https://orcid.org/0000-0002-4208-9408
ABSTRACT
This study aims to determine the intention of Chinese parents to vaccinate their children against SARS-CoV-2. Secondly, preferences for foreign- or domestically made COVID-19 vaccines were also explored. A nationwide, cross-sectional, self-administered online survey based on the Health Belief Model (HBM) and new vaccine concerns was used. Participants were eligible if they were residents of China with children aged 12 years old or younger. A total of 2,026 parents responded to the survey. Half reported a probable intent (50.7%) and 26.9% reported a definite intent. The results of the data analysis of partial least squares structural equation modeling (PLS-SEM) found that perceived cost barriers (B = −0.210, p < .001) and new vaccine concerns (B = −0.201, p < .001) had major effects in vaccination intent. Important constructs of vaccine concerns that predict vaccination intent were efficacy (B = 0.898, p < .001), followed by safety (B = 0.861, p < .001), side-effect (B = 0.806, p < .001) and faulty/fake vaccine (B = 0.579, p < .001). Perceived benefits (B = 1.81, p < .001), self-efficacy (B = 0.159, p < .001) and severity (B = 0.083, p < .01) were also significant predictors in vaccination intent. Almost two-thirds (62.0%; 95%CI 59.8 to 64.1) reported a preference for domestically made and 19.1% (95%CI 17.2 to 20.7) preferred foreign-made COVID-19 vaccines. Multivariable logistic regression analysis revealed that higher incomes and concern of side-effects of the new COVID-19 vaccine were two of the most important influencing factors of preference for a foreign-made vaccine. This study sheds light on the importance of addressing concerns of new vaccines and the helpfulness of HBM in understanding parental decisions toward their children being vaccinated against SARS-CoV-2.
Introduction
On 11 March 2020, the World Health Organization (WHO) declared the coronavirus disease (COVID-19) a worldwide pandemic. Approximately a year and a half since its emergence in Wuhan, China, over 194 million cases and 4 million deaths have been reported in at least 177 countries globally.Citation1 In mainland China, 14.4% of the population is made up of infants and children aged below 12 years.Citation2 Data showed that of the 77,314 cases (updated through February 11, 2020) in China, fewer than 1% were in children younger than 10 years of age.Citation3 Children not only appear to be less susceptible to infection than adults, but COVID-19 cases were also generally less severe than adults.Citation4,Citation5 Nonetheless, the outbreak of the coronavirus has brought fear to many parents with young children.
There is an intense global effort in developing an effective and safe COVID-19 vaccine, with an estimate of over 100 candidate vaccines currently in different development stages,Citation6 and eight vaccines are already approved by WHO for emergency use, including two vaccines from China.Citation7 In the beginning, most of COVID-19 vaccines were only recommended for use in individual aged 18 years and older. As infection rate is increasing in children, COVID-19 vaccine eligibility was expanded to children aged 12 through 15 in U.S.Citation8 In June 2021, China’s National Health Commission also approved the emergency use of its domestic inactivated COVID-19 vaccines on minors aged from 3 to 17.Citation9 Soon in August 2021, many provinces announced to extend mass vaccination program to minors aged 12–17 years.Citation10 As the COVID-19 vaccines may become available soon for children aged 12 years and below, it is timely to evaluate perspectives from parents regarding COVID-19 vaccination for their children. Parental acceptance of COVID-19 vaccination is crucial to help public health systems to reach the recommended threshold to achieve the herd immunity to halt the epidemic’s spread.
