COVID-19 Vaccine Hesitancy Among US Adults: Safety and Effectiveness Perceptions and Messaging to Increase Vaccine Confidence and Intent to Vaccinate

Abstract

Objective:

Public health agencies have a critical role in providing effective messaging about mitigation strategies during a public health emergency. The objectives of this study were (1) to understand perceptions of COVID-19 vaccines, including concerns about side effects, safety, and effectiveness and how these perceptions influence vaccine decision-making among US adults and (2) to learn what messages might motivate vaccine uptake.

Methods:

In April and May 2021, we conducted 14 online focus groups with non-Hispanic English-speaking and English- and Spanish-speaking Hispanic adults (N = 99) not vaccinated against COVID-19. We oversampled adults aged 18-39 years and rural residents and systematically assessed 10 test messages. Researchers used a standardized guide and an a priori codebook for focus group discussions, coding transcripts, and thematic analysis.

Results:

Vaccine hesitancy factors included fear of the unknown; long-term side effects, including infertility; and beliefs that the vaccines were developed too quickly and were not sufficiently effective. Motivating factors for receiving vaccination included the ability to safely socialize and travel. Health care providers were considered important trusted messengers. Participants were critical of most messages tested. Messages that came across as “honest” about what is not yet known about COVID-19 vaccines were perceived more positively than other messages tested. Messages were seen as ineffective if perceived as vague or lacking in data and specificity.

Conclusions:

Messages that were simple and transparent about what is unknown about vaccines relative to emerging science were viewed most favorably. Health care providers, friends, and family were considered influential in vaccination decision-making. Findings underscore the benefits of research-informed strategies for developing and disseminating effective messages addressing critical issues in a public health emergency.

Before approval and recommendation of a COVID-19 vaccine, national polling indicated that 70% of people in the United States were willing to get vaccinated, with the other 30% hesitant or not planning to ever get vaccinated. ¹ In December 2020, the first COVID-19 vaccine received Emergency Use Authorization from the US Food and Drug Administration (FDA), and by January 2021, a large-scale vaccine rollout plan was in motion. ² Disparities in vaccine hesitancy emerged by race (eg, among Black or African American [hereinafter, African American] populations), ethnicity (among Hispanic or Latino [hereinafter, Hispanic] populations), age group (ie, those aged 18-39 y), and geography (ie, rural populations). ³ Adults leaning toward or against vaccination, also known as the “movable middle,” had concerns about the vaccines’ safety, speed of development, and short-term and long-term side effects.^3,4 The Johnson & Johnson (J&J) vaccination pause in early April 2021 had the potential to further undermine vaccine confidence. ³

Early research indicated that messages about vaccine effectiveness increased the intent to vaccinate.^{4 -6} Studies that examined COVID-19 and influenza vaccine messaging also highlighted social norms and messenger type as vital factors for increasing vaccination intent.^{7 -9} At the time of this study in April 2021, only 56% of the vaccine-eligible US population had received at least 1 dose of a COVID-19 vaccine. ³ The Centers for Disease Control and Prevention (CDC) coordinated activities to create research-informed messaging to increase COVID-19 vaccination. The objectives of this study were (1) to understand perceptions of COVID-19 vaccines, including concerns about side effects, safety, and effectiveness and how these perceptions influence vaccine decision-making among US adults and (2) to learn what messages might motivate vaccine uptake.

Methods

From April 27 through May 7, 2021, we conducted 14 online focus groups among 99 adults not vaccinated against COVID-19. Each 90-minute group, conducted via Zoom (Zoom Video Communications Inc), had 6 to 8 registered participants. Groups were led by experienced moderators who used a discussion guide. We segmented groups according to those answering “probably will” or “probably will not” to a screening question about their likelihood of receiving the COVID-19 vaccine. Seven groups were “leaning toward” and 7 groups were “leaning against” vaccination. We held 4 groups with Hispanic participants only (2 English-speaking groups and 2 Spanish-speaking groups [n = 30]), 4 groups with non-Hispanic African American participants only (n = 28), and 6 groups of “general population,” which included African American, Hispanic, non-Hispanic Asian, non-Hispanic White, and multiracial participants (n = 41). The general population groups included an oversampling of younger adults (aged 18-39 y) and residents of rural areas. Most recruited participants were aged <40 years, and more rural than suburban or urban residents were recruited. Recruitment was nationwide and conducted through a contract with a professional research recruitment firm. The screening instrument and discussion guide were translated into Spanish and verified for accuracy by a bilingual researcher. The Spanish-speaking focus groups were led by a native speaker who is an experienced moderator. The study was reviewed by CDC and conducted consistent with applicable federal law and CDC policy for the protection of human subjects in research. The research was authorized under a waiver from the Paperwork Reduction Act resulting from the COVID-19 public health emergency. ¹⁰ All participants provided written consent.

