Children can boost vaccination rates by educating their grandparents

In a recent study published in Nature Aging, researchers conducted a randomized clinical trial (RCT) to investigate whether a health education intervention offered to Chinese college students will increase severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) booster vaccinations among their grandparents.

Study: Influence of grandchildren on COVID-19 vaccination uptake among older adults in China: a parallel-group, cluster-randomized controlled trial. Image Credit: fizkes/


Coronavirus disease 2019 (COVID-19) has had a significant impact on older individuals, making them the highest risk group for hospitalization, ICU admission, and mortality. Vaccination is successful, although the Omicron variety has decreased, necessitating booster dosage recommendations.

Despite free vaccinations and public health advice, vaccine reluctance is widespread in China, particularly among elders. New measures are required to alleviate hesitation and promote booster vaccination.

Researchers link family members’ recommendations to higher vaccination rates, and college-aged grandchildren may encourage vaccination among family members. 

About the study

In the present study, researchers evaluated the effectiveness of providing SARS-CoV-2 booster vaccinations among grandparents aged ≥60 years using an educational intervention provided to their ≥ 16-year-old grandchildren in China.

The researchers recruited volunteers between September 1 and September 22, 2022. The RCT included college students in mainland China aged 16–35, with at least one eligible living grandparent aged ≥60 years who completed the first COVID-19 immunization series but did not receive a booster dose and were willing to persuade their grandparents to obtain booster vaccinations.

The researchers eliminated children whose grandparents had received a SARS-CoV-2 vaccine booster between the baseline evaluation and randomization.

The primary endpoint was the SARS-CoV-2 vaccine booster uptake rate among grandparents. Secondary study outcomes were grandparents’ attitudes and intentions to receive the booster dosage.

The researchers randomized 202 college attendees in a 1:1 ratio to receive the health educational intervention online with 14 daily SMS reminders (188 grandparents) or the control group comprising 187 grandparents. The students reported their grandparents’ vaccine booster status at study initiation and after three weeks.

The health education campaign, built using the knowledge, attitude, and practice (KAP) paradigm, addressed the epidemiology, policy, effectiveness, safety profile, indications, contraindications, and precautions for COVID-19 vaccinations among older individuals in China.

The program was provided to participants via interactive web pages, with questions to gauge their comprehension and interest.

The primary analyses were per-protocol (PP) and intention-to-treat (ITT), with models with robust standard errors.

The team conducted subgroup analyses to evaluate the intervention’s impacts stratified by the grandparents’ age, gender, domicile, education, past cohabitation with grandchildren, and comorbidities, and sensitivity analyses using generalized estimating equations (GEE).


The intervention group grandparents were more likely to receive the vaccine booster than controls [intervention, 31% (45/147); control, 17% (26/154); risk ratio (RR) of 2.0].

In the per-protocol analysis, grandparents’ attitudes toward receiving the booster dosage increased significantly among the intervention recipients’ grandparents (from 4.9 to 5.3, change = 0.4), and a slight rise was detected among those of the control group (from 5.0 to 5.1, change = 0.1).

The intervention group grandparents showed more statistically significant alterations in attitude ratings from baseline to follow-up than those of the controls. Grandparents from the intervention group showed a statistically significant increase in their intention to receive the booster vaccination (from 5.0 to 5.4, change = 0.4).

The control group grandparents only showed a minor increase (from 5.1 to 5.2, change = 0.1). Intention rating changes were also considerably higher among intervention group grandparents compared to those of controls.

The ITT analysis results were identical to those of the PP analysis, and sensitivity analyses produced results that were compatible with the PP and ITT analyses.

In a subgroup analysis by GEE modeling, the educational intervention program was more effective for grandparents 60 to 69 years old.

The intervention proved more successful for grandparents suffering from chronic conditions when applying GEE modeling to the per-protocol analysis. The effects of chronic diseases were not significant in the ITT analysis, as by robust standard error modeling.


The study findings showed that an educational intervention aimed at college students improved SARS-CoV-2 booster vaccine uptake among grandparents in China, particularly those aged between 60 and 69 years.

The findings indicate that governments may combat vaccine reluctance by mobilizing young individuals, particularly college students with better health literacy, to persuade older family members to receive the COVID-19 vaccine.

College students may use intergenerational connections to convince grandparents to approve vaccination, citing familial duties, similar values, strong personal relationships, and emotional connections.

The social control function of family members discourages risky behaviors. Further research with larger sample sizes and longer follow-ups is needed to validate the study findings.

Future studies could determine the effectiveness of fewer frequent reminders and investigate characteristics that increase or reduce the effectiveness of intergenerational messaging tactics.

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