Parents’ Decisions to Vaccinate Children against COVID-19: A Scoping Review

Since 2019, the COVID-19 pandemic has resulted in sickness, hospitalizations, and deaths of the old and young and impacted global social and economy activities. Vaccination is one of the most important and efficient ways to protect against the COVID-19 virus. In a review of the literature on parents’ decisions to vaccinate their children, we found that widespread vaccination was hampered by vaccine hesitancy, especially for children who play an important role in the coronavirus transmission in both family and school. To analyze parent vaccination decision-making for children, our review of the literature on parent attitudes to vaccinating children, identified the objective and subjective influencing factors in their vaccination decision. We found that the median rate of parents vaccinating their children against COVID-19 was 59.3% (IQR 48.60~73.90%). The factors influencing parents’ attitudes towards child vaccination were heterogeneous, reflecting country-specific factors, but also displaying some similar trends across countries, such as the education level of parents. The leading reason in the child vaccination decision was to protect children, family and others; and the fear of side effects and safety was the most important reason in not vaccinating children. Our study informs government and health officials about appropriate vaccination policies and measures to improve the vaccination rate of children and makes specific recommendations on enhancing child vaccinate rates.


Introduction
In September 2021, the World Health Organization (WHO) [1] reported 230 million COVID-19 cases and 4.7 million COVID-19 deaths globally. In the USA, children made up 15.5% of all infected people by September 2021 and after declining in the early summer of 2021, child COVID-19 infections increased exponentially, accounting for 28.9% of all weekly reported new COVID-19 cases. Considering that children make up 22.2 percent of the US population, there are more newly infected children than people of other ages [2]. One side effect of Covid-19 has been pressure on routine healthcare, especially on childhood 1.
What were parents' attitudes towards having their children vaccinated against COVID-19? 2.
What factors and reasons influenced parents' willingness to make the vaccination decision?

Search Strategy and Data Source
The PubMed, Embase, Web of Science and Cochrane Central electronic databases were searched in July 2021 to find all potentially relevant articles without restrictions. The search strategy is described in Table 1. In brief, the keywords used were: COVID-19 and its' synonyms, vaccin*, immunization, child* or parents, hesitancy and its' synonyms or antonyms, published from 2019 to 2021.

Inclusion and Exclusion Criteria
The inclusion criteria were based on participant, outcome, and study design. The eligibility criteria of the participant was defined as adults older than 16 years and the outcome must include the attitude to COVID-19 vaccines for children. The origin studies were limited to English language articles published between December 2019 and 25 July 2021. We excluded: duplicate records, non-original research, studies with unrelated topics, and undefined outcomes.

Data Extraction and Quality Assessment
The initial literature scanning was independently conducted by two authors, based on the article titles and abstracts. All the studies meeting the requirements were exported to Excel, ensuring the removal of any duplicates. Next, each author was given a specific number of articles to read the full text to verify the inclusion decision. In this process, we designed a chart to organize all details including the first author of the study, publication year, sample size, the type of participants, the age of participants, the sex of participants, study design, sampling method, study setting, country of participants, the rate of parents' willingness to have their children vaccinated against COVID-19, the factors influencing the rate and the reasons for the vaccination decision. We combined the factors and reasons with similar meanings. During the study selection and evaluation process, the first author was responsible for resolving any differences and final evaluation.

Data Analysis
The factors that influence parents' attitudes towards COVID-19 vaccines for children were categorized and only those with p < 0.05 were included. Meta-analysis was not performed due to heterogeneity in the types of subjects in our review.

