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Factors associated with parental COVID-19 vaccine attitudes and intentions among a national sample of United States adults ages 18–45

  • Author Footnotes
    1 Co-First Authors.
    Lakeshia Cousin
    Footnotes
    1 Co-First Authors.
    Affiliations
    College of Nursing, University of Florida, Gainesville, FL, United States of America
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  • Author Footnotes
    1 Co-First Authors.
    Stephanie Roberts
    Footnotes
    1 Co-First Authors.
    Affiliations
    Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America
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  • Naomi C. Brownstein
    Affiliations
    Dept. of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Junmin Whiting
    Affiliations
    Dept. of Biostatistics and Bioinformatics, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Monica L. Kasting
    Affiliations
    Dept. of Public Health, Purdue University, West Lafayette, IN, United States of America

    Cancer Prevention and Control Program, Indiana University Simon Comprehensive Cancer Center, Indianapolis, IN, United States of America
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  • Katharine J. Head
    Affiliations
    Dept. of Communication Studies, Indiana University-Purdue University Indianapolis, Indianapolis, IN, United States of America
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  • Susan T. Vadaparampil
    Affiliations
    Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America

    Dept. of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, United States of America

    Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Anna R. Giuliano
    Affiliations
    Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America

    Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, Tampa, FL, United States of America

    Dept. of Cancer Epidemiology, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Clement K. Gwede
    Affiliations
    Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America

    Dept. of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, United States of America

    Dept. of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Author Footnotes
    2 Co-Senior Authors.
    Cathy D. Meade
    Footnotes
    2 Co-Senior Authors.
    Affiliations
    Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America

    Dept. of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, United States of America

    Dept. of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Author Footnotes
    2 Co-Senior Authors.
    Shannon M. Christy
    Correspondence
    Corresponding author at: H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., MFC-EDU, Tampa, FL 33612, United States of America.
    Footnotes
    2 Co-Senior Authors.
    Affiliations
    Morsani College of Medicine, University of South Florida, Tampa, FL, United States of America

    Dept. of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, United States of America

    Center for Immunization and Infection Research in Cancer, Moffitt Cancer Center, Tampa, FL, United States of America

    Dept. of Gastrointestinal Oncology, Moffitt Cancer Center, Tampa, FL, United States of America
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  • Author Footnotes
    1 Co-First Authors.
    2 Co-Senior Authors.
Published:January 19, 2023DOI:https://doi.org/10.1016/j.pedn.2023.01.003

      Highlights

      • Sociodemographic factors are associated with parental COVID-19 vaccine intentions.
      • Men had greater intentions to obtain the COVID-19 vaccine for their children.
      • Research should investigate tailored/targeted vaccine education for parents.

      Abstract

      Purpose

      This study explored factors associated with parents' attitudes and intentions to seek information about the COVID-19 vaccine for their children (ages 0–18) and intentions to vaccinate their age-eligible children.

      Design and methods

      As part of an anonymous online cross-sectional survey, parents' vaccine attitudes, COVID-19 vaccine intentions for their children, health literacy, health numeracy, and sociodemographic variables were assessed. Multivariable ordered logistic regression models identified factors associated with parents' COVID-19 vaccine intentions for their children.

      Results

      Parents/guardians (n = 963) were mostly White (82.3%), insured (88.0%), and college graduates (57.3%). Men reported higher intentions than women to seek information about the COVID-19 vaccine for their children (p = 0.003) and higher intentions to vaccinate their children (p = 0.049). Parental characteristics associated with increased intentions to have their children vaccinated included higher educational attainment (p < 0.001), more positive general vaccine attitudes (p < 0.001), preference for health information in a language other than English (p = 0.006), higher income (p = 0.048), having health insurance (p = 0.05), health literacy (p = 0.024), and health numeracy (p = 0.049).

      Conclusions

      Multiple sociodemographic characteristics including male gender, higher health literacy and numeracy, and language preference are noteworthy factors associated with parental COVID-19 vaccine intentions that could inform the planning and implementation of educational interventions.

      Practice implications

      Nurses are important sources of trusted information and play an important role in parent/family health education and in understanding myriad factors that may improve attitudes and enhance readiness toward vaccine uptake. Our findings emphasize the potential value of examining tailored/targeted COVID-19 vaccine education according to key influencing factors.

