Preventing and Appeasing COVID-19 Vaccine Tension in Schools to Protect the Well-Being of Children and Adolescents in Québec, Canada

Objectives: This article describes an intervention that took place in Québec, Canada, to mitigate COVID-19 vaccine tension in schools, exacerbated by the 12-17 years old vaccination campaign. Building on this initiative, it proposes guiding principles for prevention and intervention in conflict around COVID-19 vaccination in and around schools. Intervention: Three complementary tools were developed by a community program, CoVivre, in collaboration with an interdisciplinary team, to help practitioners and parents understand vaccine tensions and their impact on youth, and to suggest simple ways to prevent and intervene in vaccine related conflicts. Recommendations: A thorough research evaluation could not be performed due to the rapid crisis response; however, the tools received positive feedback by practitioners, institutions, and decision makers. Recommendations were structured around the following principles: (a) fostering transparent and nuanced health communications; (b) avoiding confrontation and refusing to escalate while strongly condemning criminal acts; (c) encouraging open dialogue; and (d) preserving relationships. Implications: Mental health consequences of public health interventions should be considered at inception to avoid collateral damages. Removing children from the heart of societal conflict and maintaining the family-school relationship is crucial to child development. It is imperative to engage interdisciplinary teams to protect youth from societal polarization, and provide an opportunity for growth and resilience. This initiative suggests that more research is needed on the impacts of encouraging an open dialogue around vaccination, and adopting an empathetic approach amongst youth towards others who may not share the same opinion.


Introduction
3 3 3 children and youth carry an important symbolic value and that society is especially invested to protect their well-being, they have often been at the heart of debates around vaccination (Mckee & Bohannon, 2016). Some families and school staff may feel that the school neutrality is lost when COVID-19 vaccination is promoted in this space, and that this is endangering the freedom of their choice. Due to this context, vaccinating in schools can both fuel school community tensions, and displace larger social tension around vaccination in and around schools. Thus, schools can then become a symbol of the struggle against vaccination and against sanitary measures.

Vaccine Tensions Impact on Children and Adolescents
Vaccine tensions impacts have been documented in children and adolescents, such as bullying among peers, increased feelings of social exclusion, and decreased cohesion within the school team (Labbé et al., 2022;Lachapelle, 2021). These impacts are to be added to the emotional distress, anxiety, or depression experienced by youth from the earlier stages of the COVID-19 pandemic, including social isolation, grief, fear, and loss, without youth and their families necessarily having effective coping strategies to address this distress (Hsieh et al., 2021;Loades et al., 2020). A Canadian cross-national study has also highlighted mental health decline in families with children under the age of 18 (Gadermann, et al., 2021). Vaccine tension has added an extra layer of burden on children, parents, and school teams, with loyalty conflicts between the family and school, as well as increased stress-related symptoms among youth (Bardosh et al., 2022;Lachapelle, 2021). Just as they must be protected from other types of tension, children and adolescents need to be shielded from COVID-19 vaccine tension, through targeted prevention and intervention strategies in and around schools. The current literature has, so far, minimally documented the impact of vaccine tension in youth, and the ways their well-being can be protected from this tension.

The CoVivre Program
The CoVivre program is an independent emergency intervention project put in place during the first wave of the COVID-19 pandemic in the Greater Montreal Area, Québec, Canada. The program has acted as a facilitator and accelerator in supporting initiatives aimed at reducing socioeconomic and health disparities caused by the pandemic (CoVivre, 2022). CoVivre has had the flexibility to respond to current needs on the ground, in a timely manner, and the discussed intervention came as a rapid response to the growing tension and polarization around  in Québec, at the end of Summer 2021. The objective of the intervention was to rapidly develop adapted tools and resources for schools and professionals in contact with youth, and in doing so, to support them in understanding, preventing, and diminishing vaccine tension. The purpose of this article is to document the steps of this rapid-response intervention, while acknowledging the methodological limits of an emergency intervention, and to describe and discuss the proposed solutions to deal with vaccine tension in and around schools, in order to inform future vaccination campaigns for youth in Canada and elsewhere.

