Considering the impact of vaccine communication in the COVID-19 pandemic among adults in Canada: A qualitative study of lessons learned for future vaccine campaigns

ABSTRACT

We aimed to understand how experiences with vaccine-related information and communication challenges during the COVID-19 pandemic impacted motivations and behaviors among Canadian adults regarding future vaccines. Semi-structured interviews were conducted with participants purposively selected to ensure diversity in age, sex at birth, self-identified gender, and region. Data were analyzed using thematic analysis; findings were mapped to the Information-Motivation-Behavioral Skills Model focusing on factors affecting vaccine hesitancy and uptake. Of 62 interviews completed, most were with woman (n = 32, 51.6%) and residents of Ontario (n = 36, 58.1%); the median age was 43.5 yr (interquartile range 23.3 yr). Themes included: 1) accessibility of information, 2) ability to assess information accuracy and validity, 3) trust in communications from practitioners and decision-makers, and 4) information seeking behaviors. Participants expressed various concerns about vaccines, including fears about potential side effects, particularly regarding the long-term effects of novel vaccinations. These concerns may reflect broader societal anxieties, which have been intensified by widespread misinformation and an overload of vaccine information. Moreover, participants highlighted a lack of trust in the information provided by government agencies and pharmaceutical companies, primarily driven by concerns regarding their underlying motives. Concerns about COVID-19 vaccine safety and effectiveness negatively impacted future vaccine attitudes and behaviors. Vaccine hesitancy studies should consider how individuals receive, perceive, and seek information within social contexts and risk profiles.

Introduction

Vaccines are among the greatest advances in human public health, saving millions of lives every year.^1,2 Understanding vaccine hesitancy is critical to the success of routine vaccination campaigns and for novel vaccinations developed in future pandemics.^3,4 While defined variably over the years, vaccine hesitancy has been recognized most recently as a state of indecision and uncertainty (considered an attitude or sentiment) that precedes one’s decision to become vaccinated – this intention or motivation is now accepted as separate to the resulting behavior (that is, to vaccinate).^5,6 Vaccine-related knowledge and general health literacy mediate core elements of vaccine hesitancy that are associated with vaccine noncompliance and reduction in broad immunization coverage,^7,8 and subsequent outbreaks of vaccine-preventable diseases.^9,10 As a construct, vaccine hesitancy is not defined as the mere inverse of vaccine acceptance,^11,12 as one may postpone, delay, or modify recommended immunization schedules.^13,14

While health communication strategies are essential tools to inform vaccine decision-making,^15–17 studies have reported little benefit of providing information on vaccines to vaccine-hesitant individuals.^18,19 Communication strategies that positively impact some populations may have null or negative impacts among other populations.^20,21 Further, communicating evidence of vaccine safety and effectiveness can be counterproductive for individuals who are already vaccine-hesitant or can even generate vaccine hesitancy if the information is inundating or too strongly advocates for vaccination.^22–24 The Council of Canadian Academies Expert Panel on Health Product Risk Communication Evaluation has addressed this paradoxical relationship by endorsing evidence-based, recommended good practices for health communication strategies.²⁵

A defining feature of the COVID-19 pandemic was the overabundance of information that included misinformation (i.e., false) and disinformation (i.e., intentionally misleading). Rampant communication of fake news, inaccurate information, and conspiracy theories undermined public trust in science and health institutions,²⁶ thereby limiting one’s understanding of the evidence and placing a real psychological and emotional burden on individuals wading through information.²⁷ This was especially true for individuals from racialized communities because a long history of systemic racism has made medical institutions untrustworthy.²⁸ Studies suggest that information and communication challenges experienced during the COVID-19 pandemic in combination with rapid rollout of the COVID-19 vaccines greatly contributed to increased hesitancy to accept the COVID-19 vaccine more broadly.^29,30 The impact this newly developed vaccine hesitancy will have on public acceptance of routine and novel vaccines going forward (e.g., measles, respiratory virus) is understudied.