      Keywords

      Introduction

      As of November 2022, >636 million cases and 6.6 million deaths are directly associated with SARS-CoV-2 worldwide, and approximately 15 million children have tested positive for the virus since the COVID-19 pandemic initially spread to the United States (U.S.) (;
      • World Health Organization
      WHO Coronavius (COVID-19) Dashboard.
      ). Although children are more likely to develop asymptomatic infections than adults and may have a milder presentation, a high percentage in this group may expose others to SARS-CoV-2 (
      • Bullard J.
      • Funk D.
      • Dust K.
      • Garnett L.
      • Tran K.
      • Bello A.
      • Poliquin G.
      Infectivity of severe acute respiratory syndrome coronavirus 2 in children compared with adults.
      ;
      • Han M.S.
      • Choi E.H.
      • Chang S.H.
      • Jin B.L.
      • Lee E.J.
      • Kim B.N.
      • Kim J.H.
      Clinical characteristics and viral RNA detection in children with coronavirus disease 2019 in the Republic of Korea.
      ). The high prevalence of asymptomatic carriers may facilitate further spread of the pandemic, especially in younger populations who may not always fully understand or effectively undertake the necessary social distancing and other public health measures (
      • Han M.S.
      • Choi E.H.
      • Chang S.H.
      • Jin B.L.
      • Lee E.J.
      • Kim B.N.
      • Kim J.H.
      Clinical characteristics and viral RNA detection in children with coronavirus disease 2019 in the Republic of Korea.
      ;
      • Moghadas S.M.
      • Fitzpatrick M.C.
      • Shoukat A.
      • Zhang K.
      • Galvani A.P.
      Simulated identification of silent COVID-19 infections among children and estimated future infection rates with vaccination.
      ). There has been a significant increase in COVID-19 pediatric cases across the U.S. due to the Omicron variant surge (). Silent transmission via pediatric populations can result in further outbreaks as children may transmit the virus to others, highlighting the importance of research about parental knowledge and attitudes regarding the COVID-19 vaccine in the pediatric population (
      • Moghadas S.M.
      • Fitzpatrick M.C.
      • Shoukat A.
      • Zhang K.
      • Galvani A.P.
      Simulated identification of silent COVID-19 infections among children and estimated future infection rates with vaccination.
      ;
      • Snider B.
      • Patel B.
      • McBean E.
      Asymptomatic cases, the hidden challenge in predicting COVID-19 caseload increases.
      ;
      • Zhang Y.
      • Su X.
      • Chen W.
      • Fei C.N.
      • Guo L.R.
      • Wu X.L.
      • Zuo L.J.
      Epidemiological investigation on a cluster epidemic of COVID-19 in a collective workplace in Tianjin.
      ;
      • Zhen-Dong Y.
      • Gao-Jun Z.
      • Run-Ming J.
      • Zhi-Sheng L.
      • Zong-Qi D.
      • Xiong X.
      • Guo-Wei S.
      Clinical and transmission dynamics characteristics of 406 children with coronavirus disease 2019 in China: A review.
      ).
      As a public health measure for mitigating the COVID-19 pandemic, several U.S. pharmaceutical companies were granted emergency use authorization (EUA) by the U.S. Food and Drug Administration (FDA) (
      • U.S. Food and Drug Administration
      Coronavirus (COVID-19) update: FDA authorizes Moderna and Pfizer-BioNTech COVID-19 vaccines for children down to 6 months of age.
      ). Initially, EUA was granted for vaccinations in adult populations aged either 16 and older or 18 and older, including at the time of data collection for the current study (
      • U.S. Food and Drug Administration
      Coronavirus (COVID-19) update: FDA authorizes Moderna and Pfizer-BioNTech COVID-19 vaccines for children down to 6 months of age.
      ). Currently, the COVID-19 vaccines authorized for children aged 6 months and older are the Pfizer-BioNTech COVID-19 Vaccine (Pfizer) and Moderna mRNA-1273 vaccine (
      • U.S. Food and Drug Administration
      Coronavirus (COVID-19) update: FDA authorizes Moderna and Pfizer-BioNTech COVID-19 vaccines for children down to 6 months of age.
      ). The Advisory Committee on Immunization Practices (ACIP) began recommending administration shortly after EUA was granted (
      • U.S. Food and Drug Administration
      Coronavirus (COVID-19) update: FDA authorizes Moderna and Pfizer-BioNTech COVID-19 vaccines for children down to 6 months of age.
      ). With the recent EUA approval of the Pfizer and Moderna vaccines for those ages 6 months and older (updated from previous approval for those ages 5 years and older), the EUA approval of the Novavax COVID-19 vaccine to be administered to those 12 and older and many individuals now eligible for booster doses (
      • U.S. Food and Drug Administration
      Coronavirus (COVID-19) update: FDA authorizes Moderna and Pfizer-BioNTech COVID-19 vaccines for children down to 6 months of age.
      ), more research is needed to add to the ever-evolving body of literature detailing pediatric COVID-19 cases and intentions to vaccinate children.
      The World Health Organization (WHO) describes vaccine hesitancy as postponing or rejecting the use of safe and available vaccines (
      • Kestenbaum L.A.
      • Feemster K.A.
      Identifying and addressing vaccine hesitancy.
      ;
      • MacDonald N.E.
      Vaccine hesitancy: Definition, scope and determinants.
      ;
      • Troiano G.
      • Nardi A.
      Vaccine hesitancy in the era of COVID-19.
      ). Prior research on COVID-19 vaccine hesitancy in adults suggests several sociodemographic groups are also more hesitant regarding the COVID-19 vaccine, including women, those with lower income, homeless, younger, and Black/African American individuals (
      • Brownstein N.
      • Reddy H.
      • Whiting J.
      • Kasting M.L.
      • Head K.
      • Vadaparampil S.T.
      • Christy S.
      COVID-19 vaccine behaviors and intentions among a national sample of United States adults ages 18–45.
      ;
      • Longchamps C.
      • Ducarroz S.
      • Crouzet L.
      • Vignier N.
      • Pourtau L.
      • Allaire C.
      • Melchior M.
      COVID-19 vaccine hesitancy among persons living in homeless shelters in France.
      ;
      • Neumann-Böhme S.
      • Varghese N.E.
      • Sabat I.
      • Barros P.P.
      • Brouwer W.
      • van Exel J.
      • Stargardt T.
      Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19.
      ;
      • Willis D.E.
      • Andersen J.A.
      • Bryant-Moore K.
      • Selig J.P.
      • Long C.R.
      • Felix H.C.
      • McElfish P.A.
      COVID-19 vaccine hesitancy: Race/ethnicity, trust, and fear.
      ). However, there is far less information regarding the impact of parental COVID-19 vaccine hesitancy on children during the SARS-CoV-2 pandemic.
      Research identifies numerous factors that influence vaccine uptake, such as social norms, health literacy (HL), ability to obtain and access accurate knowledge about vaccines, religious beliefs, and healthcare provider recommendations (
      • Kestenbaum L.A.
      • Feemster K.A.
      Identifying and addressing vaccine hesitancy.
      ;

      Montagni, I., Ouazzani-Touhami, K., Mebarki, A., Texier, N., Schück, S., & Tzourio, C. (2021). Acceptance of a Covid-19 vaccine is associated with ability to detect fake news and health literacy. Journal of Public Health (Oxford, England). Volume 43, Issue 4, December 2021, Pages 695–702 https://doi.org/10.1093/pubmed/fdab028.

