When COVID-19 vaccines were first rolled out in the UK, most people were eager to get protected. But for a small group, the decision wasn’t straightforward.

Our recent study looked at how NHS healthcare professionals responded to exactly these concerns during the COVID-19 vaccine rollout, using real-world referral data and clinicians’ notes from an interim vaccine allergy advice service in Herefordshire and Worcestershire

What we found tells an important story about trust, anxiety, and how frontline decision-making really works in public health emergencies.

What was the problem?

Early in the rollout, the UK briefly paused use of the Pfizer-BioNTech vaccine for people with a history of severe allergies. Although this guidance was quickly reversed, the initial message travelled far, and the correction didn’t. As a result, GPs, pharmacists, and vaccination teams were suddenly faced with large numbers of people worried that:

1. past allergic reactions (sometimes from childhood) put them at high risk
2. ingredients like polyethylene glycol (PEG) could cause anaphylaxis
3. vaccination centres wouldn’t be able to help if something went wrong

In areas without a formal NHS allergy service (which is common), this created a bottleneck: Who actually needs specialist care, and who can be safely vaccinated in the community?

What did we study?

We analysed anonymised records from 326 people referred to a COVID-19 vaccine allergy advice service between 2021 and 2022. The data included referral forms completed by healthcare professionals, notes documenting patient concerns and the decisions made by GPs, pharmacists, and multidisciplinary specialist teams

Crucially, these weren’t research interviews, they were real clinical notes, written under pressure during a live public health response.

What did we find?

Very few people actually needed hospital vaccination

Despite widespread fear, almost no one was advised not to be vaccinated. Around 1 in 4 people were advised to vaccinate as normal in primary care. Another 3 in 10 were advised to vaccinate with simple precautions (e.g. antihistamines, longer observation). Only 0.9% were advised to vaccinate in hospital as a necessity. About 1 in 5 cases were reviewed by a specialist multidisciplinary team, most of whom still recommended community vaccination

This matters because it shows that severe vaccine allergy is rare, even among people who are worried they are high-risk.

Allergy histories were often complex or unclear

Healthcare professionals faced a huge range of allergy stories. These included severe reactions decades earlier, self-diagnosed allergies with no clinical confirmation, reactions to food, cosmetics, antibiotics, insect stings, or unrelated vaccines  and anxiety-related symptoms that felt physical and frightening

In many cases, clinicians had to decide without clear test results or consistent records. That uncertainty often led to referrals, not because vaccination was unsafe, but because clinicians wanted to be cautious and supportive.

Anxiety played a major role, for patients and perhaps for professionals too

The notes revealed how strongly anxiety shaped decision-making.

Some people described intense fear of vaccination, even after being reassured it was safe. Others wanted vaccination but only if it happened in hospital, or only after another conversation with a trusted GP.

Healthcare professionals were often trying to balance respecting patient fears, avoiding unnecessary medicalisation and keeping vaccination moving during a public health emergency

In some cases, symptoms reported after vaccination were likely linked to anxiety rather than allergy, something the World Health Organization describes as immunisation stress-related responses.

Why does this matter beyond COVID-19?

mRNA vaccines are now being developed for a whole range of immunisations, future pandemics, and treatments. If allergy-related fears aren’t addressed clearly and consistently, the same patterns of hesitancy will repeat.

Perhaps the most important insight from this study is that vaccine hesitancy wasn’t driven by rejection of science. Many of the people in these records wanted to be vaccinated. What they wanted first was reassurance, from someone they trusted, that it was safe for them.

Understanding and supporting that process is essential if we want future vaccination programmes to be effective, equitable, and humane.

This blog post is based on Clarke et al. (2025). Managing allergy-related COVID-19 vaccine hesitancy: A multi-methods analysis of practitioner notes and referral outcomes. Click the link to read the full open access paper.

This study was a nightmare, the survey was hosted on LimeSurvey (which remains one of the least intuitive platforms I’ve ever used), suffered badly from survey bloat, and had zero analysis plan going in. Recruitment was a constant struggle, which led to some frantic learning about web-scraping email addresses and then more frantic learning about GDPR rules. I accidentally miss-emailing about 500 people in Yorkshire with the wrong details thanks to a mail-merge fail. All of this happened during the pandemic, when everything already felt stressful and uncertain. The fact that a solid, publishable paper came out of it at all still feels like a small miracle. My supervisors Nick and Merlin, who were genuinely excellent throughout a very tough period of the pandemic.

The paper looked at whether everyday behaviours people were encouraged to adopt during the pandemic. Were things like wearing face coverings, social distancing, handwashing, and avoiding crowds actually linked to a lower risk of reporting COVID-19 infection? Using a very large UK survey collected between late 2020 and mid-2021, we found pretty clear patterns: people who reported wearing face coverings, keeping their distance from others, avoiding crowded places, and washing their hands when they got home were less likely to report having had COVID-19. Other behaviours that were heavily promoted at the time (like cleaning surfaces or avoiding touching your face) didn’t show the same protective pattern, which likely reflects a mix of recall bias and the messy reality of self-reported data.

Read the full open access paper here: Francis, N. A., Becque, T., Willcox, M., Hay, A. D., Lown, M., Clarke, R., … & Little, P. (2023). Non-pharmaceutical interventions and risk of COVID-19 infection: survey of UK public from November 2020–May 2021. BMC Public Health, 23(1), 389.

What follows is a brief summary of what we found, but it’s worth saying upfront that this paper is as much about systems, workplaces, and trust as it is about individual vaccine decisions.