Previously published literature informed the development of the focus group discussion guide, which covered experiences with COVID-19; views on vaccine safety, side effects, and effectiveness; trusted sources of information; and message testing. We included questions about the pause in distribution of the J&J vaccine to assess how the pause affected participants’ views. Respondents were instructed to answer for themselves or to consider how others close to them (ie, family and friends) might respond.

We systematically assessed 10 test messages developed by the research team. We divided the 10 test messages into 2 sets (set A and set B) of 5 messages; focus groups reviewed 1 set in randomized order (Table 1). The messages were read to participants by the moderator and shared on their computer screen. We asked participants a series of questions about believability, clarity, motivation, and general feedback for each message. We asked participants to select the message that most encouraged them to get vaccinated against COVID-19. Participants were allowed to choose more than 1 best message.

Table 1.

Ten test messages systematically assessed among 99 participants in 14 online focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021 ^a

Set	Message
Set A	1: Both this disease and the vaccine are new. We don’t know how long protection lasts for those who get infected or those who are vaccinated. What we do know is that COVID-19 has caused very serious illness and death for a lot of people. If you get COVID-19, you also risk giving it to loved ones who may get sick. Getting a COVID-19 vaccine is a safer choice.
	2: All COVID-19 vaccines were tested in clinical trials involving tens of thousands of people to make sure they meet safety standards. Adults of different races, ethnicities, and ages, including adults over the age of 65, participated in the clinical trials. There were no serious safety concerns.
	3: I was first in line to get vaccinated. I’ve seen the study results and feel confident that we have a safe and effective vaccine. [For this message, the focus group moderator told participants that if this message were to be used in public messaging, it would be stated by a health care professional.]
	4: More than 100 million Americans have already received at least one dose of COVID-19 vaccine.
	5: COVID-19 vaccines work to protect you from getting sick. People who have been fully vaccinated can start to do some things that they had stopped doing because of the pandemic.
Set B	6: COVID-19 vaccination will help protect you by building immunity without the risk of severe illness.
	7: You may have some side effects, which are normal signs that your body is building protection. These reactions mean the vaccine is working to help teach your body how to fight COVID-19 if you are exposed. For most people, these side effects will last no longer than a day or two.
	8: Millions of people in the United States have received COVID-19 vaccines, and these vaccines have undergone the most intensive safety monitoring in US history. This monitoring includes using both established and new safety monitoring systems to make sure that COVID-19 vaccines are safe.
	9: COVID-19 vaccines are being held to the same safety standards as all vaccines.
	10: COVID-19 vaccines were developed quickly, in part, because of worldwide cooperation, large financial investments, and rapid enrollment in clinical trials because of high interest. No steps were skipped in the development of the vaccine.

^aThe 10 test messages were divided into 2 sets (set A and set B) of 5 messages; each focus group reviewed 1 set in randomized order.

We used a grounded theory approach ¹¹ with an iterative and inductive process to code transcripts using NVivo version 1.7.1 (QSR International).^12,13 Code families included uptake motivators; hesitancy factors; perceptions of safety, side effects, and effectiveness; sources of information; and message testing. To assess coding concordance, reconcile discrepancies, and validate the codebook, a team of 4 researchers initially coded the same transcripts independently. We calculated Cohen κ, which accounts for chance within coding, for the initial 2 transcripts to assess intercoder reliability. The mean Cohen κ across transcripts and coders was 0.84 (range: 0.76-0.91). Following the establishment of high intercoder reliability, researchers independently coded the remaining transcripts. We used a selective coding approach to further the analysis. After thematic coding, analysis identified differences and similarities between segmented groups. ¹⁴

Results

Of the 99 focus group participants, most (65.6%; n = 65) were aged 26-39 years and had some college (28.3%; n = 28) or a bachelor’s degree (39.4%; n = 39). More than half (58.5%; n = 58) were female. Participants were almost evenly divided between residing in urban (35.4%; n = 35), suburban (29.2%; n = 29), and rural (35.4%; n = 35) areas. More than one-third (36.4%; n = 36) were non-Hispanic African American, fewer than one-third were Hispanic (31.3%; n = 31), and about one-quarter were non-Hispanic White (26.3%; n = 26) (Table 2).

