewer vaccines at the same time (76.1%) and
strongly disagreed or disagreed that it is better for chil-
dren to develop immunity by getting sick than to get
a shot (77%). Approximately half (46.7%) of respondents
considered themselves to be vaccine hesitant. Half (50%)
agreed that they trust the information received about the
COVID-19 vaccine. Respondents who did not get
a graduate degree, those who believed that the vaccine
against COVID-19 was not useful for the prevention of the
disease, those who did not get the COVID-19 vaccine,
those who did not obtain information about vaccination
against COVID-19 from physicians, and those who needed
additional information on this vaccination were more likely
to be high-hesitant (Model 5 in Table 2).
3.4. Sources of COVID-19 vaccination-related
information
Almost all respondents reported a variety of sources of infor-
mation about vaccination against COVID-19 (99.2%). The phy-
sicians were indicated as their primary source (83.8%) followed
by mass media (82%), friends (76.9%), and Internet (75.4%). Of
Table 1. Demographic and key characteristics of respondents and selected
children.
N %
Gender
Male 52 13.2
Female 342 86.8
Age, in years 47.1 ± 6.8
(30–75)*
Marital status
Married/Cohabitant 354 89.8
Unmarried/Widowed/Separated/Divorced 40 10.2
Educational level
None/Primary school 5 1.2
Middle school 72 18.3
High school 174 44.2
Baccalaureate/Graduate degree 143 36.3
Working in healthcare
Yes 47 11.9
No 347 88.1
Other parent/cohabitant partner working in healthcare
Yes 31 7.9
No 363 92.1
Number of children in home
1 37 9.4
2 217 55.1
≥3 140 35.5
At least one parent/cohabitant partner contracted SARS-CoV-2
Yes 23 5.8
No 371 94.2
Having received the COVID-19 vaccine
Yes 256 65
No 138 35
Child received COVID-19 vaccine
Yes 44 11.2
No 350 88.8
*Mean ± Standard deviation (Range).
EXPERT REVIEW OF VACCINES 543

note, more than half (52.3%) expressed a desire for additional
information regarding vaccines against COVID-19.
4. Discussion
This survey represents the first experience about the preva-
lence of the hesitancy toward COVID-19 vaccination for chil-
dren among a sample of parents in Italy and how this varies
according to different variables. Findings suggest three key
messages.
First, only 11.2% of the parents reported that their child was
vaccinated against COVID-19 and the hesitancy toward this vac-
cination for children was low. Indeed, only 12.4% were classified
as high-hesitant with a total PACV-5 score ≥7. Moreover, 82.1% of
parents of unvaccinated child were willing to vaccinate their
child against SARS-CoV-2. This prevalence was similar to the
Table 2. Results of multivariate logistic and linear regression analysis to characterize factors associated with the different outcomes of interest.
Model 1. Belief that COVID-19 is a serious illness OR 95% CI
Log likelihood = −148.03, χ
2
= 39.14 (8 df), p< 0.0001
Having received the COVID-19 vaccine 3.46° 1.8–6.64
Having received information about vaccination against COVID-19 from physicians 2.37°°° 1.18–4.75
Other parent/cohabitant partner not working in the healthcare 0.29°°° 0.11–0.78
At least one parent/cohabitant partner with COVID-19 0.58 0.2–1.68
Married/Cohabitant 1.51 0.63–3.59
Graduate degree 1.33 0.66–2.67
Older 1.02 0.98–1.01
Working in healthcare 1.39 0.42–4.62
Model 2. Perceived risk that their child can be infected by the SARS-CoV-2 Coeff. t
F (7,386) = 10.06, p< 0.0001, R
2
= 15.4%, adjusted R
2
= 13.9%
Belief that COVID-19 is a serious illness 2.42° 7.21
Having not vaccinated against COVID-19 their child −0.99°° −2.6
At least one parent/cohabitant partner have contracted SARS-CoV-2 1.25°°° 2.49
Females 0.65 1.86
Unmarried/Widowed/Separated/Divorced 0.28 0.71
Other parent/cohabitant partner not working in healthcare −0.16 −0.35
Having received information about vaccination against COVID-19 from physicians 0.1 0.3
Model 3. Belief that the vaccine against COVID-19 was useful for the prevention of the disease Coeff. t
F (7,386) = 11.95, p< 0.0001, R
2
= 17.8%, adjusted R
2
= 16.3%
Having received the COVID-19 vaccine 1.15° 5.35
Having received information about vaccination against COVID-19 from physicians 1.01° 3.94
