Reflections From School Communities in Underserved Populations on Childhood COVID-19 Vaccination

This study combines data from 4 independent research studies funded by the National Institutes of Health Rapid Acceleration of Diagnostics Underserved Populations (RADx-UP) Return to School Initiative. RADx-UP is a consortium of >135 research projects studying COVID-19 testing patterns in communities across the United States, its territories, and tribal nations. The RADx-UP projects aim to understand and reduce the disparities in COVID-19 morbidity and mortality for those disproportionately affected by COVID-19. A total of 16 research groups across the country are funded by the RADx-UP Return to School Diagnostic Testing Approaches program. These are independent research teams with individualized projects and goals specific to the underserved populations in their area; these teams are investigating how children can return to school safely in the era of COVID-19. Three of the research teams collected qualitative data from various community representatives (eg, parents, students, teachers, administrators) on perceptions, experiences, and recommendations regarding COVID-19 vaccines for children and adolescents. A fourth research team collected qualitative data from a school board of directors, staff (ie, professionals, paraprofessionals), and administrators participating in their COVID-19 Return to School Diagnostic Testing Approaches program and contributed their raw data related to COVID-19 vaccination for the purposes of this study. Each site spent between 1 and 4 months collecting data during the overall time frame of September 2021 to April 2022 (Table 1).

All research teams obtained institutional review board approval from their respective institutions, conducted their qualitative data collection independently, transcribed their recordings, and performed their own thematic analyses. Each site used their own semistructured interview to guide questions for focus groups and/or interviews. Two of the 4 interview guides started with broad or general questions such as, “I am curious what you think are communities’ concerns about COVID-19 at this time?” which may have elicited responses about vaccination. Each research team also included questions specific to vaccination such as, “What misperceptions, if any, do you think the community at your school has about the COVID-19 vaccine?”, “Have you gotten a booster?”, and “Are you aware of any specific thoughts or beliefs about the COVID-19 vaccine among students (eg, its development, efficiency, side effects)?” Some sites had questions tailored to participant type (eg, school staff versus students), whereas others used the same general prompts for all respondents. Table 1 provides a list and overview of each research team that contributed data to this study, including sample description, methods, and analytical approaches. Sample quotes for each theme are listed in Table 2.

Researchers from the 4 primary studies discussed the findings from their own qualitative analyses. Primary authors requested 3 sample quotes from each research team to identify initial commonalities and discrepancies. A list of potential themes was derived from these quotes and agreed upon by all research teams. The teams then provided all original thematic quotes for analyses; authors reviewed and synthesized the data. Additional themes were generated after this review; data were recoded, if necessary. Representatives from each research team reviewed the final codes to ensure they agreed with how the quotes were matched to specific themes.

The research team for site A conducted telephone interviews with 18 staff members from a public school that had 3 sites exclusively serving students (aged 3–21 years) with intellectual and developmental disabilities (n > 400). Located in upstate New York, students came from urban, suburban, and rural households. Staff included teachers, therapists (occupational and physical), teacher’s aides, and administrative support. Staff eligible for interviews had to be enrolled in their research study (weekly testing). E-mails requesting interview participation were sent to all of those identified as being intermittent participators in weekly testing (n = 39) and 50 randomly selected individuals with consistent testing. A $25 incentive was provided to those completing the interview, which lasted ∼10 minutes. Of those interviewed, all but 2 were female, 10 were professionals (teachers or therapists), 6 were paraprofessionals, and 2 were administrative support staff. Five were intermittent testers. All but 2 had been vaccinated. No additional demographic data were collected.

Site B collected data from school personnel, families, and children in 4 school districts in Yakima, Washington. Yakima is an agricultural community in eastern Washington state with 1 of the largest Latino populations; 52% of the population self-identifies as Hispanic or Latino. Recruitment e-mails for interviews were sent to the school personnel. Nineteen (10 administrators, 5 medical staff, and 4 teachers) participated in the interview, which lasted 45 to 60 minutes. Participants were compensated for their time with a $30 gift card. Parents were eligible if they had at least 1 child in kindergarten through eighth grade in 1 of the 4 school districts. A total of 4 focus groups (2 in English and 2 in Spanish) were conducted in the summer of 2021, composed of 26 individuals total. Participants were compensated for their time with a $30 gift card. Most participants were female (96%, n = 25), ranged in age from 40 to 49 years (mean age = 43.5), and identified as Hispanic or Latino (85%, n = 22). Approximately 42% spoke only Spanish (n = 11), 19% spoke only English (n = 5), and 49% were bilingual (n = 10). Annual household incomes ranged from <$15 000 to >$75 000, with the most frequent annual income being $35 000 to <$50 000 (26%, n = 6).