Table 2.

Characteristics of participants (n = 99) in 14 online focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021

Characteristic	No. (%)
Sex or gender
Male	40 (40.4)
Female	58 (58.5)
Gender nonbinary	1 (1.1)
Geography
Urban	35 (35.4)
Rural	35 (35.4)
Suburban	29 (29.2)
Race and ethnicity
Hispanic	31 (31.3)
Non-Hispanic African American	36 (36.4)
Non-Hispanic Asian	3 (3.0)
Non-Hispanic White	26 (26.3)
Multiracial	3 (3.0)
Age, y
18-25	15 (15.2)
26-39	65 (65.6)
40-54	15 (15.2)
≥55	4 (4.0)
Education
Some high school	1 (1.0)
High school/General Educational Development	15 (15.2)
Technical school/apprenticeship	6 (6.0)
Some college/associate’s degree	28 (28.3)
Bachelor’s degree	39 (39.4)
Postgraduate/professional degree	10 (10.1)
Annual household income, $
<25 000	11 (11.1)
25 000 to <50 000	35 (35.4)
50 000 to <100 000	39 (39.4)
100 000 to <200 000	12 (12.1)
≥200 000	2 (2.0)
Vaccination intent
Lean toward	52 (52.5)
Lean against	47 (47.5)

Vaccine Hesitancy Factors

COVID-19 vaccines were generally perceived as unsafe across focus groups due to risks for short-term and long-term side effects, the speed with which the vaccines were developed, the lack of long-term studies, and the absence of full FDA approval (Table 3). Protection against COVID-19 infection was noted as a benefit of vaccines, but it was not perceived as outweighing perceived risks.

Table 3.

Illustrative quotes from participants (n = 99) in 14 online focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021 ^a

Theme	Quote
Vaccine hesitancy factors
Historical abuse	Another reason that I’ve been hesitant, and again, you know, we can’t necessarily tie it to this, but the US does have a history of abuse [of] minority communities with vaccinations. (General population, leaning toward)
Broad range of potential short-term side effects and their severity	Am I going to be able to function or am I going to be laying in my bed, not making money for the day to feed my family? (African American, leaning against)
Unknown long-term side effects	You have no idea what kind of long-term side effects that could possibly have. And that’s the scariest part for me is just, they don’t know, they just started testing it, what, a year ago? How do they possibly know what long-term effects could be? It hasn’t been tested long term. (General population, leaning against)
Impact on fertility	I do plan to have children within the next two to three years, so I’m not willing to chance that. I would rather chance getting COVID than getting the vaccine. (African American, leaning against)
Speed of vaccine development	This vaccine was manufactured very fast. They want us to believe that it’s safe. However, it is not FDA approved yet. I do know it is approved for emergency use, but not approved like gone through all the testing and trials that it’s supposed to go through for it to be truly safe. (General population, leaning against)
Absence of approval by US Food and Drug Administration	If they’re sure that it’s so safe, why is it still waiting to be FDA approved? (English-speaking Hispanic, leaning against)
Efficacy against COVID-19	Knowing and hearing about so many people actually taking both doses and they still get COVID. It is supposed to protect us, and they’re still contracting it. That’s a no for me. (General population, leaning against)
Need for booster	The fact that we might need a booster and all that stuff, and we might still get COVID if we get it. There’s a lot of those unknowns [that] don’t make the risk worth the reward. (General population, leaning against)
Few to no side effects	If we are giving some type of medicine that is going to help prevent or cure anything, if there are side effects, to me, that’s not quite effective. Because if we helped out one problem now, I feel like your side effects are now going to give me another problem that I have to take care of. (English-speaking Hispanic, leaning against)
Low risk for COVID-19 infection	Me, personally, and my friends, we have not really been affected, and COVID is pretty rampant on our college campus, but we still have not gotten it. So, it’s hard for us to justify getting something that would possibly make us sick when we’ve never actually gotten sick. (African American, leaning against)
Current safety precautions sufficient	I work from home anyway. I only go out when I have to. . . . We have hand sanitizer and all that good stuff with us at all times, so it’s not like I’m even out there in public right now. So yeah, I’m not trying to get vaccinated yet. (General population, leaning against)
Natural antibodies against COVID-19	Well, I already received the antibodies naturally. I had COVID over the summer. Everyone in my bubble did, and we got through it, so I don’t see a reason to [vaccinate]. (English-speaking Hispanic participant, leaning toward)
Lack of health care provider recommendation	I have a friend that’s a doctor, and he’s chosen kind of not to take it. And his theory makes sense, but millions of other doctors agree that everyone should take it. (English-speaking Hispanic, leaning toward)
Vaccine motivating factors
Safety socializing with friends and family	I’m gonna do it for my family. Not only because I consider that maybe it’s so great for me or not, but I want to protect my family. That’s the first instinct that is going to lead me to get vaccinated. (Spanish-speaking Hispanic, leaning against)
Travel	I travel, that’s what I enjoy doing, but I don’t want to get the vaccine, but I feel as if . . . I’m going to be forced to take it just because I want to continue the things that I do in my life. (African American, leaning against)
Positive vaccine experiences of close contacts	It is important, in my opinion, for me personally, for my family, that we are guided by close people and close friends who already got the vaccine because they are the best source to see if we’re interested or not interested in getting the vaccine. (Spanish-speaking Hispanic, leaning toward)

