Effects of the COVID-19 Pandemic on Routine Childhood Immunizations
Tracking Parental Attitudes and Behaviours
Impact Canada, Impact & Innovation Unit, Privy Council Office
Key Insights
- Up to 25% of Canadian parents and caregivers surveyed reported missing or delaying a routine immunization for their child(ren) since the pandemic began.
- Most parents intend to catch up. To facilitate catch up, parents indicated interest in convenience through greater availability and accessibility of immunization services, such as through local pharmacies.
- Parents with greater levels of vaccine confidence were less likely to miss or delay their child’s routine immunization. However, experience with barriers to vaccination substantially increased the risk of missing or delaying a child’s immunization regardless of the parent’s level of vaccine confidence.
- Results suggest that uptake of routine childhood vaccinations may be increased by providing more convenient and accessible immunization services and addressing common and pandemic-related barriers to vaccination.
1. Background
Routine childhood immunizations (RCIs) are critical for protecting the health and well-being of children in Canada. Parental confidence and uptake in RCIs has increasingly become a topic of concern since the start of the COVID-19 pandemic. According to a report published in July 2022 by WHO and UNICEF, during the pandemic global routine vaccine coverage among children showed the largest decline observed in the past 30 years.
For many Canadian parents, the pandemic interfered with access to RCI services. What’s more, the topic of vaccination has been given unprecedented centrality because of the pandemic, potentially polarizing opinions. Our teams at the Public Health Agency of Canada (PHAC) and the Privy Council Office (PCO) hypothesized that the pandemic has had a meaningful impact on vaccine timeliness – the extent to which children are up to date on all of their recommended immunizations. This survey also explored attitudes related to RCIs and estimated the impact of barriers to vaccination on missed or delayed immunizations.
This research was conducted as part of a collaboration with the Behavioural Science Office and Vaccine Behaviour and Confidence teams (Public Health Agency of Canada).
2. Methodology
A national, bilingual, and regionally representative online survey was administered in January 2023 to 2,036 respondents with at least one child under 18 years of age. The regional and demographic information for the parents is shown below in Table 1.
Table 1. Regional and demographic information for the parents.
| Canada (n=2036) | BC/YK (n=236) | AB/NT (n=181) | MB/SK/NU (n=238) | ON (n=626) | QC (n=520) | ATL (n=235) | |
| Age | |||||||
|---|---|---|---|---|---|---|---|
| 18-34 years | 32% | 29% | 34% | 36% | 30% | 32% | 37% |
| 35-54 years | 63% | 65% | 61% | 60% | 64% | 63% | 58% |
| 55 years and older | 5% | 6% | 5% | 4% | 6% | 4% | 5% |
| Gender | |||||||
| Female | 62% | 59% | 76% | 66% | 64% | 52% | 70% |
| Male | 36% | 39% | 23% | 34% | 35% | 47% | 29% |
| Other | 2% | 2% | 1% | 0% | 2% | 2% | 1% |
| Education level | |||||||
| High school or less | 18% | 13% | 18% | 22% | 18% | 18% | 23% |
| College/trades | 25% | 18% | 27% | 27% | 23% | 25% | 31% |
| University / post-graduate | 57% | 69% | 54% | 51% | 60% | 58% | 46% |
| Size of community | |||||||
| A large city | 42% | 42% | 54% | 47% | 43% | 45% | 23% |
| A suburb near a large city | 33% | 37% | 26% | 18% | 39% | 40% | 21% |
| A small city or town | 16% | 14% | 16% | 24% | 13% | 10% | 34% |
| A rural area | 8% | 6% | 4% | 11% | 5% | 5% | 22% |
| Household size | |||||||
| 2024-01-02 | 17% | 18% | 16% | 13% | 19% | 16% | 20% |
| 2024-03-04 | 67% | 71% | 67% | 67% | 65% | 68% | 68% |
| 500% | 16% | 11% | 17% | 20% | 16% | 16% | 12% |
| Language spoken at home | |||||||
| English | 80% | 97% | 96% | 97% | 93% | 38% | 91% |
| French | 17% | 0% | 0% | 1% | 2% | 58% | 8% |
| Other | 3% | 3% | 4% | 2% | 5% | 3% | 1% |
| Immigration | |||||||
| Born in Canada | 72% | 60% | 66% | 79% | 64% | 78% | 86% |
| Born outside Canada | 28% | 40% | 34% | 21% | 36% | 22% | 14% |
| Ethnicity* | |||||||
| White | 59% | 47% | 57% | 63% | 49% | 69% | 72% |
| East/Southeast Asian | 13% | 24% | 18% | 9% | 17% | 8% | 3% |
| South Asian | 8% | 11% | 6% | 6% | 15% | 2% | 3% |
| Black | 6% | 1% | 4% | 4% | 8% | 6% | 6% |
| Indigenous (First Nations, Métis and/or Inuk/Inuit) | 5% | 5% | 5% | 10% | 4% | 2% | 7% |
| Middle Eastern/North African | 4% | 4% | 5% | 1% | 4% | 6% | 2% |
| Latin American | 3% | 3% | 4% | 3% | 4% | 2% | 1% |
