Butler, Jorie M

Fagerlin, Angela

Levy, Andrea Gurmankin

Scherer, Aaron M

Scherer, Laura D

Shoemaker, Holly

Thorpe, Alistair

English

UCL Discovery

Research Letter | Public HealthParental Nonadherence to Health Policy Recommendations for Preventionof COVID-19 Transmission Among ChildrenAndrea Gurmankin Levy, PhD, MBE; Alistair Thorpe, PhD; Laura D. Scherer, PhD; Aaron M. Scherer, PhD; Jorie M. Butler, PhD; Holly Shoemaker, MPH; Angela Fagerlin, PhDIntroductionPeople are not always honest about their medical information1 or adherent to medicalrecommendations,2 including the public health measures (PHMs) against COVID-19 (eg, notreporting symptoms, breaking quarantine).3 During the COVID-19 pandemic, parents experiencedgreater increases in stress compared with nonparents due to additional child-related PHMs (eg,school closings, quarantine rules for children).4 We examined the prevalence of misrepresentationsof and nonadherence to COVID-19–related PHMs by parents regarding their children (eg, breakingquarantine rules by sending their child to school so that the parent can work), their reasons, andassociations of individual characteristics with these behaviors.MethodsThis survey study recruited a national, nonprobability sample of US adults through Qualtrics for anonline survey about COVID-19 experiences (participation, 1811 of 2260 [80.1%]) from December 8 to23, 2021. The survey asked whether parents had ever engaged in 7 types of misrepresentation andnonadherence behaviors regarding COVID-19 PHMs for their children (Table 1) and reasons for thesebehaviors (Table 2). Additional methodological information is published elsewhere.3 The Universityof Utah Institutional Review Board deemed the study exempt and granted a waiver of informedconsent owing to no risk or minimal risk to participants. The study followed the AAPOR reportingguideline.The final sample consisted of 1733 US adults. The analyses included the 580 parent participants(33.5%) who had children younger than 18 years living with them during the pandemic. Race andethnicity data were collected because COVID-19 and public health measures disproportionatelyimpacted individuals from underserved populations. Descriptive statistics examined the prevalenceof and reasons for misrepresentation and nonadherence, and multiple logistic regression was usedto explore potential associated characteristics. Significance was set at 2-sided α = .05 with P values+ Supplemental contentAuthor affiliations and article information arelisted at the end of this article.Table 1. Frequency With Which Parents Engaged in Misrepresentation of and Nonadherenceto COVID-19 RecommendationsResponse No./total No. (%) [95% CI]MisrepresentationDid not mention that they thought or knew their child had COVID-19 tosomeone their child was with or about to be with in persona63/263 (24.0) [19.2-29.5]Said that their child was older than they actually were so the child couldget vaccinated56/578 (9.7) [7.5-12.4]Said that their child was vaccinated for COVID-19 when they were notb 47/464 (10.1) [7.7-13.2]Said that their child was not vaccinated when they werec 23/189 (12.2) [8.2-17.6]Said that their child did not have to quarantine even though theywere supposed tod52/318 (16.4) [12.7- 20.8]NonadherenceAvoided getting child tested when they thought their child mighthave COVID-19e44/227 (19.4) [14.8- 25.0]Allowed their child to break quarantine rulesd 67/318 (21.1) [16.9-25.9]a Among those who thought or knew their child hadCOVID-19.b Among those whose child was not vaccinated.c Among those whose child was vaccinated.d Among those whose child was told to quarantine.e Among those who thought their child might haveCOVID-19.Open Access. This is an open access article distributed under the terms of the CC-BY License.JAMA Network Open. 2023;6(3):e231587. doi:10.1001/jamanetworkopen.2023.1587 (Reprinted) March 6, 2023 1/5Downloaded From: https://jamanetwork.com/ on 03/16/2023Table2.ReasonsParticipantsIndicatedforMisrepresentationofandNonadherencetoCOVID-19RecommendationsReasonNo.