Intervention: Preventing and Appeasing COVID-19 Vaccine Tension in Schools
The CoVivre program began documenting vaccine tension in and around schools, and how they impacted youth, as a result of observations made by the team and its community, and institutional partners, at the end of August 2021. With mass vaccination taking place in high schools and CÉGEPS in September 2021, the team focused on children and adolescents with the intention to help protect the most vulnerable from tension (CoVivre, 2022). To document vaccine tension in and around schools, the CoVivre team collected testimonials, between August and October 2021, in diverse settings including high schools, during extracurricular activities, and in discussions with other specialists.

Forming an Interdisciplinary Team
Once the relational and emotional consequences of vaccine tension on children and adolescents had been documented, CoVivre brought together an interdisciplinary team of scholars with whom to collaborate in order to develop the desired tools, guiding principles, and prevention and intervention strategies. This approach aimed to weave together perspectives from different yet complementary disciplines to address a complex situation from various angles. The transdisciplinary expertise spanned from pediatric psychiatry, public health, pediatric microbiology and infectiology, to medical anthropology, health history, cultural mediation, and communication. In collaboration with these scholars, CoVivre developed a tool to understand, prevent, and act on vaccine tension in the school setting (see Appendix A). In addition to the integral version of this tool, a two-page summary was developed to facilitate the use of the resource for schools and professionals in contact with youth (see Appendix B), as well as an illustrated annex with vignettes describing the documented vaccine tension (see Appendix C). In complement to these documents, four videos explaining the tool's key points were produced (see Appendix D).

Developing and Disseminating the Tools
After describing the social and political context around COVID-19 vaccination in Québec, in August 2021, the team analyzed the processes by which vaccine tension escalated in different social spaces, including around schools, and stated that this tension had documented impacts on children's and adolescents' well-being and on school teams' cohesion. With these observations as a basis, the team proposed guiding principles for preventing vaccine tension in the school community, and for intervening when conflict arises. The creation of the vignettes was facilitated by testimonials received by the CoVivre team. To preserve confidentiality, the vignettes' verbatim were slightly modified and pseudonyms were used.
The target population for this resource included schools and professionals in contact with youth, policy makers, public health officials, and health institutions responsible for putting in place the mass vaccination campaign. "Schools" included but were not limited to primary education, high schools, vocational schools, and post-secondary programs called "CÉGEPS". Children and adolescents affected by vaccine tension, and thus targeted through those intervention tools could be anywhere between the ages of 5 and 17.
These resources were presented (online) to institutional partners (health, school boards, police, government) and to community partners through youth-and school-oriented concertation tables in the Greater Montreal Area. Videos (French only) presenting the tools' main ideas were produced and made available online, to make the material accessible to a wider audience (in terms of age, literacy level, time availability, etc.), and to humanize the intervention through the voice and image of one of its main investigators. The written tools were made available in French and English to reach most schools in the province. The dissemination of these resources was primarily done through the above-mentioned concertation tables, through contacts at the Ministry of Education (provincial level), through school boards, and through CoVivre's partners in regional health institutions, in local public health teams, at the city level, and in pre-existing community groups and organisms, and with community or religious leaders.

Description of the Tools' Content
This section presents an overview of the vignettes tool developed by the CoVivre program, as well as the twopage summary of the main intervention tool. Both tools were illustrated in a way to make them easily accessible for professionals working in school settings or around children and families. For detailed context and suggestions for prevention and interventions in schools, please refer to the main interventional tool by Rousseau, Vanier-Clément et al. (2021; see Appendix A).

Vignettes
The proposed vignettes brought to life real perspectives, experiences, and feelings around vaccine tension and its impacts, and could serve as a starting point to initiate dialogue in the classroom and to create empathy between children and adolescents around various vaccine positions. They explored the relational and emotional consequences of the COVID-19 vaccine debate and associated tension, for children and youth. The vignettes showed different types of relations and settings in which vaccine tension and their impact were at play: in peer relations; in youth's relations with teachers at school; in relations involving the family, peers and schools; in relations within the school team; and lastly, in the school environment. Examples of the vignettes can be found in Table 1, and the tool can be found in Appendix C. "My parents don't want me to be around 'unvaccinated' people, nor do they want them to come to my house. My best friend is not vaccinated, but I want to say that he is, so I can continue to hang out with him." -Noah, age 15

