Predictors of parental acceptance to live attenuated influenza vaccine for children

ABSTRACT

To determine the influencing factors of Chinese parents' intention and behavior for children to receive live attenuated influenza vaccine during the 2022–2023 influenza season. A theoretical model was developed and included seven constructs, and structural equation modeling was used to test 11 hypotheses. From October 2022 to December 2023, a survey was conducted across 38 medical institutions in four Chinese cities and their subordinate districts, counties, and rural areas. Parents who accompanied their children for vaccinations were selected through a randomization process based on their child’s medical card numbers. Measures were taken to minimize method bias, including a diverse geographical representation and random sampling. The survey resulted in the collection of 936 valid responses, exceeding the recommended sample size for structural equation model analysis and providing robust statistical inferences. During the study period, 936 respondents were included in the study. Perceived ease of use was verified to be a predictor of perceived usefulness and perceived value. Perceived usefulness was verified as a predictor of perceived value and behavioral intention. Knowledge was a significant antecedent of perceived value and risk perception of influenza disease. Risk perception of influenza disease was proved to be a significant predictor of perceived value and self-reported vaccination behavior. Perceived value significantly affected behavioral intention, and behavioral intention significantly affected self-reported vaccination behavior. Six demographic variables significantly moderate the theoretical models. The low vaccination coverage of live attenuated influenza vaccine (LAIV) among children in China suggests a need for a deeper understanding of the factors that influence vaccination rates. Particularly, effective strategies are necessary from policymakers and practitioners to elevate childhood LAIV coverage.

KEYWORDS:

• Live attenuated influenza vaccine
• children
• parental intention
• risk perception
• China

Introduction

Influenza is a highly contagious respiratory illness caused by influenza viruses that can lead to severe complications, including hospitalization and death.^1,2 It is a global public health issue that causes significant morbidity, mortality, and economic burden each year. Annually, there are around a billion cases of seasonal influenza, including 3–5 million severe cases and 290,000 to 650,000 deaths.³ Children are vulnerable to influenza infection due to their developing immune systems and close relationships within school settings.⁴ Vaccination is considered the most effective way to protect children’s health from the impact of influenza. The World Health Organization (WHO) recommends that all children aged 6–59 months receive an annual flu vaccine, while children aged 3–12 years should receive it every two years.

In recent years, live attenuated influenza vaccine (LAIV, also known as the nasal spray flu vaccine) has become an alternative to traditional injectable vaccines for children.⁵ Live attenuated influenza vaccines are non-injectable options that are administered directly into the nose and mimic natural infection, providing immune protection against targeted influenza strains.⁶ It was approved for sale in China in 2020 for people aged 3 to 17. This alternative vaccination approach has gained attention due to its potential to enhance vaccine acceptability among children and potentially improve influenza vaccine coverage rates.⁷ According to the analysis of China’s influenza vaccine batch issuance data for the 2022–2023 influenza season, the number of influenza vaccine batches issued nationwide has reached approximately 91 million doses, with approximately 66 million quadrivalent inactivated influenza vaccines accounting for over 72.5% of the total. However, only one company in China produces LAIVs, which accounts for less than 5% of influenza vaccines. Parental attitudes play a crucial role in whether a child receives the LAIV. For instance, parents who believe the vaccine is good for their child are more likely to accept it.⁸ Understanding these factors is crucial for public health authorities, healthcare professionals, and policymakers to develop effective strategies to encourage parental acceptance and uptake of live attenuated influenza vaccines.

Studies have explored factors that influence parental acceptance of vaccination for children, including perceived benefits and risks, trust in healthcare providers, cultural beliefs, cost, and accessibility. Trust in healthcare providers is another crucial factor in parents’ decision to vaccinate their children.^9,10 Recommendations and endorsements from healthcare professionals, such as pediatricians and school nurses, have a significant impact on parental decision-making.^11,12 Cultural beliefs and values can significantly influence parents’ decisions about vaccination, and some parents place more importance on naturopathic or homeopathic remedies than medical interventions like vaccinations.^10,13 In China, the price of injectable flu vaccine is CNY50–160, while the price of live attenuated influenza vaccine is CNY334, and the cost of vaccination may become a barrier for parents to accept live attenuated influenza vaccine. Addressing cost barriers is critical by providing free or low-cost vaccination programs and working with health care providers to ensure families have access to affordable health care.^9,14 If parents lack easy access to vaccinations for their children or are unable to find a healthcare provider that provides them, they may be less likely to vaccinate their children.^15,16 Although previous studies have provided valuable insights into the factors that influence parental acceptance of childhood vaccinations, there are still several research gaps to be addressed. First, the live attenuated influenza vaccine is a novel type, and there is limited empirical data to aid policymakers in fully comprehending the factors that influence parents’ decisions. On the other hand, most studies have focused on specific populations, such as parents from specific cultural backgrounds or parents with specific socioeconomic status, and generalizing these findings to a broader population requires evidence covering a variety of subgroups. Therefore, we aimed to explore the factors that influence parents to vaccinate their children with LAIV, including psychological factors such as behavioral intention, hesitation, social influence, perceived risk, perceived value, and demographic variables, so as to bridge the gap between guardians’ cognition and self-reported children’s vaccination behavior.