(%)ofparentsExposureQuarantineVaccinationTestingDidnotmentionthattheythoughtorknewchildhadCOVID-19tosomeonechildwaswithorabouttobewithinperson(n=63)Saiddidnothavetoquarantineeventhoughweresupposedto(n=52)Brokequarantinerules(n=67)SaidchildwasolderthanactuallywassocouldgetCOVID-19vaccine(n=56)Saidvaccinatedwhennotvaccinated(n=47)Saidnotvaccinatedwhenvaccinated(n=23)AvoidedgettingtestedwhenthoughtmighthaveCOVID-19(n=44)IwantedtoexercisemyfreedomtodowhatIwantwithmychild33(52.4)19(36.5)32(47.8)37(66.1)31(66.0)NA22(50.0)Mychilddidnotfeelverysick30(47.6)20(38.5)28(41.8)NANANA15(34.1)Iwantedmychild’slifetofeel“normal”(ie,howtheyfeltbeforetheCOVID-19pandemicbegan)29(46.0)22(42.3)30(44.8)NA28(59.6)NANAIdidnotwanttomissaneventorotherfunactivitytostayhome28(44.4)18(34.6)21(31.3)NANANANAIcouldnotmissimportantnonworkresponsibilitiestostayhome(eg,getgroceries,careforlovedones)27(42.9)21(40.4)29(43.3)NANANANAIdidnotthinkmychildreallyhadCOVID-1927(42.9)22(42.3)28(41.8)NANANA14(31.8)Ididnotwantmychildtomissschooltostayhome27(42.9)19(36.5)20(29.9)NANANANAIwasfollowingguidancefromapublicfigurethatItrust(eg,politicians,scientists,peopleonthenews,celebrities)25(39.7)20(38.5)19(28.4)NA24(51.1)15(65.2)16(36.4)Ididnotwantsomeonetojudgeorthinkbadlyofmeormychild25(39.7)20(38.5)23(34.3)NA21(44.7)13(56.5)13(29.5)Ididnotwantmychildtomissaneventorfunactivitytostayhome25(39.7)21(40.4)22(32.8)NANANANAIdidnotwantmychildtomissimportantactivitiestostayhome(eg,music,sports,clubs)24(38.1)24(46.2)26(38.8)NANANANAIwasconfusedabouttherulesforquarantine23(36.5)13(25.0)16(23.9)NANANANAMychildwasboredorlonely22(34.9)16(30.8)24(35.8)NANANANAIcouldnotmissworktostayhome22(34.9)17(32.7)22(32.8)NANANANAIdidnotwantthemtobeangryatmeormychildforexposingthem22(34.9)25(48.1)NANANANANAIdidnotwantcertainpeopletoknow21(33.3)18(34.6)16(23.9)NA22(46.8)8(34.8)14(31.8)Itisnooneelse’sbusiness20(31.7)16(30.8)30(44.8)NA19(40.4)10(43.5)18(40.9)Ididnotthinkitmattered19(30.2)20(38.5)22(32.8)NA18(38.3)9(39.1)14(31.8)IdidnotthinkCOVID-19wasabigdeal18(28.6)20(38.5)14(20.9)NA15(31.9NA12(27.3)IdidnotthinkCOVID-19wasreal16(25.4)16(30.8)18(26.9)NA16(34.0)NA9(20.5)IwantedmychildvaccinatedtolowertheirriskofCOVID-19intimeforschoolorcampNANANA36(64.3)NANANAIwantedmychildvaccinatedtolowertheirriskofCOVID-19intimeforatriporavisitwithfamilyorfriendsNANANA32(57.1)NANANAIwantedmychildvaccinatedtolowertheirriskofCOVID-19ingeneralNANANA30(53.6)NANANAIwantedmychildvaccinatedtolowertheirriskofCOVID-19intimeforaneventoractivitythattheywereparticipatinginNANANA28(50.0)NANANAIwantedmychildtobeabletodosomethingwherebeingvaccinatedwasrequired(eg,aspecialevent,gettogetherwithfriendsorfamilywhowerevaccinated,etc)NANANANA28(59.6)NANA(continued)JAMA Network Open | Public Health Parental Nonadherence to Recommendations for COVID-19 Prevention Among ChildrenJAMA Network Open. 2023;6(3):e231587. doi:10.1001/jamanetworkopen.2023.1587 (Reprinted) March 6, 2023 2/5Downloaded From: https://jamanetwork.com/ on 03/16/2023Table2.ReasonsParticipantsIndicatedforMisrepresentationofandNonadherencetoCOVID-19Recommendations(continued)ReasonNo.(%)ofparentsExposureQuarantineVaccinationTestingDidnotmentionthattheythoughtorknewchildhadCOVID-19tosomeonechildwaswithorabouttobewithinperson(n=63)Saiddidnothavetoquarantineeventhoughweresupposedto(n=52)Brokequarantinerules(n=67)SaidchildwasolderthanactuallywassocouldgetCOVID-19vaccine(n=56)Saidvaccinatedwhennotvaccinated(n=47)Saidnotvaccinatedwhenvaccinated(n=23)AvoidedgettingtestedwhenthoughtmighthaveCOVID-19(n=44)IdidnotwanttohavetodealwiththeconsequencesofatestshowingthatmychildhadCOVID-19(eg,myfamilywouldhavetoquarantine,Iwouldhavetomisswork,mychildwouldmissschool,etc)NANANANANANA16(36.4)Mychildand/orIwereworrieditwouldhurtorbeuncomfortabletogettestedNANANANANANA24(54.5)IwantedtokeepCOVID-19rateslowinmyareasopublichealthmeasureswerenotputinplace(eg,closingschools,maskmandates)NANANANANANA15(34.1)Ididnotwantthegovernmenttohavemychild’spersonalinformationNANANANANANA14(31.8)IthoughtIcouldnotaffordthecostofgettingtestedNANANANANANA16(36.4)IdidnothavetimetogetmychildtestedNANANANANANA14(31.8)IdidnotknowhoworwheretogetmychildtestedNANANANANANA11(25.0)Abbreviation:NA,notapplicable.JAMA Network Open | Public Health Parental Nonadherence to Recommendations for COVID-19 Prevention Among ChildrenJAMA Network Open. 2023;6(3):e231587. doi:10.1001/jamanetworkopen.2023.1587 (Reprinted) March 6, 2023 3/5Downloaded From: https://jamanetwork.com/ on 03/16/2023adjusted using Holm-Bonferroni correction. Analyses were performed using R Studio, version1.4.1106 (R Program for Statistical Computing).ResultsAmong the 580 participants, the mean (SD) age was 35.9 (8.8) years; 403 (70.2%) identified aswomen compared with 171 (29.5%) men and 6 (1.0%) other or missing. In terms of race and ethnicity,80 participants (13.8%) were Hispanic, 5 (0.9%) non-Hispanic American Indian or Alaskan Native, 14(2.4%) non-Hispanic Asian, 86 (14.8%) non-Hispanic Black, 389 (67.1%) non-Hispanic White, 5(0.9%) more than 1 race, and 1 (0.2%) White with no ethnicity specified.One hundred fifty participants (25.9%) reported misrepresentation and/or nonadherence in atleast 1 of 7 behaviors; the most common behaviors were not telling someone who was with theirchild that they thought or knew their child had COVID-19 (63 of 263 [24.0%]) and allowing their childto break quarantine rules (67 of 318 [21.1%]) (Table 1). The most common reason was wanting toexercise personal freedom as a parent. Additional reasons included wanting their child’s life to feelnormal and not being able to miss work or other responsibilities to stay home (Table 2). In anexploratory multiple logistic regression, no characteristics (eg, education, religiosity) were associatedwith misrepresentation or nonadherence.DiscussionIn this survey study of US parents, one-quarter engaged in misrepresentation or nonadherenceregarding PHMs for their children. The most common reason was to preserve parental autonomy.Additional reasons included wanting to resume a normal life for their child and the inability to misswork or other responsibilities, among other reasons.These results suggest that some PHMs implemented to limit the spread of COVID-19 may havebeen compromised due to misrepresentation and nonadherence by parents on behalf of theirchildren, contributing to COVID-19–related morbidity and mortality. In addition, some childrenappear to have received a vaccine that was not fully tested and approved in their age group.Study limitations include the nonprobability sample, the exploratory nature of the regressionmodel, and the possibility that social desirability motivated underreporting, potentially resulting inan underestimate of the prevalence of misrepresentation and nonadherence. Nevertheless, ourfindings suggest a serious public health challenge in the immediate context of the COVID-19pandemic, including future waves affecting weary parents, as well as future infectious diseaseoutbreaks. Further work is needed to identify groups at highest risk of misrepresentation andnonadherence, to address parents’ concerns that were identified as reasons for these behaviors (eg,desire for autonomy), and to implement better support mechanisms for parents (eg, paid sick leavefor family illness) during such crises so that misrepresentation and nonadherence feel less necessary.ARTICLE INFORMATIONAccepted for Publication: January 19, 2023.Published: March 6, 2023. doi:10.1001/jamanetworkopen.2023.1587Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2023 Levy AGet al. JAMA Network Open.Corresponding Author: Andrea Gurmankin Levy, PhD, MBE, Department of Social Science, Middlesex CommunityCollege, 100 Training Hill Rd, Middletown, CT 06457 (alevy@mxcc.edu).Author Affiliations: Department of Social Science, Middlesex Community College, Middletown, Connecticut(Levy); Department of Population Health Sciences, University of Utah Spencer Fox Eccles School of Medicine, SaltLake City (Thorpe, Shoemaker, Fagerlin); currently affiliated with Department of Applied Health Research,JAMA Network Open | Public Health Parental Nonadherence to Recommendations for COVID-19 Prevention Among ChildrenJAMA Network Open. 2023;6(3):e231587. doi:10.1001/jamanetworkopen.2023.1587 (Reprinted) March 6, 2023 4/5Downloaded From: https://jamanetwork.com/ on 03/16/2023University College London, London, United Kingdom (Thorpe); Division of Cardiology, University of ColoradoSchool of Medicine, Aurora (L. D. Scherer); Veterans Affairs (VA) Denver Center for Innovation, Denver, Colorado(L. D. Scherer); Department of Internal Medicine, University of Iowa School of Medicine, Iowa City (A. M. Scherer);Division of Geriatrics, Departments of