      ). The Health Belief Model (HBM) suggests that beliefs in the threat of an illness (e.g., perceived risk, perceived severity), about benefits and perceived barriers to engaging in a behavior, cues to action, and self-efficacy can explain an individuals' engagement in health-promoting behaviors (
      • Strecher V.J.
      • Rosenstock I.M.
      The health belief model.
      ).
      • Shmueli L.
      Predicting intention to receive COVID-19 vaccine among the general population using the health belief model and the theory of planned behavior model.
      found that the HBM and Theory of Planned Behavior (TPB), the latter which involves theoretical constructs including attitudes and normative beliefs, can predict an individual's intention to receive the COVID-19 vaccine. Further,
      • Li J.Y.
      • Wen T.J.
      • McKeever R.
      • Kim J.K.
      Uncertainty and negative emotions in parental decision-making on childhood vaccinations: Extending the theory of planned behavior to the context of conflicting health information.
      found that uncertainty from receiving conflicting information and negative emotions can strongly predict parents' attitudes and perceived control regarding childhood vaccinations.
      Importantly, in the present pandemic, the circulation of COVID-19 misinformation has made it difficult for members of the public to assess the risk and severity of the pandemic, which resulted in risky behaviors such as drinking bleach or alcohol in an attempt to prevent infection (
      • Savoia E.
      • Su M.
      • Piltch-Loeb R.
      • Masterson E.
      • Testa M.A.
      COVID-19 vaccine early skepticism, misinformation and informational needs among essential workers in the USA.
      ). Those unable to deconstruct misinformation were more likely to be vaccine hesitant or against vaccines altogether (

      Montagni, I., Ouazzani-Touhami, K., Mebarki, A., Texier, N., Schück, S., & Tzourio, C. (2021). Acceptance of a Covid-19 vaccine is associated with ability to detect fake news and health literacy. Journal of Public Health (Oxford, England). Volume 43, Issue 4, December 2021, Pages 695–702 https://doi.org/10.1093/pubmed/fdab028.

      ). As COVID-19 illness and vaccine misinformation about the present pandemic persists in media, adequate HL becomes increasingly important in understanding public health policy and parsing out the truth from multiple information sources (

      Abel, T., & McQueen, D. (2020). Critical health literacy in pandemics: The special case of COVID-19. Health Promotion International. Volume 36, Issue 5, October 2021, Pages 1473–1481 https://doi.org/10.1093/heapro/daaa141.

      ;
      • Biasio L.R.
      • Bonaccorsi G.
      • Lorini C.
      • Pecorelli S.
      Assessing COVID-19 vaccine literacy: A preliminary online survey.
      ;
      • McCaffery K.J.
      • Dodd R.H.
      • Cvejic E.
      • Ayrek J.
      • Batcup C.
      • Isautier J.M.
      • Wolf M.S.
      Health literacy and disparities in COVID-19-related knowledge, attitudes, beliefs and behaviours in Australia.
      ;
      • Strecher V.J.
      • Rosenstock I.M.
      The health belief model.
      ). Further, HL demands challenge many individuals, regardless of income, when it comes to new or unfamiliar diseases, as was the case with the novel coronavirus initially. In other words, higher HL can be associated with better attitudes regarding the importance of life-saving preventive health measures such as vaccination (
      • Silva M.J.
      • Santos P.
      The impact of health literacy on knowledge and attitudes towards preventive strategies against COVID-19: A cross-sectional study.
      ).
      Closely related to HL is health numeracy (HN), or understanding medical statistics or other quantitative information related to health topics (
      • Schapira M.M.
      • Fletcher K.E.
      • Gilligan M.A.
      • King T.K.
      • Laud P.W.
      • Matthews B.A.
      • Hayes E.
      A framework for health numeracy: How patients use quantitative skills in health care.
      ). HN has been shown to be associated with a better understanding of disease risk and decreased susceptibility to inaccurate information about the COVID-19 pandemic (
      • Roozenbeek J.
      • Schneider C.R.
      • Dryhurst S.
      • Kerr J.
      • Freeman A.L.J.
      • Recchia G.
      • van der Linden S.
      Susceptibility to misinformation about COVID-19 around the world.
      ;
      • Sobkow A.
      • Zaleskiewicz T.
      • Petrova D.
      • Garcia-Retamero R.
      • Traczyk J.
      Worry, risk perception, and controllability predict intentions toward COVID-19 preventive behaviors.
      ). Overall, lower HN and/or HL has been correlated with higher mistrust in the healthcare system, meaning lower likelihood of following vaccination recommendations (
      • Roozenbeek J.
      • Schneider C.R.
      • Dryhurst S.
      • Kerr J.
      • Freeman A.L.J.
      • Recchia G.
      • van der Linden S.
      Susceptibility to misinformation about COVID-19 around the world.
      ). Nurses are an important resource in providing patient education and reducing COVID-19 vaccine hesitancy (
      • Dugani S.B.
      • Geyer H.L.
      • Maniaci M.J.
      • Fischer K.M.
      • Croghan I.T.
      • Coons T.J.
      • Burton M.C.
      Hospitalist perspectives on barriers to recommend and potential benefit of the COVID-19 vaccine.
      ). Several organizational-level interventions have found that nurses with adequate training and education regarding scientific evidence supporting COVID-19 vaccination efficacy and safety can help address misinformation and hesitancy among patients (
      • Dugani S.B.
      • Geyer H.L.
      • Maniaci M.J.
      • Fischer K.M.
      • Croghan I.T.
      • Coons T.J.
      • Burton M.C.
      Hospitalist perspectives on barriers to recommend and potential benefit of the COVID-19 vaccine.
      ;
      • Finney Rutten L.J.
      • Zhu X.
      • Leppin A.L.
      • Ridgeway J.L.
      • Swift M.D.
      • Griffin J.M.
      • Jacobson R.M.
      Evidence-based strategies for clinical organizations to address COVID-19 vaccine hesitancy.
      ).
      Due to the recency of the COVID-19 vaccine EUA for children ages 6 months and older on June 2022, 59% of children aged 6 months to 4 years remain unvaccinated and about 10.9 million children ages 5–11 have yet to receive their first COVID-19 vaccine dose (;
      • Centers for Disease Control and Prevention
      Sociodemographic variation in early uptake of COVID-19 vaccine and parental intent and attitudes toward vaccination of children aged 6 months–4 years — United States, July 1–29, 2022.
      ). Therefore, this study explored factors associated with parents' attitudes and intentions to seek information about the COVID-19 vaccine for their children (ages 0–18) and intentions to vaccinate their children.