| Prefer not to say | 3% | 2% | 1% | 4% | 3% | 2% | 5% |
| Other | 3% | 5% | 2% | 3% | 2% | 2% | 3% |
| Don’t know | 2% | 0% | 2% | 2% | 2% | 2% | 3% |
| Indigenous | 1% | 0% | 1% | 0% | 0% | 1% | 0% |
| Household income | |||||||
| Under $20,000 | 5% | 5% | 5% | 5% | 5% | 5% | 4% |
| $20,000 to just under $40,000 | 12% | 11% | 11% | 8% | 12% | 13% | 15% |
| $40,000 to just under $60,000 | 15% | 10% | 12% | 15% | 12% | 17% | 24% |
| $60,000 to just under $80,000 | 15% | 17% | 16% | 16% | 15% | 13% | 15% |
| $80,000 to just under $100,000 | 18% | 17% | 18% | 18% | 17% | 19% | 14% |
| $100,000 to just under $150,000 | 23% | 23% | 22% | 25% | 24% | 21% | 21% |
| $150,000 to just under $200,000 | 9% | 11% | 14% | 9% | 10% | 8% | 7% |
| $200,000 to just under $250,000 | 2% | 3% | 1% | 2% | 3% | 3% | 0% |
| $250,000 and above | 2% | 3% | 2% | 1% | 2% | 2% | 1% |
| Employment* | |||||||
| Full-time (]35 hours per week) | 64% | 64% | 53% | 68% | 63% | 70% | 57% |
| Unemployed | 16% | 13% | 25% | 13% | 15% | 13% | 20% |
| Part-time ([35 hours per week) | 10% | 14% | 14% | 8% | 10% | 7% | 9% |
| Self-employed | 6% | 7% | 5% | 5% | 6% | 6% | 4% |
| Leave of absence | 3% | 4% | 2% | 5% | 3% | 3% | 5% |
| Student | 2% | 3% | 1% | 2% | 2% | 3% | 4% |
| Retired | 1% | 0% | 1% | 0% | 1% | 2% | 3% |
| Prefer not to say | 1% | 1% | 1% | 2% | 1% | 1% | 2% |
| Other | 1% | 1% | 1% | 2% | 1% | 0% | 0% |
| * The employment question was given as multiple choice. Values may sum to greater than 100%. | |||||||
Parents/caregivers were shown the RCI schedule outlined by their province or territory. Parents were then asked if they had missed or delayed one or more vaccines for their child(ren) since the start of the pandemic in March 2020. If parents reported missing a vaccine, they were asked about their intentions to catch up. Parents were also asked whether they had encountered any barriers that limited their ability to vaccinate their child, as well as for input on programs or policies that might act as drivers, increasing ease of access to immunization.
The survey assessed parental vaccine-related knowledge, attitudes, beliefs, and behaviours related to their children, as well as potential pandemic-related impacts. Analysis was conducted based on the child’s age bracket*: 0-4 years (769 parents), 5-11 years (982 parents), or 12-17 years (864 parents).
*Some respondents have children in more than one age bracket and were thus counted more than once.
3. Selection of key findings
A significant proportion of parents report having missed or delayed RCIs since the COVID-19 pandemic began; Most have caught up or intend to.
A sizable group of parents/caregivers report having missed routine vaccines since the pandemic (Figure 1). Among those with children under 4 years, 25% reported missing or delaying a routine vaccine for their child since the pandemic began in March 2020. A meaningful proportion of parents with older children (between 5-11 years: 19%, and between 12-17 years: 23%) similarly reported missing or delaying a vaccine for their child since the pandemic began.
Among the 580 parents who missed a vaccine for their child, the majority intended to catch up as soon as possible (respondents with children under 4 years: 53%, between 5–11-years: 49%, between 12-17 years: 44%; Figure 2). A smaller proportion intended to catch up, but not within the next 30 days (parents with children under 4 years: 17%, between 5–11-years: 21%, between 12-17 years: 20%; Figure 2).
Figure 1. Reported missed childhood vaccines since March 2020, separated by age bracket.
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Figure - Text description
Table 1. Reported missed childhood vaccines since March 2020, separated by age bracket.
Figure 2. Reported intentions to catch-up on missed vaccines, separated by age bracket.
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Figure - Text description
Table 2. Reported intentions to catch-up on missed vaccines, separated by age bracket.
COVID-19 had a negative impact on routine childhood immunization
Parents reported a number of barriers to getting their child immunized. Many of the barriers reported had a sizeable influence on the likelihood of missing or delaying a vaccine. For example, among parents of 0-4 year olds, those who report experiencing difficulty making an appointment are over 3x as likely to have missed or delayed their child’s vaccine. Pandemic-related barriers like clinic closures were similarly impactful, increasing the odds of missing or delaying a child’s vaccine by 3.3x.