We conducted semi-structured interviews to develop a deeper understanding of how experiences with vaccine-related information and communication challenges (e.g., mis- and dis-information) during the COVID-19 pandemic could impact motivations (i.e., desire for action) and behaviors (i.e., uptake) among adults in the general public who live in Canada to receive future routine and novel vaccines. Recognizing that information and communication challenges make up one piece of the decision-making process among those who are vaccine hesitant (i.e., individuals look for information that supports their views and attitudes), we will directly infuse the findings from this work into the co-design and pilot testing of digital informational messaging interventions aimed to target the indecision and uncertainty among vaccine hesitant individuals to positively influence their decision-making on future novel and routine vaccines.

Methods

Study design

A qualitative description research design³¹ was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research³² (Supplemental Table S1). We sought to develop a deeper understanding of how experiences with vaccine-related information and communication challenges (e.g., mis- and dis-information) during the COVID-19 pandemic could impact motivations (i.e., desire for action) and behaviors (i.e., uptake) among adults in the general public who live in Canada to receive future novel and routine vaccines.

Interviews were conducted between December 22^nd 2023 and February 20^th 2024. This study was approved by the University of Calgary’s Conjoint Health Research Ethics Board (#23–0039) and the Research Ethics Board at Dalhousie University (#2023–6538); all methods were carried out according to research ethics board guidelines and regulations.

Recruitment

Participants were recruited from a representative sample of adults living in Canada in a related cross-sectional survey study conducted by an established survey firm (https://leger360.com.) on knowledge, beliefs, and behaviors toward vaccination for COVID-19 in which individuals consented to be contacted for future research.³³ We have previously reported on the evolution of factors influencing COVID-19 booster dose and bivalent vaccine hesitancy in a longitudinal semi-structured interview study using this sample.³⁴ Eligibility criteria for the present study included English or French speaking adults (≥18 years) who were able to provide informed consent.

We purposively sampled for diversity across participants based on age (18–34, 35–55, > 55 years), sex at birth (female, male), self-identified gender (woman, man, other), and provincially defined regions (British Columbia, Alberta, Saskatchewan or Manitoba, Ontario, Quebec, Atlantic provinces, and Territories). All individuals who agreed to participate were interviewed and compensated with a $25 gift card for their time.

Data collection

A semi-structured interview guide was developed iteratively by our interdisciplinary research team that included experts in qualitative research, infectious diseases, social sciences, and epidemiology. Development of the interview guide was informed by existing literature on the association of communication in the COVID-19 pandemic with intentions and behaviors toward future vaccines.^35–38 Discussion topics in the interview guide included how information and communication challenges (e.g., mis- and dis-information) develop, progress, and relate to motivational and behavioral adherence toward vaccines, and barriers and facilitators to effective messaging and communication for vaccine uptake and relevance to sociodemographic determinants (e.g., gender, education); participants were asked to reflect about their experiences in the early stages of the COVID-19 pandemic. Participants’ demographic information was collected by self-report at the end of each interview according to predefined categories in the United Nations Demographic Yearbook 2022.³⁹ The interview guide and associated demographic survey were pilot tested with three participants (connected via but external to the research team) to ensure clarity of interview questions and relevance to our study objective. Participants who pilot tested the interview guide received a $25 gift card for their time. Minor refinement of the interview guide was completed after pilot testing to improve language and conversational flow.

Three researchers (SJM, MC, JM) trained in qualitative research methods conducted the interviews. Interviews were audio recorded via Microsoft Teams and subsequently transcribed verbatim by Rev.com (www.rev.com/). The same three researchers (SJM, MC, JM) reviewed, cleaned, and de-identified transcripts prior to analysis. As a form of member checking to maximize validity,⁴⁰ all participants were offered the opportunity to review and revise their transcripts; none accepted.

