They are the light at the end of the long, dark pandemic tunnel: the Covid-19 vaccines. And, at the time of writing, more than 20 million people in the UK have received their first dose.

Among that group will be very few teachers, very few parents of current pupils and no children, but there is a sense of hope in schools regardless: that we have turned a corner and that, as more and more of the lower age groups get vaccinated, normality may soon return to education. After 12 long months, those in schools can finally see an end to all this.

Yet, with any vaccine come the so-called anti-vaxxers - those who opt out of receiving the jab themselves or decide not to have their children vaccinated. This group will be a minority, but Covid-19 anti-vax sentiment - or “vaccine hesitancy/resistance”, to use the more nuanced phrase deployed by many academics in the field - could still have big implications for the safety of staff and students in schools, and therefore big logistical implications for school leaders.

To have some idea of what those implications could be, think about the backlash against the measles, mumps and rubella (MMR) vaccine in recent years. NHS data shows that uptake for the first dose of this vaccine has been falling year on year for the past five years. And, as a result, the diseases that the MMR protects against are on the rise. In 2019, the UK lost its World Health Organization measles-free status, three years after the virus was eliminated, and in 2020, mumps cases in England reached a 10-year high.

With a virus as dangerous as Covid-19, the knock-on effects of vaccine hesitancy could be considerable, because even a relatively small outbreak could cause big problems for a school, its community and the wider population.

So, what do school leaders need to know about vaccine hesitancy that might help them to prepare for any problems they might encounter as a result of it? And what will any anti-vax sentiment mean for the role that schools may be asked to play in any rollout of the vaccine to children, further down the line?

Currently, school leaders will be focusing on the continuing challenges of the return to full face-to-face teaching and the pressure of catch-up. But pretty soon, the topic of vaccines is going to sneak into their emails and drop into their meetings; eventually, it may dominate their to-do lists, too.

The government has set out a plan to vaccinate nine high-priority groups, after which it will expand the programme to all adults by 31 July. So, over the next few months, increasing numbers of teachers and parents will be offered the vaccine, and thus any potential issues with vaccine hesitancy will increase in tandem.

Covid: Anti-vaxxers could create problems for school leaders

At present, children are not being impacted by these issues directly as there are no firm plans to vaccinate children - but that could change.

Sir Mark Walport, an influential voice on the government’s Scientific Advisory Group for Emergencies (Sage), has already backed making children part of a whole-population vaccination programme. Asked by BBC Radio 4’s Today programme in January whether vaccinations for children would be needed, he replied that although children “don’t seem to get severe disease, hardly ever, nevertheless they can transmit the infection … So, ultimately, yes”.

Walport, a former government chief scientific adviser, added: “For vaccines to work best, you need the most people [possible] vaccinated.”

Andrew Hayward, director of University College London’s Institute of Epidemiology and Health Care, who has attended Sage, agrees that a vaccine for children is a distinct possibility. He argues that “if a vaccine licensed for children reduced transmission, then a childhood vaccination programme aimed at reducing transmission would be likely to be considered, especially if there was continuing substantial adult mortality” after most adults have been vaccinated.

How might a vaccination rollout for children be carried out?

“School would seem the appropriate setting and more likely to get a higher uptake, based on experience of other immunisations given in school, notably HPV [human papillomavirus],” says Helen Bedford, professor of children’s health at UCL.

There goes your to-do list.

The logistical challenges of such a rollout are clearly enormous, but the biggest issues will arguably be mental and moral rather than physical. As Geoff Barton, general secretary of the Association of School and College Leaders, says, in the event of a vaccination programme in schools, the government would need to “support such a programme with appropriate public information to provide reassurance to parents and dispel any myths”.

In reality, though, that public information blitz would have to come much earlier, because it’s not just when children are the focus that vaccine hesitancy - and the by-products of that - are likely to hit schools. The issue of whether a teacher or parent is vaccinated will potentially be causing challenges long before that point.

How significant might those challenges be?

Jamie Murphy, a professor of psychology at Ulster University, is part of a team of researchers who have been looking at Covid vaccine hesitancy since the pandemic began via a longitudinal survey of around 3,000 people in Ireland and the UK. Their study began when Covid vaccines were hypothetical and is now assessing public views with vaccines as reality.