Materials and methods

Theoretical model and hypotheses

Previous studies have shown that multiple factors influence vaccination intention and hesitation, making it difficult to determine with linear regression models. Therefore, we incorporated previous literature on the factors affecting vaccination and proposed a composite theoretical model, as shown in Figure 1.

Figure 1. Research model.

Specifically, psychological factors in theoretical models include perceived ease of use (PEOU), perceived usefulness (PU), risk perception of influenza disease (RPID), health knowledge (HK), and perceived value (PV), they jointly determined behavioral intention (BI) and self-reported vaccination behavior (SVB), demographic variables include gender, age, education, income, residence, and number of children.

Perceived ease of use was defined as the degree to which a person believes that using a particular system is free of effort.¹⁷ In the context of vaccination, it means that individuals perceive the process of getting vaccinated as hassle-free and straightforward.¹² This includes factors such as easily accessible vaccination centers, straightforward appointment scheduling procedures, and smooth administrative processes.^18,19 Perceived ease of use is crucial in vaccination as it directly affects adoption rates. If individuals perceive the process of getting vaccinated to be complicated or cumbersome, they may be less likely to seek it out or delay it. Then, two hypotheses are proposed:

Hypothesis 1.

Perceived ease of use has a positive effect on parental perceived usefulness to vaccinate their children with LAIV.

Hypothesis 2.

Perceived ease of use has a positive effect on parental perceived value to vaccinate their children with LAIV.

Perceived usefulness was defined as an individual’s perception of improvement in performance with the use of a new technology or system.¹⁷ This conceptualization stems from the concept of outcome judgment, which refers to an individual’s expectation of a positive outcome that will motivate behavior. The perceived usefulness of a vaccine can be influenced by various factors, including scientific evidence, expert recommendations, and personal experiences. On the other hand, it will impact an individual’s decision to get vaccinated. If someone perceives the vaccine as beneficial in improving their health or protecting them from a particular disease, they are more likely to prioritize getting vaccinated.²⁰ Then, two hypotheses are proposed:

Hypothesis 3.

Perceived usefulness has a positive effect on parental perceived value to vaccinate their children with LAIV.

Hypothesis 4.

Perceived ease of use has a positive effect on parental behavioral intention to vaccinate their children with LAIV.

Health knowledge refers to the knowledge and comprehension of relevant information within the KAP model, serving as a fundamental prerequisite for altering health behaviors.²¹ Education campaigns, public health initiatives, and healthcare providers play a crucial role in promoting health knowledge and empowering individuals to make informed choices. By increasing our health knowledge and addressing misconceptions, we can enhance vaccine acceptance and uptake, leading to better protection against vaccine-preventable diseases. For behavioral intentions to vaccinate, individuals must have accurate and up-to-date knowledge about the benefits, risks, and importance of vaccines. This knowledge helps individuals make informed decisions and overcome vaccine hesitancy, contributing to the overall improvement of public health.^21,22 Therefore, we propose the following two hypotheses:

Hypothesis 5.

Health knowledge has a positive effect on parental perceived value to vaccinate their children with LAIV.

Hypothesis 6.

Health knowledge has a positive effect on parental risk perception of influenza disease.

Evaluating risk perception of influenza disease is crucial in determining an individual’s role in influenza vaccination. Previous studies have explored the effectiveness of various risk-perception measures and health-behavior theories in predicting influenza vaccination, and perceived risk predictions expressed in terms of feelings rather than purely cognitive probability judgments had better outcomes.^19,23 Most commonly used theories of health behavior do not have a sense of risk or expected regret and the data suggests that these theories lack an essential structure.²⁴ The empirical results showed that risk perception of flu virus predicted attitude and subsequent vaccination behavior.^25,26 Then, three hypotheses are proposed:

Hypothesis 7.

Risk perception of influenza disease has a positive effect on parental perceived value to vaccinate their children with LAIV.

Hypothesis 8.

Risk perception of influenza disease has a positive effect on parental behavioral intention to vaccinate their children with LAIV.

Hypothesis 9.

Risk perception of influenza disease has a positive effect on parental self-reported behavior to vaccinate their children with LAIV.

