Psychological Impact of COVID-19 and Its Influence on Parental Willingness to Vaccinate Children: A Cross-Sectional Study at a Tertiary Care Hospital in Kolkata

Abstract

Background
COVID-19 has affected the physical and mental health of people globally, and vaccination is seen as a crucial tool in controlling the pandemic. However, the readiness to vaccinate children remains a concern, particularly in India.
Aim
The study aimed to investigate the association between the psychological impact of COVID-19 and willingness to vaccinate their children among attendees of the COVID-19 vaccination clinic at Nil Ratan Sircar Medical College, Kolkata.
Method
The study used an observational, cross-sectional design and collected data from 356 participants between August and September 2022. The COVID-19 Perceived Stress Scale-10 was used to assess participants' psychological impact, and willingness to vaccinate was determined using a survey.
Results
Approximately 64% (n=227) and 71% (n=253) of the participants exhibited a high level of perceived stress and willingness to vaccinate their children. The vaccine acceptance was significantly associated with perceived stress level and other factors such as family type, presence of chronic illness, and history of acquaintances suffering from COVID-19.
Conclusion
The study highlights the importance of addressing parental stress and anxiety to enhance vaccination rates among children. To achieve this, population-level awareness of vaccine safety measures and benefits should be raised to alleviate stress and increase vaccine uptake.

Full text

Review began 11/15/2023
Review ended 11/22/2023
Published 11/28/2023
© Copyright 2023
Burman et al. This is an open access article
distributed under the terms of the Creative
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and reproduction in any medium, provided
the original author and source are credited.
Psychological Impact of COVID-19 and Its
Influence on Parental Willingness to Vaccinate
Children: A Cross-Sectional Study at a Tertiary
Care Hospital in Kolkata
Jayeeta Burman , Nivedita Roy Choudhury , Amitabha Chattopadhyay , Sembagamuthu Sembiah ,
Anubrata Karmakar , Mukesh Shukla
1. Community Medicine, Sarat Chandra Chattopadhyay Government Medical College & Hospital, Uluberia, IND 2.
Community Medicine, Nil Ratan Sircar Medical College and Hospital, Kolkata, IND 3. Community Medicine, Midnapore
Medical College and Hospital, Midnapore, IND 4. Community Medicine and Family Medicine, All India Institute of
Medical Sciences, Kalyani, Kalyani, IND 5. Community Medicine, North Bengal Medical College and Hospital, Siliguri,
IND 6. Community and Family Medicine, All India Institute of Medical Sciences, Rae Bareli, Raebareli, IND
Corresponding author: Sembagamuthu Sembiah, sembagamuthu.cmfm@aiimskalyani.edu.in
Abstract
Background
COVID-19 has affected the physical and mental health of people globally, and vaccination is seen as a
crucial tool in controlling the pandemic. However, the readiness to vaccinate children remains a concern,
particularly in India.
Aim
The study aimed to investigate the association between the psychological impact of COVID-19 and
willingness to vaccinate their children among attendees of the COVID-19 vaccination clinic at Nil Ratan
Sircar Medical College, Kolkata.
Method
The study used an observational, cross-sectional design and collected data from 356 participants between
August and September 2022. The COVID-19 Perceived Stress Scale-10 was used to assess participants'
psychological impact, and willingness to vaccinate was determined using a survey.
Results
Approximately 64% (n=227) and 71% (n=253) of the participants exhibited a high level of perceived stress
and willingness to vaccinate their children. The vaccine acceptance was significantly associated with
perceived stress level and other factors such as family type, presence of chronic illness, and history of
acquaintances suffering from COVID-19.
Conclusion
The study highlights the importance of addressing parental stress and anxiety to enhance vaccination rates
among children. To achieve this, population-level awareness of vaccine safety measures and benefits should
be raised to alleviate stress and increase vaccine uptake.
Categories: Preventive Medicine, Infectious Disease
Keywords: covid_19 vaccination, parental distress, psychological impact of covid-19, covid-19 vaccine hesitancy
india, covid-19 india
Introduction
The COVID-19 pandemic has caused a significant global public health crisis, with millions of people
affected worldwide. As the world grapples with the challenges posed by this deadly virus, the development
and deployment of vaccines have emerged as critical tools in controlling its spread and ultimately achieving
herd immunity. However, the success of vaccination campaigns heavily relies on the willingness of
individuals to get vaccinated, and parental attitudes toward vaccines play a crucial role in this context [1,2].
Studies have shown that vaccine hesitancy is a significant barrier to achieving herd immunity and ending
the COVID-19 pandemic [3].
The psychological impact of COVID-19 has also been widely documented, with the pandemic having a
significant impact on the mental health of people worldwide [4]. Parental attitudes towards vaccines have
1 2 3 4
5 6
Open Access Original
Article DOI: 10.7759/cureus.49585
How to cite this article
Burman J, Roy Choudhury N, Chattopadhyay A, et al. (November 28, 2023) Psychological Impact of COVID-19 and Its Influence on Parental
Willingness to Vaccinate Children: A Cross-Sectional Study at a Tertiary Care Hospital in Kolkata. Cureus 15(11): e49585. DOI
10.7759/cureus.49585

