COVID-19 vaccination hesitancy in pediatrics: a systematic review.

COVID-19 vaccination hesitancy in pediatrics: a systematic review - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Syst Rev . 2026 Apr 18;15:179. doi: 10.1186/s13643-026-03110-3 COVID-19 vaccination hesitancy in pediatrics: a systematic review Nasir Amanat 1 , Seyed Hossein Hosseini 2, ✉ , Reza Habibisaravi 3 , Mojgan Gholitabar Omrani 2 Author information Article notes Copyright and License information 1 Nursing Care Research Center, Semnan University of Medical Sciences, Semnan, Iran 2 Department of Paramedicine, Amol School of Paramedical Sciences, Mazandaran University of Medical Sciences, Sari, Iran 3 Department of Pre-hospital Emergency, Faculty of Allied Medical Sciences, Mazandaran University of Medical Sciences, Sari, Iran ✉ Corresponding author. Received 2025 Jan 4; Accepted 2026 Feb 4; Collection date 2026. © The Author(s) 2026 Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/ . PMC Copyright notice PMCID: PMC13220628  PMID: 41998754 Abstract Background Vaccine-preventable diseases remain among the top ten global health threats. These findings indicate an important link between health and vaccine literacy. Children are less affected by COVID-19 than adults are but can be particularly vulnerable in communities with inadequate and weak infrastructure. One in five parents was skeptical about the COVID-19 vaccine. The present study combined the findings of previous studies to identify the reasons for parental hesitancy related to children’s COVID-19 vaccination. Methods We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to investigate vaccine hesitancy among parents of children aged 0–18 years in the context of COVID-19. We searched PubMed, Scopus, Web of Science, and Google Scholar using the keywords “vaccine hesitancy,” “pediatrics,” and “COVID-19” for studies published between January 2019 and August 2024. Eligible studies were published in English and focused on parental perspectives. Two independent reviewers screened 2950 records, extracted data, and assessed study quality using the Joanna Briggs Institute (JBI) critical appraisal checklists. Thematic analysis identified key drivers of vaccine hesitancy. Results Of the 48 full-text articles screened, 22 studies met the eligibility criteria. The included studies took place in 11 different countries. The thematic analysis resulted in two main headings: (1) vaccine-related concerns, which included safety/trust concerns (100% of studies) and accessibility barriers (13.6%), and (2) user-related concerns: risk perception (31.8%), lack of knowledge (50%), cultural manifestation (13.6%), and previous medical conditions (31.8%). Universal concerns about safety and trust were evident in all studies, while cultural and accessibility barriers were context-specific and fluctuated by region and population. Conclusion The study points to interventions for reversing parental hesitation towards pediatric COVID-19 vaccination, like tailored education programs, streamlining distribution procedures, creating public acceptance through local community opinion leaders, and appropriate risk communication by public health institutions. All of these can contribute to making sound policies and making future immunization planning easier. Supplementary Information The online version contains supplementary material available at 10.1186/s13643-026-03110-3. Keywords: Vaccine, Hesitancy, Pediatrics, COVID-19 Background Vaccine-preventable diseases are among the ten health threats worldwide, and vaccines are effective at reducing the risk of many diseases [ 1 ]. Vaccine hesitancy is a worldwide phenomenon that may impede the efforts of childhood vaccination programs, contributing to a major reduction in the prevalence of VPDs [ 2 ]. In 2023, approximately 14.5 million children worldwide missed out on any vaccination [ 3 ]. In the USA, the proportion of children who reported vaccination with the new 2024–25 COVID-19 vaccine was about 13.0%, which was much lower compared to adults (23.2.) [ 4 ]. However, vaccine hesitancy fueled by misinformation and politicization is a major obstacle to achieving herd immunity [ 5 , 6 ]. The hesitancy not only affects childhood vaccination programs but also increases disease prevalence [ 2 , 7 ]. Vaccine hesitancy and politicization of vaccine development have made COVID-19 vaccine suspicion high in the USA [ 6 ]. Vaccine hesitancy is fueled by various interrelated factors. Low vaccine literacy, as manifested through a lack of knowledge about vaccines and an inability to assess health information, enhances the effects of misinformation [ 8 ]. This is also exacerbated by incorrect risk perceptions, with parents underrating the seriousness of COVID-19 among children, which increases hesitancy [ 9 , 10 ]. Although children are less severely affected by COVID-19 than adults, they can be particularly vulnerable in communities with inadequate and weak infrastructure [ 8 , 11 ]. Most recent data show that an increasing number of children are becoming infected, and children represent 11.5% of all COVID-19 cases in the USA [ 12 ]. Pediatric patients often rely on parental guidance and decision-making, which may result in a lack of immunization for some children [ 13 ]. However, various levels of hesitancy exist in different populations toward receiving vaccinations for a multitude of reasons. According to recently published research, 1 in 5 parents are vaccine hesitant against the COVID-19 vaccine [ 14 ]. Listing the concerns of vaccine-hesitant parents provides health communicators with an opportunity to proactively address these concerns and mitigate misinformation online through highly influential and relatable spokespersons for the vaccine [ 5 ]. Overcoming this challenge and increasing the uptake of vaccines are essential, particularly during the ongoing COVID-19 pandemic, in which this hesitancy might influence mothers’ intentions in vaccinating their children [ 2 ]. A systematic review by Kumar et al. that was probably aimed at adult populations found common reasons, including safety concerns, efficacy concerns, and distrust of health systems. Although the study was mostly aimed at adults, it serves as a comparative background to inform trends that can apply to parental choices for children, citing that safety and efficacy concerns are even more heightened in pediatric settings due to parental protectiveness [ 15 ]. In a different SR, Schmid et al. also analyzed perceived low risk, lack of confidence, and lack of information as factors that hinder influenza vaccination intention and behavior. In addition, this study did not focus on pediatric patients [ 16 ]. Another systematic review by Olivia et al. highlighted effective communication strategies to address general vaccine hesitancy. The key findings of this review were the use of tailored messaging, addressing specific concerns (e.g., safety, efficacy), and leveraging trusted messengers (e.g., healthcare providers) [ 17 ]. Kennedy’s review identified key predictors of vaccine uptake, such as parental beliefs, social norms, healthcare provider recommendations, and access to vaccination services [ 18 ]. There is no systematic review exclusively dealing with parental hesitation toward COVID-19 vaccination of their children, thus creating a knowledge gap to comprehend this particular context. While some studies have examined a few determinants, such as concerns over safety and cultural beliefs [ 19 – 22 ], no similar findings have been obtained, and no synthesis of these findings has been conducted. This lack of clarity makes it difficult to develop a concise picture of the problem or the design of specific interventions. By finding, aggregating, and examining the determinants of parental reluctance towards their children’s COVID-19 vaccination, this systematic review intends to fill the gap. In a bid to improve vaccine acceptance and alleviate the disease burden among pediatric populations, this review attempts to elucidate the major drivers of such resistance and offer pragmatic policy recommendations for pediatric vaccine policies and future planning and development. Methods This was a systematic review study, and we opted for a narrative synthesis employing thematic analysis [ 23 ] to capture the complexity of the findings. Information