Rachel Skinner [00:00:05] Good afternoon, everybody. Welcome to the WH&Y Wellbeing Health and Youth NHMRC Centre of Research Excellence in Adolescent Health Webinar series. I am Rachel Skinner and I'm with my colleague Cristyn Davies and we will be presenting today. 
 
Rachel Skinner [00:00:28]  I'd just like to first off acknowledge the funding support of the NHMRC and the contributions of our research partners in universities across Australia. 
 
Rachel Skinner [00:00:44] We also acknowledge the traditional owners of the country throughout Australia and recognise Aboriginal people's continuing connection to land, waters and culture. And we pay our respects to their elders, past, present and emerging and any Aboriginal people who have joined us today. 
 
Rachel Skinner [00:01:06]  As we always do, I’ll just point out that you should have a little look at WH&Y.org.au website as there's lots of information there, particularly the WH&Y Community of Practice where you will find lots of information and discussion and inspiration of importance to researchers, clinicians, policymakers and young people. Just to orient everybody, if you want to chat. First off, your microphone and your video are switched off, so you can't actually speak up in this webinar, but please interact through the chat function. Any comments that you'd like or any questions you'd like to ask us, we will answer them at the end where we will allow time to answer questions. We won't overlook your questions. Please be as interactive as you like. You can see the chat function at the bottom right of your screen. 
 
Rachel Skinner [00:02:18] Just to introduce myself, I'm hosting today, I'm a professor in pediatrics in the Faculty of Medicine and Health, Sydney University, and I'm Deputy Director of WH&Y, and I've had a strong interest in adolescent vaccination over quite a few decades actually. And I'd like to introduce my co-presenter, Cristyn Davies, who is a research fellow in the specialty of Child and Adolescent Health at the University of Sydney Clinical School and is also a WH&Y researcher. Her vaccination-related research expertise includes vaccination for adolescents and young adults and vaccination delivery systems, and implementation science and knowledge translation. 
 
Rachel Skinner [00:03:09] Today, we're going to talk to you about COVID 19 vaccine acceptance and intentions among young people, and we will present a study that we've recently conducted. We'd like to acknowledge our co-investigators in this study: Associate Professor Pip Colin, Maia Giordano, Tessa Copp, Sarita Bista, Professor Kristen McCaffery, and also our industry partner, Student Edge. And the young people, of course, who participated in the survey. And I might hand over to Cristyn now. Who is going to provide a bit of background. 
 
Cristyn Davies [00:03:55] [Slide 1 Impact of COVID 19] ] Thank you so much, Rachel. And thank you so much, everyone, for coming today. I'm actually recovering from COVID 19, so very timely, I guess, that we're giving this presentation. Adolescents have similar infection rates to adults, although the severity of illness is less severe. COVID 19 disease in adolescents is very uncommon and only very rarely causes death. However, there are substantial indirect effects for adolescents and young people, and these are mental health, learning and physical well-being of adolescents. Obviously, school closures have had a massive impact on young people, lockdowns, not being able to socialise with their peers, psychosocial distress and also loss of income and jobs and unstable housing have all impacted young people. And also young people are differentially impacted with those most disadvantaged suffering the most at this time. 
 
Cristyn Davies [00:04:57] [Slide 2 Benefits of Vaccination] The benefits of vaccination include strong immunogenicity and vaccine efficacy against symptomatic COVID 19, and vaccination also reduces infections, hospitalisations and deaths due to COVID 19 and other complications such as pediatric multisystem inflammatory syndrome associated with SARS -Covid-2 and also long COVID. Vaccinating adolescents contributes to reducing cases in the broader population and therefore will reduce the indirect impacts of the pandemic, such as reducing disruption to education, reducing potential transmission and outbreaks in schools in particular. 
 
Rachel Skinner [00:05:46] [Slide 3 Graph of cases by age Jan 2020 - June 2021] I'm going to talk a little bit about the epidemiology of COVID 19 as we've experienced it, particularly since the start of the pandemic and how it's affected young people. Just to set the scene. So with the first wave of COVID 19, as you can see by the breakdown down in this curve here, this is the Alpha wave, that first wave that we had in early 2020. And the group that were most impacted really were the older age groups, but also mid adults. And then this slide here gives the percentages of cases by male and female and a background, the black bar is the background population. So it gives you a sense of which age groups are overrepresented or underrepresented in terms of the background population in the case breakdown. 
 