been identified as an important determinant of vaccination behavior. Previous research has shown that
parents' perceptions of the safety and efficacy of vaccines, as well as their trust in healthcare providers,
influence their willingness to vaccinate their children [5]. However, psychological health seems to be a
controversial determinant of vaccine hesitancy and remains to be investigated.
Therefore, this study aims to investigate the association between psychological impact and parental
willingness to vaccinate their child against COVID-19 among attendees of the COVID-19 vaccination clinic
at a tertiary care hospital in Kolkata. Gaining insights into the complex interplay between psychological
well-being and vaccination behavior could enable the development of targeted interventions and
communication strategies. By addressing specific psychological concerns and tailoring vaccine promotion
efforts accordingly, health authorities can bolster vaccination rates and enhance public health outcomes in
the fight against COVID-19.
Materials And Methods
This study is an observational cross-sectional study conducted among attendees of the COVID-19
vaccination clinic of a tertiary care hospital in Kolkata, India from August to September 2021. An
international survey revealed that 65% of caregivers expressed their intention to vaccinate their child
against COVID-19 [6]. With a prevalence(p) of 65%, an absolute error of 5%, and a confidence level of 95%,
the sample size was calculated using the formula = z2 pq/d2 (z = standard normal deviate at 95% confidence
interval [CI]; q = 100 - p), the minimum sample size came out to be 350. The participants were selected
through purposive sampling. Ethical approval was obtained from the Institutional Ethics Committee of Nil
Ratan Sircar Medical College & Hospital vide Letter No. NMC/6422 dated 21/10/2021, and informed written
consent was taken from all participants. The study was conducted in accordance with the Declaration of
Helsinki.
The study used a pre-designed, pre-tested, structured interview schedule containing open- and close-ended
questions to collect participant data. The tool was translated into Bengali and back to English, and the face
and content validity of the instrument was checked by the experts of the institutions.
The dependent variable was the parents’ willingness to vaccinate their children under the age of 18 with a
COVID-19 vaccine using a question; the responses were “Yes”, “No” and “Not sure”; followed by an open-
ended question “Why?” or “Why not?”, with a free text box.
The main independent variable was the psychological impact due to COVID-19, which was assessed using
the COVID-PSS-10, used to assess the perception of stress associated with COVID-19 [7]. This validated tool
includes questions about feelings and thoughts during the last month, and participants were asked to
indicate how often they felt or thought in a certain way. COVID-PSS-10 is made up of 10 items, each of
which offers five response options: never, almost never, occasionally, almost always, and always. COVID-
PSS-10 presented a bi-dimensional construction: the first section named 'Stress' focused on the perceived
lack of control over the situation (question numbers 1, 2, 3, 6, 9, and 10) ranging from almost always with 4
points to never with 0 points. The second section named 'Coping' defined a set of cognitive and behavioral
strategies needed to manage stressful situations (question numbers 4, 5, 7, and 8) which were inversely
scored. The total scores obtained ranged from a minimum of 0 to a maximum of 40. Scores at or above 25
were interpreted as the high perceived stress associated with COVID-19.
The other independent variables were socio-demographics such as age, gender, residence, educational
status, monthly income, occupation, family type, addiction, and co-morbidity data. Additionally, knowledge
on COVID-19 was collected using a set of questions prepared from the literature review [8].
Ethical approval from the institutional ethical committee was obtained and informed written consent was
obtained from all participants in the study. The study was conducted in accordance with the declaration of
Helsinki.
Data were entered in Microsoft Excel 2007 (Microsoft Corporation, Redmond, USA) and analyzed using the
SPSS software version 16.0 (SPSS Inc., Chicago, USA). Logistic regression was used to elicit the relationship
between perceived stress among parents and their willingness to vaccinate their children for COVID-19. We
then used multivariable logistic regression analysis to estimate the adjusted odds ratio of agreeing to
vaccinate children, using all the variables that showed significance (p < 0.05) in the univariate analysis.
Results
Among 356 participants, most (211, 59%) of the participants belonged to the age group 18-45 years (Mean ±
SD → 41.32 ± 17.1). Males were more in number than females. About half (187, 52.5%) of the participants
were graduates. About half (182, 51.1%) of participants’ acquaintances were affected by COVID-19
infection (Table 1).
2023 Burman et al. Cureus 15(11): e49585. DOI 10.7759/cureus.49585 2 of 8

