key: cord-0681837-z1ib8uxw
authors: Gewirtz-Meydan, Ateret; Mitchell, Kim; Shlomo, Yaniv; Heller, Or; Greenstein, Michal Weiss
title: COVID-19 among youth in Israel: Correlates of decisions to vaccinate and reasons for refusal
date: 2021-11-24
journal: J Adolesc Health
DOI: 10.1016/j.jadohealth.2021.11.016
sha: 17d32ee02cb74acce1d0d6290d3afe80a953b0d6
doc_id: 681837
cord_uid: z1ib8uxw

PURPOSE: The primary aim of the present study is to examine the reasons for adolescents’ refusal to get vaccinated with the COVID-19 vaccine; and examine correlates of vaccination among adolescents aged 12-18 years in Israel. METHODS: A total of 150 youth aged 12-18 yeas participated in the study. Following parental consent (30% response rate) from an online internet Israeli participants’ pool, 150 youth completed the survey (50·5% response rate). Data was collected May through June 2021. RESULTS: Over half (64·0%) of youth in this study had received the COVID-19 vaccine (25·5% received one dose and 38·9% two doses). Of the youth who were not vaccinated the most common reasons cited for refusing the vaccine was not knowing enough about the harms that a vaccine has in the long run, not trusting the drug companies that the vaccine will be safe, believing the virus is not dangerous, and doubting the safety of the vaccine in the short term. Bivariate odds ratios indicate age (older) and having both parents vaccinated was related to increase the odds of the youth getting vaccinated. Higher distress over the effects of the vaccine was significantly related to lower odds of receiving the vaccine. Social media use was also related to a higher likelihood of being vaccinated at the bivariate level. CONCLUSIONS: Study findings provide specific ways in which peer-designed and peer-led public health programs may encourage youth to receive the COVID-19 vaccine in a manner that recognizes concerns of Israeli youth.

. While the vaccination rates (two doses) of [16] [17] [18] [19] year-olds are higher than the national average (60·96% for two doses), vaccination rates of [12] [13] [14] [15] year-olds are significantly lower than the national average, and likely contribute to lowering the national rates of vaccination [2] .

In an attempt to boost vaccination, Israel implemented incentives, including the "green pass" and exemption from quarantine [3] . When vaccines were made available to youth, the "green pass" incentive scheme, which grants access to social, cultural and sporting events for those fully vaccinated included youth and in middle and high schools as well. Following the approval of the third shot (booster shot) in Israel [4] , youth are required to have a Pfizer booster J o u r n a l P r e -p r o o f shot to be eligible for a "green pass." Currently, (6 October 2021), 26·7% of youth aged [16] [17] [18] [19] years received the booster shot [2] .

The primary aims of the present study are to is twofold: 1) to examine the reasons for adolescents' refusal to get vaccinated (with the Pfizer Inc.-BioNTech SE vaccine); and 2) examine demographic, technology use, and psychosocial (e.g., depressive symptomatology, subjective wellbeing, social support) correlates of vaccination among adolescents, aged 12-18 years, in Israel.

A total of 150 youth aged 12-18 years participated in the study. Youth were recruited from an early study conducted among 1,000 parents through Panel4All, an online internet Israeli participants' pool [5] . Parents who took part in the main study about the effects of COVID-19 on families in Israel, were approached and asked if they would provide consent to survey their children. Of the participants, 297 (29·7%) consented to approaching their children. Following the parent's consent, youth received an invitation to participate in a study about topical, emotional and social issues in their lives, provided their own assent, and received a small incentive (50 New Israeli Shekel which is equivalent to approximately 15 USD) for their participation. Out of 297 children we approached, 150 (50·5%) completed the survey. The survey took an average of 10 minutes to complete and was conducted from 6 July to 17 July. The child survey was anonymous and no data were collected that could identify participants. Youth were linked to their parents by an ID number. The [masked for review] institutional review board approved all procedures and instruments. Clicking on the link to the survey guided potential respondents to a page that provided information about the purpose of the study, the nature of the questions, and an J o u r n a l P r e -p r o o f assent form (stating that the survey was voluntary, respondents could stop at any time, and responses would be anonymous).

A total of 150 youth participated in the study. Of these, 55 were boys (37·2%) and 93 were girls (62·8%) and the mean age was 15·3 (SD = 1·9). The majority of youth came from an average (54·4%) or a high (16·8%) income family, with an average of 2·4 (SD = 1·6) siblings.