Results
In total, 1059 records were retrieved from the electronic database search (348 in PubMed, 302 in Embase, 378 in Web of science, 31 in Cochrane Library). There were 661 records left after removing the duplicates. After checking the titles and abstracts, 593 were excluded; the remaining 68 full-text articles were assessed for eligibility, and 35 studies were reserved for this review. In Figure 1, the PRISMA diagram describes the study selection and exclusion process.  Table 2 displays the 34 cross-sectional [35, and one experimental study [70]. Twenty-eight papers were published in 2021 and seven in 2020, with the majority focused on parents and two focused on general adults to estimate their attitudes towards children's vaccination against COVID-19 [42,58]. Sample size involved in studies range from 25 participants [61] to 17871 participants [44]. The participants were mainly 30-40 years old females, with two studies not clearly describing the age of the participants [35,42]. Most of the studies were conducted in one country, one study covered six countries [39], and two studies were global surveys [44,60]. Online surveys conducted through Facebook, Qualtrics, Google and similar platforms were the most common methods for data collection, resulting in non-probability samples. Stratified sampling was adopted by two studies [48,52], the snowball method in another two [60,61], and the remaining used random sampling. Offline data collection methods [39,47,48] and phone interviews [41,58,61] were undertaken by three studies each. Four studies contacted participants by email [43,49,50,56].

Parents Decision to Vaccinate the Children against COVID-19
Twenty-five studies reported a 10.4% to 92% willingness rate of parents to vaccinate the children against COVID-19, with an additional study not clearly reporting the willingness rate [65]. Among the 25 studies, rates were highly heterogeneous, and the median (unadjusted) rate was 59.3% (IQR 48.6~73.9%). As a reference, the median rate of parents' willingness to vaccinate themselves was 61.4% (IQR 50.3~78.9%). There are also eight results with limited conditions, and one qualitative interview study.
Overall, we found: Seven USA studies reported overall rates and three reported conditional rates. Seven USA studies reported the rates to vaccinate children ranging from 21.6% to 70.1% [42,43,46,50,63,64,66], four of which had a sample size of more than 1000 with the acceptance rate over 50%. A Gallup Panel web study reported a willingness to vaccinate acceptance of 48.6% [42]. Two papers, parents of patients at Cincinnati Children's Hospital Medical Center [46] and parents of Amish families [43], with low sample sizes and smaller populations (<500) reported low willingness to vaccinate rates of 21.6% and 24.3% respectively. In particular, a study of mothers with a mental health history [53] concluded that mothers with a post-traumatic stress disorder (PTSD) history were more reluctant to vaccinate than mothers without a PTSD history. One paper [70] found that regardless of the treatment children given, 19.7% of those parents did not plan to vaccinate their children. Kimberly et al. [61] qualitatively explored maternal willingness to accept a COVID-19 vaccine, finding a 16% willingness to vaccinate rate.
Four Chinese studies [48,[57][58][59] reported overall rates and one reported a conditional rate, with a willingness to vaccinate rate ranging from 44.5% to 85.3%. The lowest 44.5% willingness to vaccinate rate involved healthcare workers of five collaborative hospitals located in three Chinese provinces and the highest score, 85.3%, were among guardians who visited community health centers in the Xuhui District, Shanghai. Another Shanghai study [52] investigated acceptance at different effectiveness and safety profiles, with acceptance rates ranging from 31.3% to 87.5%.
Four Turkish studies reported overall rates and two reported conditional rates. Adopting non-probability sampling methods, four Turkish studies [37,51,54,68] reported the acceptance rates for children of 10.4%, 36.3%, 73.9% and 75%, with the highest rate focusing on pediatrics. In two studies with conditional vaccination willingness rates, Büşra et al. [41] found that the acceptance rate rose from 38.4% to 41.9% when the vaccine was free. Some parents preferred national vaccines (56.8%) over foreign vaccines (28.9%) [47].
Three Italian studies reported overall rates. Bologna residents showed a willingness to vaccinate rate of 60.4% [49], a study conducted in 20 regions in Italy showed a willingness to vaccinate rate of 91.1% [38], and the willingness to vaccinate of participants from Naples was particularly low-17.2% [69].
The following countries appeared only once in the collected studies: a Germany [55] study showed an acceptance rate of 51% for parents to vaccinate their children; a study in Calgary, Canada, in which all participants were women, had a willingness rate of 60.4% [56]; the willingness to vaccinate among physicians in Colombia was 85.7% [45]; and an online cross-sectional survey in England reported a willingness to vaccinate rate of 89.1% [40]. The acceptance reached 92%, when parents whose children had already received a campaign dose of MR vaccine at vaccination sites in Zambia [62]. Israel's researchers divided their subjects by occupation and found that the acceptance rate to vaccinate children was 70% for general population, 60% for doctors and 55% for nurses [35] and 46% participants from Qatar University stated they would not vaccinate their children [67].
Some studies were conducted in more than one country. A study conducted of caregivers in pediatric Emergency Departments (ED) across six countries had a willingness to vaccinate rate of 65.2% [39]. The snowball method was used for the study of Ruggiero et al. [60], which showed a population willingness to vaccinate rate of 49.5%, but did not mention the specific country of origin. Assuming the effectiveness of vaccines, a study conducted in 16 countries [44] among women aged 18 years or older, currently pregnant or with at least one child under 18 years of age, had a 69.2% willing to vaccine their children when efficacy was 90%.
Subjective factors in Table 4 were mostly related to personal positions and attitudes toward vaccines and the epidemic, including willingness to vaccinate family members against flu/other diseases [38,39,41,44,50,54,58], willingness to vaccinate themselves against COVID-19 [53,54,59], fear of COVID-19 infection [39,44,47,50,54], fear of a new outbreak/persistence of the epidemic [38,58,59], trust in vaccines [54,59,60,62], the source of information related to vaccines [49,54,59], support for COVID-19 policies [49,55], and participants' satisfaction with their society's environment [44,53]. These factors have appeared in more than two articles and were similar in the conclusions from univariable and multivariable analysis. The reviewed articles showed that individuals who were willing to vaccinate family members against flu/other diseases, willing to vaccinate themselves against COVID-19, had a fear of getting COVID-19 infected and fear of a new outbreak/persistence of the epidemic, trusted vaccines, supported COVID-19 policies and were satisfied with their society's environment were more likely to decide to COVID-19 vaccinate their children. In some studies, people who were exposed to information related to vaccines in the web/social media showed positive attitudes to child vaccination [54,59], while one study did not [49]. Some studies revealed study-specific factors. For example, Goldman et al. [39] argued that parents whose children were up-to-date on their vaccines were more willing to COVID-19 vaccinate their children; Yılmaz et al. [54] found that those who would recommend others to get vaccinated and those who believed that everyone should get vaccinated for herd immunity held more positive attitudes to vaccinating their children; and one study [55] argued that the characteristics of confidence in one's knowledge about safety measures and regular information seeking about the pandemic were related to child vaccination willingness. Factors like the concerns about the side effects of vaccines [59,60], and parental willingness to enroll children in COVID-19 vaccine clinical trials [38,54] reported opposite results tested by multivariable analysis, but factors such as the types of vaccines [47] and the regions [63] were only tested by univariable statistical analysis.    [39] Children that were up-to-date on their vaccines; If the child or the caregiver reported they were immunized against influenza in the last year; If the caregiver was more concerned about their child or themselves having COVID-19 when arriving to the ED Children that were up-to-date on their vaccines; If the child or the caregiver reported they were immunized against influenza in the last year; Caregiver concern that the child had COVID-19 P Büşra Akarsu [41] Who got seasonal flu vaccine Perceived risk of the virus/precautions P