Abbreviation: FDA, US Food and Drug Administration.

^aGroups were segmented according to participants answering “probably will” or “probably will not” to a screening question about their likelihood of receiving the COVID-19 vaccine. Seven groups were “leaning toward” and 7 groups were “leaning against” vaccination. Four groups had Hispanic participants (2 English-speaking groups and 2 Spanish-speaking groups), 4 groups were entirely African American participants, and 6 groups were “general population.” The general population groups included participants of any race and ethnicity and an oversampling of younger adults (aged 18-39 y) and residents of rural areas.

Common concerns about short-term side effects included arm soreness at the injection site and influenza-like symptoms, which were commonly associated with the second dose and occasionally referred to in focus groups as “baby COVID.” Interruption of daily life and loss of income were discussed as secondary negative consequences of vaccination in one-third of focus groups.

Concerns about long-term, unknown side effects due to the newness of the vaccines were more concerning than short-term side effects. Concerns about male sterility were expressed by a few participants. The potential impacts on women’s fertility, pregnancy health (including risks for miscarriage and birth defects), and menstrual cycle were specific long-term side effects of concern across all focus groups, races and ethnicity, and vaccine leaning. For example, a participant in the general population group leaning toward vaccination said,

I have a 15-year-old daughter, so I am a little more sketch about her getting the vaccine because, I mean, she’s 15. I hope she’s not thinking about children right now, but you know, later in life, is that going to affect her fertility?

The speed of vaccine development was a topic of discussion across all focus groups, races and ethnicity, and vaccine leanings, with participants expressing beliefs that the vaccines were understudied, “too new,” and “experimental.” The pause in the J&J vaccine was commonly cited as confirmation of participants’ concerns about vaccine safety and speed of development.

When asked what they knew about the COVID-19 vaccine trials, most participants reported very little knowledge. Participants were aware that all 3 vaccines had undergone testing and trials before FDA’s Emergency Use Authorization, but only a handful of participants were able to provide any details. Similarly, other than the J&J pause, few participants were aware of any vaccine safety monitoring practices.

Perceived susceptibility to COVID-19, existing precautions, and having natural antibodies against COVID-19 due to previous infection also influenced participants’ vaccine hesitancy. In 11 focus groups, participants expressed that their risk of becoming sick with COVID-19, particularly with severe or fatal illness, was very low. This belief was especially prevalent among participants who perceived themselves as “young and healthy” and those who knew people who had COVID-19 but did not get sick themselves. Another common theme was the reasoning that their current safety precautions, including wearing face masks, frequently washing hands, and practicing social distancing, were sufficient to protect them from COVID-19. For example, a participant in the general population group leaning toward vaccination said,

I’m younger, no health issues, no medications, so it’s not something urgent, but it’s something I lean towards, just for others.