Youth in the study were mostly non-religious and lived across all parts of the country. The majority of youth (72·5%) reported their parents to be married.

Demographic variables included information about age, gender, income of the family, religiosity, and parents' marital status.

COVID-19 vaccination variables included the question on whether the adolescent was vaccinated (yes/ no), and if each of the parents or both were vaccinated (yes / no / don't know).

If the adolescent did not receive the COVID-19 vaccine, he or she were provided with a list of 11 reasons for refusal to get vaccinated against COVID-19. Youth were also provided with an option to enter some other response.

COVID-19 experience/fears variables included questions about exposure to other people being infected with the virus (yes/ no to friends/family outside home tested positive to COVID- 19) , the level of fear from another outbreak (on a scale from 1 to 10), and the level of distress about the effects of vaccine (on a scale from 1 to 10).

Subjective wellbeing was measured using seven items and assesses general life satisfaction [6] . Response options range from not true about me (1) to mostly true about me (4).

Reliability for the entire scale in the current study was good (α = 0·83). Items were combined to create a total scale score (range: 6-25, M = 20·8, SD = 3·6). Missing data was no more than 4% J o u r n a l P r e -p r o o f for each item and replaced with the item mean.

Depression/anxiety symptoms were measured using the Patient Health Questionnaire -4

Items (PHQ-4) [7] . This questionnaire includes four questions on depression/ anxiety symptoms.

The first two questions relate to the feeling of being depressed and lack of interest in doing things; the second two questions relate to feeling anger and anxiety. Answers to questions are rated as not at all (0), several days (1), more than half days (2) , and almost every day (3) [7] .

Reliability for the entire scale in the current study was good (α = 0·80). While depression and anxiety can be examined as two separate scales, in the current study items were combined to create a total scale score for depression/anxiety symptoms (range: 3-13, M = 6·0, SD = 2·3).

There was no missing data for these items.

Social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSS) [8] . The MSPSS consists of 12 items assessing participant's perceived social support from three groups: family, friends, and significant other. Youth in the study were asked to indicate how strongly they agreed with each statement on a scale from very strongly disagree (1) to very strongly agree (7) . Participant responses were averaged such that higher scores indicated higher perception of social support. Cronbach's alpha was excellent (α = 0·95). Items were combined to create a total scale score (range: 11-78, M = 61·6, SD = 13·9). Missing data was no more than 1·3% for each item and replaced with the item mean.

Health was assessed using the Self-Rated Health (SRH) single item to assess the youth's overall health. The responses range from poor (1) to excellent (5). A higher score reflects better health.

Technology usage variables included two questions: 1) the amount of time the child spend on social networks each day; and 2) the usage of social media Apps (yes /no), including J o u r n a l P r e -p r o o f

Chi-square cross-tabulations were conducted to examine participant demographic differences based on receipt of the COVID-19 vaccine. Then, descriptive statistics are provided to report on the experience of the participant (e.g., testing, results) and family during the pandemic, receipt of the vaccine, and fears around COVID-19. Next, among unvaccinated youth, we report on the decision-making around vaccination including who was involved in the decision and reasons for refusal. Finally, bivariate odds ratios were conducted to examine correlates of vaccination status. Variables significant at the .05 level or better were included in a final parsimonious logistic regression model.

Most youth (80·7%) had a coronavirus test and of those, 9·9% tested positive. Thirtyseven percent of youth were in isolation once since the pandemic has begun and another 28·9% were in isolation more than once. Nearly 7 in 10 youth (68·0%) said they had a close friend or family member outside of their household who tested positive for COVID-19; 16·7% knew one person, 26·0% knew 2-4 people, 15·3% knew 5-8 people, and 9·3% knew eight or more people.

Over half (64·0%) of youth in this study had received the COVID-19 vaccine (25·5% received one dose and 38·9% two doses), 8·1% had not received the vaccine but said they intended too, and 27·5% said they had not been vaccinated. Vaccination increased with age: 16·7% of youth ages 12-13 years were vaccinated, 20·8% of youth ages 14-15 years, and 62·5% of youth ages [16] [17] [18] . When asked about their parents' vaccinations, 82·0% said both parents were vaccinated, 11·3% one of their parents, 2·0% said no but they intended too, and 4·7% said neither parent had J o u r n a l P r e -p r o o f been vaccinated. No demographic differences were noted between vaccinated and nonvaccinated youth, except for agewith older youth being more likely to have received the vaccine.