Parents' Intention to Vaccinate Children against COVID-19
Among the 35 studies, 12 stated the reasons why parents were willing/unwilling to vaccinate their children against COVID-19. From the 12 studies, we summarized the reasons to vaccinate/not vaccinate and used the number of articles displaying a reason to calculate the frequency in Figure 2, where Figure 2a showed the frequency of reasons for acceptance and Figure 2b showed the frequency of reasons for rejection. From Figure 2a, to protect family/others/children was the most common reason for COVID-19 vaccination acceptance, which varied from 9.7% to 66.2% of respondents [39][40][41]53,54]. A significant number of respondents, ranging between 3% and 64.4%, were willing to vaccine their children when they perceived a high-risk environment and advice from others [39,40,49,54,63]. Trust in science and vaccines and the desire to return to a normal life were also identified in four articles [39][40][41]53], but the overall proportion of individuals who agreed to this view was only 14.6% at most. The advantages of vaccines, such as "vaccine can end the outbreak/cause less severe symptoms" and "benefits of vaccination outweigh risks" were widely reported [40,41,54], with one study finding 75.5% of the respondents giving this answer [54]. Other reasons reported for intention to vaccinate children were general vaccine acceptance [39] and increase of the number of children infected [54]. Some respondents indicated a willingness to vaccinate while still expressing concerns about the efficacy and safety of COVID-19 vaccines [39].