      Methods

      Design and sample

      The current study involves data from a larger cross-sectional online survey of 4000 adults ages 18–45 living in the United States conducted to understand relationships between HPV and HPV vaccine knowledge, health beliefs, attitudes, and HPV vaccine behaviors and intentions as well as the impact of the COVID-19 pandemic on healthcare receipt and COVID-19 vaccine intentions (
      • Arevalo M.
      • Brownstein N.
      • Whiting J.
      • Meade C.D.
      • Gwede C.K.
      • Vadaparampil S.T.
      • Christy S.M.
      Strategies and lessons learned during data cleaning of a cross-sectional web-based health behavior survey study conducted among research panel participants.
      ). Inclusion criteria included being age 18–45, current panelists of a nationwide research panel either directly or through verified partners, living in the U.S., having internet access, and ability to understand and write in English. Prior to study initiation, the [Made Anonymous for Review] Scientific Review Committee and Institutional Review Board of record [Made Anonymous for Review] approved the study protocol as exempt.

      Procedures

      Potential participants received an email directly from the panel company with a hyperlink. Interested individuals could click on the link to be taken to the online survey which included eligibility screening and a study description. Following completion of the eligibility screener, participants were provided with informed consent information and asked to indicate their willingness to participate electronically before the survey began. Once the participant completed the survey, they were linked back to the panel company's website to receive their incentive for participation in the form of reward points to be redeemed for gift cards per the panel company's policy. Data were collected from February 25, 2021 to March 24, 2021.

      Measures

      Sociodemographic variables

      Sociodemographic variables assessed included age, gender identity, race, ethnicity, educational attainment, U.S. state of primary residence (which was collapsed into the appropriate U.S. Census region), relationship status, income, and nativity to the U.S. (both for the individual and one's parents), employment status, health insurance status, preference for health information in a language other than English, and religious service attendance.

      General vaccine attitudes

      Eleven items assessed vaccine attitudes (
      • Rosenthal S.L.
      • Weiss T.W.
      • Zimet G.D.
      • Ma L.
      • Good M.B.
      • Vichnin M.D.
      Predictors of HPV vaccine uptake among women aged 19-26: Importance of a physician’s recommendation.
      ;
      • Zimet G.D.
      • Weiss T.W.
      • Rosenthal S.L.
      • Good M.B.
      • Vichnin M.D.
      Reasons for non-vaccination against HPV and future vaccination intentions among 19-26 year-old women.
      ) using a 6-point scale, ranging from strongly agree to strongly disagree. An average score of the 11 items was utilized in analyses.

      COVID-19 vaccine intentions for one's child/children

      Parental intentions to obtain the COVID-19 vaccine for one's child (or children) were assessed using 3 items (
      • Gerend M.A.
      • Shepherd M.A.
      • Shepherd J.E.
      The multidimensional nature of perceived barriers: Global versus practical barriers to HPV vaccination.
      and using a 7-point scale (
      • Head K.J.
      • Kasting M.L.
      • Sturm L.A.
      • Hartsock J.A.
      • Zimet G.D.
      A national survey assessing SARS-CoV-2 vaccination intentions: Implications for future public health communication efforts.
      ), ranging from very likely to very unlikely. Questions were as follows: (1) “How likely is it that you will try to get more information about a COVID-19 vaccine for your child or children, if/when it becomes available?” (2) “How likely is it that you will get a COVID-19 vaccine in the next year for your child or children, if/when it becomes available?” and (3) “If your child's healthcare provider strongly recommended a COVID-19 vaccine in the next year, how likely is it that you would get your child or children vaccinated if/when the COVID-19 vaccine becomes available?” Of note, these data were collected prior to EUA for children under 16.

      Health literacy

      One HL item from the Behavioral Risk Factor Surveillance System (BRFSS) questionnaires related to HL was utilized (
      • Centers for Disease Control and Prevention
      Behavioral risk factor surveillance system survey (BRFSS) questionnaire.
      ): “In general, how difficult is it for you to understand written health information?” The question had seven responses, including very easy, somewhat easy, somewhat difficult, very difficult, I don't look for health information, don't know/not sure, or I prefer not to answer. Responses were collapsed as follows: Very easy, Difficult (including 3 response options: Somewhat Easy, Somewhat Difficult, and Very Difficult) and Other (e.g., I don't look for/pay attention to health information).

      Health numeracy

      One item from the Health Information National Trends Survey (HINTS) assessed health numeracy, as follows: “In general, how easy or hard do you find it to understand medical statistics?” Response were collapsed as follows: Very easy vs. Not very easy/Difficult) (
      • U.S. Department of Health and Human Services
      Health information national trends survey (HINTS).
      ).

      Statistical analyses

      Descriptive analyses were conducted following a systematic data cleaning process (
      • Arevalo M.
      • Brownstein N.
      • Whiting J.
      • Meade C.D.
      • Gwede C.K.
      • Vadaparampil S.T.
      • Christy S.M.
      Strategies and lessons learned during data cleaning of a cross-sectional web-based health behavior survey study conducted among research panel participants.
      ). This data cleaning process included removal of respondents who: 1) submitted their survey in less than ten minutes, 2) responded with identical responses to all of the extreme items scaled instruments that contained reverse coding (e.g., “strongly agree” or “strongly disagree” to all items), 3) provided contradictory responses, or 4) provided responses determined to be of poor quality to open-ended items (e.g., gibberish responses, use of words that did not respond to the question asked). The subsample for the current analyses is composed of responses from participants (n = 963) who identified as a parent or guardian to at least one child under the age of 18 years following the data cleaning process. Regression models examined relationships between covariates and outcomes of interest related to COVID-19 vaccine intentions and behaviors for one's child(ren). We used backward selection with a significance level of 0.10 to include variables for analysis. For binary and ordinal outcomes, we used multivariable logistic regression and multivariable ordered logistic regression models (proportional odds models), respectively. Data analysis was completed using
      • SAS Institute Inc
      Version 9.4. Cary, NC.
      , version 9.4.