Characteristics n(%)
Age in years
18-45 211(59.3)
46-60 93(26.1)
>60 52(14.6)
Gender
Male 222(62.4)
Female 134(37.6)
Education
Primary 43(12.1)
High school 72(20.2)
Intermediate 54(15.2)
Graduate 187(52.5)
All of the above 208(59.4)
Type of Family
Nuclear 176(49.4)
Joint 180(50.6)
Occupation
Homemaker / Unemployed 151(42.4)
Unskilled worker 44(12.4)
Skilled worker 13(3.6)
Clerical/ shop/ Farmers 25(7)
Professional 133(34.6)
Chronic illness
Yes 120(33.7)
No 236(66.3)
Acquaintances affected by COVID-19
Yes 182(51.1)
No 174(48.9)
TABLE 1: Distribution of study participants according to demographic profile and general
information (n=356)
Nearly two-thirds (227; 64%) of the participants had a high level of perceived stress level (scores >25) (Table
2).
2023 Burman et al. Cureus 15(11): e49585. DOI 10.7759/cureus.49585 3 of 8

Statements Never
[n(%)]
Hardly
ever [n(%)] Occasion [n(%)] Almost
always [n(%)] Always [n(%)]
I have felt as if something serious was going to happen unexpectedly
with the epidemic 17(4.8) 40(11.2) 57(16) 115(32.3) 127(35.7)
I have felt that I am unable to control the important things in my life
because of the epidemic 63(17.7) 57(16) 127(35.7) 65(18.3) 44(12.4)
I have felt nervous or stressed about the epidemic 75(21.1)
64(18) 64(18) 49(13.8) 104(29.2)
I have been confident about my ability to handle my personal
problems related to the epidemic 61(17.1) 47(13.2) 127(35.7) 109(30.6) 12(3.4)
I have felt optimistic that things are going well with the epidemic 36(10.1)
67(18.8) 156(43.8) 85(23.9) 12(3.4)
I have felt unable to cope with the things I have to do to monitor for a
possible infection 64(18) 46(12.9) 80(22.5) 136(38.2) 30(8.4)
I have felt that I can control the difficulties that could appear in my life
as a result of the infection 57(16) 45(12.6) 121(34) 88(24.8) 45(12.6)
I have felt that I have everything under control in relation to the
epidemic 49(13.8) 113(31.8) 71(19.9) 68(19.1) 55(15.4)
I have been upset that things related to the epidemic are out of my
control 53(14.9) 39(11) 11(31.2) 36(10.1) 117(32.9)
I have felt that the difficulties are increasing in these days of the
epidemic and I feel unable to overcome them 75(21.1) 42(11.8) 82(23) 64(18) 93(26.1)
TABLE 2: Distribution of study participants according to the psychological impact of COVID-19
(n=356)
About three-fourths (253; 71%) proportion of participants were willing to vaccinate their children. The most
common reason reported by caregivers willing to vaccinate was to protect their child (207, 82%) followed by
the severity of the pandemic (190, 75%), and lastly, 7% (n=18) said that the vaccines work in preventing the
disease. The most common reason reported by caregivers refusing vaccination was that the vaccine is new
and there was no adequate background information about the effectiveness of the vaccine (84, 82%),
followed by concerns over side effects and the safety of taking the vaccines (78,76%) (Table 3).
2023 Burman et al. Cureus 15(11): e49585. DOI 10.7759/cureus.49585 4 of 8