The perceived value of vaccines is determined by weighing the advantages and disadvantages of receiving them.²⁷ Vaccines have proven to be one of the most effective public health interventions in history, and acknowledging their value can guide resource allocation appropriately. In many low- and middle-income nations, there is a shortage of vaccine supplies, preventing individuals who want to be vaccinated from accessing them. On the other hand, in high-income countries where vaccines are readily available, vaccine hesitancy has become a concern. The global public health community has yet to reach a consensus on how to evaluate the overall economic and social benefits of vaccines, including COVID-19 vaccines, influenza, measles, and others. Reevaluating vaccines could elevate their priority on the global public health agenda as most policy decisions involve cost-benefit analysis. In general, Vaccinated children are more educated, they attend school more frequently, perform better on tests, and have less burden on their families.^9,28 Based on these observations, we propose the following hypothesis:

Hypothesis 10. Perceived value has a positive effect on parental behavioral intention to vaccinate their children with LAIV.

Behavioral intention refers to internal factors that drive a specific behavior, where a stronger intention to engage in the behavior increases the likelihood of it being performed.²⁹ The intention to get vaccinated is influenced by various factors such as personal beliefs, attitudes toward vaccines, perceived risks and benefits, social norms, and perceived barriers to vaccination. Understanding and addressing these behavioral intention determinants can help public health efforts in promoting vaccine acceptance and uptake, ultimately contributing to improved population health outcomes. When it comes to vaccinations, behavioral intention holds great importance as it greatly influences an individual’s decision to get vaccinated or not.

Hypothesis 11. Behavioral intention has a positive effect on parental self-reported behavior to vaccinate their children with LAIV.

Questionnaire design

The questionnaire was designed to serve structural equation model (SEM) analysis, Table 1. The questionnaire is divided into two parts, one for demographic variables and the other for 32 structured measurement items. Structured measurement items were measured using a seven-level Likert scale, and they were clearly and concisely stated and consistent with previous research. We revised the wording of the items to ensure that they are understandable and clear to respondents. Before the formal survey, we randomly selected a representative sample of 50 respondents from the target population in Changsha to participate in a pilot test, and revised the questionnaire according to the respondents’ feedback on the clarity, relevance and ease of understanding of the questionnaire description. Through pilot testing and psychometric analysis, we assessed the reliability and validity of the questionnaire. Overall, the meticulous design process aims to create a precise questionnaire that provides reliable and accurate data for subsequent SEM analysis.

Table 1. Measurement items.

Construct	Variable	Measurement Item
Perceived Ease of Use (PEOU)	PEOU1	Nasal spray flu vaccination is easily available.
	PEOU2	Nasal spray flu vaccination is convenient.
	PEOU3	Children experience peace and quiet during nasal spray flu vaccination.
	PEOU4	Children’s nasal spray flu vaccination is easy to schedule.
	PEOU5	Children’s nasal spray flu vaccination is easily accepted.
Perceived Usefulness (PU)	PU1	The nasal spray flu vaccine provides effective protection against influenza.
	PU2	Nasal spray flu vaccination can reduce the incidence of influenza in children.
	PU3	Children who get the nasal spray flu vaccine are less likely to get the flu.
	PU4	Nasal spray influenza vaccination is effective in relieving flu symptoms in children.
	PU5	Getting nasal spray flu vaccine reduce chance of influenza spreading in classroom.
Risk Perception of Influenza Disease (RPID)	RPID1	My children are at risk of catching the flu virus.
	RPID2	Riding a bus increases the risk of catching the flu virus.
	RPID3	Attending formal parties can lead to infection with the flu virus.
	RPID4	School-age children are vulnerable to influenza virus cross infection.
	RPID5	Severe cases of influenza in children require hospitalization and can lead to death.
Health Knowledge (HK)	HK1	The flu season runs from November to March.
	HK2	Annual influenza vaccination is an effective way to control the spread of influenza.
	HK3	Antibodies are produced two weeks after the flu shot.
	HK4	Persons aged 6 months or older with no contraindications should be vaccinated against influenza.
	HK5	Getting vaccinated greatly reduces the likelihood of getting the flu.
Perceived Value (PV)	PV1	The nasal flu vaccine for children is more cost-effective than the injection.
	PV2	Nasal spray flu vaccines for children offer affordable benefits.
	PV3	Although the price is higher, the nasal spray flu vaccine for children proves to be worth it.
	PV4	The nasal flu vaccine for children is a favorable alternative.
Behavioral Intention (BI)	BI1	A nasal spray is the best choice for a flu vaccine for children.
	BI2	I agree with the nasal spray vaccine for children.
	BI3	The nasal flu vaccine for children is relatively invasive and stress-free.
	BI4	I support the nasal spray flu vaccine for kids.
Self-reported Vaccination Behavior (SVB)	SVB1	I agree to my child getting the nasal spray flu vaccine.
	SVB2	I recommend to my peers that their children get the nasal flu vaccine.
	SVB3	I recommend that my relatives’ children get the nasal flu vaccine.
	SVB4	I advocate for the nasal spray flu vaccine for my friends’ offspring.