Fears around the virus during the pandemic were moderate. When asked how often they feared that they were infected with COVID-19, the average response was 3·4 (SD = 1·2) on a scale of 1 (all the time) to 5 (never). This is in comparison to their fear that something bad would happen to themselves or their family as a result of coronary heart disease (M = 3·1, SD = 1·1).

Fear of another outbreak was also moderate with a mean of 5·5 (SD = 2·6) on a scale of 1 (not at all) to 10 (very much). No differences were noted for this response based on whether the participant had received the vaccine or not. Participants who had received the vaccine were significantly less distressed about its effects (M = 3·7 for vaccinated vs M = 6·3 for unvaccinated youth (p < ·001))

Youth reported on who was involved in the decision for their vaccination (or not) -17·8% said it was only their own decision, 65·7% reported it was both their and their parents' decision, and 16·4% said it was only their parents' decision. Vaccinated youth were significantly more likely than unvaccinated youth to say this was a joint decision (71·9% vs. 54·0%) whereas vaccinated youth were less likely (10·4%) than unvaccinated youth (28·0%) to say the decision was solely their parents [X 2 = 7·8, p=0·02]. Bivariate analyses revealed that older adolescents (M = 16·4 years) were more likely than younger adolescents to say that the decision to be vaccinated was all their own. The average age for participants who said the decision was both theirs and their parents was 15·2 years, and 14·4 years for those who said the decision was only their J o u r n a l P r e -p r o o f parents (p<0·001). When asked about the likelihood that their parents would get them vaccinated or offer to get them vaccinated, 12·2% said a great extent, 29·3% said somewhat, 36·6% said very little, and 21·9% said not at all. The most common reason cited for not being vaccinated was not knowing enough about the long-term harms of the vaccine ( Table 2) . Over half (56·1%) said they did not trust the drug companies to make sure that the vaccine will be safe, 53·7% said the virus was not dangerous, 51·2% did not believe in the safety of the vaccine in the short term, and 51·2% said they preferred not to put drugs or chemicals in their bodies.

Bivariate odds ratios indicate that for each increasing year of age there is a 1·5-fold increase in the odds (p < 0·001) of getting the vaccine (Table 3) . Having both parents vaccinated was related to a 7-fold increase in the odds (p<0·001) of the youth getting vaccinated. On the other hand, higher distress over the effects of the vaccine was significantly related to lower odds of receiving it (OR = 0·7, p < 0·001). Social media use was also related to a higher likelihood of being vaccinated at the bivariate level: the more time spent on social media networks the higher the odds of vaccination (OR = 1·3, p=0·02), and specifically, use of Facebook (OR = 3·1, p=0·004) and Instagram (OR = 2·8, p =0·02) were related to being vaccinated; other social media platforms like TikTok, Snapchat, YouTube and Twitter were not influential. When these bivariate characteristics were included into a parsimonious multivariate model, age (OR = 1·4, p =0·008) and having both parents vaccinated (OR = 10·8, p < 0·001) were positively related to the youth being vaccinated, while being distressed about the effects of the vaccine was negatively related (OR = 0·7, p < 0·001).

The goals of this study were to identify the reasons why youth in Israel do not get vaccinated and the correlates of those that do get the vaccine. Most youth in the study (64·0%) had received the COVID-19 vaccine (25·5% received one dose and 38·9% two doses) with vaccination more common among older versus younger participants. Expectedly, compared to other established vaccines in Israel, such as the Tdap (93·7% of youth vaccinated in this vaccine), the rate of the COVID-19 vaccine is relatively low [9] . Our findings have a robust mix of vaccine decisions made by youth. Findings on misinformation, parental encouragement, perceived danger of the virus, and other influencing variables can provide some insight into the reasons for and against vaccination among Israeli youth.