sources and search strategy The search was conducted from the beginning of 2019 to August 27, 2024, with “vaccine hesitancy,” “pediatrics,” “COVID-19,” and their synonyms, in the PubMed, Scopus, and Web of Science databases. An additional search was conducted on Google Scholar. The search strategy and syntax are shown in Attachment file 1. All discrepancies were resolved through discussions to achieve 100% final agreement at every stage. Study screening process Two independent reviewers screened titles and abstracts of 2950 records retrieved from PubMed, Scopus, Web of Science, and Google Scholar, applying eligibility criteria based on the PICO 1 framework. Discrepancies were resolved through discussion or consultation with a third reviewer. Of these, 48 articles underwent full-text assessment. Twenty-six articles were excluded due to irrelevant interventions (e.g., studies focusing on interventions to reduce hesitancy; n = 3) or irrelevant outcomes ( n = 23). Only English-language studies were included, and gray literature was excluded. Study screening process are shown in Fig. 1 . Fig. 1. Open in a new tab PRISMA flow diagram illustrating the study selection process Eligibility criteria Population: Parents or primary caregivers of children aged 0–18 years. Exclusion: Studies focusing exclusively on adults without children, pregnant women, or healthcare providers without parental perspectives. (Intervention/exposure/phenomenon of interest): Focus: COVID-19 vaccine hesitancy, refusal, or acceptance among parents/caregivers. Included: Studies reporting qualitative or quantitative assessments of hesitancy drivers (e.g., surveys, interviews). Excluded: Interventions to reduce hesitancy (e.g., clinical trials of educational programs), unless they included baseline hesitancy data. Case studies, conferences, and other gray literature were excluded. Comparator: No direct comparator required, as the review synthesizes factors associated with hesitancy. Outcomes: Primary outcomes: Parent-reported reasons for hesitancy (e.g., safety concerns, misinformation). Secondary outcomes: Sociodemographic/cultural correlates of hesitancy, Temporal trends in hesitancy (2019–2024). Secondary consideration: Some studies compared hesitant vs. non-hesitant parents; these were included if they met other criteria. By coding the reasons for vaccine hesitancy in each study, we identified commonalities, which were then consolidated into two key overarching themes. This approach allowed us to capture the complexity of vaccine hesitancy effectively. Quality assessment The Joanna Briggs Institute (JBI) evaluation checklist was used to assess the quality of the articles [ 24 ]. The JBI Checklist is a standard tool for evaluating articles and was designed by the JBI Institute for the quality assessment of studies. The two checklists used in the present study included the checklist for descriptive studies and the checklist for qualitative studies, which included 8 and 10 items, respectively, as shown in Attachment file 2. For these tools, the score of each item was considered to be 1, and the studies that scored 5 or above were included in the study. Two independent evaluators were used for evaluation, and the included studies were evaluated by two people. In cases of disagreement, a third evaluator was used. The results of the quality assessment are shown in Table 1 . Table 1. Quality assessment of the included studies via the Joanna Briggs Institute (JBI) Study, year Cross-sectional a Qualitative b Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Overall Takeshi Yoda, 2021 [ 25 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Meltem Yılmaz, 2021 [ 12 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Chloe, 2021 [ 8 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Hetherington, 2021 [ 26 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Huangyufei, 2021 [ 27 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Stefano Zona, 2021 [ 28 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Robin, 2021 [ 29 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Celia, 2021 [ 30 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Ching, 2021 [ 31 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Luisa Russo, 2021 [ 19 ] ✓ - Yes Yes Yes Yes Yes Yes Yes Yes N/A N/A Include Yulia Gendler, 2021 [ 32 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Adam, 2021 [ 33 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Delgado, 2021 [ 21 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Mohamad-Hani, 2021 [ 20 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Yucheng, 2021 [ 22 ] ✓ - Yes Yes Yes Yes Yes Yes Yes Yes N/A N/A Include Samannodi, 2021 [ 34 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Micah Skeens, 2022 [ 35 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Bader, 2021[ 36 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Faraj Zadeh, 2023 [ 37 ] ✓ - Yes Yes Yes Yes No No Yes Yes N/A N/A Include Honcoop, 2023 [ 38 ] ✓ ✓ Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Include Aya, 2024 [ 39 ] ✓ - Yes Yes Yes Yes Yes Yes Yes Yes N/A N/A Include Olufunto, 2024 [ 40 ] ✓ - Yes Yes Yes Yes Yes Yes Yes Yes N/A N/A Include Open in a new tab a 1.Were the criteria for inclusion in the sample clearly defined? 2.Were the study subjects and the setting described in detail? 3.Was the exposure measured in a valid and reliable way? 4.Were objective, standard criteria used for measurement of the condition? 5.We’re confounding factors identified? 6.Were strategies to deal with confounding factors stated? 7.Were the outcomes measured in a valid and reliable way? 8.Was appropriate statistical analysis used? b 1.Is there congruity between the stated philosophical perspective and the research methodology? 2.Is there congruity between the research methodology and the research question or objectives? 3.Is there congruity between the research methodology and the methods used to collect data? 4.Is there congruity between the research methodology and the representation and analysis of data? 5.Is there congruity between the research methodology and the interpretation of results? 6.Is there a statement locating the researcher culturally or theoretically? 7.Is the influence of the researcher on the research, and vice- versa, addressed? 8.Are participants, and their voices, adequately represented? 9.Is the research ethical according to current criteria or, for recent studies, and is there evidence of ethical approval by an appropriate body? 10.Do the conclusions drawn in the research report flow from the analysis, or interpretation, of the data? Data extraction Data extraction was done through a data extraction form developed by the research team. Double extraction for reliability and to reduce the risk of bias was independently done by two reviewers for the extraction. Extraction of data for study characteristics, population age, study design, and reasons for vaccine hesitancy was independently done by the two reviewers. Any differences between the two reviewers were settled through discussion and consensus, consultation of a third reviewer where required. The results of the data extraction are shown in Table 2 . Table 2. The general characteristics of the included studies ( n =22) Causes of vaccine hesitancy Age Study type Country Year Authors Fear of potential side effects, distrust the vaccine efficiency Aged between 0 and 15 Cross-sectional survey Japan 2021 Takeshi Yoda et al. [ 25 ] Lack of sufficient scientific studies, concern about safety and side effects, potential inefficacy Age < 18 Cross-sectional Turkey 2021 Meltem Yılmaz et al. [ 12 ] Potential safety or effectiveness concerns, children are at low risk of infection and do not need to be vaccinated, religious or medical reasons Age < 12 Cross-sectional survey United States 2021 Chloe A et al. [ 8 ] Safety and efficacy, long-term safety, vaccine confidence, rushed process or scientific quality, recommendation from doctor or health authority, perception of risk from COVID-19, Aged between 9 and 12 Cross-sectional survey Canada 2021 Erin Hetherington et al. [ 26 ] The vaccine may not be safe, waiting for someone else to be vaccinated first, the vaccine does not work, low risk of infection, the vaccine is expensive, inadequate supplies of vaccine or don’t know where to get vaccinated Age < 18 A cross-sectional face-to-face survey China 2021 Huangyufei et al. [ 27 ] “Trust in vaccination and health institutions, the “convenience”, i.e., the ease with which vaccination can be accessed, complacency”, that is from the low perception of the risk of disease Aged between 12 and 17 Online survey Italy 2021 Stefano Zona et al. [ 28 ] Low vaccination intention was also associated with children not receiving influenza vaccine prepandemic, parents having low intention to vaccinate themselves against COVID-19 or unsafe, Age < 17 Cross-sectional national online survey Canada 2021 Robin M et al. [ 29 ] Parental vaccine status, education, perceived childhood COVID-19 susceptibility and severity, vaccine safety and efficacy concerns, community support, and FDA and physician recommendations Aged between 0 and 10 Online survey United States 2021 Celia B et al.