Rachel Skinner [00:06:51] In this early first wave, we saw an underrepresentation of the youngest age groups, but an overrepresentation of young adult and mid adult age groups and then a relatively appropriate representation for the older age groups. 
 
Rachel Skinner [00:07:13] Moving along to the Delta wave, which happened, as you know, in mid to second half of last year, September in particular. And you can see the breakdown by age here as well. And so in this older age group the  case rates are lower actually than the younger age groups that are higher. So the younger age groups are starting to experience a higher proportion of the cases in the population. 
 
Rachel Skinner [00:07:51] [Slide 4 Graph of cases June 2021 - Nov 2021]  And if we look again at this graph, which shows the differences between males and females and the background population, we can see an overrepresentation now of this younger age group for both male and female, and also that young adult and even mid adult, but an underrepresentation of the older age groups. Now this is due to a number of things, but most importantly because we focused on vaccinating the older age groups first. So they had the protection of vaccination before the younger age groups, and there was a period of catch up of vaccination coverage in the younger age groups. And so it's partly as a result of that, but it's also a result of the behaviour of young adults and younger people. They're much more social. They go out and mix with lots of different people. So they're very efficient transmitters of the virus. 
 
Rachel Skinner [00:09:03] [Slide 5 Omicron Graph] This is the Omicron wave, which really began in December or late November. And you can see the breakdown of the different age groups here represented in the different colours. If we look at this first peak, you can see that's the young adult age group and that sort of younger mid adult age group is in that sort of peak. And then this is when the teens come next and then if we go further along getting into March after school started, we can see that this group here, 10 to 19 age group, is the one that is the highest peak there. So it's just interesting to look at the different age groups and how  the proportion of cases is represented by age group and to be thinking about what the reasons for that are. I mean, there are different reasons. One is vaccination and the rollout of the vaccination program that younger age groups were able to access the vaccine only more recently than the older age groups. But it also relates to those other activities of being in contact with lots of other people, particularly in social settings and in schools. 
 
Rachel Skinner [00:10:37] [Slide 6 Vaccine administered to the NSW population to May 2022] Looking at where we are up to with vaccination coverage. I have to apologise to people who are in other states that I'm presenting New South Wales data because I'm very familiar with the New South Wales data, but I think it's similar in other states that have experienced the COVID pandemic in a similar way to New South Wales at least. 
 
Rachel Skinner [00:11:06] We have, as you can see, higher coverage for two doses of COVID vaccine in people aged 16 and over than people aged 12 to 15 and people younger than that. You can see that it has dropped right down. And this is the most recent data that we have for the third dose. So booster dose, It's only eligible for people who are 16 and over, it's only recommended in that age group. So we see that the coverage is just around two thirds of the population. 
 
Rachel Skinner [00:11:43] [Slide 7 Vaccination Coverage in NSW] And it's interesting - I'll show you this other slide, which is a little bit older, but it shows you how the coverage has really flatlined since around late November, which is approximately the time when we did the survey that we're going to present to you. As you can see from this graph, there is really no change in the coverage rates since then or very little. And we wouldn't expect that that has changed since either, because there haven't been any major campaigns to boost the coverage since. I'll hand over to Cristyn to start to present our study. 
 
Cristyn Davies [00:12:29] [Slide 8 COVID 19 Vaccination acceptance among young people] Thank you, Rachel. So at the time that we'd conducted our study, there'd been one US study in parents and adolescents which found that parental concerns about vaccine safety were of concern. Social media was a negative influence on vaccine safety for young people. And there were demographic factors associated with known inequities in vaccine access. And there are no Australian studies published about this age group as of the time that we did the study and currently. 
 
Cristyn Davies [00:13:04] [Slide 9 COVID 19 Vaccination acceptance among young people] Our aim was to measure factors associated with completion of a two dose COVID 19 vaccine schedule and also intention to receive a booster dose. And our hypothesis was that low two dose vaccine completion and intention to booster would be associated with factors common to lower vaccine coverage for other vaccines. For example, disadvantage and minority status, attitudes such as low perceived severity of disease, and low perceived efficacy of the vaccine, and also concerns about vaccine safety and efficacy. 
 