This paper explored COVID-19 vaccination beliefs, attitudes, and behaviours among health and social care workers in the UK during the very early stages of the vaccine rollout. Using a mixed-methods approach, we combined a large national survey (nearly 2,000 participants) with in-depth interviews to understand not just who was or wasn’t getting vaccinated, but why. Health and social care workers were prioritised for vaccination because of their elevated risk, yet uptake varied considerably across roles, sectors, and demographic groups.

One of the clearest findings was that access and workplace context mattered a great deal. Social care workers were more likely than healthcare workers to report not being offered a vaccine at all, often because of fragmented employment arrangements and unclear responsibility for vaccine delivery. We also found that feeling pressured by employers to get vaccinated was associated with lower uptake, while feeling positive about one’s organisation as a place to work was associated with higher uptake. In other words, trust, autonomy, and organisational culture played a central role alongside individual beliefs about safety and effectiveness.

The paper also highlighted important ethnic inequalities. Black African and Black Caribbean health and social care workers were more likely to decline vaccination and expressed greater concerns about safety, side-effects, and trust in institutions, shaped by both historical and contemporary experiences of racism in healthcare. The key takeaway was that vaccine hesitancy in this context was not about ignorance or irrationality, but about access, trust, and lived experience. Addressing these issues requires structural solutions, culturally informed engagement, and genuine partnership with organisations like the Race and Health Observatory, whose involvement made this work both possible and meaningful.

You can read the full open access paper here: Bell, S., Clarke, R. M., Ismail, S. A., Ojo-Aromokudu, O., Naqvi, H., Coghill, Y., … & Mounier-Jack, S. (2022). COVID-19 vaccination beliefs, attitudes, and behaviours among health and social care workers in the UK: A mixed-methods study. PloS one, 17(1), e0260949.

When the first COVID-19 lockdown began in England, there was growing concern that routine childhood vaccinations might quietly fall by the wayside. Messages such as “stay at home” and “protect the NHS” were essential for controlling the pandemic, but we were worried about an unintended consequence: parents being unsure whether routine childhood vaccinations were still going ahead, or feeling anxious about attending GP practices. The aim of this study was simple but urgent: to understand how parents and guardians were experiencing access to routine childhood vaccinations during the earliest phase of the pandemic, and what barriers were getting in the way.

To do this, we used a multi-methods approach, combining a large online survey with follow-up interviews. Over 1,200 parents and guardians of children aged 18 months or undertook part in the survey during April–May 2020, right in the middle of the first lockdown. We then conducted in-depth telephone interviews with a smaller group to explore their experiences in more detail. The study was framed by the COM-B model of behaviour change, which helped us think systematically about parents’ capability (knowledge and understanding), opportunity (practical access), and motivation to vaccinate.

We found that most parents strongly believed that vaccinating their children on time was important, even during a pandemic. However, many faced practical and informational barriers that made this harder than it should have been (admin! It’s always admin!). These included confusion about whether vaccination services were still running, difficulties booking appointments, cancelled or unclear reminders, and fears about catching COVID-19 when attending GP practices. Importantly, these challenges were not evenly distributed. Parents from lower-income households and from minoritised ethnic backgrounds were significantly less likely to be aware that routine vaccinations were continuing.

The key message from the study is that motivation wasn’t the problem, the systems and communication were. When parents did attend appointments, they often reported feeling reassured by the safety measures in place. The findings pointed to clear, actionable solutions: consistent national messaging, proactive invitation and reminder systems, and transparent communication from GP practices about what to expect. These lessons matter not only for COVID-19, but for future public health emergencies where maintaining routine care is essential. The full paper sets out these findings and recommendations in detail.

Bell, S., Clarke, R., Paterson, P., & Mounier-Jack, S. (2020). Parents’ and guardians’ views and experiences of accessing routine childhood vaccinations during the coronavirus (COVID-19) pandemic: A mixed methods study in England. PloS one, 15(12), e0244049.

As the first wave of the COVID-19 pandemic unfolded, it became clear that developing a vaccine would only be part of the challenge. Even before any vaccine was available, questions were already emerging about whether people would be willing to accept it, particularly when it came to vaccinating children. The aim of this study was to understand how parents and guardians in England felt about a future COVID-19 vaccine, what might encourage acceptance, and what concerns could act as barriers.

To do this, we carried out a rapid multi-methods study during the first national lockdown in spring 2020. We combined a large online survey of over 1,200 parents and guardians of children aged 18 months or under with follow-up interviews. This approach allowed us to measure overall levels of vaccine acceptability while also capturing the reasoning and uncertainty behind people’s views at a time when very little was known about vaccine safety, effectiveness, or timelines.

Overall, most parents reported that they would be likely to accept a COVID-19 vaccine for themselves, with slightly lower acceptance for vaccinating their children. Protection of family and others was a strong motivator, while concerns centred on safety and the speed of vaccine development. Importantly, lower acceptance was more common among parents from lower-income households and from Black, Asian and minority ethnic backgrounds. The findings highlight that hesitancy was driven less by opposition to vaccines and more by trust and uncertainty, pointing to the need for clear, transparent communication to avoid reinforcing existing health inequalities.

Bell, S., Clarke, R., Mounier-Jack, S., Walker, J. L., & Paterson, P. (2020). Parents’ and guardians’ views on the acceptability of a future COVID-19 vaccine: A multi-methods study in England. Vaccine, 38(49), 7789-7798.