Data analysis

Data were analyzed using thematic analysis⁴¹ and managed through NVivo 12 software (QSR International, Melbourne Australia). Two researchers (MC, JM) first read all transcripts to familiarize themselves with the data then independently reviewed and coded three transcripts in duplicate using open coding.⁴¹ Initial codes were compared and discussed with a senior qualitative researcher (JPL) to create a draft of the codebook. The same two researchers (MC, JM) analyzed an additional three transcripts using both open and axial coding,⁴² iteratively refining the codebook until all important ideas were included. Meetings were held (among SJM, MC, and JM) after the coding of every three transcripts for the duration of analysis to consider new codes, discuss ideas, and address disagreements by reaching consensus. The research team then mapped the themes to the Information-Motivation-Behavioral Skills Model that encompasses three constructs that are needed to engage in a given health behavior as specific, individual determinants of behavioral change,^43,44 including: Information that is directly relevant to the performance of health behavior and that can be easily enacted by an individual in their social ecology; Motivation that influences whether even well-informed individuals will be inclined to undertake health promotion actions (e.g., vaccination); and Behavioral Skills for performance of health promotion actions that encompasses an individual’s objective abilities and his or her sense of self-efficacy. The Information-Motivation-Behavioral Skills Model specifies that information and motivation have direct effects to work primarily through behavioral skills to influence health promotion behavior. Recognizing numerous systemic factors that support/impede vaccine uptake, the proximal behavior in question as it related to our study was engagement in conversations and discussions that drive vaccine hesitancy (an attitude), and subsequent vaccine uptake (the distal behavior).

Results

Sample characteristics

We invited 665 individuals to participate in an interview (n = 651, 97.9% from participation in previous work; n = 14, 2.1% from social media advertisements) of which 75 (11.3%) responded and were available (Figure 1). Sixty-seven (89.3%) interviews were conducted (n = 8, 10.7% did not show or reschedule) while the data from 62 (95.4%) interviews were included in the final set of transcripts for analysis (n = 5, 4.6% were deemed ineligible at the time of the interview as they did not live in Canada).

Figure 1.

Study flow diagram.

Over half of our sample reported woman gender identity (n = 32, 51.6%) and resided in Ontario (n = 36, 58.1%); the median age of participants was 43.5 years (interquartile range 23.3 years). Most participants were married (n = 35, 56.5%), had completed an undergraduate degree (n = 33, 53.2%), and were currently employed full-time (n = 39, 61.9%). Over one-quarter of participants self-identified as an immigrant to Canada (n = 16, 25.8%), and almost a third identified as a racialized person, visible minority, or person of color (n = 19, 30.6%). The majority of participants had access to private health insurance (n = 45, 72.6%) and to a primary care provider (n = 58, 93.5%) (Supplemental Table S1).

Thematic analysis

We identified four themes relating to perceived impacts of communication challenges on future intentions and behaviors toward vaccines. According to the Information-Motivation-Behavioral Skills Model, themes included: 1) accessibility of information and 2) ability to assess information accuracy and validity [Information]; 3) trust in communications from practitioners and decision-makers [Motivation]; and 4) information seeking behaviors [Behavioral Skills] (Figure 2). Participants in our sample highlighted facilitators and barriers, perceived variably within broad social environments and personal risk profiles, as well as unanswered questions relating to safety, effectiveness, necessity, and availability of COVID-19 vaccines that have negatively impacted intentions for future vaccine uptake.

Figure 2.

Themes and unanswered questions identified using thematic analysis subsequently mapped to the information-motivation-behavioral skills model.

Information

Participants highlighted that information deemed to be accessible was frequent, comprehensive, and clear. The onus on participants to have built personal health information literacy for adequate assessment of information accuracy and validity was recognized.

Accessibility of information.

Owing to the rapid distribution about COVID-19 vaccine development, it was common for participants to observe that they found themselves requiring frequent information updates. For many participants, updates on the COVID-19 vaccines were facilitated mainly through live forums and daily briefings across broadcast media:

Daily or thrice weekly appearances [of health officials on television] certainly helped to alleviate concerns and worries. (Nova Scotia, Woman)

Several participants commented that they accessed consistent information through smart devices that enabled updates through social media platforms, e-mail or text messaging, or other news-related applications:

Everywhere the messages were just coming to go get the vaccine. It was like a reminder, even if it was something you [were] still trying to think about. (Manitoba, Woman)

Other participants brought to light the importance of enabling information access through more traditional methods:

In the Yukon, the access to technology is not necessarily the same as it is in the rest of Canada. There’s still a lot of people here that don’t have reliable internet access or any internet access at all. Same with phones and smart devices and things like that. There are still people in some of the smaller communities that would be more inclined or only have the opportunity to see communications that are in paper format or posters. (Yukon, Woman)