Cristyn Davies [00:13:46] We designed a national online cross-sectional survey, and the setting was Australia wide. The survey was open from 10 November until 3 December 2021. Our participants were aged between 14 and 25 years and were recruited from a large nationally representative online panel through our research partner, Student Edge. And we examined the correlates of having two doses of a COVID 19 vaccine and also intention to receive a booster or a third dose. And at the time that we conducted the survey, the booster dose was only recommended for those 18 plus. However, we asked the question about a booster vaccine for all ages, regardless, assuming that this would be recommended in the future. And as Rachel indicated, obviously boosters meaning a third dose, not a fourth dose, recommended for young people aged 16 and 17 years old. The other thing to note is that we also boosted our sample for New South Wales. We're actually collaborating with New South Wales Health, and Rachel will talk a little bit about that later. So about a third of the sample was from New South Wales. 
 
Cristyn Davies [00:15:04] [Slide 10 Timeline of vaccine rates and mandates for COVID 19] Special thanks to Maia, who brought together this fantastic timeline to just provide a bit of a snapshot of what was happening at the time that we conducted the survey. At the time, the reported national case numbers started at around 17,979, and 84% of those case numbers were in Victoria and this dropped to 15,997 and still about 81% of that load was in Victoria. There was lockdown at the time, only in the Northern Territory until the 4th of December, and New South Wales and Victoria had come out of lockdown, but restrictions were starting to ease at this time. So the vaccination rate was around 80% for at least one dose across most jurisdictions except WA, which had a slightly lower rate at just under 68%. The booster dose was available, as I have mentioned, for 18 plus across Australia and schools had reopened in Victoria on the 5 November and in New South Wales on the 24 October. Various state borders were closed so we weren't able to easily travel interstate. And also the first reported case of Omicron was on the 26 November in Australia and from 27 November we had some international restrictions. So for example, we weren't able to travel to South Africa. At the start and the end of the survey period, 20 to 29 year olds and 10 to 19 year olds were the first and third numbers of highest cases by age groups. 
 
Cristyn Davies [00:16:55]  I'll hand over to Rachel now. Thank you. 
 
Rachel Skinner [00:17:01] [Slide 11 Demographics] We recruited just over 1,600 young people aged 14- 25. And of those, 48% were male and 52% female. They also asked about gender, 48% male, 50% female and 1% non-binary. And 1% other term. We asked about sexual orientation, so 80% of the sample identified as straight or heterosexual, 3% identified as lesbian or gay, 9% as bisexual, and 8% as other. We had 3.9% indigenous young people, young people living in regional and remote areas, 16.5% young people who spoke a language other than English at home, just 33%, a third. Of the sample, 83% had received two doses of COVID 19 vaccine on self-report. 
 
Rachel Skinner [00:18:21] [Slide 12 Socio-demographic correlates of 2-dose completion] So we looked at what factors were associated with having had two doses of the COVID 19 vaccine. Unsurprisingly, given the rolling nature of the recommendations of older age groups down to the younger age groups, having an older age was associated with two dose completion, so two doses. As you can see the difference is only small at both 19, but 19.3 versus 19.7 for the two doses group. Participants who were female sex were more likely than those of male sex to have two doses of the vaccine, and also those of female gender. Those participants who were not Aboriginal and Torres Strait Islander were more likely to have had two dose completion, 84% versus 64%, those living in urban areas, urban 84% versus rural areas 76% had two dose completion. Interestingly, speaking a language other than English at home was more likely at 88% to have a two dose completion, compared to those who only spoke English at home. And I probably should just say that this was at the time when there was the lockdown in southwestern Sydney and the Western Sydney LGAs, there was a huge push in those areas to vaccinate the population and there was a great motivation as well to vaccinate. So that perhaps explains what we would not expect with other vaccinations. So higher SES according to the SEIFA [Socio-Economic Indexes for Areas]  scale of 1 to 5, those in more socio economically disadvantaged areas compared to advantaged were less likely to have two dose completion. 
 