      Results

      Participants' characteristics

      Descriptive statistics for the participants in the subsample (n = 963) are reported in Table 1. Briefly, participants were classified as White (82.3%), Black (7.4%), or multiple or other races (10.3%). The average age was 34.4 years (range 18–45 years, Std. Dev., ± 6.7), over half of were female (59.0%), 12.3% were Hispanic, and the majority (84.0%) were married. While 93.4% were born in the United States, 16.3% reported having at least one foreign-born parent. Most of the subsample completed either graduate school (24.6%) or a bachelor's degree (32.7%), while 27.2% had completed some college, and 15.5% completed less than some college. Approximately 35.3% of the parents earned $100,000 or more. Most were employed (84.7%) and had health insurance (88.0%). While 43.4% reported having two children, 34.8% reported having one child, and 21.8% reported having three or more children.
      Table 1Sociodemographic Characteristics.
      VariableLevelN = 63%
      Age18–26

      27–45
      193

      770
      20.0

      80.0
      How do you describe yourself?Female

      Male

      Missing
      565

      392

      6
      59.0

      41.0

      -
      RaceWhite

      Black/African American

      Other

      Missing
      791

      71

      99

      2
      82.3

      7.4

      10.3

      -
      EthnicityHispanic

      Non-Hispanic

      Missing
      118

      843

      2
      12.3

      87.7

      -
      Were you born in the United States?No

      Yes

      Missing
      63

      898

      2
      6.6

      93.4

      -
      Were either of your parents born outside the United States?No

      Yes

      Missing
      798

      155

      10
      83.7

      16.3

      -
      EducationLess than high school/High school degree/GED

      Some college/Associates degree

      Bachelor's Degree

      Graduate school
      149

      262

      315

      237
      15.5

      27.2

      32.7

      24.6
      Annual Income$0–$19,999

      $20,000–$49,999

      $50,000–$74,999

      $75,000 to $99,999

      $100,000 or more

      Missing
      68

      177

      190

      186

      339

      3
      7.1

      18.4

      19.8

      19.4

      35.3

      -
      Relationship StatusMarried/Partnered

      All others
      809

      154
      84.0

      16.0
      Employment StatusEmployed

      Unemployed

      Other
      816

      53

      94
      84.7

      5.5

      9.8
      Do you currently have any form of health insurance?No

      Yes

      Missing
      115

      844

      4
      12.0

      88.0

      -
      Do you prefer to receive health information in a language other than English?No

      Yes
      884

      79
      91.8

      8.2
      Geographic RegionMidwest

      Northeast

      South

      West
      203

      162

      423

      175
      21.1

      16.8

      43.9

      18.2
      How many children do you have?1

      2

      3 or more
      335

      418

      210
      34.8

      43.4

      21.8
      In the past 12 months, how often did you attend religious services (either in-person or remotely/virtually)?Never

      Less than weekly

      Once a week or more

      Missing
      420

      418

      121

      4
      43.8

      43.6

      12.6

      -
      In your household, who is the main person who makes decisions about your child's/children's health care?You

      You and your spouse/partner share equally in the decision-making

      Your spouse or partner/someone else

      Missing
      602

      266

      94

      1
      62.6

      27.7

      9.8

      -
      In general, how difficult is it for you to understand written health information?Very easy

      Difficult

      Other

      Missing
      386

      541

      34

      2
      40.2

      56.3

      3.5

      -
      In general, how easy or hard do you find it to understand medical statistics?Very easy

      Difficult

      Missing
      254

      705

      4
      26.5

      73.5

      -
      Average Score of Vaccine AttitudesMean

      Standard Deviation

      Missing
      4.29

      0.89

      0
      -

      -

      -

      Parental COVID-19 vaccine attitudes and intentions

      The average score of general attitudes toward vaccines was 4.29 with an SD of 0.89 (range 1–6). More than half (52.6%) reported that they would be likely to seek more information about the COVID-19 vaccine if or when it becomes available for children, whereas 12.9% reported they would be very unlikely to seek more information about the COVID-19 vaccine. Nearly half of the participants (48.3%) reported that they would be somewhat or very likely get the COVID-19 vaccine for their children in the subsequent 12 months, if/when it were to become available, which increased to 52.2% with a strong healthcare provider recommendation. Predictors of outcome variables are displayed in Table 2.
      Table 2Predictors of Parental Intentions to Seek Information and Obtain the COVID-19 Vaccination for their Children.
      VariableLevelA1: Seeking informationA2: Intentions to vaccinateA3: Following recommendation
      Odds Ratio

      (95% CI)
      Overall

      P value
      Odds Ratio

      (95% CI)
      Overall P valueOdds Ratio

      (95% CI)
      Overall

      P value
      Vaccine Attitudes2.65 (2.27–3.08)<0.0012.71 (2.32–3.16)<0.0012.97 (2.54–3.48)<0.001
      Gender (ref: Female)Male1.48 (1.14–1.92)0.0031.30 (1.00–1.68)0.049
      US Born (ref: No)Yes0.62 (0.38–1.01)0.057
      Education

      (ref: GED or lower)
      Some College/ Associate's1.41 (0.96–2.06)<0.0011.14 (0.78–1.66)

      2.11 (1.41–3.15)
      <0.0010.99 (0.68–1.45)<0.001
      Bachelor's Degree2.07 (1.39–3.10)2.03 (1.36–3.05)
      Graduate School3.32 (2.11–5.21)3.61 (2.30–5.69)3.25 (2.06–5.11)
      Annual Income

      (ref: ≥ $100,000)
      $0 to $19,0001.09 (0.63–1.88)

      0.71 (0.47–1.06)

      0.76 (0.53–1.10)

      0.59 (0.42–0.84)
      0.0220.64 (0.37–1.12)

      0.74 (0.49–1.11)

      0.72 (0.50–1.03)

      0.59 (0.42–0.84)
      0.0480.63 (0.36–1.10)

      0.59 (0.40–0.89)

      0.72 (0.50–1.04)

      0.61 (0.43–0.86)
      0.037
      $20,000 to $49,999
      $50,000 to $74,999
      $75,000 to $99,000
      Health Insurance (ref: No)Yes1.43 (0.99–2.06)0.0541.58 (1.09–2.27)0.015
      # Children

      (ref: 1 child)
      2 children

      3 or more
      1.20 (0.91–1.58)

      0.82 (0.59–1.13)
      0.0491.18 (0.90–1.55)