“Vaccine hesitancy has been steadily increasing over the course of the pandemic,” says Murphy, who says it has risen from around 31 per cent among their survey respondents in March 2020 to around 36 per cent by early December 2020.

That’s around a third of those surveyed with reservations about having themselves vaccinated; in a school of 100 staff, that could be 33 refusing a vaccine.

The figures are even higher when the question is angled at parents specifically, and whether they would enable a child to be vaccinated.

“The vaccine hesitancy among parents is a little concerning,” Murphy says. The survey’s latest figures show about 52 per cent of parents to be vaccine hesitant, with 54 per cent hesitant about vaccines for their children.

A separate survey of parents by researchers at the London School of Hygiene and Tropical Medicine also shows that participants were “more likely to accept a Covid-19 vaccine for themselves than their child/children” (though the survey looked at parents with children aged 18 months or under).

What might these figures mean for schools?

Well, if we take the projections for parents alone, imagine a scenario where vaccine misinformation has spread via social media through a group of parents at a school, leading them to refuse the vaccine for their children and themselves, thus significantly reducing vaccine coverage at that school.

Staff are understandably worried. Other, vaccine-accepting, parents are alarmed. Some even refuse to send their children into school alongside children who haven’t been vaccinated.

In this situation, it would inevitably fall to school leaders to address the concerns of staff and parents. But just how much would heads be expected to do?

According to the law, the actions that heads could take would be limited. The Public Health (Control of Disease) Act 1984 states that members of the public should not be compelled to undergo any mandatory medical treatment, including vaccinations.

But what if we go a step further: let’s say we have a scenario in which school leaders are having to make decisions about pupils being able to attend school based on whether or not their family have had the vaccine. Or what if a teacher has refused a vaccine but children are yet to be vaccinated, and parents refuse to send their children in as a result - would a head have to choose between a teacher being in school or the pupils?

Admittedly, this sounds extreme, but it is not totally out of the question. As the pandemic progresses, the idea of introducing so-called “vaccine passports” to attend certain workplaces or venues, such as pubs or theatres, has been gathering steam. Although the government previously dismissed the idea of a certificate to prove your vaccine status, on the basis that this would be “discriminatory”, Boris Johnson has now promised a review on the issue.

If some form of vaccine passport for access to public places were to become a reality, or if vaccination became a condition of employment when working with children - much like a DBS check - and it fell to heads to enforce this in schools, where would school leaders stand on this issue?

Kulvarn Atwal, executive headteacher of two large primary schools in the London Borough of Redbridge, does not believe that this is a role that school leaders should fulfil.

“I don’t think that we should be put in that position at all, particularly in relation to existing staff, as [accepting the vaccine] is voluntary and there are employment laws in place. And definitely not in relation to students, as they have a right to an education and we shouldn’t deny them that,” he says.

The Equality Act 2010, which legally protects people from discrimination in the workplace and in wider society, would come into play here. According to Matthew Wolton, partner at legal firm VWV LLP, if a member of staff could show that they were refusing the vaccine based on religious or health grounds (or other protected characteristic under the Act), then a school would need to take this into account when considering their approach.

There are some big legal hurdles for the government to overcome if it does decide to make vaccines mandatory for anyone, then. However, Atwal adds that if being able to prove that you have had the vaccine does become a condition of employment for teachers, he would, of course, comply with the law here. “As always, we would follow national and local guidance, which should advise us,” he says.

Atwal’s view that leaders should not be expected to advocate for the vaccine among staff, unless they are compelled to do so by law, is shared by those working in secondary schools.

“I would not bring up the issue [of vaccines] at all, but if a member of staff asked me about it, I would have a polite conversation about the relative pros and cons,” says one secondary school senior leader, based in the South East of England, who wishes to remain anonymous.

“[My leadership team and I] believe if we took a side, similar to politics, it might be using our position to influence others and morally I am not sure I am comfortable with this. I have my own personal opinion, and they are entitled to theirs,” he adds.

But this doesn’t mean that school leaders are against working to support the vaccine rollout. On the contrary, the senior leader in the South East believes that schools can help to raise awareness about Covid-19 vaccines, particularly when it comes to educating children. This can be done without crossing the line into advocacy, he says.

