key: cord-0945920-ua6xkfjl authors: Williams, Simon N. title: “I don’t want my son to be part of a giant experiment”: Public attitudes towards COVID-19 vaccines in children date: 2022-01-24 journal: Public Health DOI: 10.1016/j.puhe.2022.01.016 sha: c2c852fd1b4446080a1da31540766b32b81f04e4 doc_id: 945920 cord_uid: ua6xkfjl Objectives This qualitative study explored public attitudes to COVID-19 vaccines in children, including reasons for support or opposition to them. Study design Qualitative study using online focus groups and interviews. Methods Group and individual online interviews were conducted with a diverse sample of 24 adults in the United Kingdom to explore their views on the issue of COVID-19 vaccination in children. Data were analysed using a framework approach. Results COVID-19 vaccination in children was framed as a complex problem (a “minefield”). Six themes emerged to explain participants views: (1) Uncertainty over whether children can catch, transmit or be severely harmed by COVID-19; (2) Lower risk tolerance for unknown longer-term effects of the vaccine in children; (3) Association of the vaccine program with government’s handling of the pandemic; (4) Local social norms as a driver of hesitancy; (5) Vaccinating children as a way to protect vulnerable adults; (6) Children’s vaccination as parental choice. Conclusions COVID-19 vaccination in children is perceived by members of the public as a complex issue, and many are torn or hesitant about the idea. Public health communications will need to combat this hesitancy if vaccine uptake for children is to be pursued as a public health policy. The question of whether to vaccinate children against coronavirus (COVID-19) remains a controversial issue globally, with no current consensus in the public health community. 1 Many public health opinion articles have tended to focus on mandatory vaccination in children, despite mandating being unlikely or even counter-productive 2 3 4 However, many of the arguments raised are also relevant for optional vaccination in children. Arguments that have been made in favour include: a potential contribution to overall population ('herd') immunity; preventing rare but severe disease in children; reducing transmission from children to adults; priming children's immune response to future (re-)infection; and helping to keep schools open. 2. Arguments made against tend to focus on the fact that children are significantly less prone to serious outcomes from COVID-19 and that it is necessary to obtain substantial safety data before widespread use amongst (non-clinically vulnerable) children. 3 The level of public acceptability of COVID-19 vaccines in children is a key criterion that determines eventual uptake. 5 Findings from public opinion surveys are mixed, with little consensus over the level of support for COVID-19 vaccinations in children. 6 7 8 Surveys have begun to explore reasons behind public attitudes to COVID-19 vaccines in children, with the most common reasons in support including to prevent the spread of COVID-19 or to prevent their children from catching COVID-19, and the most common reasons against include concerns over longterm side-effects and the belief that children are unlikely to get very ill from COVID- 19. 8 There is a dearth of qualitative research on public attitudes to COVID vaccines in children. However, qualitative research has explored hesitancy around vaccinations in children generally (i.e. not specifically related to have found that it is a complex decision affected by a range of factors including experiences, emotions, routine ways of thinking, information sources, peers/family, risk perceptions, and trust. 9 Also, research is starting to emerge on COVID-19 vaccine attitudes in adults -with views falling on a 'continuum of vaccine hesitancy', from full acceptance though to refusal. 10 . In a previous study, we found that decisions concerning COVID-19 adult vaccinations were influenced by a number of facilitators, including an emergent social norm around vaccination and the perceived 'need' for vaccines to end the pandemic, and barriers, including concerns over side effects and a preference for 'natural immunity'. 11 This paper explores the participants attitudes towards COVID-19 vaccination in children, including the reasons behind their views. J o u r n a l P r e -p r o o f Participants were recruited as part of the qualitative component of an ongoing, longitudinal mixed methods study exploring public views on the COVID-19 pandemic in the UK. More details about the methodology can be found in previous publications. 12 13 14 In this paper, we report on data from a rapid round of 4 focus groups and 3 one-to-one interviews with a total of 24 participants. The study was initially designed as a focus group study. However, the decision to include 3 individual interviews was made on pragmatic grounds (where participants were either the only ones to turn up to a given focus group or contacted the researcher after focus groups had been conducted expressing an interest to still take part). Data were collected between 1 st July -25 th July 2021. At the time in the UK, the Joint Committee on Vaccination and Immunisation (JCVI) released an official recommendation on 19 th July that COVID-19 vaccinations should be offered only to children aged 12 years and over with certain underlying health conditions, and not to all children aged 12-15. 15 This decision prompted much debate in the scientific community, given a number of countries, like the United States for example, had already approved the vaccine for general use in 12-15 year olds. 16 Participants were initially recruited to the full study from March-July 2020 and were all UK-based adults aged 18 years or older. Recruitment for the study took place via a combination of social media advertising and snowball recruitment (e.g. Facebook Ads, online free ads, Twitter). Purposive sampling was used to seek as diverse a range of ages, genders, race/ethnicities, UK locations, and social backgrounds as possible, although the limitations of the final sample are discussed below as well as in previous publications. 12 13 14 Full demographic summary details are provided in Table 1 . Data were analysed in accordance with a framework analysis approach. 