Underlying participants’ hesitation to vaccinate were beliefs that COVID-19 vaccines were not effective enough to outweigh safety concerns. Effectiveness was universally important when considering getting a COVID-19 vaccine, with participants frequently indicating that 90% to 100% effectiveness at preventing disease would be a motivating range to get vaccinated. Participants generally defined vaccine effectiveness as long-term protection against the disease it was developed to address, ranging from complete protection to reducing the risks of the disease (eg, minimizing symptoms, preventing transmission, reducing side effects). The potential need for booster doses was also described as a characteristic of an ineffective vaccine. Regarding perception of effectiveness, 1 African American participant leaning against vaccination said,

To hear someone’s got the vaccine and then, yes, you can still get COVID, that’s not effective to me.

Vaccine Uptake Motivating Factors

Participants in all focus groups discussed relaxation of prevention guidelines, such as wearing face masks and practicing social distancing, and vaccine information as potentially motivating them to receive the vaccine. Safely socializing and getting together with friends and family outside the home, including eating in restaurants, watching movies, and seeing live music, were the most commonly cited motivating factors for vaccine uptake, particularly with respect to protecting others, including older family members. The ability to travel was also described as motivating, although most participants noted that they would vaccinate to travel only if required. In 3 focus groups, participants said they would get vaccinated if it were required for school or work.

In half the focus groups, including 3 of the 4 Hispanic groups, participants discussed hearing about the vaccination experiences of family, friends, and others as influential in their vaccination decision-making, citing trust, personal connection, and relatability. When close contacts shared positive experiences, including minimal side effects, participants were more motivated to get vaccinated. A Spanish-speaking Hispanic participant leaning toward vaccination said,

It is important, in my opinion, for me personally, for my family, that we are guided by close people and close friends who already got the vaccine because they are the best source to see if we’re interested or not interested in getting the vaccine.

Sources of Information

Participants cited the positive experiences of family and friends not only as motivating vaccination but also as trusted sources of information and advice. Other groups seen as trusted sources of vaccine information were physicians and medical professionals. But medical professionals were sometimes found to both persuade and dissuade vaccination: participants in 5 focus groups (3 Hispanic, 2 general population) talked about how their physician or a friend who was a medical professional was unvaccinated or recommended against vaccination.

Most participants agreed that they do not seek information from nor trust social media for vaccine-related information. Some participants said they do not have to search for COVID-19 vaccine information because it appears unprompted on social media feeds, streaming television, and the radio. Some participants recognized that what they see on their social media feeds likely will reinforce what they already believe about the vaccine. Misinformation that was often stated as truth by participants when explaining their hesitation came from word-of-mouth and social media sources. One frequently mentioned misunderstanding was infertility resulting from the vaccine. Other themes of misinformation were sometimes recognized as such but other times appeared to be believed by participants. This misinformation included ideas that the vaccine has a tracking device, alters DNA, and infects the recipient with the virus. In several groups, participants said they heard about someone dying within a week after receiving the vaccine. For factual information, participants said they would look at scholarly articles and/or the news media. Some participants described feeling overwhelmed with information about the vaccine, leading to confusion. A Spanish-speaking Hispanic participant leaning against vaccination said,

I feel that the worst source of information we can use is social media about health because social media and online all you’re gonna find is you find some false and trustworthy information, but you also find a lot of fake information and you have no way of knowing which is the correct one.

A participant in the general population group leaning against vaccination said,

I don’t go on social media for anything I’m looking for to be absolutely true. But I see it anyways unwillingly.

In 11 focus groups, participants expressed distrust of the US government, including the president, state and local representatives, CDC, and FDA. Government distrust expressed by African American participants was rooted in a history of discrimination and abuse. Across all focus group populations, participants believed that government representatives and institutions were motivated by political agendas and financial incentives, a concern affecting distrust of pharmaceutical companies, too. Distrust in government institutions was also driven by inconsistent and conflicting messaging about COVID-19. Many participants felt “pressured” by the government to get vaccinated, which made them suspicious.

Seven focus groups, including 5 of 7 leaning against vaccination, expressed resistance to the notion of government-mandated vaccination. Opposition to mandated vaccination was voiced in 3 African American groups, 3 Hispanic groups, and 1 general population group.