Biomedical Informatics and Internal Medicine, University of Utah SpencerFox Eccles School of Medicine, Salt Lake City (Butler); Salt Lake City VA Informatics Decision-Enhancement andAnalytic Sciences (IDEAS) Center for Innovation, Salt Lake City, Utah (Butler, Shoemaker, Fagerlin); GeriatricsResearch, Education, and Clinical Center, VA Salt Lake City Health Care System, Salt Lake City, Utah (Butler).Author Contributions: Drs Levy and Thorpe had full access to all of the data in the study and take responsibility forthe integrity of the data and the accuracy of the data analysis. Drs Levy and Thorpe served as co–first authors.Concept and design: All authors.Acquisition, analysis, or interpretation of data: Levy, Thorpe, L. D. Scherer, A. M. Scherer, Fagerlin.Drafting of the manuscript: Levy, Thorpe.Critical revision of the manuscript for important intellectual content: All authors.Statistical analysis: Levy, Thorpe.Obtained funding: Fagerlin.Administrative, technical, or material support: Butler, Shoemaker.Supervision: L. D. Scherer, Fagerlin.Conflict of Interest Disclosures: Dr L. D. Scherer reported receiving COVID-19–related grant funding from the USDepartment of Veterans Affairs Health Services Research and Development. Dr A. M. Scherer reported receivingCOVID-19–related grant funding from the National Institute on Aging. Dr. Butler reported receiving COVID-19–related grant funding from the US Department of Veterans Affairs Health Services Research and Development. Dr.Fagerlin reported receiving COVID-19–related grant funding from the US Department of Veterans Affairs HealthServices Research and Development. No other disclosures were reported.Funding/Support: This work was funded by a Jon M. Huntsman Presidential Endowed Chair (Dr Fagerlin) andgrant 51300302 from the American Heart Association Children’s Strategically Focused Research Networkfellowship (Dr Thorpe; awarded to Dr Fagerlin).Role of the Funder/Sponsor: The sponsors had no role in the design and conduct of the study; collection,management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; anddecision to submit the manuscript for publication.Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect the positionor policy of the Department of Veterans Affairs, the NIH, the CDC, or the United States government.Data Sharing Statement: See the Supplement.Additional Contributions: Frank Drews, PhD, University of Utah College of Social and Behavioral Science, VanessaStevens, PhD, Salt Lake City Veterans Affairs Informatics Decision-Enhancement and Analytic Sciences Center forInnovation, and Nicole Burpo, MPH, MS, American Heart Association, assisted with this study. They were notcompensated for this contribution.REFERENCES1. Levy AG, Scherer AM, Zikmund-Fisher BJ, Larkin K, Barnes GD, Fagerlin A. Assessment of patientnon-disclosures to clinicians of experiencing imminent threats. JAMA Netw Open. 2019;2(8):e199277. doi:10.1001/jamanetworkopen.2019.92772. Cheen MHH, Tan YZ, Oh LF, Wee HL, Thumboo J. Prevalence of and factors associated with primary medicationnon-adherence in chronic disease: a systematic review and meta-analysis. Int J Clin Pract. 2019;73(6):e13350. doi:10.1111/ijcp.133503. Levy AG, Thorpe A, Scherer LD, et al. Misrepresentation and nonadherence regarding COVID-19 public healthmeasures. JAMA Netw Open. 2022;5(10):e2235837. doi:10.1001/jamanetworkopen.2022.358374. American Psychological Association. Stress in America 2020: stress in the time of COVID-19, volume one. May2020. Accessed May 16, 2022. https://www.apa.org/news/press/releases/stress/2020/reportSUPPLEMENT.Data Sharing StatementJAMA Network Open | Public Health Parental Nonadherence to Recommendations for COVID-19 Prevention Among ChildrenJAMA Network Open. 2023;6(3):e231587. doi:10.1001/jamanetworkopen.2023.1587 (Reprinted) March 6, 2023 5/5Downloaded From: https://jamanetwork.com/ on 03/16/2023

Parental Nonadherence to Health Policy Recommendations for Prevention of COVID-19 Transmission Among Children

https://discovery.ucl.ac.uk/10166705/1/levy_2023_ld_230010_1677090466.8524.pdf

Parental Nonadherence to Health Policy Recommendations for Prevention of COVID-19 Transmission Among Children

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