17 . Analysis followed the five main stages of the Framework Approach: Data familiarisation (reading/rereading transcripts); identifying key themes or codes in initial transcripts; indexing (identifying consistencies and applying codes across transcripts); charting (drawing up a visual data matrix of themes across transcripts); and data mapping (interpretation of the themes matrix). 17 Analysis followed the Coding was performed using NVivo (version 11.4.3, Overall, the issue of COVID-19 vaccination in children was framed as a complex issue. Although there was a spectrum of views represented, few participants were unequivocally in favour of COVID-19 vaccination for children. Those with relatively few reservations tended to be non-parents who argued they had less 'stake' in the issue and that they would support vaccination in children only if it had been approved as safe. All parents (n=7) in our study expressed hesitancy and concerns, with one stating outright they did not agree with vaccinating children against COVID-19. However, most participants framed the issue as "tricky", "a grey area" or a "minefield": Those who were more opposed to vaccination in children were more likely to emphasise that COVID-19 was something that children were not at high risk of dying from or being "severely impacted biologically" (Participant 10, Male, 20s, non-parent, not vaccinated) or were even "prone to" (Participant 11, Female, 30s, parent, not vaccinated). They also emphasized that because children had "young" and healthy immune systems they were more able to fight the virus "naturally": J o u r n a l P r e -p r o o f When you are young natural immune system is really strong … and that if you take care of your lifestyle and eat healthy that should, for now be sufficient than actually going for this jab. (Participant 9, Male, 40+, non-parent, vaccinated) Some participants were inclined to be more favourable to the idea of vaccinating older children ("teenagers") because they felt they were more likely to transmit the disease compared to younger children ("they are out and about a bit more" (Participant 4, Male, 40+, non-parent, vaccinated)) and they thought there was "more evidence they spread the virus" (compared to younger children) (Participant 3, Male, 20s, non-parent, not vaccinated). Many participants were "apprehensive … that the risks of the vaccine are possibly higher than the risks of them if they were to have Covid" ( These social norms often related to the factors discussed above -uncertainty around COVID-19 in children ("hopefully they won't be too ill") and lower risk tolerance for unknown longer-term effects ("it's far too early"). Participants also felt that there was or would be a wider social norm around hesitancy or even opposition towards vaccination in children: One particular concern was over how a vaccination program would be implemented and whether it would be handled poorly as had been, in their view, the contact tracing and testing programmes in schools: If they [the government] were having to vaccinate children, they were planning to do some kind of rollout of testing in schools, but they couldn't even organise that. Other participants tended to frame vaccination as way of protecting transmission to the more vulnerable in society, including their grandparents, thereby implying that they felt that although children may not "suffer" from COVID-19, they can spread it nonetheless: I think it would be a good idea to vaccinate children. I know they say children don't suffer so much when they get the virus if they catch it, but then to me its who they interact with at the end of the day, so you know they are going to go home to their parents who then go to work for example, or they are going to see their grandparentsand so to me I would be better if it was rolled out to try and flatten it down as much as possible. (Participant 4, Male, 40+, non-parent, vaccinated). These participants were mostly non-parents who caveated their views by emphasising that they themselves were not parents, and as such stated or implied that they had less say (or stake) in the decision. Hesitancy around whether or not children should be vaccinated was often framed in terms of vaccination as an individual choicein this instance the choice of the individual parents. Those without children, often suggested they felt they were "not in a position to comment or judge" (Participant 1, Male, 30s, non-parent, vaccinated) and that "it's better to leave this decision to those who have children I think (Participant 19, Male, 20s, non-parent, vaccinated). Participants acknowledged that there was a lot of responsibility for parents in making the decision, implying that a "wrong" decision could be costly: It is quite concerning when it's your children you are responsible for their health and want the best for them -and you don't want to make the wrong decision for them. (Participant 5, Female, 20s, non-parent, vaccinated) One distinction that some participants made, was between the ability of older children ("teenagers") to be able to make more informed decisions for themselves, compared to younger children who were too young to understand the issue: It comes down to people's perception of like, you know, they are children and they can't make decisions and the parents have to make decisions on whether they want to or not, whereas teenagers actually can form their own decision (Participant 3, Male, 20s, non-parent, not vaccinated) This study found that participants framed COVID-19 vaccination in children as a complex issue, or "minefield". Although a spectrum of views was found, most participants tended to be uncertain or hesitant about the idea, concluding that there was no straightforward answer. This corresponds with broader research on vaccine attitudes, which suggests that hesitancy is a nuanced concept, and one which occurs on a spectrum (and that hesitancy should not be conflated with opposition or 'anti-vax' sentiment). 10 18. Findings also provide some context and nuance to existing surveys which, overall, suggest that there is a significant proportion of people, including parents, who remain uncertain as to whether children should be given a COVID-19 vaccine. 