Message Testing

Participants were critical of most messages tested and found most of them not to be motivating. Of the 10 messages, participants noted message 1 was the most likely to motivate them to get vaccinated (Table 4). Messages that came across as honest relative to emerging science were perceived more positively than messages that came across as not honest. Messages perceived as honest included message 5, which gave simple statements of fact without being perceived as “overpromising,” and message 1, which showed honesty about what is unknown. About message 5, an African American participant leaning against vaccination said,

[T]his statement is not promising anything. It’s saying you can start to do some things. . . . To me it’s honest. . . . It can protect you from getting sick, but it didn’t say it prevents it.

Table 4.

Results of poll on 10 test messages among participants (n = 94) in 14 focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021

Participants who selected message, no./total (%) a	Message selected as the most motivating to get vaccinated against COVID-19
24 of 51 (47.1)	1: Both this disease and the vaccine are new. We don’t know how long protection lasts for those who get infected or those who are vaccinated. What we do know is that COVID-19 has caused very serious illness and death for a lot of people. If you get COVID-19, you also risk giving it to loved ones who may get sick. Getting a COVID-19 vaccine is a safer choice.
16 of 51 (31.4)	2: All COVID-19 vaccines were tested in clinical trials involving tens of thousands of people to make sure they meet safety standards. Adults of different races, ethnicities, and ages, including adults over the age of 65, participated in the clinical trials. There were no serious safety concerns.
16 of 43 (37.2)	7: You may have some side effects, which are normal signs that your body is building protection. These reactions mean the vaccine is working to help teach your body how to fight COVID-19 if you are exposed. For most people, these side effects will last no longer than a day or two.
7 of 51 (13.7)	4: More than 100 million Americans have already received at least one dose of COVID-19 vaccine.
9 of 43 (20.9)	6: COVID-19 vaccination will help protect you by building immunity without the risk of severe illness.
9 of 43 (20.9)	10: COVID-19 vaccines were developed quickly, in part, because of worldwide cooperation, large financial investments, and rapid enrollment in clinical trials because of high interest. No steps were skipped in the development of the vaccine.
5 of 51 (9.8)	5: COVID-19 vaccines work to protect you from getting sick. People who have been fully vaccinated can start to do some things that they had stopped doing because of the pandemic.
7 of 43 (16.3)	9: COVID-19 vaccines are being held to the same safety standards as all vaccines.
3 of 51 (5.9)	3: I was first in line to get vaccinated. I’ve seen the study results and feel confident that we have a safe and effective vaccine. [For this message, the focus group moderator told participants that if this message were to be used in public messaging, it would be stated by a health care professional.]
6 of 43 (14.0)	8: Millions of people in the United States have received COVID-19 vaccines, and these vaccines have undergone the most intensive safety monitoring in US history. This monitoring includes using both established and new safety monitoring systems to make sure that COVID-19 vaccines are safe.

^aThe 10 test messages were divided into 2 sets (set A and set B) of 5 messages; each focus group reviewed 1 set in randomized order. Percentages reflect the number of participants who reviewed and voted on a set; for set A (messages 1-5), the denominator was 51; for set B (messages 6-10), the denominator was 43.

Another African American participant leaning against vaccination said this about message 1:

Seems more honest. They’re being transparent and acknowledging both sides, the good and the bad, not trying to force you to get it.

Participants described several messages as ineffective because they were vague or lacked data and specificity. Participants stated that many of the messages were missing specific information, perhaps left out intentionally, making them less persuasive. Some suggestions for improving the messages involved adding detail. For example, in message 2, participants suggested providing specific information about the demographic groups involved in safety testing. For message 6, they suggested including information on how the vaccines build immunity. About message 6, a Spanish-speaking Hispanic participant leaning against vaccination said:

I’d want to know how is it building my immunity. Like what is being built exactly or how exactly is it building my immunity to prevent this severe illness? And then what is the severe illness?

When participants were asked to select the message that most encouraged them to get vaccinated against COVID-19, message 1 performed best across all focus groups (Table 4). By focus group stratification, 32.1% (9 of 28) of participants in the African American groups, 16.7% (5 of 30) in the Spanish-speaking and English-speaking Hispanic groups, and 22.0% (9 of 41) of participants in the general population groups chose message 1 as the most motivating message; 16.7% (5 of 30) of participants in Hispanic groups also selected message 2.

Discussion

Overall, during the period of initial COVID-19 vaccine rollout, participants expressed low levels of confidence in the safety and effectiveness of available COVID-19 vaccines (ie, J&J, Pfizer/BioNTech, and Moderna). These focus groups identified the specific components of these generalized concerns and provided feedback on 10 test messages.