School Team
"My colleagues laugh and insult the 'anti-vax' people, as they say, so I don't go in the teacher's lounge anymore. I'm really afraid of their judgment, and not really in the mood to come to work." -Issa, age 37 "I think some of the staff are not even vaccinated! It's not right, they're putting me in danger, I'm afraid for my family." -Javier, age 32

School Environment
"I've seen demonstrations on TV in front of schools. It's violent, it scares me, I'm afraid it's going to happen in my school. I asked my parents to stay home." -Edith, age 13 "We can't even protest now; we can't say anything! It's not right." -Simon, age 32

Two-Page Summary of the Intervention Tool
The two-page summary addressed the impact of vaccine tension on children and adolescents, the polarized socio-political context around vaccination, guiding principles for action in schools, and measures for prevention and intervention on vaccine tension in school settings (see Appendix B). Here we elaborate on the development of these guiding principles and suggested intervention measures.

Context of Vaccine Tension Around Schools in the Fall of 2021 in Québec.
In the Fall of 2021, in Québec, social and political processes at play increased vaccine tension into a polarized debate between "pro-vaccines" and "anti-vaccines". An escalation was seen between these two groups in the political discourse, in the media, and in society at large (Bardosh et al., 2022). Both positions were moralized (a "good" and solidary decision versus a "bad" and individualistic decision), generalizations and oversimplifications were made (i.e., all vaccinated people are "like this", and all unvaccinated people are "like that"), and disqualifying language, insults, and other verbal violence was tolerated and used in social and mainstream media and by public figures. All the while, democratic space to express doubts, preoccupations, or critiques about vaccines, or the measures shrunk (Bardosh et al., 2022;Lachapelle, 2021;Lord, 2022).
As a growing proportion of the eligible Québec population became vaccinated, several citizens supported the increasingly constraining measures adopted by the government in relation to vaccination. Other citizens, especially the non-vaccinated, but also many vaccinated, worried that two classes of citizens with different privileges were being created according to vaccination status. This held the risk of: increasing discrimination and marginalization of already marginalized groups; social fracture and social unrest; and decreased trust in the government, institutions, health professionals or vaccines, in the short or longer term.
Other underlying factors for the tension were the chronic stress caused by the pandemic, the lack of recognition of the emotions and distress motivating positions, the lack of historical perspective about pandemics and the role of vaccines, and the lack of understanding of the complexity and heterogeneity of vaccine hesitancy or refusal. This polarized sociopolitical context around vaccination against COVID-19 did percolate around and into school environments, especially considering the important symbolic value children and youth carry in our society, and given vaccination of 12-to 17-year-olds was massively starting in schools in September 2021.
Principles for Action. Four guiding principles were elaborated from theories and intervention approaches in interdisciplinary fields, with the goal of preventing and intervening on vaccine tension in and around schools. Firstly, it was encouraged to foster transparent, caring, and nuanced health communications (Tworek et al., 2020) by recognizing that the scientific knowledge behind institutional choices about vaccination was still limited in terms of immunization and health measures (Malecki et al., 2021), by ensuring governmental measures were followed while allowing for their respectful criticism, and by avoiding generalizations about the reasons behind individual and parental positions and choices regarding vaccination.
The second principle was to avoid confrontation and refuse escalation while strongly condemning criminal acts such as threats, vandalism, and aggression. At the same time, it was recommended to re-establish a respectful dialogue between divergent positions and normalize these differences (Capizzo, 2018).
Since safe spaces are effective foundations for anti-bullying approaches in schools (Ansary et al., 2015), the thrid principle encouraged safe spaces for individuals to speak, while restoring the legitimacy and respect for individual or parental rhythm and choice around vaccination (Capizzo, 2018;Gagneur, 2020). These spaces should have emphasized the legitimacy of the individual or parental choice (even if this choice could be worrisome), while reminding people of their obligations towards collective well-being, all of which requiring delicate negotiations (Korn et al., 2020).
