ABSTRACT
Understanding vaccine confidence among children and adolescents is important for sustaining high immunization coverage and trust in vaccination programmes because young people may participate in decisions about their vaccinations. However, little is known about how young people themselves perceive vaccines and access information. A national web-based survey on vaccination was conducted in March 2025 among 8 to 19-y-olds in Norway (n = 857). Most respondents expressed high confidence in vaccine effectiveness and safety, although confidence was lower for safety than for effectiveness. Confidence in vaccine safety differed by age group and was higher among children (age 8 to 11 y) than adolescents. Confidence in vaccine effectiveness and safety differed by parental education level and was higher among those with higher-educated parents. Parents were the primary vaccine information source (52%), followed by school health nurses (25%) and the internet (15%). With increasing age, the importance of parents decreased, and the importance of school health nurses and the internet increased. Citing parents as the primary information source was associated with higher vaccine confidence. Among adolescents who reported encountering vaccine-related content on social media, 28% had seen messages portraying vaccines as good, 21% as bad, and 39% as both good and bad. Being exposed to social media content portraying vaccines as bad was associated with lower confidence in vaccine effectiveness. These findings suggest that vaccine confidence among children and adolescents is associated with social and informational contexts that may change with age, which is important for informing age-appropriate strategies for vaccine communication.
KEYWORDS: Vaccine acceptance, vaccine hesitancy, vaccine confidence, childhood vaccination, preventive health behavior, social media, children, adolescents
Introduction
The success of population-based immunization programmes depends on achieving high coverage to protect both vaccinated individuals and the wider community from infectious diseases.1 School-aged children and adolescents are the direct recipients of vaccination, yet their perspectives and agency in decision-making are often overlooked in research on vaccine uptake. Most studies focus on parental attitudes and health system delivery,2 with less attention to how young people themselves engage with information and form opinions. However, despite parents’ central role in vaccination decisions, children and adolescents may often be exposed to vaccine-related information from multiple sources and may begin to form their own views before they are legally entitled to consent. As digital technologies continue to expand, both the ways and the extent to which young people are exposed to vaccine information are changing, with growing influence from the internet, social media and artificial intelligence. The importance of understanding how young people’s views are formed is also underscored by the fact that some adolescents may be involved in decisions regarding their own vaccination.3,4 Furthermore, childhood and adolescence represent formative stages in which health-related attitudes and behaviors may be established,5–7 and the views formed at this stage may influence vaccination decisions and trust in immunization throughout adulthood.
Most studies investigating attitudes toward childhood and adolescent vaccination focus on parents,2 while those that examine the vaccine-eligible population itself typically target adolescents and their perceptions of vaccines against human papillomavirus (HPV), meningococcal disease, or COVID-19. Recent reviews of this literature indicate that many adolescents express confidence in vaccination and are influenced by parental norms, but that hesitancy and safety concerns are also common, and that attitudes vary considerably across studies, vaccine types, and sociocultural contexts.8–10 In contrast, research exploring the views of younger children and pre-adolescents remains scarce.
The Childhood Immunisation Programme (CIP) in Norway offers vaccines against 12 infectious diseases to all resident children. Participation is voluntary, and all vaccinations are provided free of charge. For preschool-aged children, vaccines are administered through child health clinics, with several doses scheduled during the first two years of life. School-aged children are routinely vaccinated through the school health service in grade 2 (diphteria, tetanus, pertussis, inactivated polio combination vaccine (DTP-IPV)), grade 6 (measles, mumps, rubella combination vaccine (MMR)), grade 7 (human papillomavirus (HPV)), and grade 10 (diphteria, tetanus, pertussis, inactivated polio combination vaccine booster (dTp-IPV)), corresponding to approximately ages 7, 11, 12, and 15 y. Primary care physicians generally do not participate in the administration of childhood vaccines in Norway. Parents receive information and reminders from the child and school health services and retain the legal right to consent to their child’s vaccinations until the child turns 16. The Patient and User Rights Act also states that children who are capable of forming their own views on the provision of healthcare shall be given information and heard, and that due weight shall be given to the child’s opinion, in accordance with the child’s age and maturity.11 Thus, while parents hold the legal right of consent throughout the routine CIP schedule, the law recognizes the importance of the child’s perspective. In addition, if a scheduled CIP vaccine is missed, it remains available free of charge until age 20, meaning that adolescents can self-consent to catch-up vaccination once they reach 16 y of age.