Many respondents believed that COVID-19 prevention measures, such as wearing face masks, were sufficient to protect against illness. These beliefs indicate a need for increased messaging about COVID-19 susceptibility, severity, and long-term consequences, particularly directed toward people who consider themselves “young and healthy.”^15,16 Pointing toward protecting others, as did message 1, which tested best, may therefore resonate as it has in other studies.^{17 -20} Also, messages that contrast the risks of unknown, potentially adverse consequences of infection with known, benign consequences of vaccination may be useful and warrant further testing.

In addition, focus group participants identified potential motivating factors related to lifestyle changes, including socializing and traveling, so messaging should focus on these benefits of vaccination. Focusing messages on vaccine side effects, safety testing, and long-term outcomes may also motivate vaccine uptake. These lessons are relevant not only for promoting COVID-19 vaccination, including boosters, but also for other future novel vaccines.

Message 7, which explained and normalized side effects, also performed well in this study. Ultimately, participants weighed the perceived risks of short-term and long-term vaccine side effects versus their effectiveness and the threat of COVID-19. Other studies published since our study was conducted also found that adding information on side effects may be effective in messaging. ²¹ For the benefits of vaccination to outweigh the potential risks, participants desired low risk for side effects; complete, long-term protection against COVID-19 infection; and prevention of transmission. In this respect, the availability of data on the long-term effects of the COVID-19 vaccine may alleviate some concerns. More evidence on the safety and effectiveness of the vaccine is available now than it was when our study was conducted.^{22 -24}

Hearing about the vaccination experiences of friends and family was key to decision-making about vaccine uptake among our focus group participants. Our findings demonstrate that the positive experiences of friends and family were influential in allaying fears about potential side effects and their severity. These findings validate the need to create positive social norms and enlist informed, key opinion leaders in communities to minimize sensational media accounts of rare outcomes. In addition, although social media was not a “go-to” source of information among our study participants, it was potentially influencing beliefs through exposure.

The message that performed best was endorsed because it appeared to be honest and transparent about what is known and unknown about vaccines. This finding may confirm what other studies have suggested, that acknowledging uncertainty may be effective in communicating about COVID-19 vaccines.^21,25,26 In addition, balanced messages have been perceived as more trustworthy than persuasive messages among people with a negative or neutral prior belief about the message content.^27,28 This finding may indicate that using transparent messaging and acknowledging uncertainty may be even more effective than other messages tested among those who are skeptical or lean against vaccination.^{26,29 -31}

Limitations

Our study had several potential limitations. First, the sample represents a convenience sample of adults across the United States who agreed to be included in the online panel recruitment approach and participate in this particular study. Second, although we oversampled rural residents to ensure representation, we did not analyze their data separately; this study limitation warrants additional research. Third, we used a certain set of test messages; use of different messages might have yielded different findings. Lastly, our results represent the views of the focus group participants and are not necessarily generalizable to other groups.

Conclusions

Although communication programs tailored toward vaccine-hesitant populations are key to increasing COVID-19 vaccine uptake, these programs can be challenging to develop because of the wide range of demographic and individual factors that contribute to vaccine hesitancy and perceived barriers to vaccination.^{31 -34} Successful immunization programs and public health strategies require coordinated communication that uses various strategies to be effective in increasing vaccine confidence and uptake in vaccine-hesitant populations.

The use of focus groups was effective in elucidating the attitudes and beliefs of groups in the “movable middle” to inform future message development to promote COVID-19 vaccination. Findings underscore the role of health care providers serving as trusted sources of information along with friends and family. The role of health care providers is especially important for pediatric vaccination or any new vaccine in the future. Loss frames (eg, missing work, loss of income) or messaging focused on one’s positive effect on others (eg, keeping grandparents safe) may be effective. Research has shown mixed results on the notion of personal versus community benefit messaging in motivating COVID-19 vaccine, sometimes further driven by underlying worldviews or perceived risk.^{35 -37} Messages that focus on facts rather than persuasion and messages that acknowledge a person’s right to choose to be vaccinated might be more effective for some people than for others in facilitating individual decision-making. Findings underscore the benefits of research-informed strategies for message development and dissemination. Future research with a larger, nationally representative sample would allow for refinement and updating messages for rapidly changing pandemic situations.