n(%)
Willing to vaccinate their children 253 (71)
Reasons:*
Children and family members are at higher risk 207 (82)
Severity of COVID -19 190 (75)
Everyone accepting the vaccine 25 (10)
Vaccines are effective in preventing the infection 18 (7)
Not willing to vaccinate 103 (29)
Reasons:*
New vaccine; effectiveness not known 84 (82)
Side effects and safety concerns 78 (76)
COVID-19 is not a serious problem 13 (13)
Already infected, hence vaccine is not required 4 (4)
TABLE 3: Distribution of study participants according to their willingness to vaccinate their
children (n = 356)
*Multiple responses
The univariate logistic regression found a significant association between parents' perceived stress level due
to COVID-19 and their willingness to vaccinate their children against COVID-19. Other factors such as
family type, occupation, and suffering from chronic illness were also associated. In multivariable logistic
regression, all the factors remained significant. With the Hosmer-Lemeshow test being non-significant and
the Naglerke R2 value, the model is considered fit and is able to explain about 18% variability in the
willingness to vaccinate their children (Table 4).
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Variables Willingness to vaccinate their child
OR (95% CI); P value AOR (95% CI); P value
Perceived stress (high) 2.6 (1.5 – 4.5); 0.003 1.7 (1.4-3.1) 0.004
Age (>45 years) 1.06 (0.6-1.6); 0.82
Gender (Male) 1.2 (0.5-2.8); 0.51
Education (Graduation and above) 1.3 (0.8-2); 0.25
Family type (Joint) 3.5 (2.3-5.8); <0.001 2.9 (1.7-6.8); <0.001
Occupation (Working population) 3.5 (2.1-5.6); <0.001 2.7 (1.3-8.2); <0.001
History of chronic illness 7.1 (3.5-14.7); 0.001 6.7 (3.2-21.2); 0.001
Acquaintances affected by COVID-19 2.1 (0.9-3.1); 0.45
Hosmer-Lemeshow test 0.8
Nagelkerke R2 0.18
TABLE 4: Logistic regression to assess the relationship between stress level and willingness to
vaccinate their children
OR = Odds ratio; AOR = Adjusted Odds Ratio
Discussion
A globally implemented, safe vaccination program is considered one of the key long-term solutions to
effectively control and mitigate the coronavirus disease 2019 (COVID-19) pandemic. Vaccination programs
can have significant clinical and socioeconomic benefits by reducing the spread of the virus, preventing
severe cases and hospitalizations, and ultimately saving lives. Vaccinating children against COVID-19 will
play a crucial role in containing the disease's spread, as achieving herd immunity might necessitate
vaccinating around 80% of the population [9].
The current study aimed to investigate the association between the psychological impact of COVID-19 and
the willingness to vaccinate children among attendees of a COVID-19 vaccination clinic. The study found
that nearly two-thirds of the participants had a high level of perceived stress level, and this stress level was
associated with their willingness to vaccinate their children.
The finding of high perceived stress levels among participants is consistent with previous studies that
reported a significant increase in psychological distress and mental health problems during the COVID-19
pandemic [10,11]. For example, a study conducted in China found that the prevalence of anxiety and
depression symptoms among the general population was as high as 35% and 20%, respectively [12]. Another
study conducted in India reported that more than 40% of the respondents reported moderate to severe
anxiety levels during the pandemic [13].
The study also found that family type, presence of co-morbidity, and history of acquaintances suffering from
COVID-19 were associated with the perceived stress level of the participants. This finding is consistent with
previous research that has reported a significant association between COVID-19-related stress and
knowledge, perception, and attitudes towards the pandemic [14]. This finding underscores the need for
tailored communication strategies and education programs that address the specific concerns and stressors
of different subgroups of parents.
Moreover, the study found that 71% of participants were willing to vaccinate their children against COVID-
19. This is consistent with previous studies that have reported a high willingness to vaccinate children
against COVID-19 among parents [9, 15]. The present study demonstrates a significant association between
parents' perceived stress level due to COVID-19 and their willingness to vaccinate their children against
COVID-19. This finding is consistent with previous studies that have shown how stress and anxiety can
impact health behaviors, including vaccination uptake [15,16]. These studies support the idea that parents
who experience higher levels of stress related to COVID-19 may be more motivated to prioritize their
children's health and well-being, including by vaccinating them against COVID-19 and other illnesses.
However, it's important to consider the complex interplay between stress, health beliefs, and vaccine
attitudes when interpreting these findings. Future research should further explore the underlying
2023 Burman et al. Cureus 15(11): e49585. DOI 10.7759/cureus.49585 6 of 8