      0.82 (0.59–1.14)
      0.0701.13 (0.86–1.49)

      0.79 (0.57–1.09)
      0.080
      Language Preference other than English (ref: No)Yes1.90 (1.20–3.01)0.0062.16 (1.36–3.44)0.001
      In general, how difficult is it for you to understand written health information? (ref: Not very easy
      The “Not very easy” category includes response options ranging from “Difficult” to “Somewhat easy.”
      )
      Very easy1.01 (0.79–1.30)0.0180.86 (0.65–1.14)0.0240.82 (0.62–1.09)0.001
      Other
      Response options under the “Other” category included: “I don't pay attention to written health information,” and “I don't know/I'm not sure.”
      0.39 (0.20–0.75)0.40 (0.21–0.79)0.30 (0.15–0.58)
      In general, how easy or hard do you find it to understand medical statistics? (ref: Difficult)Very easy1.37 (1.01–1.87)0.0491.34 (0.97–1.84)0.074
      Legend: Analysis (A)
      A1: Predictors of parental intentions to seek more information about the COVID-19 vaccine for their child(ren)
      A2: Predictors of parental intentions to obtain the COVID-19 vaccine for their child(ren) once available
      A3: Predictors of parental intentions to obtain the COVID-19 vaccine for their child(ren) if they received a strong provider recommendation to vaccinate
      Bold font indicates there is a 95% probability that the true odds ratio is likely to fall in the designated range without bias or confounding.
      low asterisk The “Not very easy” category includes response options ranging from “Difficult” to “Somewhat easy.”
      low asterisklow asterisk Response options under the “Other” category included: “I don't pay attention to written health information,” and “I don't know/I'm not sure.”

      Predictors of parental intentions to seek more information about the COVID-19 vaccine for their child(ren)

      Higher self-reported likelihood of seeking more information on the COVID-19 vaccine for one's child(ren) was associated with strong positive attitudes about vaccines (aOR 2.65, 95% CI: 2.27–3.08), male gender (aOR 1.48, 95% CI: 1.14–1.92), and educational attainment (p < 0.0001), with respective odds ratios for completing graduate school (aOR 3.32, 95% CI: 2.11–5.21), holding a bachelor's degree (aOR 2.07, 95% CI: 1.39–3.10), and completing high school (aOR 1.41, 95% CI: 0.96–2.06) compared to less than high school education. Lower likelihood of seeking additional information about the COVID-19 vaccine was related to not understanding written health information (aOR 0.39, 95% CI: 0.20–0.75) (see Table 2). Intentions to seek more information about the COVID-19 vaccine also varied by income level (p = 0.0218), with odds ratios lower for all but the lowest income group compared to the highest income group ($100 K or more). Specifically, lower information seeking odds were associated with income levels of $75-99 K (aOR 0.59, 95% CI: 0.42–0.84), and marginally lower for income levels $20-49 K (aOR 0.71 95% CI 0.47–1.06) and $50-74 K (aOR 0.76, 95% CI 0.53–1.10). Odds of seeking additional COVID-19 vaccine information also differed by number of children (p = 0.0485), with higher odds for two children compared to one child (aOR 1.20 95% 0.91–1.58) and lower odds for three children (aOR 0.82, 95% CI 0.59–1.13).

      Predictors of parental intentions to obtain the COVID-19 vaccine for their child(ren) in the next year, if/when available

      Among parents, greater self-reported intentions of getting a COVID-19 vaccine for one's child(ren) in the subsequent 12 months were associated with the following: strong positive attitudes about vaccines in general (aOR 2.71, 95% CI: 2.32–3.16), male gender (aOR 1.30, 95% CI: 1.00–1.68), educational attainment (p < 0.0001), especially completing graduate education compared to less than high school (aOR 3.61, 95% CI: 2.30–5.69), or holding a bachelor's degree compared to less than high school (aOR 2.11, 95% CI: 1.41–3.15), higher numeracy (aOR 1.37, 95% CI: 1.01–1.87), having health insurance (aOR 1. 43, 95% CI: 0.99–2.06), and preferring to receive health information in a language other than English (aOR 1.90, 95% CI: 1.20–3.01). Likelihood of parental intentions to obtain the COVID-19 vaccine for their children was related to income level (p = 0.0480), with higher intentions associated with the highest income level ($100 K or more), lower income of $50 K-$75 K (aOR 0.72, 95% CI: 0.50–1.03), and income of $75 K-$99 K (aOR 0.59, 95% CI: 0.42–0.84). Individuals reporting more difficulty following written health information (aOR 0.40, 95% CI: 0.21–0.79; p = 0.0235) reported lower intentions. (see Table 2). Mirroring the information seeking model, intentions differed by number of children, with higher odds for parents of two children (aOR 1.19 95% CI 0.9–1.55) and lower odds for parents of three or more children (aOR 0.82, 95% CI 0.59–1.14) compared to parents of only one child.

      Factors associated with parental intentions to obtain the COVID-19 vaccine for their child(ren) in the next year if they received a strong provider recommendation to vaccinate

      Parents were asked their intentions of getting the COVID-19 vaccine in the next year if a healthcare provider strongly recommended it for their child(ren). Findings show higher reported parental vaccination intention odds with a strong healthcare provider recommendation associated with strong positive attitudes about vaccines (aOR 2.97, 95% CI: 2.54–3.48), educational attainment (p < 0.0001), particularly completing graduate education compared to less than high school (aOR 3.25, 95% CI: 2.06–5.11) or holding a bachelor's degree compared to less than high school (aOR 2.03, 95% CI: 1.36–3.05), having health insurance (aOR 1.58, 95% CI: 1.09–2.27), preference for receiving health information in a language other than English (aOR 2.16, 95% CI: 1.36–3.44), and higher health numeracy (aOR 1.34, 95% CI: 0.97–1.84). Lower likelihood of parental intentions after a strong recommendation from a healthcare provider was related to having two children (aOR 1.13, 95% CI: 0.86–1.49), and lower odds for having three or more children (aOR 0.79, 95% CI: 0.57–1.09) compared to having one child. Odds of higher parental intentions to vaccinate their children after a strong healthcare provider recommendation was associated with higher self-reported HL (aOR 0.82, 95% CI: 0.62–1.09) compared to lower self-reported HL. Odds of parental intentions if a healthcare provider strongly recommended the COVID-19 vaccine for one's child(ren) varied by income level, with odds highest in the $100 K or more group, and lower values for other groups compared to $100 K or more (aOR 0.63 for <$20 K, 95% CI 0.36–1.10, aOR 0.59 for $20-50 K, 95% CI: 0.40–0.89, aOR 0.72 for $50 K-$74 K, 95% CI: 0.50–1.04, or aOR 0.61 for $75-99 K, 95% CI: 0.43–0.86).