The last principle emphasized the preservation, even the nurturing, of relationships beyond existing disagreements. Indeed, although political, linguistic, organizational, religious, and other disagreements have always been present between people, social cohesion remains possible (Jupp et al., 2007). This guiding principle emphasized the need to recall, especially at a time of crisis, the crucial social and psychological role of these bonds (between youth, parents, school colleagues, children and school staff, school staff and parents, etc.), and to prioritize these relationships over visions, positions, and decisions around vaccines or health measures (Catalano et al., 2004). In the case of the school team, this meant uniting first and foremost all school personnel around their mandate (i.e., the education and development of children, adolescents, and young adults) especially as the centrality of this mandate was being more than ever demonstrated with pandemic-related school closures (Catalano et al., 2004;Gilligan, 1998).
Preventing Tension in Schools. Proposed measures were formulated for different settings to appease tension and prevent conflict, including within the school administration, the school team, and in the classroom.
At the school administration level, it was proposed to send a message to parents that: (a) encouraged reserve and kindness in discussions to maintain an atmosphere of tolerance and respect, (b) encouraged vaccination but also respected individual and parental choice and rhythm while protecting youth and families from exclusion, while at the same time (c) reassuring parents and teachers that health measures were applied in the school.
Within the school team, conflict prevention efforts included recognizing the right to individual choice, and encouraging respect for different visions and choices regardless of what one might think is right. It was also recommended to acknowledge tensions (if they existed), and try to normalize them, while working to maintain cooperation and cohesion among coworkers.
In the classroom, it was suggested to provide students with safe and respectful spaces for exchange around vaccination and possible vaccine tension, using for example the vignettes tool to initiate dialogue, and to normalize the different visions and experiences students may have (see Appendix C). It was recommended to enter in respectful, caring, and non-judgmental dialogue with students, and to present individual or parental choice about vaccines as legitimate. Age-appropriate information on vaccines and their purpose could be provided based on the students' interest and needs, all the while continuing to restrain from judgmental and moralistic language.
Moreover, the concept of vaccine hesitancy could be introduced and discussed to familiarize students with the fact that choosing to get vaccinated or choosing not to is a normal and dynamic decision-making process involving weighing advantages versus potential risks of vaccination, and that getting vaccinated is often not just a matter of willingness . It could also be said that the decision has a legitimate complexity because of the different aspects it touches upon, for example the lack of or difficult access to vaccination and to adapted information about vaccines, as well as personal, family, or collective past or present experiences with the health system or with vaccination itself. In addition to this, social pressure and various beliefs may come into play when considering to get vaccinated or not (Dubé et al., 2016;. Youth were encouraged to be empathetic and respectful towards those who might not have the same perspectives as themselves. In efforts to reduce tension and feelings of divide or exclusion among students, it was recommended to carry out inclusive activities that do not distinguish between vaccinated and unvaccinated youth. Moreover, in the case where the family unit did not agree on a common choice regarding a child's vaccination (i.e., parental consent was necessary for the vaccination of youth 13 years-old and under), preserving the family's cohesion and relationship should be put forward, and mediation should be recommended, if needed.
Intervening When Conflict Arises. Despite prevention and mediation efforts and measures, in the case of a demonstration or protest near a school, or in the case of an internal incident, it was suggested to first reassure children or teenagers, and to explain the situation to them at an age-appropriate level, bringing back the concept that disrespect or violence cannot be justified by disagreement or opposing opinions. The team also insisted on the importance to remain specific, to avoid generalizations about any position, and to refrain from using degrading or stigmatizing expressions (for instance, avoid using "anti-vaxxer", "pro-vax" or similar terms). If an incident were to occur within the school community, the primary suggestion was to ensure that the school team cohesion was maintained throughout the response. Also, appropriate consequences were to be encouraged independently of individual positions, while minimizing exclusionary measures. Where possible, it was recommended to mediate and promote open dialogue between those involved (whether it be students, staff, or parents) rather than divide them, encouraging first and foremost the maintenance of the relationship.