Data collection and statistical analysis

From October 2022 to December 2023, a comprehensive survey was conducted at 38 prestigious medical institutions or community hospitals in four major Chinese mainland cities, i.e., Beijing, Guangzhou, Wuhan, and Changsha, and their subordinate districts, counties (including small and medium-sized cities within these regions), and rural areas. The aim was to gather insights from parents who accompanied their children seeking medical treatment or vaccinations. The selection process was based on a thorough randomization process, where parents were selected based on their children’s medical card numbers at child health centers or pediatric clinics within these institutions. Before taking part in the survey, respondents took several essential steps. Initially, they were required to sign an informed consent form to ensure their participation was voluntary and based on a clear understanding of the survey’s nature and purpose. Furthermore, the survey team thoroughly briefed the individuals on the survey’s contents and objectives, ensuring they had all the necessary information to provide accurate responses.

To ensure that the statistical results were free from common method bias, several extensive measures were taken into the survey design. First, to minimize selection bias, we deliberately included participants from both urban and rural regions, to represent diverse geographical locations. This approach ensured that the sample was not biased toward any particular demographic or socio-economic group. Secondly, to reduce sampling bias, a random sampling method was employed. This ensured that each individual in the target population had an equal chance of being selected, thus improving the representativeness of the sample. Furthermore, to address potential response bias, we used standardized questionnaires and trained interviewers to collect data. This minimized the influence of interviewer effects and ensured consistency in data collection. During the survey period, 1100 questionnaires were distributed, and the effort resulted in a commendable collection of 936 valid questionnaires. It is worth mentioning that Bollen (1991) that the sample size for structural equation model analysis should exceed 15 times the number of variables.³⁰ In this study, we achieved robust results with 32 variables and a sufficient sample size of 936 valid samples, ensuring the feasibility and suitability of conducting structural equation analysis.

The previous section’s theoretical model explains the relationship between variables, including the hypothesized causality and measurement models that define how the underlying structure can be measured by the observed indicators. Amos 24.0 and SPSS 22.0 were used for statistical analysis. First, descriptive statistics of demographic variables were performed. Second, the reliability and validity tests were conducted. This involved using Cronbach’s alpha and confirmatory factor analysis to assess the internal consistency of each structure, and the structural convergence effectiveness was measured by average variance extracted (AVE). Thirdly, evaluate the overall fit of the measurement model by examining various fit indices: chi-square/freedom (NC value < 5), root mean square error of approximation (RMSEA) (<0.08), normed fit index (NFI) (>0.9), relative fit index (RFI) (>0.9), comparative fit index (CFI) (>0.9), Tucker-Lewis’s index (TLI) (>0.9), and adjusted goodness-of-fit index (AGFI) (>0.85). If the initial model does not provide an acceptable data fit, changes to the model may be required, involving adding or removing paths, modifying the metric model, or including additional variables. Finally, test the structural model and interpret the results. By using the structural equation model approach, examine the path coefficients to determine the strength of the relationship and examine the significant moderating effect of demographic variables on the relationships.

Results

Population description

Table 2 provides a comprehensive overview of the key characteristics of our study population. Most participants were female (56.5%) and the majority were under 50 years old (92.9%). Concerning the LAIV vaccination, girl figures surpass boy slightly; children aged 3–6 years comprise 50.6% of the total, children aged 6–12 years comprise 38.1%, while the segment aged 12–18 years exhibits the least demographic. In terms of education, approximately half of the participants (53.0%) held a college degree, 27.7% had a vocational college degree, only 6% had a high school degree or lower, and the remaining participants had a master’s degree or higher. With respect to annual household pretax gross income, around 45.9% of participants reported earnings between CNY 70,001 to 140,000, another 25.6% reported earnings between CNY 140,001 to 210,000, and the low-income group (earning less than CNY 70,000) accounted for 11.5%, while the remaining participants were in high-income subgroups (earning above CNY 210,001). Living in cities was the case for 87.2% of the respondents. Regarding the number of children, families with one child made up 43.6%, families with two children made up 46.8%, and families with three or more children were in the minority.

Table 2. Socio-demographic characteristics.

Items	n	%
Gender of respondent
Male (1)	407	43.5
Female (2)	529	56.5
Age of respondent
Under 30 years old (1)	386	41.2
31–40 years old (2)	240	25.6
41–50 years old (3)	244	26.1
51 years old and above (4)	66	7.1
Gender of Child
Boy (1)	409	43.7
Girl (2)	527	56.3
Age of Child
3–6 years old (1)	474	50.6
6–12 years old (2)	356	38.1
12–18 years old (3)	106	11.3
Education Level
High school degree or below (1)	56	6.0
Vocational or College degree (2)	259	27.7
Bachelor degree (3)	496	53.0
Master Degree or above (4)	125	13.4
Annual Household income before tax
Less than CNY70,000 (1)	108	11.5
CNY 70,001–140,000 (2)	430	45.9
CNY 140,001–210,000 (3)	240	25.6
Over CNY 210,001 (4)	158	16.9
Residential District
Rural (1)	120	12.8
Urban (2)	816	87.2
Number of children
One (1)	408	43.6
Two (2)	438	46.8
Three and more (3)	90	9.6
Total	936	100