Discussion
Our systematic review of the existing literature on parents' decision-making on vaccinating their children identified the subjective and objective influencing factors in the vaccination decision to help health policy and government vaccination decision-making. We assessed 35 articles on parents' attitudes to vaccinating children against COVID-19. Overall, the median unadjusted parents' willingness rate to vaccinate children against COVID-19 was 59.3%, and the median willingness rate of parents to vaccinate themselves was 61.4%. Most of the literature showed that parents were more cautious about vaccinating their children [35,[40][41][42]47,[50][51][52]54,55,[57][58][59][67][68][69][70] than vaccinating themselves. In addition, due to the different medical system backgrounds and composition of studies in different countries, there is great heterogeneity among the willingness rates making direct comparisons difficult. Differences among respondents across regions reflected different COVID-19 policies and cultural backgrounds [71]. For example, 92% of Zambia parents tended to vaccinate their children [62], a cross-sectional study from Turkey showed an 20-85 year vaccination rate of only 10.4% [68], and only 24.3% of Amish families wanted to get their children vaccinated [43]. Overall, we recommend that diverse interventions should be taken to improve parents' willingness to vaccinate their children in different countries and areas considering the varied COVID-19 willingness rates and backgrounds.
The objective factors influencing parental attitudes, respondents' education level [41,42,44,47,49,50,[54][55][56]58,[63][64][65], sex [39,47,48,50,57,[63][64][65], age [39,44,49,50,54,55,65], and race [40,42,50,53] remained the most reported factors for parents' decisions to vaccinate their children against COVID-19 [71]. Respondents with lower education, who were female, of younger age or those who were in the BAME group were generally more cautious about COVID-19 vaccines for children than other groups. It could be explained by the fact that higher education, such as Master' s degree and post-graduate degrees, was associated with decreased vaccine risk perceptions [65] and better informed groups tended to be more caring about their health and well-being [72]. Parental experience was important, with women more hesitant than men in vaccinating generally [73]. As the primary caregiver of children in families, mothers should be the focus of COVID-19 vaccine promotion and BAME groups should also be a special vaccine education target group. By targeting these groups, public health campaigns can raise vaccination awareness to protect children and families. Since the fatality rate of young people was lower than that of the elderly [74], young people may have a lower risk perception of the epidemic, which highlights the importance for young parents to correctly understand the key role of themselves in the spread of the epidemic and family protection. The interpretation of race should be deliberative because the literature on this subject is sparse, although there is evidence that BAME groups and people living in the most deprived areas are at high risk of acquiring COVID-19 infection and at increased risk of death from COVID-19 [40]. It is important not to racially profile BAME groups, since emphasizing vaccine hesitancy risks taking a victim-blaming perspective on race [75]. Governments and medical institutions should make vaccines easily accessible to BAME groups, perhaps with local distribution points connected to religious, sporting and other community centers. One policy recommendation is to leverage trusted community leaders to engage communities of color in public health campaigns [76].
Parents with more children [40,44,54], who were unemployed [40] and those with lower income [35,40,44,48,50,54,56,64,65] and no insurance [41,44] have been reported to be more likely to refuse the vaccine, which might reflect financial distress. One constraint is vaccine accessibility, with only 3.1% of people in low-income countries having received at least one dose [77]. Akarsu [41] also found that the proportion of people willing to vaccinate their children increases when the vaccine was free. Therefore, to expand the vaccine coverage, policies need to address vaccine accessibility for the poor. Some studies suggest that parents tended to refuse vaccinations for children with chronic diseases [39,60] and those in younger age groups [39,49], that possibly reflects safety concerns. More research and information are required to address the issue of vaccine side effects in these groups [78]; before that, these children could strengthen physical protection measures and be protected in a safe environment by vaccinating people around them.