Youth who were not vaccinated at the time of the study indicated various reasons for their reluctance. The most common reason cited for not receiving the vaccine was not knowing enough about the long-term harms (82·9%) and the short-term harms (51·2%), and not believing the vaccine is effective (34·1%). These reasons correspond with the most common reasons for adults refusal for the vaccinethat the vaccine is seen as not safe [10] , and the long-term effects are unknown [11] . In a study conducted among 1,541 caregivers arriving with their children to 16 pediatric Emergency Departments (ED) across six countries, vaccine effectiveness was also important for the majority of parents (58·0%). [12] . Of those providing reasoning for not being vaccinated against COVID-19, 51·6% were concerned over the novelty of the vaccine (not enough testing), and 17·0% responded that they may vaccinate if more information became available [12] . In a study conducted among 911 youth in the United States, youth indicated they want to receive information on the vaccine and actively search for information on scientific websites (e.g., "CDC" and "WHO") [13] . Thus, providing more updated and reliable information on the vaccine may encourage more youth to receive it.

Importantly, among these unvaccinated youth, when asked how likely their parents are to get them vaccinated or encourage them to get vaccinated, over half (58·5%) said "very little" or "not at all." This finding may be explained by caregiver's concerns over the novelty of the vaccine, and corresponds with a previous study indicating 65% of caregivers reported that they intend to vaccinate their child against COVID-19 [12] . Moreover, overall, having both parents vaccinated significantly predicted vaccination. Clearly, for some youth, education around the vaccination needs to be inclusive of the parents as they are required to provide consent for their child's medical needs and decisions. Findings raise complex questions about parents' rights to make these medical decisions on behalf of their adolescent children and adolescents' ability to make informed choices about their own health.

Another main reason for not being vaccinated is the mistrust some youth have towards the drug companies (56·1%) and the government (41·5%). Trust in the safety and effectiveness of vaccines and the system through which they are delivered is a main factor in vaccine hesitancy [14] . Moreover, trust also includes believing healthcare professionals, health services, and policy makers that they have clean motives when they make decisions about vaccines [14] . Gurwitz [15] explains that the mistrust of Israelis to the vaccine started when the agreement between the Israel government and Pfizer was signed, in which Israel agreed to serve as a real-world testing ground for the vaccine in return for sharing with Pfizer the aggregated information on COVID-19 vaccination and infection rates. At the time of this manuscript, details of this agreement remain undiscloseda fact which has led to a lack of government transparency and mistrust.

Increasing transparency about the disease and the vaccine can enhance youth's trust in the vaccine [16] . Engaging youth in the fight against COVID-19 and developing vaccination J o u r n a l P r e -p r o o f educational strategies can also increase the likelihood of youth's commitment towards the vaccines [16] .

More than half of unvaccinated youth (53·7%) said that the coronavirus is not dangerous.

Previous research shows COVID-19 vaccine hesitancy increases when the vaccine does not deemed necessary to preventing the disease [14] , or when people do not believe they will be infected with COVID-19 [17] . Although it is true that, when compared with older adults, severe or fatal COVID-19 disease is much less common in infants, children, and young adults [18, 19] , the impact of the pandemic has had some devastating effects on children's physical and mental health. Youth are experiencing elevated symptoms of anxiety, depression, and posttraumatic stress disorder due to illness [20] [21] [22] . In terms of physical health, a variety of physical conditions may not be treated optimally, as a result of restricted access to health services [23] . Taken together, this has some clear implications for public health messages around this virus.

Vaccination in youth can help in achieving herd immunity and reduce outbreaks. Establishing clear messages is critical in order to stop the continued spread of the virus, as well as reminders about how increasing immunity to the virus will improve lives for children and youth directly, like being in school mask-free and a return to a more stable way of living and socializing. Even if youth do not believe coronavirus is dangerous to them, they need to understand that they can still spread the disease and vaccination means protecting othersfamily, friends, and the larger community, and this message should be included in the campaign strategies for vaccination.

Increasing the motivation for vaccination should not be based on intimidation because youth may not perceive the coronavirus as dangerous to them. The commitment and motivation for vaccination should be based on both protecting oneself and others, which are the main correlates for the willingness to get vaccinated among youth [13] .

J o u r n a l P r e -p r o o f unvaccinated youth indicated that they were unvaccinated because their friends were unvaccinated. Peer pressure and peer social norms have been found to be influential in changing adolescent behaviors like unhealthy weight-control behaviors [24] , distracted driving [25] , alcohol use [26] , and sexual behavior [27] , and would likely be effective for increasing COVID-19 vaccination uptake as well. As such, improving social norms around the COVID-19 vaccine among peers would likely support vaccination uptake (or support positive vaccine decisionmaking). Campaigns that include youth themselves in the messages may be usefulboth in terms of developing the messages that are meaningful to today's youth and as the distributors of those messages via social media. Given the widespread use of social media among Israeli youth, brief public education and awareness campaigns provided by youth may be beneficial. It should be noted that while we asked about peer pressure as one of the reasons for not vaccinating, given that the majority of the sample were vaccinated may imply that the pressure may be influencing them to vaccinate.