Reliability and validity tests

Confirmatory Factor Analysis (CFA) was used to measure the reliability and validity of the scale. The measurement model corresponding to each construct was analyzed in turn, and the Standard Factor Loading (SFL) of each item was determined to be greater than 0.6, indicating that the scale has acceptable reliability. Secondly, Cronbach’s Alpha and Composition Reliability of all constructs were greater than 0.7, and Average Variance Extracted (AVE) values of all constructs were greater than 0.5, indicating that the validity of the current scale is acceptable. Finally, the AVE of each construct and the correlation coefficients between each construct were compared, and it was found that all correlation coefficients are lower than the square root of the AVE value of the correlation constructs, indicating that the scale has reliable discrimination validity. The results of the reliability and validity tests are presented in Table 3.

Table 3. The results of reliability and validity tests.

Constructs	Variables	Standardized Factor Loading	Cronbach’s Alpha	Composition Reliability	Average Variance Extracted
Perceived Ease of Use (PEOU)	PEOU1	0.86	0.92	0.92	0.70
	PEOU2	0.78
	PEOU3	0.87
	PEOU4	0.89
	PEOU5	0.76
Perceived Usefulness (PU)	PU1	0.83	0.91	0.91	0.66
	PU2	0.77
	PU3	0.81
	PU4	0.87
	PU5	0.79
Risk Perception of Influenza Disease (RPID)	RPID1	0.81	0.91	0.91	0.67
	RPID2	0.80
	RPID3	0.86
	RPID4	0.85
	RPID5	0.77
Health Knowledge (HK)	HK1	0.86	0.92	0.92	0.69
	HK2	0.80
	HK3	0.81
	HK4	0.79
	HK5	0.87
Perceived Value (PV)	PV1	0.82	0.89	0.89	0.68
	PV2	0.81
	PV3	0.84
	PV4	0.81
Behavioral intention (BI)	BI1	0.83	0.91	0.92	0.72
	BI2	0.87
	BI3	0.87
	BI4	0.85
Self-reported Vaccination Behavior (SVB)	SVB1	0.79	0.88	0.88	0.64
	SVB2	0.82
	SVB3	0.81
	SVB4	0.78

Structural model analysis

The fitting parameters of the model meet the requirements recommended by previous literatures as follows. Chi-square/freedom = 3.66 < 5, RMSEA = 0.053 < 0.08, NFI = 0.92 > 0.9, RFI = 0.94 > 0.9, CFI = 0.94 > 0.9, TLI = 0.94 > 0.9, AGFI = 0.89 > 0.85. These coefficients indicated that the fit between data and the theoretical model is acceptable.

The standardized path coefficients and levels of significance were used to examine 11 hypotheses, which can be found in Table 4. The analysis indicates that, except for the path coefficient from risk perception of influenza disease to behavioral intention, all other relational paths were statistically significant. Perceived ease of use was verified to be a significant predictor of perceived usefulness (β = 0.20) and perceived value (β = 0.17). Perceived usefulness was also been verified as a significant predictor of perceived value (β = 0.36) and behavioral intention (β = 0.14). Knowledge, as a newly added construct, was a significant antecedent of perceived value (β = 0.14) and risk perception of influenza disease (β = 0.37). Furthermore, risk perception of influenza disease was proved to be a significant predictor of perceived value (β = 0.43) and self-reported vaccination behavior (β = 0.34). Perceived value significantly affected behavioral intention (β = 0.26), and behavioral intention significantly affected self-reported vaccination behavior (β = 0.63). Therefore, all hypotheses are supported by empirical data except H8.

Table 4. The results of hypotheses tests.

Hypotheses	Paths			t	β	P	Comments
H1	^aPEOU	—>	^bPU	5.67	0.20	***	Supported
H2	PEOU	—>	^ePV	5.68	0.17	***	Supported
H3	PU	—>	PV	11.13	0.36	***	Supported
H4	PU	—>	BI	3.63	0.14	***	Supported
H5	^dHK	—>	PV	4.25	0.14	***	Supported
H6	HK	—>	^cRPID	10.59	0.37	***	Supported
H7	RPID	—>	PV	12.40	0.43	***	Supported
H8	RPID	—>	^fBI	1.463	0.06	0.144	Not Supported
H9	RPID	—>	^gSVB	11.684	0.34	***	Supported
H10	PV	—>	BI	5.483	0.26	***	Supported
H11	BI	—>	SVB	18.404	0.63	***	Supported

^aPEOU: Perceived Ease of Use; ^bPU: Perceived Usefulness; ^cRPID: Risk Perception of Influenza Disease; ^dHK: Health Knowledge; ^ePV: Perceived Value; ^fBI: Behavioral intention; ^gSVB: Self-reported Vaccination Behavior.