We found that the subjective factors influencing parental attitudes towards COVID-19 vaccines for children were mainly related to personal positions and attitudes towards vaccines and the epidemic of COVID-19. Parents who believed in vaccines [54,59,60,62], supported vaccination policies [49,55], and felt more satisfied with their society [44,53], showed a higher tendency to get their children vaccinated. These factors are related to people's attitude towards politics and science, which indicates the importance of people's trust and support for policies and society. A trusted government and social environment can play a positive role in the development of herd immunity [79,80]. One study [54] found that people who were willing to get their children vaccinated, also preferred to recommend others to get vaccinated. The numbers of parents who wished to see all members of society vaccinated for herd immunity were significantly higher among those who were willing to allow the COVID-19 vaccine to be given to their children. Therefore, parents with such characteristics could be marshalled to become community health service volunteers, provided with professional vaccine knowledge training, and engaged to play an important role in community vaccine publicity and education through active communication with residents.
People who feared to get infected by coronavirus [39,44,47,50,54], feared a new COVID-19 outbreak or were concerned about the persistence of the epidemic [38,58,59], showed a positive correlation towards vaccinating. This means that people who are more alert and concerned about the epidemic were more inclined to seek the protection of vaccine, which suggests increasing the vigilance of the population by releasing information about the development of the epidemic through official institutions might increase vaccine acceptance. Notably, some parents may refuse to vaccinate their children because they perceive that their children are not at risk for COVID-19 [39,40,47,53,54,64], and this idea might be one of the reasons for recent rising infection rates among children [2]. To raise parents' awareness, campaigns should provide more information about risks and hazards associated with children infected with COVID-19.
The role of social media is unclear. In some studies [54,59], those who obtained COVID-19 information through social media showed an active intention to vaccinate their children, while other studies [49] indicated social media active people were unwilling to have their children vaccinated, which highlights the complexity of the information dissemination. When people receive information about the benefits of vaccines, they will be more inclined to accept the vaccine, and if they receive more negative information about the vaccine, they would be less likely to get vaccinated, and this indirectly explains the contradictory role of the social media played. Unfortunately, we found a sentiment analysis [81] that concluded negative tweets populate pro-and anti-vaccine communities, thus confirming the popularity of negative sentiment on social media. At present, one of the greatest risks to human health comes from the deluge of misleading, conflicting, and manipulated information currently available online, including health misinformation. Vaccination is a topic particularly susceptible to online misinformation [82]. Information about vaccines on social media platforms should be more strictly supervised and managed to avoid the wide spread of false information and ensure that the public can receive authentic and effective COVID-19 related information [83]. The control of social media, and the exclusion of misleading information, raises issues of free access to information and freedom of the internet. The types of controls on vaccine and COVID-19 (mis)information will depend on the country-specific rules on information and social media access, making overall recommendations on social media difficult. The challenge is to use social media to provide accurate information on the benefits of vaccination, especially for children.
Some respondents were afraid to have their children vaccinated because of the side effects of the vaccine [59,60], which was also the top reason for rejecting the vaccine [39][40][41]44,47,53,54,61,64,67]. In addition to improving the quality of the vaccine itself, authorities should strengthen surveillance and management of COVID-19 vaccines and make the process transparent, and conduct further research on vaccine contraindications and adverse reactions. Increasing public confidence in COVID-19 vaccines and the need for vaccines may be an effective way to improve vaccination coverage. To promote the COVID-19 vaccine, concerted effort by healthcare workers is required [84]. An education campaign may be necessary for healthcare workers to improve their knowledge about the epidemic and COVID-19 vaccines, improve their ability to explain the effects of vaccines patiently and correctly, and enhance their responsibilities for monitoring the vaccination process. Healthcare workers are on the front line, so it is crucial that they are able to provide community health education on COVID-19 vaccination issues and interview parents with vaccine hesitation to increase child vaccination rates [85].
There are some parental vaccination decision-making reasons that occurred only in specific countries, such as doubt about the necessity of vaccines [41,47,54], fear that vaccines were biological weapons/contained microchips [41,47,54], and preferred other means to protect children [41,54]. For example, respondents from the USA. frequently mentioned that they were concerned about the COVID-19 vaccines being produced rapidly for political reasons [44,53,61]. These studies point to the need to tailor policy responses to the socio-political environment of each country. One recommendation is that countries with developed vaccination infrastructure for the child and adolescent could consider integrating COVID-19 vaccines into the existing routine immunization programs.

