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Only 1 in 2 young people (aged 9 - 18) said they would have an approved COVID-19 vaccine. A study found that the younger they were, the less likely they were to accept the vaccine.

Vaccination against COVID-19 reduces the chance of being admitted to hospital and decreases the chance of dying from the infection. It has been a key part of the UK’s COVID policy. Most adults have now been vaccinated, and younger people are being offered the vaccine.

Some adults (around 4%) have been reluctant to receive a vaccine. Researchers asked children and adolescents how they felt about having the vaccine. They then asked a further 250 questions, covering the young people's physical and mental health, whether they had previously had COVID-19, loneliness, social connections, and other issues.

Half of the group (50%) said they would have the vaccine if it was offered to them. Around 1 in 3 (37%) were undecided, and around 1 in 10 (13%) said they would not have the vaccine. The researchers found hesitancy to be higher among the youngest children (aged 9 - 15).

To address the young people's concerns, the researchers are exploring how best to use social media to spread accurate information. Materials for children and teenagers based on this research, are available on Tik Tok, Twitter, Youtube and Instagram. The team is also looking at the impact of translating information into different languages.

They hope targeting information for this age group will allay fears about getting vaccinated.

What’s the issue?

Vaccines against COVID-19 have been a huge advance in reducing the impact of the pandemic. However, a small proportion of adults (around 4%) remain hesitant about being vaccinated. Their views are likely to influence their children. Younger age groups can also become unwell when infected, and can spread the virus to older family members.

Many countries (including the USA, Israel and the UK) are offering vaccination to young children and adolescents. Studies to date have focussed mainly on parents’ opinions. Few have so far looked at vaccine hesitancy in children and young people.

Researchers therefore explored how many children and adolescents are unwilling to have the vaccine. They say that understanding barriers to vaccination will mean information can be better designed and targeted.

What’s new?

A survey was sent to 180 schools in 4 counties across England. In all, 27,910 children aged 9 - 18 years completed it. The survey asked whether the young people would accept a COVID-19 vaccine if offered to them. This was one in more than 250 questions on factors associated with mental health and wellbeing. It covered gender, physical health, previous suspected or confirmed COVID-19 infection, mental health, loneliness, social connections and other issues.

The researchers grouped responses according to the young people’s attitudes to vaccination.

  • Opt-in (eager and willing to have the vaccine): 1 in 2 (50%) said they would have the vaccine. Those with higher anxiety and depression scores were more likely to be in this group. Younger children (9 - 12 years) were less likely than those aged 17+ to opt-in.
  • Undecided (do not know or not bothered): More than one in three (37%) were undecided. Children whose parents were both born outside the UK were more likely than others to be undecided about, but not against, having the vaccine.
  • Opt-out (unwilling or anti-vaccination): Just over 1 in 10 would not have the vaccine. Those giving the most extreme opt-out answers had more markers of social marginalisation (for instance, feeling they do not belong at their school). These young people were more likely to be bullied and had slightly higher levels of paranoia.

Students in the ‘undecided’ and ‘opt-out’ groups students had similar profiles. Compared with students who were grouped as opt-in for vaccination, they:

  • were more likely to attend a school in a more deprived area
  • were less socially connected (for instance, not identifying with their school community), but spent longer on social media
  • showed less healthy behaviours (for instance, were more likely to smoke or vape, and did less exercise)
  • had lower levels of anxiety and depression.

The ‘opt-out’ group had more confirmed or probable previous COVID-19 infections than the ‘opt-in’ group. Students who were undecided had similar rates of previous infection to the ‘opt-in’ group.

Why is this important?

The research found that children and adolescents are more reluctant than adults to have the COVID-19 vaccine. The younger they were, the less likely to opt for vaccination.

The young people were more likely to be undecided about the vaccine than to opt out. Better and more targeted information could help reassure them that the vaccine is both safe and important.

People living in more deprived areas are more likely to have multiple long-term conditions. They are more likely to develop complications from COVID-19 and are therefore likely to benefit most from vaccination. More effort is needed to provide young people who live in deprived areas or feel marginalised with information from sources they trust.

Young people who thought they had had COVID-19 may not think they need the vaccine. This group was more hesitant than others. The researchers say messages need to make clear that the vaccine is still necessary after infection.

Children whose parents were not born in the UK tended to be more undecided. The researchers say translating information into different languages could help people whose first language is not English to make an informed decision.

A Young People’s Advisory Group helped the researchers to interpret the findings. The Advisory Group, made up of 17 - 25 year olds, said that if children did not feel they belonged at their school, then a school-based vaccination programme might not engage them. Other venues outside of school, such as shopping centres, might improve access. Children might feel less conspicious in front of critical peers outside of school.

What’s next?