mechanisms linking stress and vaccine hesitancy, as well as identify effective strategies for reducing parental
stress levels and increasing vaccine uptake. The public’s positive views and trust in a fast-tracked COVID-19
vaccine will be essential because some individuals are unsure about its safety and necessity due to concerns
surrounding new vaccines.
The study had some limitations. It was cross-sectional in design, limited to one geographic setting, and did
not consider the characteristics of the children. Additionally, the study relied on self-reported data, which
may be subject to response bias and social desirability bias.
Conclusions
This study examined the link between parents' perceived stress levels due to COVID-19 and their willingness
to vaccinate their children. The findings revealed a significant association, highlighting the importance of
addressing parental stress and anxiety to enhance vaccination rates among children. To achieve this,
population-level awareness of vaccine safety measures and benefits should be raised to alleviate stress and
increase vaccine uptake. Public health officials play a crucial role in this process by providing evidence on
COVID-19 vaccines' safety and efficacy, emphasizing the risks and consequences of infection in children,
and educating caregivers on the role of vaccination. Incorporating these factors into vaccination campaigns
and communication strategies can effectively encourage parents to consider vaccinating their children
against COVID-19, thus contributing to overall public health efforts to combat the pandemic.
Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.
Concept and design: Sembagamuthu Sembiah, Jayeeta Burman, Nivedita Roy Choudhury, Amitabha
Chattopadhyay, Anubrata Karmakar, Mukesh Shukla
Acquisition, analysis, or interpretation of data: Sembagamuthu Sembiah, Jayeeta Burman, Nivedita Roy
Choudhury, Amitabha Chattopadhyay
Drafting of the manuscript: Sembagamuthu Sembiah, Jayeeta Burman, Nivedita Roy Choudhury,
Amitabha Chattopadhyay, Anubrata Karmakar
Critical review of the manuscript for important intellectual content: Sembagamuthu Sembiah, Jayeeta
Burman, Nivedita Roy Choudhury, Amitabha Chattopadhyay, Mukesh Shukla
Supervision: Sembagamuthu Sembiah, Jayeeta Burman
Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Nil Ratan Sircar Medical
College & Hospital Institutional Ethics Committee issued approval No/NMC/6422. APPROVED. It is placed
on record that the decision regarding your proposal was unanimous and therefore did not require any voting
procedure. Members absent have reviewed the same documents and have not expressed any objection or
dissent toward approval. Animal subjects: All authors have confirmed that this study did not involve
animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all
authors declare the following: Payment/services info: All authors have declared that no financial support
was received from any organization for the submitted work. Financial relationships: All authors have
declared that they have no financial relationships at present or within the previous three years with any
organizations that might have an interest in the submitted work. Other relationships: All authors have
declared that there are no other relationships or activities that could appear to have influenced the
submitted work.
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