The Intervention's Scope: Reception of Intervention by Partners
The current intervention rapidly addressed the COVID-19 little spoken vaccine tension in and around schools in Québec, and its impact on youth and school teams, in Fall 2021. It encouraged actors at the macro-level (political decision-makers, ministries, health institutions, public health, school boards) and at the micro-level (school teams and other professionals working with youth), to be attentive to possible vaccine tension and their impacts on youth, and to try preventing or acting on them. The intervention provided professionals and policymakers with tools, including guiding principles and strategies, to help understand, prevent, and intervene on tensions. Given these tensions were poorly documented, and school teams were either frightened and relatively helpless or sometimes in denial of any vaccine tension, this initiative was listened to and overall welcomed. However, it elicited questions and concerns: what was the school's appropriate role and position in this urgent mass vaccination campaign (promoting vaccination, hosting vaccination clinics, remaining "neutral"); was there really a problem in and around schools (tension, polarization and their impact) and would talking about it make it worse?
Although this intervention project was implemented in urgency without the ability to have a structured research method, it took a reflexive approach. The intervention was put forward as the need presented itself, and no formal evaluation of its impact has yet been made. Observations and feedback from partners, through online and inperson meetings, phone calls, and email exchanges, were documented by the CoVivre team to improve resources and answer questions. Initial findings showed a mixed reception from school partners, questioning whether these partners considered vaccine tensions existed and had an impact in school settings: while some welcomed the tools with an apparent relief (possibly because they saw or experienced some of those vaccine tensions), the majority initially remained silent and made few comments. We presume the initial silence could mean several things: a form of disagreement (i.e., they didn't think there were tensions), surprise, or an uneasiness to discuss disagreements in the context of a crisis, in which everyone was being instructed to work together in solidarity to overcome the pandemic (i.e., at that point, "working together" translated into promoting vaccination). Final feedback and reactions to the intervention were constructive and appreciative, implying they were distributed and used widely, paving the way for an impact on youth, families, teachers, and decision makers. A key limitation to this intervention remains that this impact was not measured. in Québec, Canada 8

The Teachers
At the level of the teachers, attitudes varied regarding whether vaccine tensions existed at school or not. While it was generally accepted that there were vaccine tensions and exclusion processes between parents and in the population, teachers did not necessarily see these tensions or exclusion processes at play, between children or between students and staff at school. Some said for example, that regardless of a family's position on vaccination and regardless of vaccination status, they wanted to focus on their students' needs and provide them with a reassuring and positive environment, especially in the context of a crisis. They also mentioned that considering this difficult context and the extra pressure that it put on them, they did not have energy to give to vaccine tensions between parents. Nevertheless, they stated that they would certainly intervene if they saw or were informed of a situation of exclusion or bullying between children, due to parental position over vaccines or to vaccine status, as they would in any other similar intimidation or bullying situation. A thorough evaluation of the usefulness for school professionals of the CoVivre program's tools would certainly shed light on how these tools could be adapted to teachers' and school professionals' realities.

The Institutional and Community Partners
In this health crisis, in which scientific knowledge and governmental actions have been evolving daily, it has been difficult to analyze (with little or no ability to take a step back) the complex political and social dynamics associated with the rapid changes, and to know how to best respond to them without taking too many wrong turns. The documents developed by CoVivre with various scholars, and widely distributed to institutional and community partners, rapidly offered school professionals tools to help them make sense of the ever-changing and complex social situation linked to vaccination in the school context and their effects on youth. Working in collaboration with university experts from different disciplines, from health sciences and social sciences, was necessary to develop tools trying to help understand and respond, from different vantage points to a complex social situation requiring these multiple perspectives. In fact, integrating interdisciplinary teams in public health initiatives and mediation efforts is imperative to develop this type of intervention, and, at another level, to protect youth from societal polarization and its effects, and to provide them with an opportunity for growth and resilience.
Overall, the tools were meant to reinforce school professionals' resilience to the stressful, demanding, and conflictual context of mass vaccination during a pandemic, and consequently, through those professionals, to have a ripple effect on children and adolescents, helping them become more adaptable and resilient to the uncertain and conflictual context. Considering that the consequences of vaccine tension on youth are often kept in silence and remain invisible both in the short-and long-term, it is necessary that they be considered in governmental, institutional, and public health approaches to vaccination, as well as by school actors working more closely with youth. We believe that the observations made around and during this intervention are likely to apply to other school settings outside of Québec and Canada, and should thus be taken into consideration when promoting vaccination for youth. In future interventions, it could be beneficial to find ways to also raise awareness among parents about vaccine tensions and their impact on youth and schools, to have a more comprehensive approach to protect children, their families, and schools from these tensions and their impacts.