Indeed, time spent on social media networks was correlated with higher odds of vaccination, and specifically, use of Facebook and Instagram, at the bivariate level. This finding may be explained by higher exposure to COVID-19 related news, higher exposure of youth to vaccination campaigns, and more access to and communication with like-minded peers. This finding also corresponds with recent studies indicating that exposure to a greater number of traditional media sources and more hours spent on social media were associated with increased COVID-19 related distress [28] [29] [30] . Considering 42% of youth in Israel spend three or more hours on social media a day, social media can play a significant role in motivating youth to get vaccinated. Additionally, social media can be a platform to provide clear and relevant J o u r n a l P r e -p r o o f 14 information for younger audiences that can be harder to reach through traditional channels.

Partnership with social media influencers to empower and engage youth in the fight against COVID-19 can also be effective [16] . Social media is also a central channel in which misinformation (manipulations of facts and unproven scientific theories) circulates [16] , placing youth at the highest exposure to misinformation. Thus, efforts should be made to not only provide scientific and evidenced-based information on social media, but also increase youth's ability to detect misinformation.

It should be noted, that youth under the age of 18 in Israel need parental consent (parents can either accompany their child to get the vaccine or send a written consent form) to receive the COVID-19 vaccine. Thus, a "refusal" is not necessarily the child's decision, but can in fact be the parent who refuses to vaccinate the child. While the current study shows that in the majority of cases both youth and their parents are involved in this decision, in other cases (16·4%) the decision to vaccinate the child is only the parents' decision. Parents can also disagree about vaccinating the child. In a recent court decision the Haifa Family Court president, Judge Shelly Eisenberg, authorized a mother to vaccinate her two 15-year-old minors (with the COVID-19 vaccine) despite their father's objection [31] . With the requirement for parental consent at this age, educational efforts directed toward the parents may be of equal importance. Parental consent also raises some ethical questions over children who cannot receive the "green pass" because their parents refuse to vaccinate them.

In the current study, 37% of youth were in isolation once since the pandemic has begun and another 28·9% were in isolation more than once. A report on the isolation rates in Israel, suggests isolation rates are even higher for one isolationwith 52% of the children of Israel experiencing one isolation, and 17% experiencing more than one isolation in the 2020-2021 school year [32] . Due to the high prevalence of isolations in schools, it is possible exempt from isolation (according to the green-pass scheme) is a central motive for youth to get vaccinated.

While the different strategies to boost vaccination among youth in Israel are important and will minimize risks of COVID-19 infections, some strategies, such as the green-pass in schools also raise moral, ethical, and legal questions. Promoting public health in a time of a global pandemic often requires using measures that puts further specific human rights. However, controlling and limiting the spread of the pandemic would also diminish the need to choose between different rights. As for youth, for example, implementing the green-pass scheme in schools is important in minimizing COVID- 19 infections. Yet such this strategy will prevent unvaccinated children from fully fulfilling their right to education and will provide them with a less than ideal educational experience [33] . Although early findings have described the booster shot as safe and effective [4] , the government should also way whether the purpose of promoting vaccination among youth justifies the violation of the rights of non-vaccinated youth because their choiceor moreover their parents' choicenot to be vaccinated.

Findings should be interpreted in the context of certain limitations. Data were crosssectional, so causal or temporal interpretations cannot be made. Our work limitations also include the small number of youth participants, and only youth who received parental consent participated in the study, which can create a sampling bias. Furthermore, youth participating in the study were primarily Jewish, secular, and reported coming from average or high-income familieswhich may limit the generalizability of our findings. Future studies would benefit from examining correlates of decisions to vaccinate and reasons for refusal in a more diverse sample of youth that reflects the multiculturalism of Israel.

J o u r n a l P r e -p r o o f may be more pervasive in Israel, as Israel had a rapid rollout of the vaccines in comparison with other countries. Findings from this study suggest a variety of reasons why youth and families may be reluctant to get the COVID-19 vaccine, and, in turn, provide specific insights by which peer-designed and peer-led public health programs may encourage youth to receive the COVID-19 vaccine in a manner that recognizes Israeli youth's concerns. 

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