[ 30 ] Causes of vaccine hesitancy Children age Methods Country Year Study Safety of vaccines, regular use of medication, children’s comorbid N/A Online questionnaire survey Taiwan 2021 Ching-Shu et al. [ 31 ] Perceived safety and efficacy of vaccines and perceived risk of transmitting infection to adults, perceived risk of being infected and being hospitalized, Age < 18 Online survey Italy 2021 Luisa Russo et al. [ 19 ] Reliable information regarding the COVID-19 vaccine Aged between 12 and 15 A cross-sectional survey Israel 2021 Yulia Gendler et al. [ 32 ] Vaccine’s safety, efficacy, and necessity, Parent and peer norms Aged between 12 and 17 Across-sectional United States 2021 Adam A et al. [ 33 ] Adverse effects from the vaccine, obtaining influenza immunization prompted interest in obtaining the COVID-19 younger-aged parents are much more concerned with having their children vaccinated, policymakers and health authorities should design strategies to gain confidence and provide security N/A Online cross-sectional Mexico 2022 Juan Luis Delgado et al. [ 21 ] Were inadequate safety information, worry about side effects, parents who received COVID-19 vaccine, older parents, and parents with lower education levels N/A Cross-sectional a national survey Saudi Arabia 2021 Mohamad-Hani et al. [ 20 ] Psychological distress psychological distress was more likely to suffer vaccine hesitancy for themselves, for their spouses and children Primary and middle schools age Cross-sectional online survey China 2021 Yucheng Xu, et al. [ 22 ] Causes of vaccine hesitancy Children age Methods Country Year Study The most commonly reported reasons for vaccine refusal history were reading published articles about the safety/harmful effect of the vaccine, not believing in the benefit of the vaccine, and allergies. Around two-thirds of the study participants reported that the child’s age affected their decision (Example: it is unsafe to vaccinate your infant/toddler); The most commonly reported reason for hesitancy was poor awareness about the vaccine’s effectiveness on children. Adequate information about the COVID-19 vaccine was the most agreed cause to accept the vaccine. Having five or more children was a significant predictor for poor vaccination acceptance. N/A Cross-sectional Saudi Arabia 2021 Mohammed Samannodi et al. [ 34 ] Concerns for vaccine side effects both in the child and parent to reliable and trustworthy vaccine related information. Parents with at least a bachelor’s degree were less vaccine hesitant compared to those with some college or high school education only, we observed a weak positive correlation between parent age and vaccine hesitancy, inferring younger parents were more likely to be vaccine hesitant Aged between 0 and 17 Cross-sectional United States 2022 Micah Skeens et al. [ 35 ] Lack of information about COVID-19 vaccine (97.5%) followed by lack of evidence about the vaccine (96.6%). The third most common reason for parents’ refusal of vaccinating their children was that they thought their children were not at risk of getting COVID-19 infection (94.1%). N/A Cross-sectional Saudi Arabia 2021 Bader A et al. [ 36 ] Illness at the time of vaccination, vaccination is unnecessary, worry about severe complications Age < 7 Cross-sectional Iran 2023 Faraj Zadeh N et al. [ 37 ] Infertility, trust, sources of information Aged between 2 and 17 Qualitative United States 2023 Honcoop A et al. [ 38 ] Safety concerns, decision, conflict due to complexity and uncertainty surrounding vaccine-related information Aged between 0 and 11 Web bases a cross sectional Japan 2024 Aya S et al. [ 39 ] Misinformation, access barriers, negative perceptions about vaccines Aged between 5 and 11 A cross-sectional United States 2024 Olufunto A et al. [ 40 ] Open in a new tab Data synthesis and investigate heterogeneity The thematic analysis was performed based on a systematic coding scheme. Two coders worked independently through the extracted data regarding reasons for parental vaccine hesitancy from included studies. They applied open coding to create initial codes for various reasons or concerns. The codes were compared and discussed to smooth out differences as well as to condense the coding framework to more general themes and broader categories. The data were independently coded by two coders, and inter-rater reliability was established through discussion and consensus. To appraise and adjust for the heterogeneity of evidence, our strategy was aimed at identifying possible sources of heterogeneity and addressing it affecting the review findings. We noted anticipated differences in: method (e.g., qualitative interviews vs. cross-sectional surveys), population characteristics (e.g., child age subgroups), and country income level. Results The study selection process is outlined in Fig. 1 . A total of 2950 articles were retrieved and listed separately in the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) table. In total, 48 articles were included in the full-text study process. Twenty-six articles were excluded at the “full text” reading stage because of other interventions ( n = 3) and irrelevant outcomes ( n = 23), and none were excluded because of non-English language, gray literature, and insufficient quality, leaving 22 articles for final evaluation. The methodological quality of the studies included in this review was evaluated using Joanna Briggs reporting checklists with scores of 1 to 8 for quantitative studies and 1 to 10 for qualitative studies (maximum possible). Of the 22 articles evaluated, 4 scored perfectly on this study’s scoring system, indicating high quality. The remaining 18 articles received a 6 score, which indicated a moderate quality. Notably, there were no articles rated as low quality. Table 1 shows the characteristics of the 22 studies included. A meta-analysis was not possible since the studies that were included reported significant heterogeneity. This heterogeneity was present in study designs, populations (e.g., different age groups), as well as outcome measure variability for vaccine hesitancy. The geographic distribution of the studies included is shown in Fig. 2 . Six studies were conducted in the USA, three in Saudi Arabia, two in China, Italy, Canada, and Japan, and one each in Turkey, Taiwan, Iran, Israel, and Mexico. Among the 22 studies included, vaccine safety and trust issues were most frequently cited, being raised in 100% of the studies (22/22). Lack of knowledge were raised in approximately 50% of the studies (11/22). Vaccine accessibility and cultural issues were less frequently raised; each being cited in approximately 14% of the studies (3/22). Risk perception and past medical conditions were prominent topics seen in a notable majority of studies, depicting numerous reasons for parental hesitancy. Important differences in parental vaccine hesitancy were found across child age groups. Infants and Young Children (0–5 years) had the highest hesitancy rates (68–72% in the USA and Saudi Arabian studies), mostly due to concerns about side effects (84.9% in Yoda et al., Japan) [ 25 ], the absence of pediatric side effect information [ 12 ], and perceived low risk. Parents considered COVID-19 disease milder in children [ 19 , 30 ]. School-aged children (6–11 years) had moderate hesitancy toward vaccine engagement (45–60%, with some of the main vaccine hesitancy concerns being: Rapid vaccine development, Adolescents (12–18 years) had the lowest hesitancy (30–40%, with the largest factors influencing their acceptance being peer/school requirements: they had high levels of acceptance where mandates existed [ 28 ], and parental vaccination status. Vaccinated parents had a 2.3 times greater probability of having their adolescents vaccinated. Moreover, 4.9% of parents were uncertain about the safety of the vaccine due to its accelerated approval [ 34 ]. Our systematic review revealed substantial heterogeneity in parental vaccine hesitancy across different income levels of countries. In high-income countries (HICs) such as the USA, Canada, Japan, and Italy, hesitancy estimates ran from 35 to 55%. In the USA, 78.2% of parents expressed doubts regarding vaccine safety, with 32.9% believing there were unproven side effects such as blood clots and infertility [ 34 ], while 54.7% felt COVID-19 was a severe disease for children [ 25 ]. In upper-middle-income countries (UMICs) such as Turkey, the hesitancy prevalence in some studies was between 50 and 65%. Moreover 17% said they did not vaccinate for reasons of cost or logistics [ 21 ]; 44.9% questioned the rapidity of vaccine approval [ 34 ]; while 8.5% mentioned a religious exemption [ 8 ]. We did not have low-income countries in this review. Fig. 2. Open in a new tab Geographical distribution of included studies Reasons for hesitation in vaccination The analysis of the included studies revealed two themes: vaccine-related concerns and user-related concerns. Vaccine-related issues consisted of two subthemes: concerns about safety and trust and access to the vaccine, and user-related issues consisted of four subthemes: risk perception, lack of knowledge and information, past medical conditions, and cultural issues. Table 3 shows these. The safety and trust were the most frequent subthemes and were present in all 22 studies. The lack of knowledge was found in half of the studies and the vaccine accessibility and cultural issues subthemes. The results were organized according to the importance and weight of the subthemes. Figure 3 and Table 3 show these. Table 3. Themes and subthemes extracted from the studies Themes Subthemes Number of study mention subtheme Percentage of study mention subtheme Vaccine-related concerns Safety and trust 22 100 Vaccine accessibility 3 13.6 User-related concerns Risk perception 7 31.8 Lack of knowledge 11 50 Cultural issues 3 13.6 Past medical condition 7 31.8 Open in a new tab Fig. 3. Open in a new tab Country-specific subthemes Vaccine-related concerns Safety and trust Issues of safety and lack of confidence have been mentioned in all studies. Several studies have mentioned the fear of side effect [ 21 , 27 , 36 ]. In a study conducted by Voda and colleagues, a significant proportion of participants expressed concerns about vaccine side effects. Specifically, 399 out of 470 participants (84.9%) reported worries regarding potential adverse reactions to the vaccine. Furthermore, the study revealed that 264 participants (54.7%) reported doubts about the vaccine’s safety [ 25 ]. In an American cohort of parents and caregivers of US children aged 12 years and younger, a sizable majority of respondents were concerned about the safety and effectiveness of vaccines according to a survey from Tesdal and coworkers. In particular, 78.2% were concerned and felt that the vaccine was not safe or would not give them protection [ 8 ]. In a study by Zona et al. that aimed to determine factors associated with COVID-19 vaccination hesitancy, the strongest determinants discovered were related to trust in vaccines and healthcare organizations [ 28 ]. In the study by Delgado et al., the response option “I am concerned that my child will experience an adverse effect from the COVID-19 vaccine” showed that a high degree of parental concern existed about vaccine-associated side effects. This anxiety is especially prominent in parents of younger children [ 21 ]. As the most common reason (60.6%) given for vaccine refusal, concerns about adverse effects and lack of safety information represented the most common reason for vaccine refusal, as reported by Mohamad Hani et al. [ 20 ]. In the study by Samanoodi et al. [ 34 ], the top reason reported for refusing the vaccine was that they did not know if it would work in children (56.3% agreed with this reason). The second most reported reason (44.9% agree) was the rapid approval process of the vaccine, causing concerns of insufficient evaluation of safety. The third reason was the belief that the vaccine could generate blood clotting emboli (32.9% agreed). The average score for vaccine hesitancy in Skeens’ study was 2.8 (out of 4). Concern about side effects was the most common reason for refusing immunization. In other words, the better individuals knew about the vaccine, the more they were informed, and the less their anxiety and hesitance were [ 35 ]. The predominant reason was safety concerns (55.59%), which is consistent with the findings of Feng. The second common reason was skepticism toward vaccine efficacy (11.64%) [ 27 ]. Similarly, 46.3% of participants refused the vaccine because of fear of side effects, and 8% cited no trust in the vaccine [ 19 ]. User-related concerns Lack of knowledge Based on the study results, one of the important factors for vaccine refusal is a lack of knowledge and enough information which was found in half of the studies, indicating the importance and weight of this subtheme. Teasdale et al. reported that low levels of parental knowledge and awareness were strong predictors of vaccine hesitancy [ 8 ]. One of the most common messages concerning vaccine hesitancy was a lack of scientific evidence and studies about the vaccine [ 12 , 19 , 39 , 40 ], which was also cited as a reason for hesitancy by one-third of participants in Russo’s study [ 19 ]. A large proportion (97.5%) of nonvaccinated subjects mentioned a lack of information, and 96.6% reported a lack of pertinent evidence [ 36 ]. In another study, 69% of the subjects reported that their main reason for refusing vaccination was that they felt that they had not received enough information about the vaccine’s safety [ 20 ]. The spread of information through multimedia and cyberspace has the most important influence on whether people decide to vaccinate [ 32 , 38 ]. According to Samanoudi et al., the majority of reasons for refusal were a lack of knowledge about the efficacy of vaccines in children and a lack of proper information regarding the vaccine [ 34 ]. Risk perception Research has established perceived risk as a dominant factor in vaccination hesitancy. A lower level of COVID-19 risk perception, as shown in Rogers’ study, led individuals to be unvaccinated. Many of these individuals thought that the disease was benign or that they were less at risk because of their age group [ 33 ]. Teasdale reported that 23% of parents surveyed believed that children were at low risk and did not need vaccination [ 8 ]. Similarly, in a previous study in which parents believed that children were less likely to develop severe disease due to COVID-19 infection, Fisher et al. reported such misconceptions among parents [ 30 ]. The perception of risk was one of the themes identified from the qualitative analysis of Hetherington’s study. Parents thought that they could handle the disease without a vaccine. In addition, positive and negative attitudes toward the influenza vaccine are associated with the order of the COVID-19 vaccine [ 26 , 27 ]. In Feng’s study, 82.6% of participants rated COVID-19 as very serious, but only 70.5% considered themselves to be at low risk of infection [ 27 ]. A cross-sectional study in Italy by Russo of children < 12 years of age revealed that a reason for parents not vaccinating was their belief that children were at a lower risk than adults. Moreover, the perceived threat of disease transmission and hospitalization plays an important role [ 19 ]. When multivariate regression analysis was used, a positive parental attitude was associated with a lower parental acceptance rate (AOR = 0.432), and a negative parental attitude was associated with a higher parental acceptance rate (AOR = 1.358). Moreover, 94 parents reported that their children were not susceptible to COVID-19 [ 36 ]. Past medical condition One predominant factor affecting vaccine hesitancy among children that has been widely investigated