Implications
The current intervention intended to respond to an urgent situation of growing social division and polarization around the COVID-19 vaccination that manifested itself in and around schools, and that had documented impacts on youth and schools, in Fall 2021. As it is often the case, schools revealed themselves as microcosms of society, and vaccine tensions in and around the Greater Montreal Area schools in early Fall 2021, were a warning signal of growing dissatisfaction and social division. Indeed, the anti-COVID-19 vaccine mandates movement that culminated in early 2021 in weeks-long protests in Ottawa and other Canadian cities (Dyer, 2022), confirmed the social polarization and radicalization around vaccines and vaccine mandates in Canada, the accompanying social fabric deterioration, and the ever-growing need for and importance of opponents to be heard, respectfully, in a democratic society.
While there are limits to this intervention, especially in terms of the little documentation collected and the absence of an evaluation, because of the emergency pandemic context and the CoVivre program's mandate, this article highlights the importance of documenting the intervention process and results. It indicates the need for research on eventual vaccine tension emerging in and around schools, especially in a crisis context with limited time to offer adapted public vaccine education, and in which the population and resources are already, at various levels, under heightened pressure. Future research and interventions should integrate an evaluative component to provide insights on the impact of youth protection brought through encouraging caring, nuanced, and transparent health communications, and team cohesion in schools.
Truly grasping the complexity of public health crises requires the collaboration of interdisciplinary teams to ensure mental health and social factors are accounted for early on. The current intervention suggests there is potential for reducing vaccine polarization among citizens and youth, in and around schools, by nuancing and respecting positions on vaccination, and through adapted vaccine and vaccine hesitancy education. Maintaining a collaborative family-school relationship, and removing children from the heart of a polarized sociopolitical conflict is necessary to protect their well-being, foster their development, and strengthen their resilience. By encouraging open dialogue, and respect around vaccination within the school community and with the parents, the moral discourse around COVID-19 vaccines can be nuanced, and help youth feel comfortable sharing their views and experiences not only around vaccines, but eventually around other polarized topics. In the present societal context in Canada and elsewhere, capacity to show empathy towards those with different positions is imperative, and we must encourage such practices among youth at every jab there is.

Funding
The CoVivre program would like to acknowledge it's funding by the Trottier Foundation and McGill Interdisciplinary Initiative in Infection and Immunity (MI4). Funders had no role in intervention, interpretation of intervention, writing of the manuscript or decision to submit the manuscript.
• Lack of understanding of the structural barriers that influence choices about vaccination: these are seen as coming solely from the will of individuals. There is a lot of conflation: being hesitant or critical of the institution or government would mean being a conspiracy theorist; conversely, being vaccinated would mean adhering to vaccination without questioning and following the government's instructions without thinking. • Loss of perspective on what vaccine hesitancy (VH) is: a multiple, complex and dynamic phenomenon that can be seen on a continuum from total acceptance of all vaccines to systematic refusal of vaccines, with a multitude of intermediate positions involving questioning, doubts, fears, delaying, etc., and possibly also, for example, acceptance of the COVID-19 vaccine for one's self and one's elderly parents but not for one's child. Vaccine hesitation is nevertheless normal and even healthy, since it is beneficial to ask questions and to be critical before making a choice. • The pragmatic considerations needed to be taken into account by the government and various political stakeholders (allowing economic activity and a certain normality for the vaccinated, protecting the most vulnerable, protecting a weakened health system, politicizing the debate for electoral gain), seem to have led to a gradual loss of perspective in the Quebec public health approach to vaccination, which is traditionally based on prevention and awareness rather than coercion. Yet, evidence shows that a motivational approach to vaccine hesitancy ultimately produces better results than coercion or obligation, since it fosters lasting trust in institutions and encourages individuals to exercise choice. • There seems to be a gradual shift towards a perception of vaccination as quasi-obligatory, through the rise of increasingly restrictive measures: vaccination passport for those aged 13 and over for activities deemed nonessential (including extracurricular activities), compulsory vaccination in certain workplaces, the ban on demonstrating against vaccination within 50 meters of certain places including schools (forms of institutional constraints), setting aside the basic principle that vaccination is an individual or parental choice even if it also implies consideration of collective well-being. • These constraining measures, which can be seen as disguised forms of vaccine obligation, tend to cause tension among those who are hesitant or refuse vaccination. In other words, the consequences of choosing not to be vaccinated involve being excluded from society to a large extent, and are experienced and seen as a socially and politically accepted form of discrimination that goes beyond the simple public health objective of controlling the virus. • In addition, several institutions, such as libraries and hospitals, have instituted their own policies with regards to the unvaccinated that further restrict their access to their services, creating for the unvaccinated more anxiety and a sense of exclusion from society. • These institutional constraints can provoke either silence (among opponents who fear retaliation), or anger and frustration leading to public demands, associated in a small number of cases with violent deviations, or virtual or direct violent acts (threats and violence). The more implicit violence on the side of the vaccine supporters is minimized overall (insults-derogatory attitudes towards the sick, blame and scapegoating placed on the nonvaccinated). • Vaccinating in schools, for a number of parents, is going to feel like an incitement, since somewhere along the line, public schools represent the State. These parents, who see vaccination in schools as the school's positioning in favor of vaccination, may see their trust in institutions (the government, the school) diminish, which could have non-negligible consequences on their children, who could be taken out of the school system (see point 2.8). • Tensions and polarization are also related to the lack of recognition of the underlying emotions (fear, anger, frustration) on both sides. Underlying these tensions are fear (of contracting or transmitting COVID but also of never returning to "normal" life), psychological distress (at the thought of reliving isolation and lockdowns, lack of socialization, estrangement from loved ones, loss of activities). This emotional state, now often referred to as "pandemic fatigue," is related to feelings of frustration (arising from health measures and their consequences, or arising from the fact that unvaccinated people are "threatening" others and "delaying the return to normal life"). These emotions and distress, coupled with the gradual shift towards quasi-obligatory vaccination as the only way out of the crisis, provide fertile ground for polarization and the deterioration of social ties (already damaged by the previous waves and isolation measures). Kindness and empathy, which require tolerance in the face of disagreement, must be prioritized again.