Parental decision-making for vaccination of their children is complex and impacted by many factors depending on parents’ perspectives. The Health Belief Model (HBM) explains and predicts health behaviors by focusing on the attitude and beliefs of individuals. It includes concepts such as perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. The HBM model has been used extensively to study vaccination beliefs and behaviors, and has also been used in many previous influenza vaccination studies to identify parental behavioral intentions on childhood vaccination.Citation11 HBM constructs have been recognized as an important predictor of influenza vaccine uptake in many previous studies,Citation12,Citation13 including a study on Chinese parents’ decisions to vaccinate their children against seasonal influenza.Citation14
Trust in vaccines and immunization programs are important elements in public health efforts in infectious disease control or eradication. In mainland China, several unfortunate vaccine-related events have resulted in vaccination hesitancy and distrust in the country’s immunization program.Citation15 In many of the serious adverse events following immunization in China, children were put in life-threatening danger. There were a series of vaccine-related adverse events where children were vaccinated with faulty vaccines, resulting in serious detrimental effects including death and disability.Citation16,Citation17 Consequently, these events have terrified the public and resulted in favoring imported vaccines as well as an increasing number of people seeking vaccination abroad.Citation15,Citation18,Citation19 To date, the global effort for COVID-19 vaccine research and development in response to the COVID-19 pandemic is unprecedented in terms of scale and speed. An estimated 19 countries in the world, including China, are developing vaccines against SARS-CoV-2.Citation20 Decision making in COVID-19 vaccine choices is predicted to be challenging when many COVID-19 vaccines become available. The concern that the public in China is more inclined to choose a foreign-made COVID-19 vaccine over vaccines produced in China has been raised.Citation21
With the reasons mentioned above, this study first attempted to determine parental intention to vaccinate their children aged 12 years and younger against COVID-19. The constructs of HBM and new vaccine concerns were used as the framework for understanding parental intention to vaccinate their children against SARS-CoV-2. Secondly, this study also determined parent preferences, over foreign- or domestically made COVID-19 vaccines.
Methods
Study participants and survey design
An anonymous, web-based survey was designed for use in this study. The social network app WeChat (the most popular messaging app in China) was used to advertise and circulate the survey link to people in all provinces across mainland China. WeChat was used as it is reported as the most frequently used application on mobile phones among 87.6% of users in China and it is used more than one hour a day among 81.5% of users.Citation22 The inclusion criteria were residents of China who have children aged 12 years old or below. The participants were informed that their participation was voluntary, and consent was implied through their completion of the questionnaire. The survey link was disseminated from 1 to 19 May 2020.
Instruments
The survey consisted of questions that assessed 1) demographic background; 2) perception of COVID-19 and COVID-19 vaccination based on HBM; 3) new COVID-19 vaccine concerns; 4) intention to vaccinate their children with a COVID-19 vaccine; and 5) vaccine preferences.
The health belief was assessed by single-item measures for each construct. Five major HBM constructsCitation23 were assessed: (1) perceived susceptibility to COVID-19; (2) perceived severity of COVID-19; (3) perceived benefits of COVID-19 vaccination; (4) perceived barriers to COVID-19 vaccination; and (5) self-efficacy to carry out vaccination on time.
Vaccine concerns consisted of four questions that assess perceived worry about: (1) side-effects; (2) efficacy; (3) safety of the new COVID-19 vaccine; and (4) the possibility of faulty/fake COVID-19 vaccine unfortunate events. All of the response options were ‘strongly agree,’ ‘agree,’ ‘disagree’ or ‘strongly disagree.’
The intention to accept a COVID-19 vaccine was measured using a one-item question (‘If a vaccine against COVID-19 was available on the market, would you want to vaccinate your child against COVID-19ʹ) on a four-point scale (‘definitely not,’ ‘probably not,’ ‘probably yes’ and ‘definitely yes’). Vaccine preference queried participants about their preferences on domestically made or foreign/imported COVID-19 vaccines for their children using three item choices (‘foreign-made vaccine,’ domestically-made vaccine’ and ‘no preference’).
Statistical analysis
Partial least squares structural equation modeling (PLS-SEM) was used to quantify the contributing factors (socio-demographics, HBM constructs, and new vaccine concerns) of COVID-19 vaccination intent. All variables showing statistically significant associations with vaccination intent in the univariate analyses were included in the PLS-SEM. A bootstrapping approach was used to evaluate the significance of associations in the proposed model. This technique not only assesses the reliability of the dataset but also the statistical significance of the coefficients and the error of the estimated path coefficients.Citation24 The bootstrapped significance calculation was performed in SmartPLS software version 3.2.8 (SmartPLS GmbH).Citation25 In the model, the HBM was a single-item construct; however, the construct of new vaccine concerns was a multi-item measure.