Married/Cohabitant 1.09° 3.45
Number of children in home
1 a
2 −0.19 −0.53
≥3 −0.52°°° −2.51
Working in healthcare 0.38 1.24
Graduate degree 0.03 0.02
Model 4. Willingness to vaccinate against COVID-19 their child OR 95% CI
Log likelihood = −86.21, χ
2
= 157.95 (10 df), p< 0.0001
Belief that the vaccine against COVID-19 was useful for the prevention of the disease 2.58° 2–3.31
Not needing additional information about vaccination against COVID-19 0.39°°° 0.16–0.94
Working in healthcare 4.96 0.52–47.3
Belief that COVID-19 is a serious illness 1.85 0.67–5.13
Not having received information about vaccination against COVID-19 from physicians 0.63 0.18–2.1
Concern that their child can be infected by the SARS-CoV-2 1.01 0.84–1.22
Having received the COVID-19 vaccine 1.05 0.46–2.44
Number of children in home
1 a
2 0.93 0.21–4.07
≥3 0.99 0.41–2.35
Married/Cohabitant 1.07 0.29–3.9
Model 5. High-hesitant toward anti-COVID-19 vaccination OR 95% CI
Log likelihood = −187.91, χ
2
= 161.02 (12 df), p< 0.0001
Belief that the vaccine against COVID-19 was not useful for the prevention of the disease 0.53° 0.43–0.66
Not graduate degree 0.33° 0.19–0.58
Not having received the COVID-19 vaccine 0.41°° 0.23–0.71
Needing additional information about vaccination against COVID-19 1.93°°° 1.16–3.22
Not having received information about vaccination against COVID-19 from physicians 0.49°°° 0.25–0.98
Females 2.17 0.91–5.19
Number of children in home
1 a
2 0.45 0.18–1.14
≥3 1.01 0.63–1.88
Other parent/cohabitant partner not working in healthcare 0.31 0.09–1.11
Not working in healthcare 0.67 0.27–1.71
Younger 0.99 0.95–1.03
Belief that COVID-19 is not a serious illness 0.97 0.42–2.19
a
Reference category.
544 A. BIANCO ET AL.

87.5% among parents in China [18] and higher than the 61.9% in
the United States [19], the 51% in Germany [10], the 48.2% in
England [13], and the 28.9% in Turkey with a COVID-19 vaccine
from abroad and 56.8% with a national one [20]. Results among
other groups in Italy showed that the willingness to receive the
vaccine was 91.5% in nurses [21], 84.1% in a university popula-
tion [14], 81.9% in the general population [22], and 80.7% in
HCWs [4]. It is important to mention that these studies differ
partly in their methodology and periods from the present one,
but are a useful benchmark to evaluate the present results. The
three most common reasons for this positive attitude were con-
fidence in the vaccine (29.3%), having their child’s doctor who
recommended the vaccine (28.9%), and that the COVID-19 was
a severe disease (22.6%). However, the most reported barrier for
the unwilling to the vaccination was the confidence that the
COVID-19 vaccine was unsafe (55.4%). This finding reinforces
earlier reports, either as barrier to vaccination or to the willing-
ness [13,19,20,23]. Therefore, HCWs play an essential role in
educating and providing accurate information on the benefits
and risks of vaccines for addressing parental concerns and cor-
recting their misconceptions. This is also important since the
belief that the vaccine against COVID-19 is useful significantly
influences the intent to vaccinate the children.
Second, the sample mostly received information from
physicians, followed by mass media, friends, and Internet.
This finding is relevant because physicians are a significant
influential source for parents and this exposure has been
demonstrated to be exceptionally effective in disseminating
credible information about COVID-19 and its vaccination.
Indeed, parents who had received information from physi-
cians were more likely to believe that COVID-19 is a serious
illness and that the vaccine against COVID-19 is useful.
Additionally, those who have not received information
from physicians were more likely to be high-hesitant.
These findings highlight the value of communications and
information from physicians, as other HCWs, that positively
impact the level of knowledge, the higher perception of
vaccine usefulness, and the appropriate practice [24–27].
Therefore, it is crucial that parents should be encouraged
to routinely gather information primarily from HCWs to help
them to discern credible from non-credible information.