Strengths and Limitations
This paper is the first assessment of the extant global literature on parents' decisions to COVID-19 vaccinate their children. Our analysis reported the univariate and multivariate statistical results used in different studies by dividing the influencing factors into objective and subjective factors. Our review has some limitations. First, most of the included studies were cross-sectional studies, so the association between influencing factors and vaccination intention cannot be explained from the perspective of causality. Second, most of these studies were nonprobability-based sampling, which may lead to selection bias. Third, parents may have recall bias when filling in the questionnaire themselves, which may also affect the accuracy of the papers' results. Fourth, methodologically, due to the limitations of the volume and heterogeneity of published literature, there is no strict meta-analysis in our study.

Conclusions
We found that the median rate of parents willing to vaccinate their children was 59.3%. While vaccination intention rates were highly heterogeneous across countries, the factors influencing parents' attitudes towards children's vaccination were similar. Parents' education level was the most important factor, but sex, age, and household income were also key factors in the vaccination decision. Among all the reasons for vaccinating, or not, protecting children, family and others was the leading reason to vaccinate, and the fear of side effects and safety were the top reasons to not vaccinate. The most important policy recommendations are for healthcare workers and government to create an informed and transparent environment for the rollout of COVID-19 vaccines, to ensure the accuracy and timeliness of COVID-19-related information, and to carry out targeted publicity and education campaigns. These key policy directions can reinforce vaccine adherence and address vaccine hesitancy.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author.

Conflicts of Interest:
The authors declare no conflict of interest. Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.
2 Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

3
Information sources * 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed.
3 Search 8 Present the full electronic search strategy for at least 1 database, including any limits used, such that it could be repeated. 3 Selection of sources of evidence † 9 State the process for selecting sources of evidence (i.e., screening and eligibility) included in the scoping review. 3 Data charting process ‡ 10 Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators. 3

Data items 11
List and define all variables for which data were sought and any assumptions and simplifications made. 3 Critical appraisal of individual sources of evidence § 12 If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

Synthesis of results 13
Describe the methods of handling and summarizing the data that were charted.

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

4
Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations. 5 Critical appraisal within sources of evidence 16 If done, present data on critical appraisal of included sources of evidence (see item 12). NA

Results of individual sources of evidence 17
For each included source of evidence, present the relevant data that were charted that relate to the review questions and objectives.

7
Synthesis of results 18 Summarize and/or present the charting results as they relate to the review questions and objectives. 12

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

23
Limitations 20 Discuss the limitations of the scoping review process. 26

Conclusions 21
Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.
27 JBI = Joanna Briggs Institute; PRISMA-ScR = Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews. * Where sources of evidence (see second footnote) are compiled from, such as bibliographic databases, social media platforms, and Web sites. † A more inclusive/heterogeneous term used to account for the different types of evidence or data sources (e.g., quantitative and/or qualitative research, expert opinion, and policy documents) that may be eligible in a scoping review as opposed to only studies. This is not to be confused with information sources (see first footnote). ‡ The frameworks by Arksey and O'Malley (6), Levac and colleagues (7), and the JBI guidance (4,5) refer to the process of data extraction in a scoping review as data charting. § The process of systematically examining research evidence to assess its validity, results, and relevance before using it to inform a decision. This term is used for items 12 and 19 instead of "risk of bias" (which is more applicable to systematic reviews of interventions) to include and acknowledge the various sources of evidence that may be used in a scoping review (e.g., quantitative and/or qualitative research, expert opinion, and policy document).