The reliability of the vaccine concerns construct was assessed in terms of composite reliability (CR). The average variance extracted (AVE) was used to assess the convergent validity of the construct. The 4-item construct of the vaccine concerns (side-effects, efficacy, safety, and faulty/fake vaccine) was found to have adequate reliability (CR = 0.871) and convergent validity (AVE = 0.633). Discriminant validity assessment through heterotrait-monotrait (HTMT) ratio of correlations method also indicated that all HTMT values were lower than the most restrictive threshold (0.85) proposed by Kline (2011),Citation26 thus indicating adequate discriminant validity. The loading factors for items related to vaccine concerns construct were above 0.5, whereby the item efficacy recorded the highest loading factor (λ = 0.898), followed by safety (λ = 0.861), side-effects (λ = 0.806) and faulty vaccine (λ = 0.579).
Ethics approval
This study was approved by the Medical Ethics Committee at the Fujian Medical University, Fuzhou, China (Approval: FJMU 2020 NO.1). Respondents were informed of the study objectives and that their participation was voluntary. All data were collected anonymously.
Results
Demographics
A total of 2,026 complete responses were received. shows the mapping of the geographical distribution of respondents and the regional distribution of the total number of confirmed cases of COVID-19 as of May 22, 2020. Although the study has lower representation of participants from the western and central regions, a high proportion of participants was received from regions with a high number of confirmed COVID-19 cases. The proportion of responses closely corresponds to the total number of confirmed cases. The demographic backgrounds of study participants are shown in .
Table 1. Demographics characteristics of parents and factors associated with intention to vaccinate their children against COVID-19 (N = 2026)
Figure 1. Geographical distribution of responses of the study and confirmed cases of COVID-19 as of 22nd May 2020.
Health belief model
Two-thirds stated that they strongly agree/agree that there was a high chance of their children being susceptible of COVID-19 if not vaccinated (). With regards to perception of severity, the majority of parents strongly agree/agree that their children may easily contract COVID-19 (81.8%). A high perception of the benefits of COVID-19 vaccination for their children was reported with the majority stating that they strongly agree/agree that COVID-19 vaccination will help their children’s health (90.0%). Under the perceived barriers construct, almost half strongly agree/agree that COVID-19 vaccination cost was a barrier for vaccination (45.2%). For the self-efficacy construct, majority reported strongly agree/agree that they will get their children vaccinated against COVID-19 once the vaccine is available (84.8%).
Vaccine concerns
With regard to concern over new COVID-19 vaccines, the highest proportion reported that they strongly agree/agree over concerns of faulty/fake vaccines (81.8%), followed by safety (72.7%), efficacy (71.1%) and side-effects (68.8%) ().
COVID-19 vaccination intent
shows the proportion of parents who would immunize their children against COVID-19. On the whole, a total of 1,573 (77.6%) parents responded yes to COVID-19 vaccine intent, while only 453 (22.3%) responded no. For a more specific breakdown, the majority responded probably yes (50.7%; 95% CI 48.5–52.9) followed by definitely yes (26.9%; 95% CI 25.0–28.9%). Only 5.1% (95% CI 4.2–6.2) responded definitely not and 17.2% (95% CI 15.6–18.9) responded probably not.
Figure 2. Definite intention to vaccinate child with COVID-19 vaccine and vaccine preferences (N = 2026).
The third and fourth columns of show the responses of definitely yes against the other options (probably yes/probably no/definitely no) in vaccination intention by demographics, HBM constructs and concerns regarding the new COVID-19 vaccine. By demographics, univariate analyses showed that there was a significant difference in having a definite intention to vaccinate their children by age, marital status, occupational category and location. All of the HBM constructs and concerns surrounding COVID-19 were significantly associated with having a definite vaccination intention. Worry about faulty/fake vaccines was not significantly associated with a definite vaccination intention.
The PLS-SEM in shows the hypothesized associations between the HBM constructs, demographics, concerns of new vaccine, and intention to vaccinate against COVID-19. All structural model paths were statistically significant except perceived susceptibility. In the model, three components of HBM including perceived benefit (B = 0.181, p < .001), self-efficacy (B = 0.159, p < .001) and severity (B = 0.083, p < .001) had a positive and significant effect on intention vaccination while perceived barriers (B = −0.210, p < .001) had a negative and significant effect. This result also indicated that concern over new COVID-19 vaccine had a negative influence on intention to vaccinate (B = −0.201, p < .001). The effect of age on intention to vaccinate was positive and significant (B = 0.039, p = .048). Being a single parent (B = −0.041, p = .034) made it less likely that parents would have their children vaccinated against COVID-19. Occupation types were categorized as working parents and housewives. The model shows that working parents (B = −0.038, p = .032) were less likely to have their children vaccinated against COVID-19. The results for the adjusted R2 indicate that this model explained 18.5% of the total variance in intention to vaccinate.