Moreover, on the other hand, the reported use of the
mass media and Internet is an issue of concern. Previous
studies have reported that, despite the extraordinary public
health efforts to promote accurate information, radio and
television, social media, and Internet have disseminated
misleading or nonfactual information that is not verified or
that contradicts what the evidence normally reports [28–30].
Third, additional results of the multivariate regression analysis
indicated that respondent/cohabitant having contracted COVID-
19 perceived a higher risk that their child can be infected by the
SARS-CoV-2. Those married/cohabitant and those with no more
than one other child at home were more likely to believe that the
vaccine against COVID-19 was useful. Finally, respondents without
a university degree were more likely to be hesitant. The role of the
educational level may be explained by the assumption that those
with a university degree have easier access to medical information.
This finding aligns with previous studies that showed that parental
education impacted on the value and importance of the vaccina-
tion [31–33]. Therefore, educational programs about COVID-19
vaccination need to be urgently designed and targeted for
females and for those with no formal education to reduce the
hesitancy and, therefore, to increase their willingness toward the
vaccination program to protect their children in the near future.
The findings should be evaluated considering potential
few methodological limitations. First, the cross-sectional
design and, therefore, the estimates are only an approxima-
tion to the unknown association and causal inference
between the determinant factors and the outcomes of inter-
est cannot be drawn because it is difficult to establish the
temporal sequence. Second, participants were recruited
from two geographic areas and, therefore, the generalizabil-
ity to the whole country needs to be carefully considered.
Third, social desirability bias may also be a factor, since
parents might have consciously selected responses that
were positively oriented toward vaccination and may not
Table 3. Responses to individual PACV-5 items about COVID-19 vaccine of the target population.
PACV-5 items N (%)
Adolescents get more shots than are good for them
Strongly agree/Agree 84 (24.2)
Not sure 115 (27.1)
Strongly disagree/Disagree 195 (48.7)
It is better for my child to develop immunity by getting sick than to get a shot
Strongly agree/Agree 20 (5.8)
Not sure 68 (17.2)
Strongly disagree/Disagree 306 (77)
It is better for adolescents to get fewer vaccines at the same time
Strongly agree/Agree 192 (48.7)
Not sure 108 (27.4)
Strongly disagree/Disagree 94 (24.9)
Overall, how hesitant about COVID-19 vaccine would you consider yourself to be?
Very hesitant/Somewhat hesitant 184 (46.7)
Not sure 48 (12.2)
Not hesitant at all/Not too hesitant 162 (41.1)
I trust the information I receive about COVID-19 vaccine
Strongly agree/Agree 193 (50)
Not sure 141 (35.8)
Strongly disagree/Disagree 60 (15.2)
EXPERT REVIEW OF VACCINES 545

indicate their future practices. However, this bias may have
been limited by performing an anonymous survey. Despite
these limitations, this is the first attempt to provide impor-
tant insight on parents who have an important role to
promote COVID-19 vaccination and to reduce missed oppor-
tunities for its prevention.
In conclusion, the findings from this survey illustrated
a low hesitancy toward COVID-19 vaccination and a high
willingness to vaccinate their child against SARS-CoV-2 and
for those with poor attitudes appear a lack of information
received from physicians and a concern that the COVID-19
vaccine was unsafe. Communication and public health
interventions emphasizing the scientific evidence must be
intensified to enhance the attitude and to help parents on
deciding on COVID-19 vaccination of adolescent children
that would help them to return to relative normalcy.
Acknowledgments
The authors express their gratitude to the directors of the selected schools
for their valuable support and to all individuals who participated in the
survey and generously provided their time.
Author contributions
G.D.P. participated in the design of the study, contributed to the data
collection, the data analysis, and interpretation; F.L., S.A., A.B. contributed
to the data collection, the data analysis, and interpretation; C.P.
P. contributed to the data analysis and interpretation; I.F.A., the principal
investigator, designed the study, was responsible for the statistical analy-
sis and interpretation, and wrote the article. All authors have read and
approved the final version of the manuscript.
Funding
This paper was not funded.
Declaration of interest
The authors have no relevant affiliations or financial involvement with
any organization or entity with a financial interest in or financial con-
flict with the subject matter or materials discussed in the manuscript.
This includes employment, consultancies, honoraria, stock ownership or
options, expert testimony, grants or patents received or pending, or
royalties.