The research team for site C collected data at 20 schools (elementary, middle, and high) within the Kansas City Public School District. These schools are composed of primarily racial/ethnic minority students, and 100% of the student population are eligible for free and/or reduced lunch. The team conducted 30 interviews with parents, 20 with school nurses, 8 with teachers, and 7 with administrators. Additionally, a total of 6 focus groups were conducted with 13 elementary school students, 15 middle school students, and 16 high school students. This team did not collect demographic information. Interviews with parents were conducted in English or Spanish; participants were asked which language they preferred when they signed up for an interview. All other interviews and focus groups were conducted in English. Interviews with parents, school nurses, teachers, and administrators were conducted virtually using Microsoft Teams; focus groups were conducted in person. Parents received a $50 gift card; nurses, teachers, and administrators received a $100 gift card; and students received a $25 CVS gift card and promotional items (ie, water bottle, sidewalk chalk).

The research team for site D collected data at 2 high schools and 1 middle school in Miami-Dade, Florida (previously described by Kenworthy et al²⁰ ). These schools are composed of primarily racial/ethnic minority students, many being recent immigrants from Haiti, Central America, or South America. Approximately 90% of the student population is eligible for free or reduced lunch.²¹  Inclusion criteria were being a staff member, student (16 years or older), or the parent/caregiver of a student at 1 of the 3 target schools, as well as being able to speak, read, and write English, Spanish, or Haitian Creole at a minimum of fifth-grade level. A total of 7 focus groups were conducted in the fall of 2021, with 52 individuals participating. Most participants were school staff (n = 25), followed by parents/caregivers (n = 17). Nine students participated and 1 participant identified as both a school staff member and parent/caregiver. Focus groups were conducted in person and lasted ∼1 hour. Participants were given snacks and a $25 gift card for their participation. The majority of participants were women (71.7%); 51.2% were Hispanic, Latino, or Spanish; and 50.0% were Black. Participants ranged in age from 16 to 72 years (mean age = 47.7, SD = 2.12). A large range of average annual household income was reported, from <$15 000 to >$100 000, with school staff reporting a median of $50 000 to $99 000 (n = 10) and parents/caregivers reporting a median of $15 000 to $24 000 (n = 5).

Among all of the sites, 6 main themes emerged with regard to COVID-19–related vaccination concerns for children: (1) potential side effects, (2) vaccine development, (3) misinformation (subthemes: content of vaccine and negative intent of the vaccine), (4) vaccine effectiveness, (5) timing of vaccine administration/availability for children, (6) fear of needles, and (7) mistrust. Table 2 includes definitions of each theme, which sites endorsed these themes, and illustrative quotes.

Potential side effects of the COVID-19 vaccine were a concern most often endorsed by participants in this study, with 3 of 4 sites contributing data to this category. Participants were worried about short- and long-term side effects, including experiencing COVID-19–like symptoms immediately postvaccination, potential infertility, vision problems, kidney failure, losing hair, heart attacks, and death. Many participants also expressed worries about allergies, or how the vaccine would affect them if they had a weak immune system or preexisting condition. Anecdotes were reported about a participant or someone they knew having significant side effects postvaccination. Of particular concern was the variability of side effects reported.

The second most endorsed theme across studies was worries about the manner and speed with which the vaccine was developed, and whether there was enough consequent evidence to promote safety. The most common concern was the speed with which the vaccine was developed and made available to the public. Participants compared the COVID-19 vaccine timeline to other vaccine timelines and worried about the lack of research and safety data. The term “emergency approval” and need for additional boosters increased skepticism about the effectiveness of vaccine development. Three of the 4 sites reported data for this theme.

Participants reported a wide range of misinformation (ie, inaccurate comments and perceptions regarding the COVID-19 vaccine) that they personally endorsed or reported hearing from others in their communities. Most of the misinformation was categorized into 2 subthemes: content of the vaccine and negative intent of the vaccine.