Figure 3. Partial least squares structural equation model (PLS-SEM) of factors predicting parental intent to obtain COVID-19 vaccination for their children (N = 2026).
The findings for the preference of domestically made or foreign-made COVID-19 vaccines revealed that 62.0% (95% CI 59.8–64.1) reported a preference for domestically made and 19.1% (95% CI 17.2–20.7) preferred foreign-made COVID-19 vaccines (). A total of 19.1% (95% CI 17.4–20.9) reported no preference. Multivariable analysis in shows that the odds of a preference for foreign-made vaccines were highest by income group compared to other factors, and that the odds increase with increasing income. Parents in the age group 18–25 years (OR = 1.91, 95% CI 1.04–3.52) also reported a higher likelihood of a preference for foreign-made COVID-19 vaccines than those in the age group from 46 to 70 years. Worry about side-effects and the efficacy of a new COVID-19 vaccine were significant in the univariate analyses; however, in the multivariable analyses, only concern about possible side effects of a new COVID-19 vaccine was a significant predictor of preference for a foreign-made COVID-19 vaccine.
Table 2. Univariate and multivariate analyses of factors vaccine preference (N = 2026)
Discussion
Parental perspectives and beliefs about vaccines are an important factor in predicting a child’s immunization status. Given that there have been no studies related to the predictiveness of these factors, this study examines parents’ COVID-19 vaccination perspectives using the HBM in the Chinese context, and provide an important contribution to the current literature on parental psychosocial factors related to their intentions.
Firstly, descriptive statistics show that Chinese parents in this study had a high level of perceived severity of SARS-CoV-2 infection and benefit in vaccination. Of note, this study was conducted after China had declared that the coronavirus outbreak was largely under control. This perhaps explained why only two-third of parents viewed their children’s susceptibility to SARS-CoV-2 infection as being high. Sustainable preventive and control measures should be encouraged despite COVID-19 being under control to prevent the probability of COVID-19 resurgence.Citation27 Findings imply the need to enhance risk perception among parents as high-risk perception translates into better preventive actions and is associated with enhanced epidemic control.Citation28 The tragedy with the COVID-19 pandemic in China has perhaps contributed to the prioritization of parents on protecting their children, which could explain why over half of the parents disagree that the cost of immunization will be a burden. Findings focused on concerns of new vaccines revealed that safety, side-effects, and the efficacy concern of new vaccines are heightened. The common vaccine-related adverse events perhaps explain why a high proportion of parents expressed worry about the possibility of faulty or fake COVID-19 vaccines.
Previous findings suggest that new vaccines usually generate greater hesitancy among parents during the vaccine introduction period.Citation29 As found in this study, only 27% of parents expressed a definite intention, and half reported a probable intention to vaccinate their children against SARS-CoV-2 infection. Parents who reported probable intention are those who perhaps are uncertain or undecided about COVID-19 immunization for their children. Hence, the findings of this study imply that there is a need to improve the COVID-19 vaccine perceptions and vaccine intentions among parents in China, to increase the acceptance of the newly introduced COVID-19 vaccine. The PLS-SEM model indicated that new vaccine concerns had major effects and played an important role in vaccination intention. Among all of the concerns, efficacy has the foremost important role in vaccination intention, followed by safety and side-effects of the vaccine, while concerns over faulty vaccines had little effect. The safety, efficacy, and side-effects of vaccine reported in this study were common vaccine-related concerns among parents.Citation30 Hence, it is important when discussing COVID-19 vaccination with parents to emphasize its potential side-effects and the efficacy of the vaccination. It is critically important that COVID-19 vaccine manufacturers produce adequate clinical evidence regarding the efficacy, immunogenicity, and safety of the new COVID-19 vaccine to increase the uptake of COVID-19 vaccines in children.