Reviewer disclosures
Peer reviewers in this manuscript have no relevant financial or other
relationships to disclose.
ORCID
Aida Bianco http://orcid.org/0000-0003-4674-0306
Giorgia Della Polla http://orcid.org/0000-0002-3182-4905
Silvia Angelillo http://orcid.org/0000-0001-8103-5368
Concetta P Pelullo http://orcid.org/0000-0003-4228-8703
Francesca Licata http://orcid.org/0000-0003-3704-6822
Italo F. Angelillo http://orcid.org/0000-0003-1213-6602
References
Papers of special note have been highlighted as either of interest (•) or of
considerable interest (••) to readers.
1. Istituto Superiore di Sanità. COVID-19 epidemic. 25 August 2021
national update. 2020. Available from: https://www.epicentro.iss.it/
en/coronavirus/sars-cov-2-integrated-surveillance-data [Available
from 1 September 2021].
2. Agenzia Italiana del Farmaco. Determina 31 maggio 2021.
Estensione dell’indicazione terapeutica del vaccino
«Comirnaty». (Determina n. 73/2021). (21A03431) (GU Serie
Generale n.130 del 01–06–2021). Determina 31 maggio:
https://www.gazzettaufficiale.it/atto/serie_generale/
caricaDettaglioAtto/originario?atto.dataPubblicazioneGazzetta=
2021-06-01&atto.codiceRedazionale=
21A03431&elenco30giorni=false [Determina 31 maggio].
3. Han K, Francis MR, Zhang R, et al. Confidence, acceptance and
willingness to pay for the COVID-19 vaccine among migrants in
Shanghai, China: a cross-sectional study. Vaccines (Basel). 2021;9
(5):443.
4. Di Giuseppe G, Pelullo CP, Della Polla G, et al. Surveying willingness
toward SARS-CoV-2 vaccination of healthcare workers in Italy.
Expert Rev Vaccines. 2021;20(7):881–889.
•• This study highlights a very high willingness regarding a
future COVID-19 vaccination and the need of communication
and health educational campaigns to raise awareness regard-
ing the safety and benefits of the vaccination.
5. Shih SF, Wagner AL, Masters NB, et al. Vaccine hesitancy and
rejection of a vaccine for the novel coronavirus in the United
States. Front Immunol. 2021;12:558270.
6. Acheampong T, Akorsikumah EA, Osae-Kwapong J, et al. Examining
vaccine hesitancy in Sub-Saharan Africa: a survey of the knowledge
and attitudes among adults to receive COVID-19 vaccines in Ghana.
Vaccines (Basel). 2021;9(8):814.
7. Kessels R, Luyten J, Tubeuf S. Willingness to get vaccinated against
COVID-19 and attitudes toward vaccination in general. Vaccine.
2021;39(33):4716–4722.
8. Chun JY, Kim SI, Park EY, et al. Cancer patients’ willingness to take
COVID-19 vaccination: a nationwide multicenter survey in Korea.
Cancers (Basel). 2021;13(15):3883.
9. Lin Y, Zhijian Hu Z, Zhao Q, et al. Understanding COVID-19 vaccine
demand and hesitancy: a nationwide online survey in China. PLoS
Negl Trop Dis. 2020;14(12):e0008961.
10. Brandstetter S, Böhmer MM, Pawellek M, et al. Parents’ intention to
get vaccinated and to have their child vaccinated against COVID-
19: cross-sectional analyses using data from the KUNO-Kids health
study. Eur J Pediatr. 2021;180(11):3405–3410.
11. Wagner AL, Huang Z, Ren J, et al. Vaccine hesitancy and concerns
about vaccine safety and effectiveness in Shanghai, China. Am
J Prev Med. 2021;60(1 Suppl 1):S77–S86.
12. Goldman RD, Yan TD, Seiler M, et al. Caregiver willingness to
vaccinate their children against COVID-19: cross sectional survey.
Vaccine. 2020;38(48):7668–7673.
13. Bell S, Clarke R, Mounier-Jack S, et al. Parents’ and guardians’ views
on the acceptability of a future COVID-19 vaccine: a multi-methods
study in England. Vaccine. 2020;38(49):7789–7798.
14. Di Giuseppe G, Pelullo CP, Della Polla G, et al. Exploring the
willingness to accept SARS-CoV-2 vaccine in a university popu-
lation in southern Italy, September to November 2020. Vaccines
(Basel). 2021;9(3):275 .