Coverage for CIP vaccines is consistently high. Among 2-y-olds, national coverage exceeds 95% for all vaccines. At age 9, coverage is 94% for the most recent DTP-IPV dose and 97% for MMR. At age 16, coverage is 93% and 94% for the most recent dTp-IPV and MMR doses, respectively, and 93% and 90% for completion of the two-dose HPV series among girls and boys, respectively.12
Previous surveys have demonstrated high confidence in childhood vaccination among adults in Norway,13,14 but little is known about vaccine confidence among the target population of the CIP. This study aimed to investigate, among children and adolescents in Norway: (1) confidence in vaccine effectiveness and safety; (2) sources of vaccine information; and (3) associations between vaccine confidence and sources and content of vaccine information.
Methods
Study population and procedures
We conducted a web-based survey targeting children and adolescents aged 8 to 19 y residing in Norway, corresponding to a target population of approximately 792,000 individuals in this age group. Respondents were recruited from the ISO-certified Ipsos web panel, which is open to all and comprises approximately 100,000 individuals who are representative of the Norwegian population in terms of age, sex and geographical region (Oslo; East (Akershus, Buskerud, Innlandet, Telemark, Vestfold, Østfold); West (Agder, Rogaland, Vestland); Central (Møre og Romsdal, Trøndelag), North (Nordland, Troms, Finnmark)). The data were collected from March 7 to March 27, 2025, by the market research and consulting firm Ipsos on behalf of the Norwegian Institute of Public Health.
To balance statistical precision with practical considerations, the target sample size was set to a minimum of 750 respondents, with at least 250 in each of three age groups (8 to 11, 12 to 15, 16 to 19 y), ensuring a reasonable margin of error and allowing analyses across broad sociodemographic categories. Adolescents aged 16 to 19 y were recruited directly from the panel. Children aged 8 to 15 y were recruited through their parents by targeting panelists who had previously indicated to the panel provider that they had a child in this age range, as well as panelists in age groups considered likely to have a child aged 8 to 15 y.
Parents were instructed: “Please respect the participant’s right to respond confidentially, unless the child requests assistance and is under 10 y of age.” Eligible panelists were notified about the survey through e-mail, app, browser or SMS (according to their own preferences), and accessed the survey via a unique URL. Respondents earned 1,000 points for completing the survey, equivalent to approximately 1 USD, which could be redeemed for gift cards. Additionally, all respondents were entered into a lottery for 20 gift cards, with a combined total value of approximately 2,400 USD.
All respondents actively consented to participate, with parental and child consent obtained for children aged 8 to 15 y. According to the Norwegian Health Research Act, ethical approval is required only for research intended to generate new knowledge about health or disease.15 This study consisted solely of questionnaire data on attitudes toward vaccination and did not generate health-related data. Therefore, it falls outside the scope of the Act and did not require ethical approval. Only anonymous data was accessible to the research team. The study complied with the requirements of the Norwegian Personal Data Act and the General Data Protection Regulation (GDPR).
Questionnaire development and items
The questionnaire was developed by the CIP team at the Norwegian Institute of Public Health in collaboration with survey experts and technical staff at Ipsos. The items were phrased in simple, age-appropriate language and limited in number to minimize the cognitive burden for young participants. Draft items were reviewed for clarity, relevance, and alignment with study objectives by the full development team, which included expertise in vaccinology, pediatric infectious diseases, public health nursing, epidemiology, communication, and behavioral science. A draft questionnaire was piloted with five children and adolescents (aged 8, 11, 13, 15, and 19 y) and revised based on their feedback. The final version was subsequently field-tested with eligible respondents to assess technical performance and usability. No comprehension or usability issues were identified, and the survey was then launched to the full target population. These development procedures support content and face validity, although formal psychometric validation of the questionnaire was not undertaken.
At the start of the survey, respondents reported their age. Age-eligible respondents were then shown a brief introductory text that provided contextual information about vaccination. The text read: “All children and adolescents in Norway are offered vaccines through the childhood immunisation programme, and vaccines can also be taken throughout life. We will now ask you some questions about vaccines in general. This includes all vaccines you are familiar with.” The questionnaire comprised 11 items related to vaccines, of which five addressed the objectives of the present study and are analyzed here.
The first two items assessed confidence in vaccines. Respondents were asked to indicate their agreement with the statements “I think vaccines protect me from disease” (vaccine effectiveness) and “I think vaccines can be harmful for me” (vaccine safety) using a five-point Likert scale ranging from “Completely agree” to “Completely disagree.” Consequently, the direction of the Likert scale in terms of confidence was opposite for the two items, with complete vaccine confidence expressed by “Completely agree” for effectiveness and “Completely disagree” for safety.