Rachel Skinner [00:20:42] [Slide 13 Wellbeing, attitudes, information correlates of 2-dose] We looked at well-being and attitudinal and informational correlates of two dose completion as well. We measured psychosocial distress using the K 5 tool five and we found that overall it was a very high level of psychosocial distress, much higher than we would expect generally from other pre-pandemic population surveys. And what we did find was that those who had higher levels of psychosocial distress were more likely to have had two doses of the vaccine. Interestingly, those with chronic conditions were no more likely to have two doses, but there was still high coverage across the sample. But those who had a chronic condition versus those who didn't, there was really no difference. And then we looked at intention to have a booster. And it was if they had had two doses or if they had not had two doses, they were more unlikely to  intend to have a booster versus those who'd had two doses, 92% were more likely. So those who had previously had COVID 19 were actually less likely to be fully vaccinated, versus those who hadn't. And those who had personal concern about COVID 19, yes, so 89% of those had had two doses versus those who were not concerned. Unsurprisingly, they had a lower two dose completion.  Those who perceived higher COVID 19 vaccine efficacy were much more likely to have had two doses at 93% versus 44%. Those who perceived a higher public health threat of COVID 19 were much more likely to have had two doses, and those who had higher e-health literacy scores in the scale that we used were more likely to have had two doses than those who had lower e-health literacy. And those who rated government information sources in their top five were more likely to have had two doses. 
 
Rachel Skinner [00:23:12]  [Slide 14 Multivariate model: 2-dose completion] We then put in all of the factors, all of the correlates into a multivariable model to see which were independently associated with two dose completion. Some of those correlates did drop out, but older age remained. So that older age group, 22 to 25, versus the younger age groups. Speaking a language other than English at home versus English only, they had higher odds of having two dose completion. And also if they were in a lower versus a higher SEIFA quintile they were less likely to have had two doses. So, SES advantage predicts two-dose completion. Higher levels of psychosocial distress also had higher odds of two dose completion and that was just statistically significant in the model. Higher perceived vaccine efficacy versus a perceived vaccine efficacy not effective. The odds if the young person perceived that the vaccine was not effective, their odds of two doses was much lower. So that was an important predictor. And also higher perceived public health threat was significantly associated with two dose completion. 
 
Rachel Skinner [00:24:47] [Slide 15 Intention to have booster dose] Then we looked at intention to have a booster. Knowing that there was only that recommendation for the 18 to 25 age group of our sample but thinking that that would extend potentially in the future to the younger age groups, we asked everybody. Without going into great detail on the percentage who intended, overall, it was approximately 65% intended to have a booster. Not as high as the two dose completion. And again, we found similar socio demographics, older age versus younger age having a greater intention. Not surprisingly it was recommended for them. Being female predicted a greater intention, being non-indigenous or not Aboriginal and Torres Strait Islander, living in an urban versus a rural area, living in an area of high risks or higher socioeconomic advantage, and having a chronic illness in this univariate analysis was associated with intention to have a booster. In terms of attitudes and well-being, no previous COVID 19 , was still associated with intention to have a booster, personal concern about COVID 19, about catching COVID 19, and then sort of thinking about it from a population level, COVID 19, perceived as a public health threat to the community, was associated with having a booster. If young people reported that they had barriers to accessing the vaccine, like not being able to go to the doctor or the pharmacy on their own to get the vaccine or not being able to leave school were the sorts of barriers that were put to young people. And  if they didn't report any barriers to accessing the vaccine, they were more likely to intend to have a booster. Those who reported higher perceived vaccine efficacy and higher health literacy were more likely to intend to have a booster dose. And then those who'd nominated government websites, but also health professionals as information sources, were more likely to intend to have a booster. 
 
Rachel Skinner [00:27:25] [Slide 16 Multivariate model intention to have a booster] When we put all of these variables into a multivariable model, what we found was English spoken at home versus language other than English, actually predicted a greater intention to have a booster. So if they spoke another language, a language other than English, their odds of intending to have a booster versus those who spoke English was 0.8. So it's reduced. So if they lived in an urban versus rural area, they were more likely to intend to have a booster. If they lived in areas of higher advantage, they were more likely to intend to have a booster. Or, on the other hand, the way it's presented there, the odds ratio of 0.5 relates to lower SIEFA  quintiles versus higher. If they had already completed two doses, they were more likely to intend to have a booster. If they'd only had 1 dose versus two doses, the odds of intending to have a booster were much less. Those who reported no access barriers were more likely to intend to have a booster. If they had a barrier versus no barrier, the odds that they would intend to have a booster is only 0.2, so much lower if they had barriers. If they perceived higher vaccine efficacy, they were more likely to intend to have a booster. If they perceived COVID 19 as a public health threat, they were more likely to intend to have a booster than those participants who didn't. If they had higher COVID 19 e-health literacy, they were more likely to intend to have a booster than those who didn't or had lower COVID 19 e-health literacy. And then those who'd reported in their top five information sources, a health professional, were more likely to intend to have a booster than those who did not include a health professional. 
 