•• This study highlights a positive willingness to receive the
future COVID-19 vaccine with concerns regarding effectiveness
and safety
15. Scott VP, Opel DJ, Reifler J, et al. Office-based educational handout
for influenza vaccination: a randomized controlled trial. Pediatrics.
2019;144(2):e20182580.
16. Oladejo O, Allen K, Amin A, et al. Comparative analysis of the
Parent Attitudes about Childhood Vaccines (PACV) short scale
and the five categories of vaccine acceptance identified by Gust
et al. Vaccine. 2016;34(41):4964–4968.
546 A. BIANCO ET AL.

17. StataCorp. Stata Statistical Software: release 15. TX USA: StataCorp
LLC.: College Station; 2017.
18. Lu J, Wen X, Guo Q, et al. Sensitivity to COVID-19 vaccine effectiveness
and safety in Shanghai, China. Vaccines (Basel). 2021;9(5):472.
19. Teasdale CA, Borrell LN, Shen Y, et al. Parental plans to vaccinate
children for COVID-19 in New York city. Vaccine. 2021;39
(36):5082–5086.
20. Yigit M, Ozkaya-Parlakay A, Senel E. Evaluation of COVID-19 vaccine
refusal in parents. Pediatr Infect Dis J. 2021;40(4):e134–e136.
21. Trabucco Aurilio M, Mennini FS, Gazzillo S, et al. Intention to be
vaccinated for COVID-19 among Italian Nurses during the
pandemic. Vaccines (Basel). 2021;9(5):500.
22. Del Riccio M, Boccalini S, Rigon L, et al. Factors influencing
SARS-CoV-2 vaccine acceptance and hesitancy in a
population-based Sample in Italy. Vaccines (Basel). 2021;9(6):633.
23. Skjefte M, Ngirbabul M, Akeju O, et al. COVID-19 vaccine acceptance
among pregnant women and mothers of young children: results of
a survey in 16 countries. Eur J Epidemiol. 2021;36(2):197–211.
24. Della Polla G, Pelullo CP, Napolitano F, et al. HPV vaccine hesitancy
among parents in Italy: a cross-sectional study. Hum Vaccin
Immunother. 2020;16(11):2744–2751.
25. Napolitano F, Della Polla G, Capano MS, et al. Vaccinations and
chronic diseases: knowledge, attitudes, and self-reported adher-
ence among patients in Italy. Vaccines (Basel). 2020;8(4):560.
26. Napolitano F, Bianco A, D’Alessandro A, et al. Healthcare workers’
knowledge, beliefs, and coverage regarding vaccinations in critical
care units in Italy. Vaccine. 2019;37(46):6900–6906.
27. Napolitano F, D’Alessandro A, Angelillo IF. Investigating Italian
parents’ vaccine hesitancy: a cross-sectional survey. Hum Vaccin
Immunother. 2018;14(7):1558–1565.
28. Kim HK, Ahn J, Atkinson L, et al. Effects of COVID-19 misinforma-
tion on information seeking, avoidance, and processing:
a multicountry comparative study. Sci Communication. 2020;42
(5):586–615.
• This study examined the implications of exposure to misinfor-
mation about COVID-19 in the United States, South Korea, and
Singapore in the early stages of the global pandemic.
29. Hoffman BL, Felter EM, Chu KH, et al. It’s not all about autism: the
emerging landscape of anti-vaccination sentiment on Facebook.
Vaccine. 2019;37(16):2216–2223.
30. Tustin JL, Crowcroft NS, Gesink D, et al. Internet exposure asso-
ciated with Canadian parents’ perception of risk on childhood
immunization: cross-sectional study. JMIR Public Health Surveill.
2018;4(1):e7.
31. Rhodes A, Hoq M, Measey MA, et al. Intention to vaccinate against
COVID-19 in Australia. Lancet Infect Dis. 2021;21(5):e110.
32. Santibanez TA, Nguyen KH, Greby SM, et al. Parental vaccine hes-
itancy and childhood influenza vaccination. Pediatrics. 2020;146(6):
e2020007609.
33. Kempe A, Saville AW, Albertin C, et al. Parental hesitancy about
routine childhood and influenza vaccinations: a national survey.
Pediatrics. 2020;146(1):e20193852.
EXPERT REVIEW OF VACCINES 547