The questionnaire examined eight demographic variables: gender of respondent, age of respondent, gender of child, age of child, education level, annual household income before tax, residential district, number of children, and resultant moderator impacts were detailed in Table 5. Respondents’ gender significantly influenced the magnitude of the link between perceived usefulness and behavioral intention (Z = -3.31). Females (children’s caregivers) expressed strong commitment toward child vaccination due to LAIV effectiveness, contrasting male commitments. Gender of child significantly moderated the path from perceived usefulness to behavioral intention (Z = -2.84), with parents of girls having significantly higher relationship strength. The age of the child significantly modulated both pathways, from perceived value to behavioral intention (Z = 2.34), and from behavioral intention to self-reported vaccination behavior (Z = 2.29). Respondents’ age (Z = 2.83) and education level (Z = 2.75) significantly impacted the path relationship from perceived value to behavioral intention. The younger generation (under 40 years) displayed greater willingness for LAIV vaccination driven by perceived value, whereas elders exhibited minimal impact. Lower education tiers (vocational college and below) distinctly demonstrated stronger links compared to higher educational groups (bachelor degree and below). Pre-tax annual household income was a notable moderator impacted three connections: from risk perception of influenza disease to behavioral intention (Z = 2.70), from risk perception of influenza disease to self-reported vaccination behavior (Z = 6.18), and from behavioral intention to self-reported vaccination behavior (Z = -4.25). Residential district significantly shaped the relationship from risk perception of influenza disease to self-reported vaccination behavior (Z = -2.42). Lastly, the number of children the respondents significantly moderated the relationships from perceived usefulness to behavioral intention (Z = -2.71), risk perceptions of influenza virus to self-reported vaccination behavior (Z = 3.55), and from behavioral intention to self-reported vaccination behavior (Z = -2.16).

Table 5. The moderating effects testing of demographic variables.

Paths	^aPU—>BI	^bRPID—>BI	^cPV—>BI ^d	RPID—>SVB^e	BI—>SVB
Gender of respondent
Male(1)	-0.003^f	0.179	0.103	0.296	0.532
Female(2)	0.246	0.068	0.133	0.325	0.546
Z-value	-3.31	1.23	-0.47	-0.52	-0.29
Age of respondent
Under 40 years old (1)	0.156	0.073	0.204	0.355	0.583
41 years old and above (2)	0.047	0.222	0.013	0.355	0.583
Z-value	1.35	-1.56	2.83	1.30	1.59
Gender of Child
Boy (1)	0.023	0.183	0.122	0.310	0.543
Girl (2)	0.236	0.057	0.123	0.330	0.545
Z-value	-2.84	1.42	-0.02	-0.35	-0.04
Age of Child
Under 6 years old (1)	0.128	0.084	0.226	0.338	0.610
6 years old or above (2)	0.110	0.119	0.085	0.316	0.498
Z-value	0.24	-0.43	2.34	0.40	2.29
Education Level
Vocational degree or below (1)	0.097	0.060	0.243	0.328	0.579
Bachelor degree or above (2)	0.230	0.075	0.059	0.302	0.523
Z-value	-1.69	-0.17	2.75	0.49	1.14
Annual Household income before tax
Less than CNY140,000 (1)	0.068	0.272	0.105	0.528	0.460
Over CNY140,001 (2)	0.175	0.035	0.184	0.196	0.666
Z-value	-1.41	2.70	-1.28	6.18	-4.25
Residential District
Rural (1)	0.131	0.003	0.236	0.169	0.598
Urban (2)	0.126	0.090	0.100	0.307	0.502
Z-value	0.07	-0.88	1.49	-2.42	1.49
Number of children
One (1)	0.017	0.161	0.174	0.451	0.504
Two or more (2)	0.221	0.086	0.132	0.260	0.608
Z-value	-2.71	0.88	0.69	3.55	-2.16

Notes: ^aPU: Perceived Usefulness; ^bRPID: Risk Perception of Influenza Disease; ^cPV: Perceived Value ; ^dBI: Behavioral intention; ^eSVB: Self-reported Vaccination Behavior; ^fStandardized Coefficients Beta.

Discussion

This study employed structural equation modeling to investigate the influence of various factors on the willingness of Chinese parents to have their children receive the live attenuated influenza vaccine, as well as any associated cross-over effects. A comprehensive theoretical framework, comprising of seven structures, was constructed and examined using survey data gathered during the 2022–2023 influenza season to identify correlations. This research introduces a unique analytical framework that explores the multidimensional aspects of childhood live attenuated influenza vaccination, encompassing psychological factors and demographic variables. The empirical analysis of the correlation between multiple factors and parental willingness has revealed intriguing findings and brought forth new perspectives.