Rachel Skinner [00:29:40] If you can keep all of those things in mind, we're going to move on to some of the qualitative findings. So this is different from the two doses. We found what we'd expect, that English spoken at home they're more likely to intend to have a booster that is what we see as a correlate of vaccination, generally, urban locations have higher coverage rates as well, higher socioeconomic advantage. All of these sociodemographic correlates are what we expect. And it's interesting how important these other correlates are. So perceptions of barriers to accessing vaccination have an influence on intentions. Perceptions around how well the vaccine works, and then perceptions about COVID 19 and how much of a threat it is to the community generally. These things are really interesting, higher e-health literacy and who they access for information. These are the sorts of things that we actually don't know much about with adolescent vaccination, certainly not with COVID vaccination. We do find some of these associations with adolescent vaccination more generally, but it's particularly pronounced in this study, which is interesting. I'll hand over to Cristyn now, who's going to provide a little bit more of a picture to the participants who completed the survey and provided more detailed responses. 
 
Cristyn Davies [00:31:39] [Slide 17 Intention to have booster dose: Neutral booster intention (qualitative responses] Thank you, Rachel. The survey was 10 minutes long, so it was pretty quick. We really had to focus on key information. And we put in a qualitative question because we wanted to understand in particular, why young people were not getting a booster.  I'm just going to present some data here regarding young people who indicated that they were neutral with regard to getting a booster and also those unlikely and highly unlikely to get a booster. Regarding those who were on the fence, if you like, about getting a booster, of those that responded neither likely or not likely to get a booster, they were mainly from city and urban areas. They were more likely to be over 18 years. And just to recap, our sample is 14 to 25 year olds. A  slightly higher proportion were male compared to female, and the majority had received at least one dose of a COVID 19 vaccine. 
 
Cristyn Davies [00:32:39]  [Slide 18 Booster dose intention: Neutral intention] This is regarding the young people who provided qualitative responses, who were neutral about their intention to get a booster. Some indicative quotes from young people are ‘only if I'm required to get it'. 'It's not necessary'.' I only wanted it for freedom'. And then 'not needed' or 'not necessary'. So 'not against a booster, but don't know how needed it is'. Young people indicated they were unsure of the vaccine effectiveness and safety, and young people said it depends on the safety and testing of the booster as well as the purpose of the actual booster. And another young person said, 'because it seems to have significant health risks with unknown health benefits'. Some people were open to having a booster. And that was indicated by 'if I already am fully vaccinated, what do I risk getting a booster shot?' So that was a risk going in the other direction if you like. Some young people just didn't know and said, 'I don't know if I'll need it'. Young people expressed concerns about side effects, so undecided about the booster shot as the side effects could be severe and some young people thought they might be safe to get the booster because it'd be safe and protected. ‘To ensure I'm protected from getting the variants, as well as symptoms’. And some young people indicated a need for more information or research. So not sure we'll see the information released. And also, ‘I'd like more information about how it's better or more effective than what I've already received’. That's all the logic behind young people who are neutral or on the fence about receiving a booster. 
 
Rachel Skinner [00:34:32]  [Slide 19 Booster dose intention: Unlikely/highly unlikely] And these are the reasons provided by the young people who said that they were either unlikely or highly unlikely to receive a booster, so 'only if required' was very popular. 'I will only get it if it is mandatory to do things I want to do'. And 'I was forced to get the first two'. And I have to say these kinds of responses were much more common in young men than young women. The mandates really did have a very strong impact, particularly people who needed to get that to be employed, for example, people working in construction in the building industry. Many young people indicated that they believed it wasn't needed or necessary, 'two is enough and I don't want to'. There were concerns about side effects, 'so much uncertainty on how effective it is and scared of side effects'. And then a lot of young people that had one dose of the vaccine and then had side effects and that put them off getting further doses. And that's indicated by 'I had horrible side effects from the first dose'. There were concerns about safety. So 'because it's only provisionally approved by the TGA and I don't consent to being part of a medical trial,' that was not uncommon, that kind of response. Some young people thought that the booster dose undermined the first two doses. So 'I just feel like they said we have to get two doses and now all of a sudden we're thinking of getting a third'. 'What other vaccine has ever required six monthly boosters?'. Some younger people expressed needle phobia, so they didn't want another needle, they were sick of needles. And some young people indicated they were against COVID 19 vaccination. So 'I don't like the vaccine'. And other young people indicated that they needed more information or research. And by saying, 'I'm not planning on getting the vaccine as of yet, I'm unsure about the level of testing that has been done'. 
 