Hesitations about the vaccine’s composition were expressed by participants in all 4 research sites, with questions about the ingredients and potential placebos being noted.

This subtheme summarizes the extreme fears, sometimes to the extent of persecution, reported by participants at 3 of the sites. Speculation of “chips” or “magnets” being inserted, becoming “zombies,” or receiving the “mark of the beast” postvaccination were noted by participants at 3 sites. Participants did not necessarily believe these fears, but shared such concerns on behalf of their community.

Uncertainty about how well the vaccine would protect against infection or hospitalization was endorsed by many participants across the 4 sites. There was also unease about the number of boosters required and the influence of variants on vaccination recommendations. There were many reports of people who were vaccinated and still contracted or died of COVID-19. On the other hand, a minority of participants reported feeling safer postvaccination because of its protection, recognizing that, although the vaccine may not be able to prevent COVID-19 infection, it would at least mitigate the risk of more serious consequences, including death.

Three sites contributed data regarding when and at what age to vaccinate children. Parents expressed their sense of responsibility (and in some cases, the burden) regarding the decision to vaccinate or not vaccinate their children, especially younger children. Many parents reported being vaccinated themselves, but not vaccinating their children, or deciding to wait before vaccinating them to feel more secure about their decision. Some parents reported their decisions were not solely their own, others involved their children in the decision-making process, and some left the decision to the child (mostly for adolescents). Aside from the child’s age, some participants identified other conditions such as pregnancy or time since their last COVID-19 infection as factors that influenced whether and when to vaccinate.

Three of the 4 sites had data related to fear of needles and overall discomfort or pain associated with injections. This theme had the least amount of endorsement across participants; however, there is consensus that people, especially children, do not like needles or pain, thereby presenting another potential barrier to vaccination adherence.

An overall lack of trust was expressed by participants at 2 of the sites. Participants articulated many reasons why there is a lack of trust that overlapped with other themes such as vaccine development and content of vaccine. Nonetheless, the value placed on trust warranted its own theme and attention, because it was expressed adamantly by participants. Some cultural mistrust was voiced, as well as concerns with the government and public figures.

Childhood vaccine hesitancy is on the rise, with 20% to 25% of parents expressing concern over vaccinating their children for routine and recommended vaccines.^2,3  COVID-19 child vaccination has been particularly limited.¹¹  Our study combined data from 4 independent qualitative research groups across the country to examine childhood COVID-19 vaccine hesitancy within the context of school communities. Our purpose was to understand families’ beliefs around vaccine uptake, as well as normative beliefs from underserved youth school communities. We observed that the most salient themes surrounding childhood vaccine hesitancy focused on potential harm to children resulting from side effects of the vaccine, because of its development or content, pain the injection may cause, and potential ineffectiveness. A significant amount of concern regarding misinformation, mistrust, and debate on the timing of vaccine administration for children was also reported. These findings have implications for school-based health promotion, primary care settings, and pediatric vaccination sites to promote individual, family, school, and population health.

Several key themes related to childhood vaccination in school settings emerged across underserved communities nationally, including typically reported contributing factors for vaccine hesitancy, such as safety, trust, vaccine origins, and perceived value. Distrust of the vaccine related to misinformation or misleading information found online (eg, Twitter) was also a prominent theme previously reported elsewhere, particularly among historically marginalized and underserved populations.^22–28  Misinformation has been linked to low health literacy in previous studies, and may be a target area for reducing vaccine distrust.²⁹  Surprisingly, we did not observe access to the vaccine as a source of childhood vaccine hesitancy, despite previous reports demonstrating this as an important barrier for parents.⁶  The individuals we studied were possibly aware and/or receiving greater access to COVID-19 testing and vaccination because of their participation in the study. Additional qualitative studies are needed to determine if our findings are consistent with school settings in other geographic regions and underserved populations that may not be serviced by large research-funded institutions.