      Discussion

      This study examined associations between sociodemographic characteristics, and other factors such as HL, health numeracy, vaccine attitudes, and intentions to obtain the COVID-19 vaccine for one's child(ren) among parents ages 18–45 living in the U.S. Data were collected February 25, 2021, to March 24, 2021, prior to approval of COVID-19 vaccines for the majority of children. Overall, males had greater intentions to seek information on and to obtain the COVID-19 for their children even without provider recommendation, as were parents who had higher education, higher annual income, were insured, and found it easier to understand medical statistics. Further, our study highlights the importance of various sociodemographic characteristics and other factors, such as HL and health numeracy, related to parents' intentions. Only 48.3% reported a high likelihood of obtaining the COVID-19 vaccine for their children within 12 months, which increased to 52.2% with a strong healthcare provider recommendation. In the U.S., about 15.3 million children aged 6 months to 4 years old have yet to receive their first COVID-19 vaccine dose and only 10% received at least one dose and only 31% of children ages 5–11 had completed the primary COVID-19 vaccination series since November 2022 highlighting the importance of our study (). These findings having important educational implications for nurses and other providers working in pediatric or school settings working to promote COVID-19 vaccination uptake.
      Interestingly, parental intentions varied with the number of children, with higher vaccine intentions among parents with two children compared to parents with one child and lower intent among parents of three or more children compared to parents with one child. This is in contrast to another U.S. study that found as the number of children increased in the household, the willingness to obtain the COVID-19 vaccine increased (
      • Catma S.
      • Reindl D.
      Parents’ willingness to pay for a COVID-19 vaccine for themselves and their children in the United States.
      ). Therefore, this study emphasizes the need to explore parental barriers to vaccine uptake for their children and deliver appropriate education and decision-making for parents concerned about the vaccine.
      In our study, males reported higher intentions to get more information about the COVID-19 vaccine for their child(ren). These findings are consistent with prior parental COVID-19 vaccine studies (
      • Goldman R.D.
      • Yan T.D.
      • Seiler M.
      • Parra Cotanda C.
      • Brown J.C.
      • Klein E.J.
      • Staubli G.
      Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.
      ;
      • Goldman R.D.
      • Staubli G.
      • Cotanda C.P.
      • Brown J.C.
      • Hoeffe J.
      • Seiler M.
      • Klein E.J.
      Factors associated with parents’ willingness to enroll their children in trials for COVID-19 vaccination.
      ;
      • Scherer A.M.
      • Gedlinske A.M.
      • Parker A.M.
      • Gidengil C.A.
      • Askelson N.M.
      • Petersen C.A.
      • Lindley M.C.
      Acceptability of adolescent COVID-19 vaccination among adolescents and parents of adolescents - United States, April 15-23, 2021.
      ). Specifically, these studies, conducted in the U.S., Canada, Israel, Spain, and/or Switzerland (
      • Goldman R.D.
      • Yan T.D.
      • Seiler M.
      • Parra Cotanda C.
      • Brown J.C.
      • Klein E.J.
      • Staubli G.
      Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.
      ;
      • Goldman R.D.
      • Staubli G.
      • Cotanda C.P.
      • Brown J.C.
      • Hoeffe J.
      • Seiler M.
      • Klein E.J.
      Factors associated with parents’ willingness to enroll their children in trials for COVID-19 vaccination.
      ;
      • Scherer A.M.
      • Gedlinske A.M.
      • Parker A.M.
      • Gidengil C.A.
      • Askelson N.M.
      • Petersen C.A.
      • Lindley M.C.
      Acceptability of adolescent COVID-19 vaccination among adolescents and parents of adolescents - United States, April 15-23, 2021.
      ), found that fathers were more willing than mothers to get the COVID-19 vaccination for their children, and that mothers reported more concerns regarding adolescent vaccine safety. The similarity of our findings with current literature may be explained by males' role in making decisions about their children's healthcare. Prior literature reported that fathers who receive discouraging or conflicting information, father's ethnicity, father's vaccination hesitancy, and male children are parental determinants of vaccination timeliness and can impact intentions to receive the COVID-19 vaccination for their children (
      • Gilchrist C.A.
      • Chelimo C.
      • Tatnell R.
      • Atatoa Carr P.
      • Camargo Jr., C.A.
      • Morton S.
      • Grant C.C.
      Vaccination information fathers receive during pregnancy and determinants of infant vaccination timeliness.
      ;
      • Goldman R.D.
      • Ceballo R.
      Parental gender differences in attitudes and willingness to vaccinate against COVID-19.
      ). On the other hand, prior literature suggest that mothers experienced vaccine hesitancy due to concerns about safety and efficacy and felt a sense of confusion over conflicting information (
      • Walker K.K.
      • Head K.J.
      • Owens H.
      • Zimet G.D.
      A qualitative study exploring the relationship between mothers’ vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months.
      ). Leveraging the role of nurses in parental COVID-19 vaccine education can help to promote vaccine uptake among children for both parents. Recent literature supports nurses having the training, knowledge, and confidence to actively execute COVID-19 vaccine educational interventions to increase parental knowledge and increase vaccine uptake among children (
      • Blake H.
      • Fecowycz A.
      • Starbuck H.
      • Jones W.
      COVID-19 vaccine education (CoVE) for health and care workers to facilitate global promotion of the COVID-19 vaccines.
      ).
      Based on the variety of sociodemographic information and health behaviors regarding COVID-19 vaccine intentions and hesitancy, providing appropriate health education information to families must contain multiple strategies to increase parental confidence and promote positive attitudes. Our study adds insights about the relative importance of HL and numeracy to the body of the pediatric COVID-19 vaccine literature and showed positive associations between HL, numeracy, and pediatric COVID-19 vaccine intentions and seeking additional vaccine information. The provider's role in promoting clear communications and in deconstructing difficult COVID-19 vaccine terminology and concepts is emphasized here. However, more research is needed to understand the uptake and impact of how parents and adolescents understand and use health messages regarding COVID-19 vaccination. Compared to similar literature among adults,
      • McCaffery K.J.
      • Dodd R.H.
      • Cvejic E.
      • Ayrek J.
      • Batcup C.
      • Isautier J.M.
      • Wolf M.S.
      Health literacy and disparities in COVID-19-related knowledge, attitudes, beliefs and behaviours in Australia.
      found individuals with limited HL had a poorer understanding of COVID-19 symptoms and were less able to identify health behaviors that can prevent infection and to rate social distancing as necessary. Additionally, having higher numeracy skills and more trust in scientists has been associated with lower susceptibility to COVID-19 misinformation (
      • Roozenbeek J.
      • Schneider C.R.
      • Dryhurst S.
      • Kerr J.
      • Freeman A.L.J.
      • Recchia G.
      • van der Linden S.
      Susceptibility to misinformation about COVID-19 around the world.
      ).
      Our findings underscore the important role of the nurse in health education for implementing ongoing assessments that verify comprehension and use of vaccine information as well as being able to discern misunderstandings (such as teach-back). With the Healthy People 2030 definition of literacy also including a focus on organizational HL (beyond personal HL), nurses need to be diligent in monitoring healthcare system demands and implementing system adjustments that might further enhance health literacy and understanding (such as creating additional multi-language resources, ensuring health protocols are understood and followed, disseminating evidence-based information, recommending streamlined navigation processes, etc.). Moreover,
      • Ratzan S.C.
      • Parker R.M.
      Vaccine Literacy-helping Everyone Decide to Accept Vaccination.
      maintain that vaccine literacy is a fundamental building block of health communication to ensure ‘all understand what they need to know and do to get vaccinated.’ This entails aligning people's skills and abilities with the content, processes, and systems needed to access and get vaccinated. They summarize a series of eight principles by which vaccine literacy can be facilitated, such as communicating trustworthy, up-to-date evidence, understanding risks/benefits for self and society, being aware of policies that incentivize vaccination, and equity among a few. Nurses can play integral roles in applying these principles and making recommendations to parents.