Cristyn Davies [00:36:34]  [Slide 20 Case study: neutral about a COVID 19 booster] We actually put together a case study. This is a real case study from using the data from the survey. And this is a young person who is neutral about receiving a COVID 19 booster and we thought we'd present this in order to generate conversation. This young person was aged 20. They lived in Chester Hill in New South Wales. They identified as heterosexual or actually female. Case 1’s father was born overseas, and she speaks Arabic at home. She attends university and works casually. She gets most of her information about COVID 19 vaccines from uni, and then her parents and family, and news on TV, radio and websites. Regarding a COVID 19 booster and COVID 19 vaccination Case 4 reported 'the waiting time is too long to receive the vaccine'. If she had the vaccine, she'd like to have it at a big vaccination centre or hub. Their most trusted sources of information, a university followed by TV, radio and websites, and then her doctor or pharmacist. She would be concerned about getting a COVID 19 booster because she might not know the side effects. Case 1 believes that COVID 19 vaccines are moderately effective at reducing someone's chance of catching the virus and of passing the virus on to others. And she also reported poor mental health across the Kessler–5 (K-5) scale. And we just wanted to point out a couple of things. And, Rachel, would you like to make some observations about this case with regard to some of the barriers that this young person might be experiencing. 
 
Rachel Skinner [00:38:21] I think it is interesting to see where they are finding their information and where they're accessing their information, because that is an avenue through which we can reach the young people, particularly those who are neutral, on the fence about accessing a booster. I mean, she's eligible to have a booster. And we also know that in the quantitative findings that certainly the doctor or the health professional is a very important mechanism for getting that information, and  whenever a young person sees the health professional, we generally recommend when it comes to vaccination more broadly, not just COVID 19, that a doctor should make a recommendation to have a vaccination there and then if the person is eligible and they haven't been vaccinated and that should apply to COVID 19. So checking on vaccination status and providing information and making a recommendation to have the vaccine. But clearly, for her, the university is another channel for getting information, and also designing the information in a way that's appealing to that age group is really important. You know, as public health providers, we need to engage with young people and communicate with them in the ways they want to hear, in the ways that resonate with them and the channels that they access. 
 
Cristyn Davies [00:40:00] I also note that the young person speaks Arabic at home, so it would be really great to have resources translated into Arabic so that she could have discussions with other family members about getting the vaccine. And it might be useful for community groups and NGOs to have that information at hand in case she wants to access that a website through her community groups as well. Also, she's quite time poor so I'm assuming she's attending university, working casually. While she said she wanted to go to a vaccination center, it's really important that there are walk-ins available for young people, and that often can happen in a pharmacy setting, sometimes at a vaccination hub. But largely young people had to book. So these are some of the other barriers. I'm sure other people have excellent observations about this case as well, but we might move onto the next slide. 
 
Cristyn Davies [00:41:03]  [Slide 21 Sociodemographic correlates of acceptance and intention to vaccinate] We found socio demographic correlates of acceptance and intention to vaccinate were similar to other sociodemographic correlates of vaccination more broadly, and attitudes about vaccine effectiveness. Perceived COVID 19 threat, and e-health literacy was strongly associated with intention to receive a booster. Governments and health organisations should deliver practical information and training to support young people's skill development to find and act on quality COVID 19 vaccinations. 
 
Cristyn Davies [00:41:34] I'm just going to hand over to Rachel because we actually did work with New South Wales Health as part of this project, and she'll give you a little bit more information about that. 
 