6 14 23 Fifthly, those who were more in favour, tended to emphasise the potential role of COVID-19 vaccines for children in reducing overall infection rates, possibly by bringing up population ('herd') immunity. In this sense, individual vaccinations were framed as a collective act -in line with a common justification of adult vaccination. 13 24 Conversely, many participants also framed children's vaccination as one of individual choice and responsibility. Non-parents tended to emphasise that the overall issue of whether vaccination should be made available for children was one that parents had a greater say or stake in. Parents tended to emphasise how difficult the issue was and how much responsibility they felt over the potential decision of whether or not they would have their child vaccinated. Thus, many may have a lower risk tolerance meaning that even those parents very accepting of vaccination in adults were more undecided or hesitant over whether vaccination in children was currently desirable. As with all qualitative studies, the generalizability of the findings is limited. Additionally, due to the rapid nature of the call for participation from the participant pool, the sample size was smaller than in previous rounds of data collectionalthough the total sample was deemed sufficient for the purposes of the analysis. Also, due to the pragmatic decision to include a small number of interviews, saturation of themes may not have occurred here. A larger number of one-to-one interviews might have explored themes that did not emerge in the group setting (perhaps due to desirability or conformity bias). Future research plans to follow ongoing views on this topic, and more one-to-one interviews will be considered. There are a number of potential policy implications of this study. For example, many countries are yet to offer COVID-19 vaccines to children (including in the UK to all 5-11year old's). If high uptake amongst children is deemed by a country's public health policymakers to be important to contribute to a reduction of COVID-19 rates, or keep the virus 'under control' then it is important for the reasons for hesitancy to be better understood particularly amongst parents as key stakeholders. In order to improve uptake, public health authorities need to ensure clear public communication that emphasises: that vaccines have strong scientific evidence to suggest they are safe and effective in children (as demonstrated by a growing number of global childhood vaccinations) and that vaccines are developed by J o u r n a l P r e -p r o o f scientific and medical research (i.e. should not be seen as 'political'). Also, uptake might be improved by emphasizing the collective benefits that vaccination can have (even where the vaccinated person-e.g. most childrenis at relatively low individual risk of serious outcomes). The value of emphasizing the collective, 'greater good' in COVID-19 policies have been found elsewhere, e.g. contact tracing and isolation. 13 . Finally, it is important for public health to recognize that not all members of the public, including parents, are supportive of COVID-19 vaccinations in children, and recognizing it as an act that is of collective significance (e.g. to help 'protect vulnerable adults') but which is fundamentally seen as a 'personal choice' ; as research on attitudes towards adult vaccinations have shown, any measures or messages that are perceived to be to strong or are perceived to infringe too greatly on individual choice could ultimately prove counter-productive. 25 It is important to note that the science of COVID-19 vacines is rapidly evolving, 1 and public attitudes are doing so with them -Social norms around vaccination in children is variable across countries and over time, and that additional research will be needed to explore any future attitudinal changes. Should children get COVID vaccines? What the science says Considering Mandatory Vaccination of Children for COVID-19 Herd immunity and vaccination of children for COVID-19 Mandating COVID-19 Vaccines Should We Mandate a COVID-19 Vaccine for Children? 3 in 4 Britons support offering children the vaccine By 53% to 18%, parents with underage children say they would get them vaccinated against COVID-19 COVID-19 Schools Infection Survey: England, Round 5 Underlying factors impacting vaccine hesitancy in high income countries: a review of qualitative studies The COVID-19 vaccines rush: participatory community engagement matters more than ever Public attitudes to COVID-19 vaccines: A qualitative study Public perceptions and experiences of social distancing and social isolation during the COVID-19 pandemic: a UK-based focus group study Public attitudes towards COVID-19 contact tracing apps: A UK-based focus group study Public perceptions of non-adherence to COVID-19 measures by self and others in the United Kingdom JCVI statement on COVID-19 vaccination of children and young people aged 12 to 17 years: 15 US authorizes Pfizer coronavirus vaccine for children ages 12 to 15. The Guardian 10 th Using the framework method for the analysis of qualitative data in multi-disciplinary health research Report of the SAGE working group on vaccine hesitancy Resistance of children to Covid-19. How? Risk as Analysis and Risk as Feelings: Some Thoughts about Affect, Reason, Risk, and Rationality Social norms and vaccine uptake: College students vaccination intentions, attitudes, and estimated peer norms and comparisons with influenza vaccine Predictors of self-reported adherence to COVID-19 guidelines. A longitudinal observational study of 51,600 UK adults Doing it for us: Community identification predicts willingness to receive a COVID-19 vaccination via perceived sense of duty to the community The potential impact of vaccine passports on inclination to accept COVID-19 vaccinations in the United Kingdom: Evidence from a large cross-sectional survey and modeling study The author is grateful to the participants of the study as well as to Dr Kimberly Dienes, Dr Tova Tampe and Professor Christopher Armitage for their conversations and contributions to the wider research on public attitudes towards COVID-19 policies.