Perceived ease of use is an important factor, which significantly affects both perceived usefulness and perceived value in the context of parental willingness to vaccinate their children with live attenuated influenza vaccines. These findings confirm previous consistent studies in which parents reported vaccinating themselves and their children, such as that factors positively associated with influenza vaccination include adequate knowledge of the flu vaccines, and easy access to vaccination.¹⁹ A study conducted in four cities in mainland China on parents’ behavioral intentions toward children’s influenza vaccination revealed that perceived ease of use is a significant factor influencing behavioral intentions (β = 0.227).³¹ The current study further suggests that perceived ease of use influences parents’ behavioral intentions by influencing perceived usefulness and perceived value, thereby influencing the final decision regarding children’s LAIV vaccination. This finding is not necessarily surprising, because Chinese medical institutions are often overcrowded, and children’s LAIV vaccination is more convenient and time-saving than the traditional flu vaccine, which greatly reduces the difficulty of vaccination and improves the possibility of vaccination for children. Making the vaccination process more user-friendly can help increase vaccination rates and overall public health, which can be achieved through clear communication, user-friendly appointment systems, and streamlined administrative processes that eliminate perceived barriers or inconveniences.

Perceived usefulness is an important anaphora that influences parents’ behavioral intention to vaccinate their children with live attenuated influenza vaccine. The literature confirms the efficacy of the LAIV vaccine, as evidenced by a systematic review and meta-analysis showing a higher probability of seroconversion with LAIV compared to placebo (pooled OR = 2.26 (95% CI = 1.12–4.54), specifically for the A/H1N1 serotype.⁵ Prior data demonstrates that for children aged 2–8, live attenuated influenza vaccine is both more effective and less costly than more effective than inactivated influenza vaccine.³² The current study further confirmed that perceived usefulness not only directly affects parents’ behavioral intention to vaccinate their children with LAIV, but also enhances behavioral intention by influencing perceived value.

Health knowledge is an important positive antecedent affecting perceived value and harmful effects of influenza disease, thereby positively influencing parental behavioral intentions. This conclusion is consistent with a large number of previous studies.^21,27 A study using a Knowledge, Attitude and Practice (KAP) model of influenza vaccination among older adults in eastern China showed that 92% of those who knew about the flu vaccine believed it was effective, and 55% of those who knew about the flu virus said they were worried about getting the flu this season.²² Public health campaigns, educational initiatives, and reliable sources of information play a crucial role in shaping individuals’ perceptions about the usefulness of LAIV vaccines. It is important for public health policymakers to clearly communicate the benefits of LAIV, such as reduced risk of disease, prevention of severe symptoms, or herd immunity, leading to increased vaccination rates and improved public health outcomes.

Research suggests that risk perception of influenza disease significantly influences parental self-reported vaccination behavior regarding their child’s LAIV vaccination, which is consistent with previous research on the impact of risk perception on vaccination behaviors, e.g., COVID-19 Vaccination,¹⁸ HPV vaccination,³³ and influenza vaccination.^19,23 The positive correlation found between risk perception and behavioral intention indicates that parents who perceive a higher risk associated with the flu virus are more likely to intend to vaccinate their child against LAIV. Conversely, parents with a lower perception of risk may be less motivated to vaccinate their child. It is worth noting that risk perception of influenza disease is not a significant anagram of behavioral intention.^34,35 The possible reason is that respondents’ understanding of influenza risk is still quite different. These findings underscore the importance of understanding individuals’ perception of flu virus risk and have implications for healthcare professionals and policymakers as they develop effective interventions and communication strategies to promote vaccine uptake. Healthcare providers have a critical role in addressing parents’ risk perceptions during clinical encounters by engaging in open and honest conversations, addressing concerns, and providing accurate information to prevent misconceptions. These efforts can lead to increased vaccination rates and protect individuals and communities from potential consequences of the flu virus.

Perceived value plays a crucial role in influencing parents’ behavioral intentions toward their children’s LAIV vaccination. This aligns with previous studies that have also found perceived value as a predictor of health-related behavioral intentions.^4,12 One important factor contributing to the perceived value of LAIV is its convenience and ease of administration compared to traditional injectable flu vaccines. Parents may perceive LAIV as a more attractive option for their children due to its ease of use and reduced discomfort associated with receiving the vaccine. This supports the idea that people are more likely to engage in behaviors that they perceive as convenient and minimally invasive. However, LAIV is significantly more expensive than many parents would expect to pay for a flu vaccine. The cost factor can affect parents’ perceived value of LAIV, as it raises questions about whether convenience and pain reduction are worth the additional expense. Parents may weigh the perceived benefits of LAIV against their financial considerations, potentially influencing their behavioral intentions regarding their children’s vaccinations. Hence, healthcare professionals and policymakers must take into account the cost factor and ensure that parents are adequately informed about the financial implications of choosing LAIV. Policymakers should also consider implementing initiatives to reduce the cost burden of LAIV, such as exploring cost assistance or subsidies that make LAIV more accessible and affordable for parents.