      Strengths and limitations

      Our study is one of the earlier studies to examine the parental intentions and behaviors of the COVID-19 vaccine after initial EUA approval, but prior to EUA authorization of the vaccine for most child age cohorts. Despite our novel findings, our study had several limitations. First, the participants in our study were majority White, English-speaking, with higher socioeconomic status, higher educational levels, and limited to those aged 18–45 and research panelists, which may limit generalizability to the larger population of parents of children eligible for the COVID-19 vaccine. Our measures of HL and HN relied on single item questions to gauge difficulty in understanding written health information and/or the ease or difficulty in understanding medical statistics respectively. Future research might include additional measures of comprehension to assess application and use of the information specific to this health content (i.e., vaccination). Generalization is vital to understand parental attitudes regarding COVID-19 vaccinations for children in diverse populations. Second, the data are cross-sectional; we are unable to make a causal inference. In addition, we did not examine knowledge about COVID-19 symptoms, COVID-19 illness, or the COVID-19 vaccine, which may be associated with our outcomes of interest. Lastly, limitations to the studies are exacerbated by the constantly evolving context of the COVID-19 vaccine information and availability to the general population.

      Conclusions

      In summary, we report the factors associated with parental COVID-19 vaccine attitudes and intentions, which can give practitioners insights into how we can improve the uptake of COVID-19 vaccinations in the pediatric population. Having strong positive attitudes about vaccines was correlated with COVID-19 vaccine intent, and males generally had higher intentions to obtain the COVID-19 vaccine for their children, suggesting a gender difference in intentions. Future research should investigate the use of targeted and tailored education materials for COVID-19 vaccine-hesitant parents. Our study demonstrates the need to focus public health campaigns on vaccine-hesitant populations and to increase awareness of the importance of children receiving COVID-19 vaccinations. Nurses have multiple opportunities to provide trustworthy and clear COVID-19 vaccine information and influence parental attitudes and COVD-19 vaccine uptake through health education.

      CRediT authorship contribution statement

      Lakeshia Cousin: Writing – original draft, Writing – review & editing, Visualization, Conceptualization. Stephanie Roberts: Writing – original draft, Writing – review & editing, Conceptualization. Naomi C. Brownstein: Writing – original draft, Methodology, Formal analysis. Junmin Whiting: Writing – original draft, Methodology, Formal analysis. Monica L. Kasting: Writing – original draft. Katharine J. Head: Writing – original draft. Susan T. Vadaparampil: Writing – original draft, Writing – review & editing. Anna R. Giuliano: Writing – original draft, Writing – review & editing. Clement K. Gwede: Writing – original draft, Writing – review & editing. Cathy D. Meade: Writing – original draft, Writing – review & editing, Conceptualization. Shannon M. Christy: Conceptualization, Methodology, Writing – original draft, Writing – review & editing, Supervision, Investigation, Funding acquisition.

      Declaration of Competing Interest

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

      Acknowledgments

      The study was supported with funding from a Moffitt Center for Immunization and Infection Research in Cancer Award (PI: Christy) and a Moffitt Merit Society Award (PI: Christy). This work has been supported in part by the Participant Research, Interventions, and Measurement Core and the Biostatistics and Bioinformatics Shared Resource at the H. Lee Moffitt Cancer Center & Research Institute, a comprehensive cancer center designated by the National Cancer Institute and funded in part by Moffitt's Cancer Center Support Grant (P30-CA076292). Dr. Kasting's work on this project was made possible with support from Grant Numbers, KL2TR002530 (B. Tucker Edmonds, PI), and UL1TR002529 (S. Moe and S. Wiehe, co-PIs) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award. Dr. Cousin's work on this project was made possible by the University of Florida Claude D. Pepper Older Americans Independence Center P30AG028740

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