Vaccinations are only given if the child or adolescent consents, even if parental consent is given. Adolescents increasingly take charge of their own healthcare, and should be empowered to make their own decisions. Materials based on this research are available on social media platforms that adolescents engage and identify with (such as Tik Tok, Twitter and Instagram). The researchers hope this will encourage children and adolescents to accept the COVID-19 vaccine.

The researchers did not collect data around ethnicity, for example, and therefore do not know how representative their sample is of the general population. Vaccine hesitancy may be greater in some ethnic groups than others. More work is needed to explore what sort of health information is most appropriate to help different ethnic groups come to informed decisions on vaccination.

You may be interested to read

This NIHR Alert is based on: Fazel M, and others. Willingness of children and adolescents to have a COVID-19 vaccination: Results of a large whole schools survey in England. EClinicalMedicine 2021;40:101144.

Materials for children and teenagers based on this research, on Tik Tok, Twitter, Youtube and Instagram.

Further research on vaccine hesitancy: Martin CA, and others. SARS-CoV-2 vaccine uptake in a multi-ethnic UK healthcare workforce: A cross-sectional study. PLoS Medicine 2021;18:11

A previous NIHR Alert on how to reduce vaccine hesitancy: Stressing the personal benefits of the COVID-19 vaccine could encourage more people to accept.

A paper discussing the use of young people’s advisory groups in health research: Sellars E, and others. Young people’s advisory groups in health research: scoping review and mapping of practices. Archives of Disease in Childhood 2020;106:698-704


Funding: This study was funded by the NIHR Applied Research Collaboration Oxford and Thames Valley, and the NIHR Oxford Health Biomedical Research Centre

Conflict of Interest: One author (Andrew Pollard) is chief investigator on clinical trials of Oxford University’s COVID-19 vaccine. Oxford University has entered a joint COVID-19 vaccine development partnership with Astra Zeneca.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.


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Commentaries

Study author

We have never in our lifetime known a public health emergency like COVID-19. As the pandemic has progressed, there has been increasing emphasis on younger people since many of them are now starting to get unwell. They are all now offered the vaccine, so we wanted to find out the extent of hesitancy in this group. Our survey included a number of factors that could be associated with it.

It is essential that we find ways to inform work with the student voice, especially on health matters. Our study called upon a Young People’s Advisory Group to help us interpret the findings. Their insight is helping us to think of ways we might improve vaccine uptake in younger age groups. They told us that young people find it difficult to find accurate information about the vaccine. They also said that concerns might not be specific to the COVID vaccine. They might be afraid of needles, for example, so we are also addressing these fears in resources for this age group.

Mina Fazel, Consultant in Children’s Psychological Medicine, Oxford University Hospitals

Researcher

In terms of public policy, areas of high deprivation continue to be an area of concern with regards to health messages. This paper should give healthcare professionals and commissioners a better indication of where to target vaccination programmes for seldom heard groups. We need joint and collaborative working between public health, the NHS, local authorities and communities to target resource and information.

The results were from England only. I would like to see similar studies undertaken in Scotland and other areas of the UK.

Janette Pow, Lecturer and Researcher, Edinburgh Napier University 

Member of the public

This paper is especially important for those in deprived and minority cohorts whose health is often compromised at the best of times.

Most research into COVID-19 in general, and long COVID in particular, has concentrated on adults. The authors acknowledge the difficulty of conducting a survey while education was disrupted by the pandemic. Importantly, they addressed the issue of parental consent, which is not relevant when considering adults who can consent.

I review grant funding applications for the NIHR, and this research reinforces my awareness of the concerns of children and the consequences of the pandemic for them.

Rodney Basford, Public Contributor, Aberdeen

Member of the public

I am a COVID-19 survivor and am keen to promote and support any measure which will lead to greater acknowledgement of the threat of COVID-19 to the wider population. Those responsible for forming vaccination strategy and publicity should know about this research.

Teachers and educators, and anyone working with adolescents and children, have a part to play in ensuring this group are informed. There should be a focus on delivering accurate information directly to schools and young people, with specific focus on those groups who reported being hesitant or undecided.

Nigel Simm, Public Contributor, Worcester

Researcher

Health and education bodies will need to engage with children and adolescents to explore their needs and develop appropriate resources. The research provides insight into the factors associated with vaccine hesitancy.

More than 1 in 2 primary schools participated but the study does not compare participating and non-participating schools. There are also limited data on adolescents in year 11 due to exam leave. However, the study has a good sample size recruited from 180 educational establishments in 10 local authority areas across 4 English counties.

Eleanor Curnow, Researcher, Queen Margaret University, Edinburgh 

Nurse 

As a children’s nurse, I see the great importance of national and global vaccination take-up.

Further research is needed as to what information marginalised and under-represented young people would find useful. Perhaps peer support, vaccination champions or a buddy system in schools and colleges would be useful challenging vaccine hesitancy in this age group.

Katie O’Connell-Binns, Children’s Nurse, West Yorkshire

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