is a person’s physical and medical condition. In Teasdale’s study, 11.2% of respondents reported medical reasons for hesitance toward vaccination [ 8 ]. Studies have shown that parents who self-report receiving the seasonal flu vaccine are more likely to vaccinate their children [ 36 ]. Some studies have correlated medication usage and preexisting comorbidities with vaccine hesitancy [ 8 , 31 , 37 ]. In the research of Fisher and Mohammad Hani, a determining factor in parental decision-making regarding vaccinating their children was their own vaccination status [ 20 , 30 ]. Another study suggested that if an individual does not receive the flu vaccine, the likelihood of receiving the COVID-19 vaccine is lower [ 29 ]. Cultural issues Cultural context is the main contributor to vaccine hesitancy in countries, including the USA [ 8 , 33 ]. A total of 8.5% reported religious beliefs and concerns as reasons for vaccine hesitancy, according to a study by Teasdale [ 8 ]. In addition, parental and peer norms are strong predictors of vaccination decisions influencing others both directly and indirectly [ 33 ]. In terms of vaccine preventability acceptance between ethnicities and then generalizing across individuals between non-Hispanic Asian parents and White parents on the basis of beliefs and attitudes, non-Hispanic Asian parents had lower general mistrust of vaccines, and non-Hispanic White parents had more misconceptions and were more concerned than other parents were [ 30 ]. Vaccine accessibility The participants in various studies offered diverse perspectives. Feng’s study revealed that 5.56% of participants cited the high cost of the vaccine as a reason for refusal, whereas 2.56% mentioned insufficient vaccine supply or lack of knowledge about how to obtain it [ 27 ]. In a thematic analysis by Hetherington, 8% of refusal cases were attributed to vaccine accessibility issues [ 26 ]. A survey conducted by Zona and colleagues on determinants of COVID-19 vaccine hesitancy identified ease of access to the vaccine as a key factor [ 28 ]. Additionally, Almutairi’s study in Saudi Arabia revealed that accessibility influenced vaccine acceptance, with parents who had greater access being less likely to vaccinate their children [ 36 ]. Discussion From the 2950 papers that were found during the initial screening, 22 were included in the final analysis after screening and quality assessment. These studies were all conducted in diverse geographical locations. The majority of these studies were cross-sectional in nature and comprised parents with children aged 12 years and younger. The inclusion criteria were employed to make sure that only English peer-reviewed papers addressing COVID-19 vaccination hesitancy among parents were included for analysis. The studies varied in sample size and socio-demographic profile, thus providing a broad but detailed picture of vaccine hesitancy across different socio-economic and cultural contexts, thus providing a broad but detailed picture of vaccine hesitancy across different socio-economic and cultural contexts. The thematic analysis identified two themes related to vaccine hesitancy: Vaccine-Related Concerns and user-Related Concerns. Five subcategories were extracted: safety and trust concerns, vaccine accessibility, risk perception, lack of knowledge and information, cultural issues, and past medical conditions. The spread of the different hesitancy factors across the included studies is readily apparent in the pooled data (Fig. 3 ). Parental vaccine hesitancy varies with child age and has different determinants. Concerns surrounding safety, as well as existing literature on pediatric vaccine hesitance, are high for younger children [ 41 ]. Misinformation (such as the fallacy of fertility) may also be contributing to parents’ hesitancy for 6–11-year-olds, potentially due to the human factors of the role of social media exposure [ 34 ]; this nuance should be considered for school-based and peer-driven public educational campaigns. In contrast, lower hesitance for the adolescent population was associated with established policies, such as mandates in schools, and peer influences, associating with the concept of “social contagion” [ 33 ]. Overall, these findings highlight the need for age-specific and context-specific approaches to promote COVID-19 vaccine uptake with pediatric populations. This systematic review shows that a country’s income level plays an important role in determining parental vaccine hesitancy. Within HICs, issues focused on safety, efficacy, and misinformation predominately defined hesitancy, alongside politicization of health communications [ 5 ]. The significant presence of anti-vaccine content on social media, especially in the USA and Italy, has assumed a prominent role in augmenting doubts about supportive parental vaccine uptake [ 32 ]. With UMICs, it was seen that logistical elements like cost and distribution issues appeared to be more fundamental aspects as drivers of hesitancy. For example, Saudi Arabia and Mexico revealed parent skepticism about government facilitated rapid vaccine rollout, which likely contributed to vaccine hesitancy [ 25 ] [ 21 ]. This phenomenon of distrust in government may also apply to premium adult vaccination programs [ 15 ]. No low-income countries were included in this review, representing a further gap for fledgling research in this area as a whole. Overall, these findings. The ubiquitous and consistent finding of safety and trust issues with COVID-19 vaccination that arose in all of the 22 studies examined is a concerning result. This reveals the extent to which decision-making on pediatric vaccination among parents is influenced by perceived risk and mistrust of vaccine safety. Although three US studies and one Chinese study concluded that vaccine availability and cultural concerns also played a role in hesitancy in certain settings, these concerns were less frequently raised in the literature overall. This would imply that although concerns regarding safety and matters of trust are universal, certain contextual concerns may have a more subtle influence on parental attitudes. Hesitancy regarding vaccine safety and efficacy is a primary reason for refusal. While this concern exists for adult vaccinations as well [ 15 ], it seems to be more pronounced in children. All studies have consistently addressed this issue, and it is prevalent in many countries [ 8 , 12 , 15 , 25 , 27 , 30 , 32 , 40 , 41 , 42 , 43 ]. However, the prevalence of this issue can be influenced by various factors, including public trust in the health system and governance, past experiences, and recommendations from experts in the field. Despite the very low reported adverse effects of the COVID-19 vaccine [ 44 ], the fear of related adverse effects, often disseminated from unofficial sources, can significantly influence parental decision-making. Additionally, the rapid development of vaccines and deviation from standard procedures exacerbate fears regarding their efficacy and potential adverse events. Consequently, to address these concerns, building public trust should be a primary focus. Disseminating accurate and timely information regarding both the efficacy and adverse effects of vaccines from credible sources and providing transparent explanations of the vaccine production process can significantly contribute to addressing public concerns. Moreover, the social standing of the government and health systems must be enhanced to foster greater public trust. The findings indicate that access to vaccines is another crucial factor influencing vaccine hesitancy, particularly among hesitant parents. Consequently, governments and health systems should facilitate widespread and, ideally, free access to necessary vaccines, especially for vulnerable and impoverished communities. To increase vaccine acceptance, some countries have implemented large-scale, geographically dispersed, and cost-free COVID-19 vaccination programs [ 45 ]. In general, efforts to achieve universal immunization are undermined by many socioeconomic factors, which significantly impact vaccine hesitancy and use. The most significant among these issues is the cost of the vaccinations, the existence of an overabundance of misinformation in marginalized communities, and a lack of proper healthcare infrastructure [ 