This study provides valuable insights into six demographic variables that influence parents’ behavioral intentions regarding their children’s LAIV vaccination. Gender has become an influential factor, with females, who are typically the primary caregivers for children, showing stronger commitment toward child vaccination with LAIV, based on perceived usefulness. Healthcare professionals tailor their communication and educational strategies to effectively promote LAIV vaccination. The younger generation, under 40 years old, showed a greater willingness to vaccinate their children with LAIV, driven by perceived value. This suggests that younger parents are more likely to prioritize the benefits and advantages of LAIV when making decisions. On the other hand, elders appear to be less influenced by perceived value when making vaccination decisions for their children. These findings emphasize the significance of considering age-related differences in educational campaigns and interventions promoting LAIV. Lower educational attainment may place a greater emphasis on the perceived value of LAIV in influencing their decision to vaccinate their children. Healthcare professionals and policymakers should focus on increasing awareness and understanding of the value proposition of LAIV among all educational groups, particularly those with lower levels of education. The pretax household income was a significant moderator, affecting three key connections in the study. This impacted the relationship between flu virus risk perception and both behavioral intention and self-reported vaccination behavior, indicating that income level may play a role in parents’ decision-making process regarding LAIV. This finding suggests that financial considerations related to vaccinations may vary based on income levels. Residential district was found to shape the relationship between risk perception of the flu virus and self-reported vaccination behavior. This implies that the perception of risk related to the flu virus may differ depending on the local context and prevalence of the flu. Targeted interventions aimed at addressing specific concerns in different residential districts can boost vaccination rates and community protection. Lastly, the number of children respondents had also moderated the relationship between perceived usefulness, risk perception of the flu virus, and self-reported vaccination behavior. This suggests that the decision-making process may differ for parents with different numbers of children. Understanding these differences can help healthcare professionals better understand the specific factors that influence parental acceptance of LAIV vaccine, so they can provide tailored information and support to parents of children to improve LAIV vaccination rates.

Although the current study has produced valuable findings, there are still limitations that need to be acknowledged. Firstly, there could be significant variations in the understanding of LAIV among different groups, which may limit the generalizability of the study’s findings to populations already familiar with LAIV. As LAIV is a relatively new influenza vaccine approved for use in China within the past four years, it has not yet gained widespread adoption. Secondly, surveys conducted in major cities and their surrounding areas may not accurately reflect the views of the entire Chinese population, given the country’s vast size and varying levels of development. Therefore, the findings presented in this study primarily reflect the perspectives and attitudes of individuals living in urban areas. To gain a more comprehensive understanding of the national perspective, further research is needed to delve into the underlying reasons for the lack of interest in LAIV vaccination among parents for their children residing in smaller cities, medium-sized towns, and rural areas. Such investigations would provide valuable insights into the regional disparities and challenges faced in promoting LAIV coverage across China. Thirdly, we did not fully consider the parents’ concerns about possible side effects of LAIV vaccination, which could have significantly impacted our understanding of factors that influence parental acceptance. Our framework only focused on LAIV, neglecting parents’ behavior regarding other vaccines. This limitation may hinder a comprehensive understanding of parents’ overall vaccination practices and attitudes. Additionally, several crucial factors were omitted from our study. One factor is the willingness of children, who are able to express their preferences, to be vaccinated. Their attitudes toward vaccinations could greatly influence parents’ decisions. Another overlooked aspect is the status of vaccinations effectively done or accepted for other children in the family. This information could provide valuable insights into family vaccination decisions. To gain a more comprehensive understanding, future research should incorporate these factors.

Conclusions

In conclusion, this study offers valuable insights into the determinants influencing Chinese parents’ willingness to vaccinate their children with the live attenuated influenza vaccine. The findings demonstrate that factors such as perceived ease of use, perceived usefulness, health knowledge, risk perception of influenza disease, and perceived value play a pivotal role in shaping parents’ intentions to LAIV. Improving the user-friendliness of the vaccination process has the potential to augment the LAIV coverage rates. Public health campaigns and educational initiatives should emphasize the benefits associated with the live attenuated influenza vaccine. Health knowledge positively impacts parents’ inclination toward vaccination. Policymakers should consider alleviating financial burdens and ensuring parental awareness regarding LAIV-associated costs. Policymakers and healthcare professionals should prioritize effective communication strategies and educational campaigns to foster greater acceptance of LAIV and improve public health outcomes.

Disclosure statement

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.

Data availability

The authors do not have permission to share data.

Additional information

Funding

This work was supported by Natural Science Foundation of Hunan Province (2023JJ30839, 2024JJ5119).