As hypothesized, the HBM constructs influence parental vaccination intention. In particular, this model indicated that perceived cost barrier was the most important of all of the HBM constructs. This finding implies the need to overcome financial barriers for economically disadvantaged populations in China to access the COVID-19 vaccination. Of note, this study was conducted in May 2020, before the COVID-19 vaccines are available for the public. During the survey period, the public was unknown if they have to pay for the COVID-19 vaccine, hence many of the study participants perceived cost as the main barrier for vaccination. Currently, China government has made COVID-19 vaccine free for every citizens, which might partly explain the high speed of vaccination of 1.8 billion doses by August 2021. A recent study in China revealed that an inactivated SARS-CoV-2 vaccine was well tolerated, safe and induced humoral responses in children and adolescents aged 3–17 years.Citation31 In March 2021, Canada is the first country to approve the COVID-19 vaccine for children aged 12–15 years.Citation32 The U.S. Food and Drug Administration has also recently expanded the emergency use authorization of the COVID-19 vaccine to include adolescents 12 through 15 years of age.Citation33 Hence, the COVID-19 vaccine may soon be available for children and adolescents in China. The finding of this study implies that if the COVID-19 vaccine is available for children and adolescents in China, it should be also made free of charge to enhance parental acceptance of the vaccine for their children. Of note, the Chinese government implemented a 2-category administration of vaccines. The Category 1 vaccines are managed by the government and are provided free of charge to all children through 14 years of age. Category 2 vaccines are optional vaccines and that has to be paid for by the parents. The pandemic H1N1 vaccine (H1N1) was classified as a Category 1 vaccine.Citation34 Similar the COVID-19 vaccine should also be a Category 1 vaccine and made available at no cost to the public. Another positive highlight of this study is that despite the relatively small effect of demographics influence on parents’ intentions to immunize their children, the disparities, namely housewives, older age, and married parents expressing higher vaccination intentions, provide information for future targeted interventions.
A high proportion of parents in this study expressed acceptance of a domestically made COVID-19 vaccine. The new Vaccine Administration Law of the People’s Republic of China, effective December 1, 2019, has greatly enhanced regulations in the vaccine industry. The new law stipulates more stringent regulatory requirements for researching, producing, distributing and using vaccines, as well as tough penalties for violating regulations on the production and sale of vaccines.Citation35 The implementation of China’s new vaccine administration law has perhaps boosted the public’s confidence and increased public trust in domestic vaccines. As concern over side effects of the new COVID-19 vaccine significantly predicts a preference for a foreign-made COVID-19 vaccine, this again emphasizes the need to provide the public with safety data for the domestic vaccine when it is available.
There are some limitations of the current study that need to be considered when interpreting the results. Firstly, the use of an online survey may result in sampling bias, so results may not be generalizable to the wider community. Furthermore, the responses were based on self-reporting and may be subject to self-reporting bias and a tendency to report socially desirable responses. Thus, the findings of this survey should be interpreted in light of the above-mentioned limitations.
Conclusion
Interventions to increase parents’ intention to vaccinate their children against SARS-CoV-2 infection are needed when the vaccine becomes available on the market for children. Implementing strategies to overcome the concerns around new vaccines and also the use of HBM in understanding parental decisions toward their child being vaccinated against SARS-CoV-2 must be the top priorities. Fear of faulty or fake vaccines was evident, and although this was not a significant predictor of vaccination intention, it warrants stringent regulatory oversight to prevent a negative vaccine event in the future. Building trust in new domestically made COVID-19 vaccines as a result of strong evidence of the efficacy and safety of the vaccine is essential.
Data Availability
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to ethical restrictions.
Authors’ contributions
LPW, YL, ZH and QZ planned the study. YL and ZH obtained the data. LPW, HA and MD performed the statistical analysis and data summarization. LPW drafted the manuscript. All authors discussed the results and contributed to the final manuscript.
Acknowledgments
The authors would like to thank all participants of the study for their participation in the investigation.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- World Health Organization (WHO). Weekly epidemiological update on COVID-19-27 July 2021. 2021 [accessed 2021 Aug 5]. https://www.who.int/publications/m/item/weekly-epidemiological-update-on-covid-19—27-july-2021.
- National Bureau of Statistics of China. The sixth national census. 2011 Apr 28 [accessed 2020 July 1]. http://www.stats.gov.cn/tjsj/pcsj/rkpc/6rp/indexch.htm.