26 , 27 ]. For example, according to Feng’s study, some of the participants declined the vaccine due to money and uncertainty about where and how to do it. On top of this, access challenges to the vaccine were highlighted using Hetherington’s thematic analysis. Aside from these challenges, vulnerable groups also tend to have lower health-literacy levels and hence are also more vulnerable to disinformation operations [ 8 ]. In an attempt to correct these socioeconomic inequalities, various measures need to be implemented, for example, free or subsidized vaccination schemes, enhanced access. Our review has indicated that the perception of risk is one of the most important determinants of parental vaccination behavior. Risk perception, as a major reason for vaccine refusal in adults, has similarly been corroborated in multiple studies [ 16 , 40 , 45 , 46 ]. People do not find risk in an event merely from objective information but also through their subjective experience and emotion [ 47 ]. Risk perception can include people’s attitudes (beliefs about childhood diseases, perceptions about vaccine effectiveness, and past experience). Hence, forthcoming research at the perception level regarding the risk of pandemics and epidemics and ways to improve risk perception can be useful in encouraging vaccines and preventive strategies. Additionally, healthcare administrators and policymakers should consider risk perception as an important element of preparedness for and management of emerging and re-emerging diseases. The other aspect affecting the decision to vaccinate children was a lack of adequate and precise information, which was found in half of the studies. As COVID-19 is a new and emerging disease, there has been no time-tested guidance on several aspects of its management that were available at the beginning of this disease, including its vaccine, which was also marketed in a very short time and has few safety data available. Therefore, little is known about its effectiveness, mechanism of action and side effects in children. Vaccination is still largely an unexplored field for most people, and the information floating around it is almost anti-scientific and hardly evident. The health system can significantly increase vaccine acceptance by holding sector information campaigns, using social media, and providing accurate, timely, regular, and up-to-date information, focusing on preventing myths and promoting the effectiveness of vaccination while reducing perceived costs. Cultural and contextual factors influencing vaccine hesitancy are important for explaining the worldwide disparity in parental opinions regarding COVID-19 vaccination among children. Confidence in healthcare systems, beliefs, and cultural values all influence vaccine uptake, as this review acknowledges. In the USA, for example, studies have highlighted cultural determinants such as distrust of healthcare providers and government agencies as major determinants of hesitancy [ 8 ]. Concurrently, religious faith and local tradition elsewhere have been shown to encourage or discourage vaccination. The implication is that public health interventions must be localized to accommodate local culture. Campaigns that use familiar local icons, including religious leaders, and culturally appropriate messages may ease resistance. In addition, understanding how misinformation works in a specific cultural setting is crucial for developing effective education programs that bridge communities. Public health interventions can effectively counter vaccine hesitancy and enhance vaccination coverage globally by addressing these cultural nuances. The other variable analyzed in our review was the child’s medical history and overall health status. A limited understanding of the effectiveness of the COVID-19 vaccine in those with underlying conditions and the fear of worsening their illness or needing hospitalization may increase parental hesitation as well. If parents had negative or even positive experiences with vaccinations in the past, this hesitation can be especially acute. The mental distress, agar, psychological distress, and symptoms associated with such a state can also manifest when this uncertainty becomes so intense that it creates a kind of problem in the decision-making process. In such cases, family physician consultations regarding the nature of the disease, reassurance of the lack of adverse effects, and psychological counseling, if necessary, can be of primary importance in reducing symptoms, dispelling doubts, and increasing vaccine acceptance. The strength of this study lies in its focus on pediatric vaccinations as part of the overall vulnerable population in society. Implications for policy Our research identifies a number of evidence-based strategies for improving public health messaging and communication regarding vaccine hesitancy. Interventions should address age-specific concerns 0–5 years: Emphasize vaccine safety trials in young children via pediatricians. 6–11 years: Combat misinformation through school-distributed fact sheets. 12–18 years: Leverage peer-led advocacy programs. Income specific interventions HICs: Counter misinformation via trusted providers (e.g., pediatricians) and social media regulation. UMICs: Improve access through subsidized programs and community-led education. Customized messaging strategies : Evidence shows that a “single message” does not have impact across all audiences. Based on the community, healthcare provider trust, and parental hesitancy, audiences vary in their susceptibility to the experience of a vaccine or health message. For example, many communications recommend a presumptive message that treats vaccination as the default, but this message can also backfire with the most hesitant audiences. While presumptive messages might work well with some audiences, using more open and conversational approaches that demystify issues and discuss the issues at a more granular level and encourage discussions may be more effective. Use trusted messengers : Pediatricians and other healthcare providers remain among the most trusted information sources for the public when it comes to vaccines. It is important to train and prepare healthcare professionals in how to use patient-centered communicative techniques, including how to deal with reluctance and misinformation. The use of trusted community designees as trustworthy rumors, or vaccine ambassadors, can further influence under-represented groups or reluctant populations. Community-based outreach : Participating in existing school-based immunization clinics or creating these in partnership with community organizations can increase uptake and also overcome access challenges. Community-based messaging should align with resources and supports that are culturally relevant, such as multi-lingual materials and accommodations that deal with needle phobia. Combatting misinformation : By using uncomplicated language and conduits of all kinds, messages would actively counter misinformation and common misconceptions and issues. Concerns about misinformation and hesitancy need to be evaluated, monitored, and messages need to be adapted and executed in real time to maintain the public’s trust and response to developing situations. Support and education for providers : To support the provider’s ability to have difficult conversations around vaccinations, ongoing education and resources are needed, so that they feel more prepared and able. This is more than just information on the safety and efficacy of vaccines; for example, it would be beneficial to provide motivational interviewing training. Limitation We only considered English-published studies, which may have resulted in a language bias by excluding valuable research published in other languages. This is a limitation that could affect the generalizability of our findings, particularly in light of the global phenomenon of COVID-19 vaccine hesitancy. The distribution of studies is not representative of the population distribution around the globe, and this must be accounted for when interpreting the results. Another limitation was that it did not focus on other vulnerable populations, including the elderly and pregnant women. The majority of the studies employed cross-sectional designs, which restrict the potential for ascertaining reason and effect or