Rachel Skinner [00:41:44] In my role as Senior Clinical Adviser for Youth Health in the New South Wales Ministry of Health, I have been the COVID clinical lead for youth. We worked with the State Health Emergency Operations Center Strategic COVID 19 Communications Team to help them design messaging for young people, adolescents as well as young adults, who were clearly a target group at that time for boosting vaccination coverage. And also just to communicate messages about COVID 19 and how to prevent the spread of COVID 19. We drew on the findings of the research, as well as our own knowledge about young people and the types of communication that would resonate most with young people and the channels through which they access information, the various social media channels in particular. Together with young people's input, we designed youth friendly communications, which were then disseminated through social media channels broadly to young people. And they were regularly updated. That was all during the second half of last year in particular and earlier this year. 
 
Rachel Skinner [00:43:31] I think it's an example of trying to do research that can inform policy in a real time way. We haven't yet published this work. We're about to submit a manuscript for publication. But as you can see the urgency of vaccination and controlling COVID 19 has reduced the perceptions tn the community generally, and we no longer have the restrictions that we did have. Publications take a long time to disseminate. So it's really important to be able to translate the findings that we have directly to the Health Department who are managing the pandemic. And so that's what we tried to do as much as possible. 
 
Rachel Skinner [00:44:39]  And I probably should say that it wasn't just me, but it was a whole team and it also included Youth Action,  a youth peak group, but also WH&Y, and Young & Resilient are co authors on this paper, and the WH&Y Commissioners. We're involved in developing those communications for New South Wales Health. 
 
Rachel Skinner [00:45:12] [Slide 22 Recommendations] These are our recommendations. That we have conversations with young people about COVID 19 vaccination and their beliefs and their behaviour. So we need to open up the conversation and if they have any concerns or questions, that's an appropriate time to speak to them about it. And if they have myths and misconceptions, to explore those beliefs, understand where they're coming from, and then provide correct information in a non-judgmental way, and direct them to reliable sources about COVID 19 and vaccination. And there are some really good resources that have been developed by the National Center for Immunisation, Research and Surveillance (NCIRS) on this slide. Decision aids for parents and also for children under 16. And as I mentioned, those series of communication messages, there are videos that were disseminated through TikTok and Instagram, NCRIS has quite a number of other resources around COVID 19 vaccination acceptance more broadly in the adult population, and also for parents of younger children and frequently asked questions. 
 
Rachel Skinner [00:46:38] [Slide 23 References] I think that's our last slide. We have some references as well to back up some of the earlier comments we made if you were interested in further reading about this topic. 
 
Rachel Skinner [00:46:52] Thank you for your attention. If there are any questions, we'd be happy to answer them. 
 
Rachel Skinner [00:47:04]  I think that there is a question from Dan. “A couple of quick questions about the quant analysis. Were any non-linear relationships tested e.g. between stress and intention”. And two,, and to I assume this would become significant with greater sample size. Any comments on the likelihood of this?”

Rachel Skinner [0048:08] I'm going to answer the second one first, Dan, because it's easier for me to answer, actually. So while Aboriginal and Torres Strait Islander status was associated in the univariate analyses or just simple correlations, it was associated with the lower two dose completion. It was not assessed that characteristic, so being Aboriginal Torres & Strait Islander was not associated with two dose completion or intention to have a booster dose in the multivariable model. I presume that it was accounted for by other factors like SES, and rural versus urban location. And while Aboriginal & Torres Strait Islander people do have lower coverage for other vaccines in general, quite significant efforts have been made at least through New South Wales Health.. I'm not so familiar with other states, but enormous efforts were made to engage with communities and to co-design messaging to explain the threat of COVID 19 and the importance of vaccination.  I think that even if we had a larger sample size, I mean, it's possible if we had a very large sample size that might show an association. But I do feel that it's other factors that are the most important, and, you know, living in rural and remote areas. 
 
Rachel Skinner [00:49:14] And with respect to the statistical question, I have to say no, we just undertook fairly straightforward analyses at this stage, but would be very happy to get some advice from you, Daniel, if you would like to make any suggestions. That psychosocial distress and intention. question. So distress was not associated with intentions, while it was associated in the multivariable model for two doses. We need to do further exploration around that. But I do think that there are some statistical issues with distress because such a high proportion of the sample were experiencing high levels of distress, that may have an impact. Be interested to hear what people think and we will be doing further analysis on the issue of the psychosocial distress and why these young people were so distressed during that period of time. And it certainly will be interesting to look at whether that has continued, and that's something that researchers should continue to look at, and also health departments as well. 
 