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for disease control and prevention. JAMA. 2020;323:1239–42. doi:10.1001/jama.2020.2648.
- CDC COVID-19 Response Team. Coronavirus disease 2019 in children-United States, February 12-April 2, 2020. MMWR Morb Mortal Wkly Rep. 2020;69:422–26 [assessed 2020 July 1]. https://www.cdc.gov/mmwr/volumes/69/wr/mm6914e4.htm
- Ludvigsson JF. Systematic review of COVID‐19 in children shows milder cases and a better prognosis than adults. Acta Paediatrica. 2020;109:1088–95. doi:10.1111/apa.15270.
- World Health Organization (WHO). Draft landscape of COVID-19 candidate vaccines. 2020 Jun 11 [accessed 2020 Jun 13]. https://www.who.int/who-documents-detail/draft-landscape-of-covid-19-candidate-vaccines.
- World Health Orgnization (WHO). Status of COVID-19 vaccines within WHO EUL/PQ evaluation process. 2021 Jul 15 [accessed 2021 Aug 12]. https://extranet.who.int/pqweb/sites/default/files/documents/Status_COVID_VAX_15July2021.pdf.
- Centers for Disease Control and Prevention. COVID-19 vaccines for children and teens. 2021 Jun 23 [accessed 2021 Aug 12]. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/recommendations/adolescents.html.
- The State Council Information office The People’s Republic of China. China approves emergency use of domestic vaccines for 3–17 age group. 2021 Jun 12 [accessed 2021 Aug 12]. http://english.scio.gov.cn/pressroom/2021-06/12/content_77564263.htm.
- The State Council Information office The People’s Republic of China. China to extend mass vaccination program to minors aged 12–17. 2021 Jul 18 [accessed 2021 Aug 12]. http://english.www.gov.cn/news/topnews/202107/18/content_WS60f361e3c6d0df57f98dd2ca.html.
- Brewer NT, Chapman GB, Gibbons FX, Gerrard M, McCaul KD, Weinstein ND. Meta-analysis of the relationship between risk perception and health behavior: the example of vaccination. Health Psychol. 2007;26:136. doi:10.1037/0278-6133.26.2.136.
- Shahrabani S, Benzion U. Workplace vaccination and other factors impacting influenza vaccination decision among employees in Israel. IJERPH. 2010;7:853–69. doi:10.3390/ijerph7030853.
- He L, Liao QY, Huang YQ, Feng S, Zhuang XM. Parents’ perception and their decision on their children’s vaccination against seasonal influenza in Guangzhou. Chin Med J (Engl). 2015;128:327. doi:10.4103/0366-6999.150099.
- Yang R, Penders B, Horstman K. Addressing vaccine hesitancy in China: a scoping review of Chinese Scholarship. Vaccines. 2020;8:2. doi:10.3390/vaccines8010002.
- Chen B, Zhang JM, Jiang Z, Shao J, Jiang T, Wang Z, Liu K, Tang S, Gu H, Jiang J. Media and public reactions toward vaccination during the ‘hepatitis B vaccine crisis’ in China. Vaccine. 2015;33:1780–85. doi:10.1016/j.vaccine.2015.02.046.
- Halimi M, Alishahi M, Abbaspour MR, Ghorbanpoor M, Tabandeh MR. Valuable method for production of oral vaccine by using alginate and chitosan against Lactococcus garvieae/Streptococcus iniae in rainbow trout (Oncorhynchus mykiss). Fish Shellfish Immunol. 2019;90:431–39. doi:10.1016/j.fsi.2019.05.020.
- Liu B, Chen R, Zhao M, Zhang X, Wang J, Gao L, Xu J, Wu Q, Ning N. Vaccine confidence in China after the Changsheng vaccine incident: a cross-sectional study. BMC Public Health. 2019;19:1564. doi:10.1186/s12889-019-7945-0.
- Wong LP, Wong PF, Megat Hashim MMAA, Han L, Lin Y, Hu Z. Multidimensional social and cultural norms influencing HPV vaccine hesitancy in Asia. Hum Vaccin Immunother. 2020;16(7):1611–22. doi:10.1080/21645515.2020.1756670.