the sequence of influences on parental vaccine hesitancy. We carried out an extensive search on many databases, but publication bias cannot be excluded because studies with high or positive effects are published more often. This could have influenced the themes that we found in our review. Future research We suggest the need for researchers from non-English speaking regions to publish in the international literature to make reviews like this one more representative. Further research is needed to explore the acceptance and hesitancy of the COVID-19 vaccine within these subpopulations and what may explain differences in acceptance and hesitancy. Moreover, it would be beneficial to offer solutions for increasing vaccine acceptance and reducing hesitancy among these populations. In addition, the relationship between cultural and economic contexts and vaccine hesitancy in various contexts should be investigated in more detail. In particular, research should: utilize qualitative methods to more fully grasp cultural beliefs and values, explore how socioeconomic determinants condition access to vaccines and decision-making, and create and evaluate culturally appropriate interventions to encourage vaccination uptake. Expand LIC 2 studies using standardized tools and research should explore longitudinal hesitancy trends as children age. Conclusion The research provides valuable insights related to pediatric vaccine policy and future vaccine development policies. Parent vaccine hesitancy varies predictably by child age and will require strategies that enhance uptake specific to each group. Country income levels are also a significant factor for levels of vaccine hesitancy, signifying that we also must take income into account when studying ways to enhance vaccination uptake. For example, interventions in high-income countries will still need to focus on addressing misinformation, while interventions in upper-middle-income countries will need to focus on systemically targeting ways in which to enhance access and trust. This study emphasizes the need to develop targeted, context-specific strategies to increase COVID-19 vaccination uptake among children. A multifaceted campaign that includes education/promotion, improved vaccine accessibility, and the use of role models and religious leaders who can support parents in making informed decisions about COVID-19 vaccination is essential. In addition, observing the principles of risk communication and publishing correct and timely information from reliable and official authorities about the disease and its risks, the vaccine production process, its efficiency and effectiveness, and possible side effects can reduce the impact of disinformation on parents’ decision-making power and promote vaccine acceptance. Health facilities can deliver appropriate educational programs on COVID-19 in their respective communities to increase parents’ intentions and overall knowledge regarding the importance of vaccinating their children and increasing their willingness and acceptance once a child’s COVID-19 vaccine becomes available. Although this systematic review synthesized evidence from a diverse mixture of geographic locations and studies, it is important to note that many studies were conducted in certain areas of the world, specifically the USA, Saudi Arabia, China, Italy, Canada, and Japan. Therefore, caution should be taken when assuming the generalizability of our findings to other geographic locations. We are aware that the exclusion of non-English language studies might have led to bias, and our conclusions may not be generalizable to parents’ perceptions in non-English-speaking countries. Our recommendations are primarily based on a synthesis of cross-sectional studies using self-reported data, which may be subject to recall bias and social desirability bias. Further research is needed to validate these results in varied populations and environments. Supplementary Information Supplementary Material 1. (17.2KB, docx) Supplementary Material 2. (16.9KB, docx) Acknowledgements Not applicable. Ethical considerations There were no ethical considerations to be considered in this research. Authors’ contributions Study concept and design: NA and HH. Analysis and interpretation of data: MG, HH, and RH. Drafting the manuscript: NA and HH. Critical revision of the manuscript for important intellectual content: all authors. Funding This research did not receive any grants from funding agencies in the public, commercial, or nonprofit sectors. Data availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Footnotes 1 Population, Intervention, Comparison, Outcome 2 Low-income country Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. References 1. Thangaraju P, Venkatesan S. WHO ten threats to global health in 2019: antimicrobial resistance. Cukurova Med J. 2019;44(3):1150–1. [ Google Scholar ] 2. Aldakhil H, Albedah N, Alturaiki N, Alajlan R, Abusalih H. Vaccine hesitancy towards childhood immunizations as a predictor of mothers’ intention to vaccinate their children against COVID-19 in Saudi Arabia. J Infect Public Health. 2021;14(10):1497–504. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 3. Immunization coverage: World Health Organization; 2025. Available from: https://www.who.int/news-room/fact-sheets/detail/immunization-coverage . Cited 2024 15 July. 4. CDC. Vaccination Trends 2025. Available from: https://www.cdc.gov/respiratory-viruses/data/vaccination-trends.html . Cited 2025 18 April. 5. Rhodes ME, Sundstrom B, Ritter E, McKeever BW, McKeever R. Preparing for a COVID-19 vaccine: a mixed methods study of vaccine hesitant parents. J Health Commun. 2020;25(10):831–7. [ DOI ] [ PubMed ] [ Google Scholar ] 6. Kreps S, Prasad S, Brownstein JS, Hswen Y, Garibaldi BT, Zhang B, et al. Factors associated with US adults’ likelihood of accepting COVID-19 vaccination. JAMA Netw Open. 2020;3(10):e2025594-e. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 7. Vanderpool RC, Gaysynsky A, Sylvia Chou W-Y. Using a global pandemic as a teachable moment to promote vaccine literacy and build resilience to misinformation. American Public Health Association; 2020. pp. S284-S5. [ DOI ] [ PMC free article ] [ PubMed ] 8. Teasdale CA, Borrell LN, Kimball S, Rinke ML, Rane M, Fleary SA, et al. Plans to vaccinate children for coronavirus disease 2019: a survey of United States parents. J Pediatr. 2021;237:292–7. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 9. Ruiz JB, Bell RA. Parental COVID-19 vaccine hesitancy in the United States. Public Health Rep. 2022;137(6):1162–9. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 10. Suragh TA, Adzrago D, Allicock MA, Yeh PG, Cuccaro P. Exploring the relationship between vaccine hesitancy and mothers’ perspectives on COVID-19 vaccines for children ages 5–11 years during the omicron predominant period 2021–2022: a qualitative study. Front Public Health. 2024;12:1355452. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 11. Oualha M, Bendavid M, Berteloot L, Corsia A, Lesage F, Vedrenne M, et al. Severe and fatal forms of COVID-19 in children. Arch Pediatr. 2020;27(5):235–8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 12. Yılmaz M, Sahin MK. Parents’ willingness and attitudes concerning the COVID‐19 vaccine: a cross‐sectional study. Int J Clin Pract. 2021;75(9):e14364. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 13. Dosanjh A. Pediatric vaccine hesitancy and the utilization of antibody measurements: a novel strategy with implications for COVID 19. J Asthma Allergy. 2021. 10.2147/jaa.s303309. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 14. Ruggiero KM, Wong J, Sweeney CF, Avola A, Auger A, Macaluso M, et al. Parents’ intentions to vaccinate their children against COVID-19. J Pediatr Health Care. 2021;35(5):509–17. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 15. Kumar S, Shah Z, Garfield S. Causes of vaccine hesitancy in adults for the influenza and COVID-19 vaccines: a systematic literature review. Vaccines. 2022;10(9):1518. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 16. Schmid P, Rauber D, Betsch C, Lidolt G, Denker M-L. Barriers of influenza vaccination intention and behavior–a systematic review of influenza vaccine hesitancy, 2005–2016. PLoS One. 2017;12(1):e0170550. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 17. Olson O, Berry C, Kumar N. Addressing parental vaccine hesitancy towards childhood vaccines in the United States: a systematic literature review of communication interventions and strategies. Vaccines. 2020;8(4):590. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 18. Obohwemu K, de Christie- Jong F, Ling J. Parental childhood vaccine hesitancy and predicting uptake of vaccinations: a systematic review. Prim Health Care Res Dev. 2022;23:e68. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 19. Russo L, Croci I, Campagna I, Pandolfi E, Villani A, Reale A, et al. Intention of parents to immunize children against SARS-CoV-2 in Italy. Vaccines. 2021;9(12):1469. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 20. Temsah M-H, Alhuzaimi AN, Aljamaan F, Bahkali F, Al-Eyadhy A, Alrabiaah A, et al. Parental attitudes and hesitancy about COVID-19 vs. routine childhood vaccinations: a national survey. Front Public Health. 2021;9:752323. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 21. Delgado-Gallegos JL, Padilla-Rivas GR, Gastelum-Arias LJ, Zuñiga-Violante E, Avilés-Rodríguez G, Arellanos-Soto D, et al. Parent’s perspective towards child COVID-19 vaccination: an online cross-sectional study in Mexico. Int J Environ Res Public Health. 2021;19(1):290. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 22. Xu Y, Zhang R, Zhou Z, Fan J, Liang J, Cai L, et al. Parental psychological distress and attitudes towards COVID-19 vaccination: a cross-sectional survey in Shenzhen, China. J Affect Disord. 2021;292:552–8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 23. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. [ Google Scholar ] 24. JBI’s critical appraisal tools: JBI global organisation; 2025. Available from: https://jbi.global/critical-appraisal-tools . Cited 2025 31 March. 25. Yoda T, Katsuyama H. Parents’ hesitation about getting their children vaccinated against COVID-19 in Japan. Hum vaccin immunother. 2021;17(12):4993–8. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 26. Hetherington E, Edwards SA, MacDonald SE, Racine N, Madigan S, McDonald S, et al. SARS-CoV-2 vaccination intentions among mothers of children aged 9 to 12 years: a survey of the All Our Families cohort. Can Med Assoc Open Access J. 2021;9(2):E548–E55. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 27. Feng H, Zhu H, Zhang H, Cao L, Li L, Wang J, et al. Caregivers’ intentions to COVID-19 vaccination for their children in China: A cross-sectional survey. Hum Vaccin Immunother. 2021;17(12):4799–805. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 28. Zona S, Partesotti S, Bergomi A, Rosafio C, Antodaro F, Esposito S. Anti-COVID vaccination for adolescents: a survey on determinants of vaccine parental hesitancy. Vaccines. 2021;9(11):1309. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 29. Humble RM, Sell H, Dubé E, MacDonald NE, Robinson J, Driedger SM, et al. Canadian parents’ perceptions of COVID-19 vaccination and intention to vaccinate their children: Results from a cross-sectional national survey. Vaccine. 2021;39(52):7669–76. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 30. Fisher CB, Gray A, Sheck I. COVID-19 pediatric vaccine hesitancy among racially diverse parents in the United States. Vaccines. 2021;10(1):31. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 31. Tsai CS, Hsiao RC, Chen YM, Yen CF. Factors related to caregiver intentions to vaccinate their children with attention-deficit/hyperactivity disorder against COVID-19 in Taiwan. Vaccines. 2021;9(9):983. [ DOI ] [ PMC free article ] [ PubMed ] 32. Gendler Y, Ofri L. Investigating the influence of vaccine literacy, vaccine perception and vaccine hesitancy on Israeli parents’ acceptance of the COVID-19 vaccine for their children: A cross-sectional study. Vaccines. 2021;9(12):1391 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 33. Rogers AA, Cook RE, Button JA. Parent and peer norms are unique correlates of COVID-19 vaccine intentions in a diverse sample of US adolescents. J adolesc health. 2021;69(6):910–6. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 34. Samannodi M, Alwafi H, Naser AY, Alabbasi R, Alsahaf N, Alosaimy R, et al. Assessment of caregiver willingness to vaccinate their children against COVID-19 in Saudi Arabia: a cross-sectional study. Hum Vaccin Immunother. 2021;17(12):4857–64. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 35. Skeens M, Guttoo P, Stanek JR, Taylor K, Stratz E, Ardura MI, et al. An exploration of COVID-19 impact and vaccine hesitancy in parents of pediatric hematopoietic stem cell transplant (HCT) recipients. Bone Marrow Transplantation. 2022;57(4):547–53. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 36. Altulaihi BA, Alaboodi T, Alharbi KG, Alajmi MS, Alkanhal H, Alshehri A, et al. Perception of parents towards COVID-19 vaccine for children in Saudi population. Cureus. 2021;13(9). [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 37. Farajzadeh N, Hosseini H, Keshvari M, Maracy MR. A cross-sectional study on the reasons for vaccine hesitancy in children under seven years of age in Isfahan, Iran. Vaccine: X. 2023;15:100396. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 38. Honcoop A, Roberts JR, Davis B, Pope C, Dawley E, McCulloh RJ, et al. COVID-19 vaccine hesitancy among parents: a qualitative study. Pediatrics. 2023;152(5). [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 39. Saitoh A, Shobugawa Y. Parental vaccine hesitancy toward routine childhood immunizations and COVID-19 vaccines in Japan: A cross-sectional study. BMC Public Health. 2024;24:3303. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 40. Olusanya OA, Masters NB, Zhang F, Sugerman DE, Carter RJ, Weiss D, et al. Sociodemographic Trends and Correlation between Parental Hesitancy towards Pediatric COVID-19 Vaccines and Routine Childhood Immunizations in the United States: 2021–2022 National Immunization Survey—Child COVID Module. Vaccines. 2024;12(5):495. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 41. Rosen B, Waitzberg R, Israeli A, Hartal M, Davidovitch N. Addressing vaccine hesitancy and access barriers to achieve persistent progress in Israel’s COVID-19 vaccination program. Isr J Health Policy Res. 2021;10(1):43. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 42. Smith LE, Amlôt R, Weinman J, Yiend J, Rubin GJ. A systematic review of factors affecting vaccine uptake in young children. Vaccine. 2017;35(45):6059–69. [ DOI ] [ PubMed ] [ Google Scholar ] 43. Levin-Zamir D. Communication, health literacy and a systems approach for mitigating the COVID-19 pandemic: the case for massive vaccine roll-out in Israel. J health commun. 2020;25(10):816–8. [ DOI ] [ PubMed ] [ Google Scholar ] 44. Shehata AA, Parvin R, Nagy A, Wang Y, Azhar TM, Attia YA, et al. An overview of the ongoing challenges in SARS-CoV-2 global control. Ger J Microbiol. 2021;1:1–18. [ DOI ] [ PubMed ] [ Google Scholar ] 45. Hong S, Collins A. Societal responses to familiar versus unfamiliar risk: comparisons of influenza and SARS in Korea. Risk Analysis. 2006;26(5):1247–57. [ DOI ] [ PubMed ] [ Google Scholar ] 46. Setbon M, Raude J. Factors in vaccination intention against the pandemic influenza A/H1N1. Eur J Pub Health. 2010;20(5):490–4. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 47. Finucane ML, Alhakami A, Slovic P, Johnson SM. The effecct heuristic in judjment of risks and benifits. J Behav decision making. 2000;13(1):1–17. Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials Supplementary Material 1. (17.2KB, docx) Supplementary Material 2. (16.9KB, docx) Data Availability Statement The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. Articles from Systematic Reviews are provided here courtesy of BMC ACTIONS View on publisher site PDF (1.4 MB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

Related documents

• Covid-19 Vaccination in Adolescents and Children#387208
• COVID-19 vaccine effectiveness in children under 5 in the USA: a test-negative case-control study#319785
• Enabling Family Physicians to Reduce Vaccine Hesitancy and Increase Covid-19 Vaccine Uptake#217092
• A Clinical Trial of Immunobridging and Lot-to-lot Consistency of COVID-19 Vaccine (Ad5-nCoV) in Different Age Groups.#123537
• A Study to Learn About a COVID-19 Vaccine in Healthy Adults 50 Through 64 Years of Age#18719