“We believe we have a duty to make sure students are given the facts. This is not to try and persuade anyone to take the vaccine, but to enable them to make an informed decision,” he explains.

As such, he adds, his school has recently rearranged its religious education curriculum to make sure that students cover the ethics of vaccination. The science and statistics behind vaccination will also be covered through science lessons.

Atwal points out that a similar approach can be taken to addressing concerns among parents and staff. Rather than policing communities, he believes that school leaders should be working with communities to increase understanding about the vaccines.

“I would want to address the concerns in the community, definitely,” he says.

Most school leaders would probably agree with that sentiment: some would voluntarily advocate for vaccines and others would do so if the government prescribed it. So, if the government stops short of mandatory vaccines for those in schools and instead goes down the advice and mediation route, how should heads address vaccine hesitancy in practice? What steps can school leaders take to help their communities?

To start with, researchers argue that it is important to understand why certain people might hold these views and where their distrust for the Covid-19 vaccine might stem from. There are “different streams of vaccine-hesitant people and you have to address them differently, depending on what their underlying concerns are”, says Stephan Lewandowsky, chair in cognitive psychology at the University of Bristol and lead author on the Covid-19 Vaccination Communication Handbook.

That guide, produced by an international group of scientists pulling together a wealth of research, bills itself as being for “journalists, doctors, nurses, policymakers, researchers, teachers, students, parents - in short, it’s for everyone who wants to know more” about the Covid vaccines, how to talk to others about them, and how to challenge misinformation.

According to the handbook, the vaccine-hesitant include those who “oppose the vaccine for ideological reasons because Covid-19 and the response to it have become politicised in some countries”. And where that occurs, “opposition is generally greater on the political right and among populists”.

Meanwhile, people from ethnic minorities, LGBTQ+ people, homeless people, people with low incomes, people with disabilities “and other marginalised populations traditionally face obstacles and inequalities in healthcare”, and “may also have collective histories of experience with medical malpractice that affect current trust”.

Additional groups of the vaccine hesitant include people who “understand the need for a Covid-19 vaccine but have safety concerns” and the “third of people who are not intending to be vaccinated against Covid-19 [who] are committed vaccination opponents and often believe in conspiracy theories”, the handbook says.

Those conspiracy theories spread easily on social media and can be hard to argue against. We’ve all heard the falsehoods: that Bill Gates is using the vaccine to implant people with trackable microchips; that vaccines turn people weightless and Nasa is using them to float people up to the Moon as a substitute for the space programme; that vaccines make you like aubergines. A couple of these might not have had much exposure yet - but they could still make it on to your Facebook feed.

“There’s nothing surprising about these conspiracy theories; any pandemic is ripe for them,” says Lewandowsky. “People try to control their fear … one way to do that is to deny the problem.”

The psychological factors underlying vaccine hesitancy have also been analysed by Murphy and colleagues through their survey. The results, published in the journal Nature Communications in January, show that vaccine-hesitant/resistant respondents across Ireland and the UK “differed on a number of sociodemographic and health-related variables but were similar across a broad array of psychological constructs”.

The research reports that the vaccine- hesitant/resistant were “distinguished from their vaccine-accepting counterparts by being more self-interested, more distrusting of experts and authority figures (ie, scientists, healthcare professionals, the state), more likely to hold strong religious beliefs … and also conspiratorial and paranoid beliefs”.

They were also “more likely to believe that their lives are primarily under their own control, to have a preference for societies that are hierarchically structured and authoritarian”, to be “more impulsive in their thinking style” and have “a personality characterised by being more disagreeable, more emotionally unstable, and less conscientious”.

There is a lot to unpack in that list of characteristics and much of it is out of a headteacher’s control. However, given the scepticism felt towards experts among the vaccine hesitant and resistant, the study suggests that “the early and frequent engagement of religious and community leaders” in vaccine messaging could be the key to winning over this group. Could that include school leaders?

“Very much so,” thinks Murphy, who suggests that having such alternative figures involved could help to overcome “intolerance of information from scientific experts or authority figures” among the vaccine hesitant or resistant.