The third item was: “Who would you primarily ask if you had questions about vaccines?” Response options were parents/guardians, school health nurse, internet search, teacher, friends, other, and don’t know. The order of response options was randomized for each respondent, except for “other” and “don’t know,” which were always presented last.
The remaining items assessed exposure to vaccine-related content on social media. Respondents were first asked: “Have you read or heard about vaccines on social media, for instance on TikTok, Snapchat, Facebook, Instagram or YouTube?” Those who answered “Yes” were then asked: “Was what you read or heard about vaccines on social media any of the following?” with response options: “Information that said vaccines are good,” “Information that said vaccines are bad,” “Information that said vaccines are both good and bad,” “None of the above,” and “Don’t remember.” Questions on social media exposure were administered only to respondents aged 12 to 19 y, since most social media platforms in Norway require users to be at least 13 y old.
The survey also included additional items on social media use and behavior commissioned by other parties.
Statistical analysis
We present analyses by sex, age groups (8 to 11, 12 to 15, 16 to 19 y) and parental education level using Rao – Scott design-adjusted tests of association for complex survey data. Test statistics were reported as F statistics, which are a standard transformation of the Rao – Scott adjusted chi-square and account for the survey design.16,17 To assess the association between confidence in vaccine effectiveness and safety, we used Spearman’s rank correlation on the Likert-scale confidence scores. For this analysis, responses were coded so that higher scores indicated greater confidence for both items.
Multivariable-adjusted associations between vaccine confidence and information sources or social media content were estimated using binary logistic regression models. For these analyses, each Likert-scale item was dichotomized to capture complete confidence in vaccine effectiveness or safety. Specifically, responses indicating the highest level of confidence (i.e., “Completely agree” for vaccine effectiveness and “Completely disagree” for vaccine safety) were coded as 1, while all other response categories were coded as 0. This approach aligns with the conceptualization of vaccine hesitancy as a continuum ranging from complete acceptance to refusal of vaccines18 and distinguishes respondents expressing unequivocal confidence from those reporting any degree of uncertainty or hesitation. The most confident response category therefore uniquely reflects the absence of doubt, whereas all other responses indicate some level of reservation. We also report sensitivity analyses using an alternative dichotomization of the Likert responses in the Supplementary Material.
To ensure adequate cell sizes and stable statistical estimates, parental education level was dichotomized into two categories: “low” (up to and including upper secondary or vocational school) and “high” (university education). Similarly, for the analyses of primary information sources, the categories “teacher,” “friends,” and “other” were combined into a single category (“other”) due to small numbers of respondents selecting each option.
We performed sensitivity analyses excluding children aged 8 to 9 y, as these respondents may have received assistance from a parent when completing the survey items.
All estimates were weighted to match the distributions of age, sex, and geographic region in the general population, based on official statistics from Statistics Norway. Calibrated survey weights were generated using the calibrate() function with the raking method from the survey package in R,17 adjusting iteratively across 30 cross-classified cells defined by age group, sex, and region (Supplementary table 1). Weighted sample sizes are reported as rounded integers in the tables; category totals may therefore not sum exactly to the overall sample size. Percentages were calculated from unrounded weighted values. The application of survey weights had only a moderate effect on the demographic distributions (Table 1), indicating good alignment between the unweighted sample and the general population with respect to the weighting variables.
Table 1.
Characteristics of the study population.
| Unweighted N (%) | Weighted N (%)a | Chi-squared testb | |
|---|---|---|---|
| Total | 857 (100) | 857 (100) | |
| Sex | |||
| Male | 409 (47.7) | 442 (51.6) | |
| Female | 448 (52.3) | 415 (48.4) | χ2 = 2.4, P = .12 |
| Age group (years) | |||
| 8–11 | 262 (30.6) | 273 (31.9) | |
| 12–15 | 275 (32.1) | 291 (34.0) | |
| 16–19 | 320 (37.3) | 293 (34.2) | χ2 = 1.9, P = .39 |
| Parental education | |||
| Lowc | 160 (18.7) | 164 (19.1) | |
| Highd | 608 (70.9) | 603 (70.3) | |
| Missing | 89 (10.4) | 91 (10.6) | χ2 = 0.1, P = .96 |
| Region of residence | |||
| Oslo | 127 (14.8) | 94 (11.0) | |
| East | 352 (41.1) | 333 (38.9) | |
| South/West | 207 (24.2) | 242 (28.2) | |
| Central | 104 (12.1) | 117 (13.7) | |
| North | 67 (7.8) | 71 (8.3) | χ2 = 9.1, P = .06 |
aWeighted by sex, age and region of residence.
bTest for differences in distribution between unweighted and weighted populations.
cBoth parents ≤ Upper secondary school, or vocational school.
dAt least one parent with university education.