Respondents who intentionally delayed (n=247) or missed (n=173) a child’s routine vaccination cited COVID-19-related concerns among their selected reasons. These include the fear of contracting COVID-19 at the immunization appointment and/or concerns about routine vaccines interacting with the COVID-19 vaccine.
Though vaccine confidence was generally high among sampled respondents, there are some signs that this may be shifting. Vaccine confidence was measured using a scale derived from the 2019 childhood National Immunization Coverage Survey (cNICS 2019). While agreement with positive statements such as “In general, vaccines help to protect my child’s health” was high (90%), there was a marked increase in agreement with statements with a negative valence relative to pre-pandemic data. For example, 24% of parents agreed that “In general, the use of alternative practices, such as homeopathy or naturopathy, can eliminate the need for vaccination”, a rate of agreement that is more than twice what was observed by cNICS in 2019.
Experience with barriers to vaccination substantially decreases timely vaccination, even among the vaccine confident
Logistic regression was used to better understand the factors contributing to timely vaccination using the Capability, Opportunity, and Motivation framework for Behaviour (COM-B) as a guide for variable selection. Generally, cognitive factors such as vaccine confidence, taken here as a measure of Motivation, and self-reported understanding of how and where to find vaccines and vaccine-related information, taken as a measure of Capability were positively associated with timely vaccination. However, among parents reporting experience with one or more barriers to vaccination, a measure of Opportunity, the positive effects of Motivation and Capability were eliminated (Figure 3).
Figure 3. Predictors of timely vaccination among 0-4 year olds
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Figure - Text description
Table 3. Predictors of timely vaccination among 0-4 year olds
These findings suggest that intention to vaccinate and positive attitudes toward vaccination on their own are not sufficient to ensure timely vaccination. Rather, encountering barriers that limit the ease and convenience of access to vaccines can thwart the intention to vaccinate even among the positively disposed.
Parents and caregivers want increased ease, convenience, and access to RCI services to help catch up.
Parents were asked what would make their catch up easier. The top three potential drivers of immunization they identified were:
- Greater access to vaccine services, such as having RCIs available at their local pharmacy (selected by 34%)
- Improvements to healthcare services by being able to set up appointments on a convenient time and day (selected by 34%)
- Tracking and record-keeping support by receiving a reminder when their child is due for an immunization (selected by 34%).
These responses complement the top barriers to vaccination observed by parents, such as difficulty making appointments and uncertainty about which vaccines are needed (particularly among older children), highlighting the importance of facilitating access to vaccination.
4. Discussion
Throughout the COVID-19 pandemic, especially during its peak, the delivery of RCIs was disrupted, with 19-25% of parents reporting that their child(ren) missed or delayed a routine immunization. Though most Canadians have high vaccine confidence and intention to routinely vaccinate their children, this study found evidence suggesting that concern about RCIs has increased since March 2020. This heightened concern comes at a time when parents also report a number of barriers to accessing RCIs, some of which directly reflect stresses to the healthcare system since the onset of the pandemic. Respondents reported that more convenient access to RCIs, including their availability in pharmacies and schools, flexibility in making appointments, as well as text or email-based reminders would help them catch up on missed or delayed vaccines.
From a Behavioural Science perspective, this research points to the interaction between cognitive factors such as vaccine confidence and practical factors like the experience of barriers as being crucial in determining the risk of missing or delaying a child’s routine immunization. While work to improve confidence in the efficacy, safety, and importance of routine immunizations is an essential part of the effort to drive greater rates of vaccine uptake, even parents with high levels of vaccine confidence are at greater risk of missing their child’s appointment if faced with one or more barriers. The results of this study furnish an inventory of such barriers, along with a ‘wish list’ of potential drivers that could increase the ease of vaccination, pointing the way toward policy goals that could measurably contribute toward Canada’s vaccine coverage goals as we recover from the pandemic and into the future.
For Further Information
To learn more or connect about Impact Canada activities, please contact us at iiu-uii@pco-bcp.gc.ca
5. Related Resources
- Global public perceptions about the importance of vaccines for children since the COVID-19 pandemic: Results from the April 2023 UNICEF report.
- Vaccination coverage in Canadian children: Results from the 2019 and 2021 cNICS.
- COVID-19 pandemic fuels largest continued backslide in vaccinations in three decades: Results up to 2021 from WHO and UNICEF.
Library and Archives Canada Cataloguing in Publication
Effects of the COVID-19 Pandemic on Routine Childhood Immunizations
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Cette publication est également disponible en français : Effets de la pandémie de COVID-19 sur la vaccination systématique des enfants
ISBN:
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CP22-213/2024E-PDF