On the basis of the data we collected, we identified key areas of COVID-19 vaccination concerns from school community members and, therefore, recommend the following to increase vaccination rates: First, clear and realistic expectations postvaccination are necessary to educate the public about potential side effects, vaccine development and content, and how the vaccine mitigates (but does not eradicate) the risk of COVID-19 infection and associated consequences. Second, questions regarding the timing of vaccination for children, those with underlying conditions, and pregnancy should be addressed with a health care provider on an individual basis. Third, many parents reported their willingness to let their child decide when and if to get vaccinated, which is perhaps developmentally appropriate for older adolescents. Consequently, promoting health literacy in adolescents may be another way to increase vaccination rates. Fourth, misinformation, particularly the content of the vaccine and the potential for harm as a result of receiving the vaccine, was expressed consistently and spontaneously across 4 unique study sites. This type of misinformation is also common on social media and news outlets.^28,30,31  Although these fears may seem irrational to researchers and health care professionals, these concerns need to be addressed in a nonjudgmental manner. Finally, fear of needles is a common barrier to vaccination, especially for children,^32–34  and remains a concern for COVID-19 vaccination. Fortunately, there are evidenced-based interventions for fear of needles specific to childhood vaccines that are available and promising.^32,35,36 

Strengths of this study include drawing from multiple qualitative studies examining childhood vaccine hesitancy among children, families, and staff in school settings. Data came from multiple US regions and stakeholder groups, as well as from underserved communities that have been hardest hit by the COVID-19 pandemic.^37,38 

Our study also had several limitations. Because data were collected from 4 separate studies, the interview guides, coding schemes, and analytical approaches differed. Future research should include multisite or collaborative projects with consistent methodology, similar to the National Institutes of Health Common Data Element, which are a set of standardized questions and responses used across multiple research studies to systematically collect information on the same topic/research question. Additionally, interviews may have served >1 purpose, influencing inclusion criteria, or were collected from convenience samples, therein limiting generalizability of findings. Data were also collected at different time points over the course of the pandemic (April 2021–April 2022). These time points accounted for the different timelines for each site, challenges with recruitment, and the prevalence of hesitancy in the target population, although the time points may also have contributed to differences in concerns and priorities for participants across studies. For context, vaccines were first approved for emergency use in adults in December 2020, for adolescents aged 12 to 15 years in May 2021, for children aged 5 to 11 years in October 2021, and for children aged 6 months to 5 years in June 2022.³⁹  However, parental vaccine hesitancy, which historically has presented additional barriers to vaccination,^3,40  may not reflect knowledge gains and shifting guidelines on vaccine safety and availability. Lastly, conducting research on COVID-19 during the pandemic was challenging. Significant care was taken by all research teams to respectively collect data on sensitive, politicized, and personal medical decisions. Consequently, many of the questions were focused on community perspectives, rather than individual perspectives to reduce stigma and encourage participation.

Childhood vaccine hesitancy is not unique to COVID-19. With the exception of the speed at which the COVID-19 vaccine was developed, the main concerns expressed across these studies have been previously reported. In fact, vaccine novelty, even without parental concerns over the speed of vaccine development, has been cited as a barrier to nonmandated vaccines (eg, human papillomavirus).⁴¹  To foster herd immunity and promote population-level health, the majority of the population must get vaccinated (including boosters). Although some participants questioned the need for boosters, much of these data were collected before boosters were widely available or recommended for all age groups. If an adult is vaccine-hesitant, one can understand why this same adult may not be willing to give their child a vaccine and/or booster. Moreover, at the time these data were collected, the vaccine was not yet approved for children aged <5 years. Because only 36% of US children aged 5 to 11 years have received at least 1 COVID-19 vaccine as of July 2022,¹¹  it will likely be even more difficult to convince parents to get their younger children (aged <5 years) vaccinated. Delaying or refusing COVID-19 vaccination will likely result in recurrent outbreaks similar to other vaccine-preventable illnesses.⁴² 

Increasing rates of childhood vaccine hesitancy, particularly for nonmandated vaccines,⁴¹  highlight the need to address vaccine hesitancy in schools. School settings can provide a unique context for understanding family and school culture-based concerns, particularly in underserved communities. Developing careful, culturally sensitive school-based strategies that address parent and child concerns will be critical to reducing health inequities related to COVID-19 vaccination.

We thank the many students, families, school employees, and community partners for their time to participate in these studies. We acknowledge support from the RADx-UP Return to School Program (OTA-21-007) including editorial support and manuscript submission by Erin Campbell and Brooke Walker, Duke Clinical Research Institute. We also thank the investigators, staff, students, and trainees who contributed to the individual studies represented in this paper.

COVID-19

coronavirus disease 2019

RADx-UP

Rapid Acceleration of Diagnostics Underserved Populations