All survey items had a “don’t know” or “don’t remember” answer option. We report the frequency of these answers, but they are treated as missing in the statistical analyses. We had complete information on sex and age of the respondents, but lacked information on parental education for 89 children, who were excluded from analyses that included parental education. Sample sizes can thus differ between analyses.
Analyses with p-values below 0.05 were considered statistically significant. All data management and statistical analyses were conducted using R 4.4.0.
Results
A total of 857 children and adolescents aged 8 to 19 y responded to the survey. The mean (standard deviation) age of the respondents was 13.9 (3.5) y.
Confidence in vaccine effectiveness and safety
The majority (77.8%) of respondents completely agreed to the statement “I think vaccines protect me from disease,” thus expressing complete confidence in vaccine effectiveness (Table 2). The degree of agreement did not differ by sex or by age group, but there was a significant difference by parental education level (F = 5.9, p = .0001). The weighted marginal distributions showed a higher proportion of complete confidence in vaccine effectiveness among respondents with highly educated parents (Table 2 and Figure 1(a)).
Table 2.
Vaccine confidence and information sources among children and adolescents aged 8 to 19 y in Norway, N (%).
| Sex |
Age group (years) |
Parental education |
||||||
|---|---|---|---|---|---|---|---|---|
| Total | Male | Female | 8 to 11 | 12 to 15 | 16 to 19 | Lowa | Highb | |
| ‘I think vaccines protect me from disease’ | ||||||||
| Completely agree | 636 (77.8) | 316 (75.6) | 320 (80.0) | 213 (82.2) | 210 (76.7) | 213 (74.8) | 104 (65.8) | 478 (82.6) |
| Partly agree | 136 (16.7) | 79 (18.9) | 57 (14.3) | 30 (11.6) | 51 (18.6) | 55 (19.4) | 38 (24.0) | 78 (13.5) |
| Neither agree nor disagree | 29 (3.6) | 15 (3.5) | 15 (3.7) | 13 (4.8) | 6 (2.3) | 11 (3.8) | 12 (7.4) | 14 (2.4) |
| Partly disagree | 6 (0.8) | 2 (0.6) | 4 (1.0) | 0 (0.0) | 4 (1.5) | 2 (0.8) | 3 (1.9) | 3 (0.5) |
| Completely disagree | 10 (1.2) | 6 (1.4) | 4 (1.0) | 4 (1.4) | 2 (0.9) | 3 (1.2) | 1 (0.8) | 6 (1.1) |
| Design-adjusted chi-square testc | F = 0.9, P = .44 | F = 1.6, P = .13 | F = 5.9, P = .0001 | |||||
| Don’t know | 40 | |||||||
| ‘I think vaccines can be harmful for me’ | ||||||||
| Completely agree | 43 (5.7) | 20 (5.2) | 23 (6.1) | 12 (5.6) | 19 (7.2) | 12 (4.3) | 6 (4.4) | 33 (6.0) |
| Partly agree | 73 (9.6) | 47 (12.2) | 26 (7.0) | 17 (7.8) | 25 (9.5) | 32 (11.1) | 14 (9.5) | 55 (10.1) |
| Neither agree nor disagree | 104 (13.6) | 55 (14.1) | 50 (13.1) | 19 (8.4) | 46 (17.6) | 40 (14.0) | 31 (21.6) | 58 (10.6) |
| Partly disagree | 151 (19.8) | 71 (18.3) | 81 (21.3) | 31 (14.0) | 50 (19.3) | 70 (24.7) | 27 (18.8) | 101 (18.7) |
| Completely disagree | 393 (51.4) | 194 (50.2) | 199 (52.5) | 142 (64.3) | 122 (46.4) | 130 (45.9) | 66 (45.6) | 297 (54.6) |
| Design-adjusted chi-square testc | F = 1.6, P = .16 | F = 3.4, P = .0007 | F = 3.1, P = .01 | |||||
| Don’t know | 91 | |||||||
| Primary vaccine information source | ||||||||
| Parents | 428 (51.6) | 204 (48.3) | 224 (55.1) | 180 (68.7) | 141 (50.6) | 107 (37.1) | 70 (44.8) | 330 (56.0) |
| School health nurse | 206 (24.9) | 109 (25.8) | 97 (23.9) | 49 (18.8) | 75 (27.0) | 81 (28.3) | 43 (27.7) | 133 (22.5) |
| Internet | 121 (14.5) | 69 (16.3) | 52 (12.8) | 12 (4.4) | 35 (12.4) | 74 (25.9) | 28 (17.9) | 78 (13.3) |
| Other | 74 (9.0) | 41 (9.7) | 34 (8.3) | 21 (8.1) | 28 (10.0) | 25 (8.7) | 15 (9.7) | 48 (8.1) |
| Design-adjusted chi-square testc | F = 1.4, P = .23 | F = 12.4, P < .0001 | F = 2.0, P = .11 | |||||
| Don’t know | 28 | |||||||
| Have been exposed to social media vaccine informationd | ||||||||
| Yes | 252 (52.1) | 121 (48.5) | 131 (55.8) | – | 95 (40.2) | 157 (63.4) | 49 (51.1) | 170 (51.8) |
| No | 232 (47.9) | 128 (51.5) | 104 (44.2) | – | 141 (59.8) | 91 (36.6) | 46 (48.9) | 158 (48.2) |
| Design-adjusted chi-square testc | F = 2.5, P = .11 | F = 24.7, P < .0001 | F = 0.01, P = .91 | |||||
| Don’t know | 101 | |||||||
aBoth parents ≤ Upper secondary school, or vocational school.