Rachel Skinner [00:50:36] We have another question from Sharon. "How successful do you think social media was for communicating with young people?" I'm going to hand that one over to Cristyn. Would you like to ask that? 
 
Cristyn Davies [00:50:51]  I think social media is really important to young people, and that's how a lot of them are receiving either accurate information or misinformation or disinformation. And indeed, I think Melanie, who was on this, is investigating this in her thesis, and I'll be using some data to dig more deeply into that very question. We got really great anecdotal information from young people with the co-designed communications that we did. We got great feedback from many young people. So I think what is incredibly important is that we have co-designed communications with young people for young people, and also, of course, health experts working in the area and parents and the communities. But certainly the communitie  involved in the communication, should be involved in an integrated knowledge translation way from inception to dissemination. And that's what we tried to enact using this research. I hope that answers your question, Sharon, great question. 
 
Rachel Skinner [00:51:58] This is another one for you, Cristyn. 
 
Cristyn Davies [00:52:03] Yes. As many of you will know, I advocated at the UN Human Rights Council a few years ago regarding collecting accurate data around gender and sexuality in particular. So great question, Fiona. Thank you so much. We use the ABS standard for sex, gender, variations of sex characteristics, and sexual orientation variables. And they were very excited that we were using this because it's one of the first studies to use it that isn't specifically doing research on sexuality and gender per se but is actually using the measure as part of a different topic area such as COVID 19 vaccination. We've worked quite closely with the ABS in order to analyse the data. I hope that answers that question. 
 
Rachel Skinner [00:53:01] I think all of you researchers out there, you need to go and look at the ABS standards for collecting gender and sexuality information and make it a routine part of sociodemographic data collection. 
 
Rachel Skinner [00:53:15]  Keith from Myanmar has asked "What kind of COVID vaccines did you provide to children under 18? Is that the similar one that adults received? In our country vaccines are only provided to adults over 18 years of age, and children under 18 did not receive the vaccine". 

Rachel Skinner: [00:53:32] We have MRNA vaccines that are available for adults as well, and that is the vaccine that's recommended for teenagers and children. I suppose the question is really about resourcing and the benefit of vaccination at different age groups. And given that the oldest age groups experience the highest morbidity and mortality associated with COVID 19, they are the age groups that were prioritised at the beginning of the pandemic in Australia and generally prioritised across the world. And where there's an issue of resourcing, these are expensive vaccines, so perhaps a country can't afford to justify providing vaccines to all age groups. It is true that adolescents and children have much lower morbidity and mortality associated with COVID infection. I mean, they still experience morbidity and can die, but very infrequently, very rarely, it's not common. But they do play a role in the transmission of the virus. Now that we have different strains, it's not clear how effective the vaccine really is in preventing transmission of the virus, as everyone would now appreciate that despite being vaccinated, we're still contracting COVID 19. It's clearly still spreading, but it still has an impact on reducing severity of disease. So, Keith I hope that answers your question.  I think that different vaccines are  available in different countries globally. But that's the one that we have. 
 
Rachel Skinner [00:55:42] I think we've come to the end of our questions. Oh, yes, we wanted to do a shout out about an upcoming event, the WH&Y Research Pride. I'm going to hand over Cristyn to talk about this. 
 
Cristyn Davies [00:56:01] We'd love to invite everyone to this event, it will be on Wednesday, the 29th of June, from 6 p.m. in the eastern states. It’s the WH&Y Research Pride: What's the best way to engage and approach LGBTQI+  young people in health research and what works well and what we can improve on. Pride Month is celebrated in June in many countries, and it's to celebrate the diversity of the lesbian, gay, bisexual, transgender, queer or questioning intersex and asexual, agender community. And we really look forward to inviting you to this very exciting event. 
 
Rachel Skinner [00:56:49] Thanks, Cristyn, and thank you to the WH&Y Commissioners who organised this. I think that's it. I'm going to finish with just a couple of minutes to spare but thank you all for your attention. And also just to let you know that we'll see you again in a month. We Will send out the information for the next  WH&Y Webinar. If you have any other questions and you want to get in touch, I’ve noted Daniel said he would, that would be great. I might say goodbye to everybody. And thank you. 
 
Cristyn Davies [00:57:25] Thank you so much, everyone, for attending. Bye bye.