-Impact of this context on children, adolescents and young adults
Tensions between supporters and opponents of health measures or vaccines are experienced around the school, but are also present among peers, within the school team, among parents and in the community around the school, weakening ties, leading to the creation of alliances (for or against vaccines) and polarizing the environment. This context has consequences for children's mental health and development.
The consequences described here were documented in the fall of 2021 on a repeated basis. The most frequent ones will be illustrated with anonymous vignettes in an attached document (peer relations; student-school relations; familyschool-peer relations; school team; school environment).

Peer-to-peer bullying
• Unvaccinated or partially vaccinated youth may be ridiculed and insulted by their peers, either in groups or individually. These comments may be directed at their families (derogatory comments). The strength of the group heightens the hurtfulness of these interactions. • Unvaccinated youth may be ostracized and isolated, peers being unwilling to sit near them.

Increased social exclusion
• Unvaccinated youth constitute a minority group, and are also vulnerable because they cannot participate in certain activities, which increases their sense of exclusion and exacerbates social inequalities, because of the association between vaccination status and parental education level, SES and diversity. • Beyond the current context, these experiences will impact the perceptions that future parents (today's children) will have of vaccination, which is an important concern.

Family-School Loyalty Conflicts
• Many young people find themselves caught between their families, friends and school regarding vaccination. They feel like they have to take a stand or hide their family's position regarding the vaccine, as if it were shameful. Some youth 14 and over get vaccinated in secret (without their parents' knowledge). • For young people in opposition-rebellion with their parents, or with the school, these divisions are an opportunity to aggravate cleavages and conflicts, with one side being protected over another. The school and family can no longer work as a team. • When parents who disagree with vaccination end up having their children vaccinated so their child doesn't get excluded at school or from other activities, the child may not feel safe, perceiving that his or her parents are concerned. This can undermine trust within the family.

Fragility of the school team and risk of polarization within it
• Conflicts between vaccinated and unvaccinated staff within the school team. Fear of the non-vaccinated who do not dare to say what their position is. Non-vaccination of some school team members can generate discomfort, tension or stigmatization. • School teams are not homogeneous. The emotional charge of the debate and its moral character make it difficult to dialogue or even share positions. Tensions, said or unsaid, can affect the school team's ability to cope together with the situation. • School teams are worn out by the burden of changing health measures. Current tensions can lead to avoidance or burnout.

Insecurity about the physical and social environment of the school
• Because of demonstrations against vaccines or health measures that have taken place around some schools (banned by the government within fifty meters of schools since then), students, parents, and professionals may feel that school is no longer a safe place to be. The media coverage of such incidents contributes to this feeling of insecurity.