bAt least one parent with university education.
cTwo-way Rao-Scott design-adjusted chi-square reported as an F-statistic.
dThis item was not presented to the 8 to 11 y age group.
Significant estimates shown in bold.
All estimates weighted by sex, age and geographical region.
Figure 1.
Confidence in (a) vaccine effectiveness, and (b) vaccine safety among children and adolescents aged 8 to 19 y in Norway by parental education level (High: at least one parent with university education; Low: both parents ≤ upper secondary school, or vocational school). Estimates weighted by sex, age and geographical region.
High confidence in vaccine safety, expressed as “Completely disagree” to the statement “I think vaccines can be harmful for me,” was reported by 51.4% of the respondents (Table 2). The degree of confidence did not differ by sex, but there was a significant difference by age (F = 3.4, p = .0007). The weighted marginal distributions showed that the youngest age group (8 to 11 y) had a higher proportion expressing complete confidence in vaccine safety compared with the older age groups (Table 2). Moreover, confidence in vaccine safety also differed by parental education level (F = 3.1, p = .01). A higher proportion expressing complete confidence in vaccine safety was observed among respondents with highly educated parents (Table 2 and Figure 1(b)).
The correlation between confidence in vaccine effectiveness and safety was moderate but highly significant (Spearman’s rho = 0.38, p < .0001).
Sensitivity analyses excluding children aged 8 to 9 y produced results similar to the main analyses (Supplementary table 2).
Primary vaccine information sources
Parents were the primary vaccine information source for most respondents, followed by school health nurses and the internet, reported by 51.6%, 24.9% and 14.5%, respectively, among those who indicated a primary vaccine information source. The distribution of the primary information source did not differ significantly by sex or by parental education level. However, 44.8% of the respondents with parents of low education reported parents to be the primary information source, compared to 56.0% among respondents with parents of high education (Table 2). There was a significant difference in the primary information source by age group (F = 12.4, p < .0001). Weighted marginal distributions showed that the proportion of respondents citing parents as their primary vaccine information source decreased with age, while the proportion citing the internet or the school health nurse increased (Table 2 and Figure 2). Sensitivity analyses that excluded children aged 8 to 9 y produced results similar to the main analyses (Supplementary Table 2).
Figure 2.
Preferred vaccine information source among children and adolescents in Norway by age group. Estimates weighted by sex, age and geographical region.
Children and adolescents who identified parents as their primary source of vaccine information reported a significantly higher proportion of complete vaccine confidence than those who identified the school health nurse, the internet, or other sources. After adjustment for age, sex, and parental education, these differences remained significant for vaccine confidence in both effectiveness and safety (Table 3). Sensitivity analyses excluding children aged 8 to 9 y from the analysis yielded similar results (Supplementary table 3). Using an alternative outcome definition that combined complete and partial vaccine confidence, yielded similar effects as the main analyses for vaccine safety, but non-significant effects for vaccine effectiveness (Supplementary Table 4).
Table 3.