But faced with all the various types of anti-vaccine sentiment, would headteachers even be willing to dip into advocacy? This would certainly go against the usual approach that school leaders would take around the vaccination programmes that currently take place in schools - such as the HPV vaccine.

“If a parent refused consent [for the HPV vaccine], then we would accept that was their choice,” explains a senior leader at a secondary school in the South West of England, who wishes to remain anonymous.

“If they had questions about the vaccine, then, in the first instance, we’d pass it to the head of year to speak to the parents. However, it would usually be referred on to the vaccination team.

“If there was a conflict between parent consent and a child - ie, the child wanted the vaccine but the parents hadn’t consented, or vice versa - then [again] the vaccination team would deal with it,” she adds.

There may not be a precedent here, but if heads do wish to be an advocate for the Covid-19 vaccine - or are made to be - apart from being a vocal supporter, what will be the best way to do it?

While research into effective strategies for overcoming vaccine hesitancy is somewhat thin on the ground, it seems that dialogue-based interventions could be the most helpful. This was a key finding of a 2014 review into strategies for addressing vaccine hesitancy (Jarrett et al).

This basically means talking to any teacher or parent who is hesitant about the vaccines, but that talk should be of a certain type. Penalising people or being confrontational is unlikely to be effective.

In those discussions, showing empathy will be important, Murphy says. So school leaders may need to put their own views aside when addressing any parental concerns.

“There are legitimate reasons for people to be hesitant,” says Murphy. “These are new vaccines.”

His team’s research shows that vaccine hesitancy is higher among groups such as those with serious health conditions (in Ireland) and pregnant women (in the UK), whose concerns are in many ways understandable.

This is why language is also very important - not just the language used with these groups but the language a head may use in private, which then colours their opinion of these people.

Murphy and his team avoid the generic label “anti-vaxxers”. There are different groups - the hesitant, the resistant - acting for different reasons, and it’s important not to “castigate a particular group for holding those positions”, Murphy says.

Australian researchers who interviewed “non-vaccinating” parents noted the “animosity” around the topic, including the use of “such labels as ‘irresponsible rogues’ by a state health minister, and ‘anti-vax dingbats’ and ‘baby killers’ in a national news outlet”. That type of language can have “a polarising and subsequently detrimental effect on public health advocacy”, they warn.

Of course, that’s preaching to the converted: most school leaders are naturally empathetic types, who are used to diplomacy and would never call a parent a dingbat (even when a parent is being a dingbat).

But there is another factor to tackle that comes up time and again in debates around vaccine hesitancy throughout history, and that is a lack of trust. And here is a huge barrier that heads may struggle to overcome, no matter what they do.

Writing in a blog post discussing the findings of a survey into Covid-19 vaccine hesitancy, Daniel Freeman, professor of clinical psychology in the department of psychiatry at the University of Oxford, points out that vaccine scepticism “is linked to a wider crisis of trust” that currently exists in society.

“This is all taking place after a long period in which trust in science, medicine and key institutions has been steadily eroded,” he writes. “We can’t overcome the virus if health experts aren’t trusted; yet that’s exactly how many people have been primed to react.”

This raises a bigger question about the role that schools can play in tackling vaccine hesitancy. If the real issues are, indeed, systemic, how far can headteachers really be expected to shoulder the burden of addressing those issues themselves?

Given that tackling vaccine hesitancy could be crucial to the success of national efforts to bring Covid-19 under control, the hope would be that any actions a headteacher takes here could be informed by clear and timely guidance from the government.

Yet throughout this pandemic, headteachers have time and time again been left to make the critical decisions about the best way to manage unprecedented scenarios - be that how to ensure that social distancing happens safely in schools, how to provide all students with access to remote learning or how to implement a mass coronavirus testing programme at short notice (during the Christmas holidays, no less).

Given that track record, it seems that school leaders can certainly not assume that the matter of addressing vaccine hesitancy in their communities will be taken off their hands. That means they will need to start considering the legal, moral, health and psychological issues at play here now, so that if those issues do come to a head in the future, they will be ready to face them.

John Morgan is a freelance journalist

This article originally appeared in the 12 Month 2021 issue under the headline “Schools’ vaccination quandary”