- Thanh LT, Andreadakis Z, Kumar A, Gómez Román R, Tollefsen S, Saville M, Mayhew S. The COVID-19 vaccine development landscape. Nat Rev Drug Discov. 2020;19:305–06. doi:10.1038/d41573-020-00073-5.
- Wee SL. China’s Coronavirus vaccine drive empowers a troubled industry. New York Times. 2020 May 4 [accessed 2020 May 31]. https://www.nytimes.com/2020/05/04/business/coronavirus-china-vaccine.html.
- Becker MH. The health belief model and personal health behavior. Health Educ Monogr. 1974;2(4):324–508. doi:10.1177/109019817400200407.
- China Academy of Information and Communications Technology Industry and Planning Research Institute. WeChat economic and social impact report 2017. 2018 April [accessed 2021 Sep 26]. http://www.caict.ac.cn/kxyj/qwfb/ztbg/201805/P020180529380481819634.pdf
- Chin WW. The partial least squares approach to structural equation modelling. In: Modern methods for business research (Ed.), Marcoulides , G. A. Mahwah (NJ): Lawrence Erlbaum Associates; 1998. p. 295–336.
- Ringle CM, Wende S, Becker JM. SmartPLS 3.2. 7. Bönningstedt (Germany): SmartPLS GmbH; 2015.
- Kline RB. Principles and practice of structural equation modeling. New York (NY): Guilford Press; 2011.
- Zhao K, Long C, Wang Y, Zeng T, Fu X. Negligible risk of the COVID-19 resurgence caused by work resuming in China (outside Hubei): a statistical probability study. J Public Health (Oxf). 2020:1–2. doi:10.1093/pubmed/fdaa046.
- Verelst F, Willem L, Beutels P. Behavioural change models for infectious disease transmission: a systematic review (2010–2015). J R Soc Interface. 2016;13(125):20160820. doi:10.1098/rsif.2016.0820.
- Facciolà A, Visalli G, Orlando A, Bertuccio MP, Spataro P, Squeri R, Picerno I, Di Pietro A. Vaccine hesitancy: an overview on parents’ opinions about vaccination and possible reasons of vaccine refusal. J Public Health Res. 2019;8:1436. doi:10.4081/jphr.2019.1436.
- Damnjanović K, Graeber J, Ilić S, Lam WY, Ž L, Morales S, Pulkkinen T, Vingerhoets L. Parental decision-making on childhood vaccination. Front Psychol. 2018;9:735. doi:10.3389/fpsyg.2018.00735.
- Zheng Y, Rodewald L, Yang J, Qin Y, Pang M, Feng L, Yu H. The landscape of vaccines in China: history, classification, supply, and price. BMC Infect Dis. 2018;18:1–8. doi:10.1186/s12879-018-3422-0.
- Han B, Song Y, Li C, Yang W, Ma Q, Jiang Z, Li M, Lian X, Jiao W, Wang L, et al. Safety, tolerability, and immunogenicity of an inactivated SARS-CoV-2 vaccine (CoronaVac) in healthy children and adolescents: a double-blind, randomised, controlled, phase 1/2 clinical trial. Lancet Infect Dis. 2021;S1473-3099(21)00319–4. doi:10.1016/S1473-3099(21)00319-4.
- Zou X, Cao B. COVID-19 vaccines for children younger than 12 years: are we ready? Lancet Infect Dis. 2021:S1473-3099(21)00384–4. doi:10.1016/S1473-3099(21)00384-4.
- U.S. Food & Drug Administration. Coronavirus (COVID-19) update: FDA authorizes Pfizer-BioNTech COVID-19 vaccine for emergency use in adolescents in another important action in fight against pandemic. 2021 May 10 [accessed 2021 Sep 26]. https://www.fda.gov/news-events/press-announcements/coronavirus-covid-19-update-fda-authorizes-pfizer-biontech-covid-19-vaccine-emergency-use.
- Government Report. Ministry of Health of China: the pandemic H1N1 vaccines should not be charged for any kinds of person. 2009 Oct 3 [accessed 2021 Sep 26]. http://www.gov.cn/jrzg/2009-10/31/content_1453527.htm.
- Huang B. The new China vaccine administration law: re-establishing confidence in vaccines. Biologicals. 2019;61:95–96. doi:10.1016/j.biologicals.2019.08.007.