Associations between complete vaccine confidence and primary vaccine information source among children and adolescents aged 8 to 19 y in Norway.
| Effectiveness: ‘I think vaccines protect me from disease’ |
Safety: ‘I think vaccines can be harmful for me’ |
|||||||
|---|---|---|---|---|---|---|---|---|
| Primary vaccine information source | N total | N (%) completely agree | adj OR (95% CI)a | Pa | N total | N (%) completely disagree | adjOR (95% CI)a | Pa |
| Parents | 410 | 349 (85.3) | 1 (reference) | 372 | 238 (64.1) | 1 (reference) | ||
| School health nurse | 200 | 144 (72.1) | 0.46 (0.29 to 0.74) | .001 | 191 | 84 (44.0) | 0.47 (0.33 to 0.67) | <.0001 |
| Internet | 121 | 91 (75.5) | 0.54 (0.31 to 0.95) | .03 | 117 | 46 (39.0) | 0.41 (0.26 to 0.65) | .0002 |
| Other | 68 | 41 (61.0) | 0.30 (0.16 to 0.56) | .0001 | 69 | 21 (29.9) | 0.24 (0.13 to 0.44) | <.0001 |
aEstimates adjusted by sex, age and parental education. adjOR = adjusted odds ratio, CI = confidence interval.
All estimates weighted by sex, age and geographical region.
Social media exposure
Social media use was very common in the population, and especially in the older age groups. Daily use increased with age across all social media platforms, except for YouTube, which was the only platform commonly used by those aged 8 to 11 y. Snapchat and TikTok had the highest number of users. Nearly all respondents aged 12 or older reported daily use of at least one social media platform (Table 4).
Table 4.
Social media use among children and adolescents aged 8 to 19 y in Norway, N (%).
| Age group (years) |
|||||
|---|---|---|---|---|---|
| Platform | Use frequency | Total | 8 to 11 | 12 to 15 | 16 to 19 |
| Daily | 158 (18.5) | 18 (6.6) | 52 (17.9) | 88 (30.0) | |
| Occasional | 273 (31.9) | 23 (8.4) | 88 (30.2) | 163 (55.6) | |
| Never | 425 (49.6) | 232 (85.0) | 151 (51.9) | 42 (14.3) | |
| Snapchat | Daily | 510 (59.5) | 38 (14.0) | 213 (73.2) | 259 (88.1) |
| Occasional | 103 (12.0) | 36 (13.2) | 37 (12.7) | 30 (10.2) | |
| Never | 244 (28.5) | 198 (72.8) | 41 (14.1) | 5 (1.7) | |
| TikTok | Daily | 431 (50.3) | 35 (12.8) | 176 (60.5) | 220 (75.1) |
| Occasional | 91 (10.6) | 26 (9.5) | 39 (13.4) | 26 (8.9) | |
| Never | 335 (39.1) | 212 (77.7) | 76 (26.1) | 47 (16.0) | |
| YouTube | Daily | 421 (49.1) | 142 (52.0) | 165 (56.7) | 115 (39.1) |
| Occasional | 375 (43.8) | 106 (38.8) | 117 (40.2) | 152 (51.7) | |
| Never | 61 (7.1) | 25 (9.2) | 9 (3.1) | 27 (9.2) | |
| Daily | 294 (34.3) | 17 (6.2) | 90 (30.8) | 187 (63.6) | |
| Occasional | 211 (24.6) | 24 (8.8) | 101 (34.6) | 87 (29.6) | |
| Never | 352 (41.1) | 232 (85.0) | 101 (34.6) | 20 (6.8) | |
| Ever use of any SoMea | Yes | 835 (97.4) | 251 (91.9) | 291 (100) | 293 (100) |
| No | 22 (2.6) | 22 (8.1) | 0 (0) | 0 (0) | |
| Daily use of any SoMea | Yes | 729 (85.1) | 171 (62.6) | 272 (93.5) | 286 (97.6) |
| No | 128 (14.9) | 102 (37.4) | 19 (6.5) | 7 (2.4) | |
aUse of any of the social media platforms listed in the table.
All estimates weighted by sex, age and geographical region.
Among respondents who recalled whether they had encountered vaccine information on social media, exposure was reported by approximately half (Table 2). The distribution did not differ by sex or parental education (F = 2.5, p = .11; F = 0.01, p = .9, respectively), but differed significantly by age (F = 24.7, p < .0001), with a markedly higher proportion of exposure among 16 to 19-y-olds than 12 to 15-y-olds. Sensitivity analyses with alternative coding of those who did not recall whether they had encountered vaccine information on social media gave similar results (Supplementary table 5). Among the 252 respondents who reported exposure to vaccine information on social media, 27.7% reported the content indicated that vaccines are good, 21.0% that vaccines are bad, and 39.1% that vaccines are both good and bad. The remaining respondents reported that the content fit none of these categories (3.4%) or that they did not remember (8.8%).
Compared with adolescents who had been exposed to social media content portraying vaccines as good, those exposed to content portraying vaccines as bad reported a significantly lower frequency of complete confidence in vaccine effectiveness (Table 5). No other significant differences were observed among adolescents exposed to positive, negative, or mixed vaccine-related content on social media in terms of the reported frequencies of complete (Table 5) or of complete or partial (Supplementary Table 6) confidence in vaccine effectiveness or safety.
Table 5.
Associations between complete vaccine confidence and exposure to vaccine content on social media among adolescents aged 12 to 19 y in Norway.
| Effectiveness: ‘I think vaccines protect me from disease’ |
Safety: ‘I think vaccines can be harmful for me’ |
|||||||
|---|---|---|---|---|---|---|---|---|
| Type of vaccine content exposure on social media | N total | N (%) completely agree | adjOR (95% CI)a | Pa | N total | N (%) completely disagree | adjOR (95% CI)a | Pa |
| “Vaccines are good” | 70 | 61 (87.5) | 1 (reference) | 69 | 31 (45.7) | 1 (reference) | ||
| “Vaccines are good and bad” | 98 | 83 (84.1) | 0.75 (0.31 to 1.86) | .54 | 97 | 41 (42.1) | 0.86 (0.46 to 1.61) | .64 |
| “Vaccines are bad” | 53 | 38 (72.3) | 0.37 (0.14 to 0.97) | .04 | 52 | 23 (43.8) | 0.92 (0.44 to 1.92) | .83 |
aEstimates adjusted by sex, age and parental education. adjOR = adjusted odds ratio, CI = confidence interval.
All estimates weighted by sex, age and geographical region.
Discussion
This national survey showed that vaccine confidence among children and adolescents in Norway is high, consistent with the country’s high coverage in the childhood immunization programme, including adolescent vaccines. Confidence was higher for vaccine effectiveness than for vaccine safety. Vaccine confidence was associated with parental education, with higher confidence observed among children and adolescents with highly educated parents. Parents were the primary source of vaccine information, particularly among younger respondents, while the importance of school health nurses and the internet increased with age. Respondents citing parents as their primary information source had the highest frequency of complete confidence in vaccine effectiveness and safety. Exposure to vaccine-related content on social media was often negative and was associated with a lower frequency of complete confidence in vaccine effectiveness.
Recent studies indicate that while adolescent confidence in vaccination is generally high, some adolescents also report concerns, particularly regarding vaccine safety.19–23 Our findings align with this pattern, showing high confidence in both vaccine effectiveness and safety, though confidence in safety was somewhat lower, including among children aged 8 to 11 y. This pattern is also consistent with extensive literature on vaccine hesitancy among adults, which similarly shows greater concern about safety than effectiveness.24,25 Although direct comparisons across studies are hampered by differences in study design and vaccination context, the confidence estimates of adolescents and children in the present study appear relatively high. This aligns with the generally high vaccination coverage among children and adolescents in the Norwegian CIP.12
We also found that the factors associated with confidence in vaccine safety and effectiveness were largely similar. Children and adolescents with higher-educated parents reported greater vaccine confidence, both regarding effectiveness and safety. International studies on adult populations have reported inconsistent associations between vaccine confidence and education level.26 Likewise, studies examining parental education or deprivation level in relation to childrens’ or adolescents’ vaccine hesitancy27 or intention to vaccinate28,29 against COVID-19 have yielded mixed results. The association between education level and vaccination thus appears to be context-specific. In the Norwegian context, adults with higher education show greater childhood vaccine confidence or readiness than those with lower education,13,30 which is consistent with the findings of the current study on the sub-adult population.
Our study shows that parents are an important source of vaccine information for young people, which supports continued efforts to keep parents well-informed about childhood and adolescent vaccination. This is consistent with recent research showing that parental norms play a key role in shaping adolescents’ vaccine acceptance and hesitancy.10,19 Moreover, school health nurses emerged as important sources of vaccine information, which also is consistent with findings from previous studies.19,31,32 In our study, the role of school health nurses as a primary source of vaccine information increased after primary school and remained largely stable throughout lower and upper secondary school.
We observed that confidence in vaccine safety was highest among the youngest respondents (8 to 11 y), with a similar, though non-significant, pattern for vaccine effectiveness. Children in this age group also reported relying more on their parents than on other sources of vaccination information, largely consistent with existing literature.8,19,33,34 These results should be interpreted cautiously since we did not control to what extent the respondents recruited to the survey through their parents may have been assisted by their parents when completing the survey. However, parental involvement in the children’s survey response was explicitly discouraged in the survey instructions. Moreover, sensitivity analyses excluding children aged 8–9 y, who were more likely to receive assistance from their parents when completing the questionnaire, consistently yielded results similar to those of the main analyses.
In contrast to our findings, Fazer et al.28 reported lower willingness to accept COVID-19 vaccination among children than among adolescents in England during the pandemic, underscoring the context-specific nature of vaccine attitudes. Relatively low COVID-19 vaccine acceptance among children may be expected, given that the risk – benefit balance of COVID-19 vaccination in this age group was debated, vaccination policies varied between countries, and coverage remained low.35–37 However, our study did not focus specifically on COVID-19 vaccination and was conducted several years after the pandemic. In this post-pandemic context, children in our sample expressed greater confidence in vaccination than did adolescents. A similar pattern was observed in a pre-pandemic study from Italy.34
In the present study, we found no evidence of gender differences in vaccine confidence among children and adolescents in Norway. This finding is consistent with several surveys conducted in other countries and contexts.20,27,38 Conversely, other studies have documented gender disparities,23,39,40 with females often showing lower confidence or willingness to be vaccinated than males. Taken together, the literature presents a mixed picture, suggesting that gender-related patterns in vaccine confidence also may be context- and vaccine-specific.
Few previous studies have quantified adolescents’ exposure to vaccine-related information on social media. We found that the reported exposure to vaccine-related content was moderate despite high overall social media use, suggesting that such content may not be highly prominent in the social media environments Norwegian adolescents typically engage with. Among those who reported exposure, a substantial proportion had encountered content portraying vaccines negatively. Our findings regarding associations between exposure to vaccine-related content on social media and confidence in vaccines should be interpreted cautiously due to limited data and the cross-sectional study design. Most analyses showed no significant association between social media exposure and vaccine confidence. However, a lower frequency of complete confidence in vaccine effectiveness was observed among adolescents exposed to negative vaccine-related content. Further research is needed to better understand how social media content may relate to adolescents’ views on vaccination.
Strengths and limitations
This is the first national survey to assess vaccine confidence and information sources among children and adolescents in Norway, and one of few studies internationally to obtain data directly from children on these topics. The use of a large, probability-based web panel enabled collection of data from a geographically and demographically diverse sample, which was weighted to reflect the corresponding national population. The questionnaire covered both confidence in vaccine effectiveness and safety, as well as the main channels through which young people receive vaccine information, allowing examination of associations rarely explored in this age group. However, the cross-sectional design precludes causal inference, and self-reported measures are subject to recall and social-desirability bias. The analyses are also prone to residual confounding, as we lacked information on several factors that may influence vaccine confidence, including parental vaccine confidence, prior vaccination experiences, and cultural influences. Moreover, younger respondents were recruited through their parents, which may have influenced participation or responses. A further limitation is that the number of eligible individuals reached during recruitment was unknown, precluding calculation of a response rate. Although the survey was weighted to national demographics, the panel-based recruitment may limit generalizability to adolescents less likely to participate in online panels. Finally, the survey did not distinguish between accurate information and misinformation encountered on social media, nor did it measure social media exposure frequency or engagement level, which could further clarify the role of digital content in shaping vaccine confidence.
Conclusions
Overall, the findings suggest that vaccine confidence among children and adolescents is shaped within a broad social context involving family, school health services, and digital media. The results also highlight the importance of considering age when investigating vaccine confidence in this population, as both confidence and the information environment may change with age. Future studies could build on these findings by more closely examining information dynamics within and between families and school health services, as well as by assessing how different types of online content relate to vaccine confidence among young people. Longitudinal designs may clarify how vaccine confidence develops across childhood and adolescence and how it interacts with changing information sources and content. In addition, repeated representative cross-sectional surveys of vaccine confidence among young people and their parents may serve as a useful surveillance tool for monitoring and sustaining high childhood vaccination coverage.
Supplementary Material
Acknowledgments
We wish to thank Ellen Furuseth, Anita Daae, Ingfrid B Østlie, Evy TD Furøy, Berit S Wiklund, Fredrik Skår and Ingunn H Tveteraas for questionnaire development, and Karen Lillebø and Karin Gram for questionnaire development and for conducting the survey.
Biographies
Bo Terning Hansen, PhD, is Senior Researcher at the Norwegian Institute of Public Health, specializing in preventive health behaviors and interventions.
Margrethe Greve-Isdahl, MD, is a paediatrician and Senior Medical Officer at the Norwegian Institute of Public Health and Programme Manager for the Childhood Immunisation Programme.
Funding Statement
The work was supported by the Norwegian Institute of Public Health.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
Data will be made available on request to the corresponding author.
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2639798
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
Data will be made available on request to the corresponding author.