Most participants commented on the complexity of information surrounding COVID-19 vaccines. While participants desired comprehensive information, they noted that foundational health literacy was often required to understand the information that was being presented:

So, that’s where I think there was a—and that probably applies to all sorts of vaccines today—huge gap. It’s the people who are doing the messaging … I don’t think they actually are really going out and finding out who they are [their audience] and how to reach them.” (Ontario, Woman)

I think that [lack of health literacy] could probably be a barrier for people trying to access or understand what the facts are. So that could prevent people not following the scientific evidence. (Ontario, Man)

This emphasizes the importance of considering the accessibility of vaccine communication, ensuring that it is clear, consistent, and contextually-response.

Information clarity was underscored among participants whose mother-tongue was neither English nor French. For these individuals, clear information was challenging to access, prompting them to seek out information from their home countries over Canadian messaging despite potential differences in COVID-19 vaccine development processes and distribution protocols.

I am an immigrant to Canada. That’s why for me, it’s faster reading [my] native language, so I got a lot of information from my country. But my country traditionally is very on the anti-vaxxer side. (Ontario, Woman)

Even if it was a translated resource, the grade level of it was so high … Which, if you’re English as a second language, that’s really tricky to navigate. (Alberta, Man)

I’m [an] immigrant, so English is not my mother language. I don’t understand totally about the information. I think the government should try to get some different languages to let people understand more about the vaccine. (British Columbia, Woman)

Translated information was found to have acted as a motivator for vaccination for the participants in our study. Personalized information was perceived as more relevant, potentially fostering a stronger sense of trust.

Ability to assess information accuracy and validity.

In contrast to health literacy, the emphasis that for health information literacy humans play an active role when carrying out information discovery, was made evident by most participants. Several participants described taking action to conduct further research on what was communicated online about COVID-19 vaccines:

The news, they have, four-to-five-minute segments? … I felt that I needed to research further in medical journals or reading articles from reputable sources. (British Columbia, Man)

Communications that originated from or cited reputable public health institutions were preferred while participants filtered through wads of information to determine what was truthful and real:

Ideally, it would’ve been from a public health resource, provincial or federal, or it would be from a peer review journal. Yeah, something peer reviewed, something vetted, I guess, from a trustworthy source. (Nova Scotia, Woman)

I, early on, was turning more to government and news sources, just because that was what was out there and that was what was more frequently communicat[ed]. I might [also] look to more scientific or research-based sources to know what they’re talking about and [that they] weren’t just interpreting things as a secondary source. (Ontario, Man)

Nonetheless, despite their best efforts, nearly all participants commented feeling barraged by the sheer quantity of communications – including misinformation and disinformation – as they struggled to assess the accuracy and validity of information on COVID-19 vaccines:

It was just too much information, but not enough substantial information. I was getting little bits and pieces, and it created a mess, and it scared me more, if anything. (Ontario, Man)

More broadly across Canada I think there was more misinformation out there than there was actual information posted. … It was hard to keep up with the misinformation, because you have one organization versus 100 individuals spreading stuff. (Nova Scotia, Man)

As the volume of vaccine-related information continues to expand, it may be more effective to shift focus from quantity, to delivering high-quality messaging. Reducing the noise in communication channels may help to ensure that key messages are more easily accessed and thereby impactful among the general public.

Motivation

Participants unequivocally regarded that their trust in health communications from practitioners and decision-makers impacted how they perceived, experienced, and were subsequently motivated to act on information that was provided about the COVID-19 vaccines.

Trust in communications from practitioners and decision-makers.

Many participants perceived long-term relationships with general practitioners or pharmacists as integral to grounding their trust in vaccine-related information during the COVID-19 pandemic:

I prefer to have one-on-one conversations with my practitioner or pharmacist simply because I’ve been long-term adher[ing] to their particular medical practices and I have reason to trust them, not explicitly, but significantly. (Alberta, Man)

However, a handful of participants reported limited or no access to a GP. This lack of primary care access raises concerns about potential barriers to future vaccine uptake, as trusted GPs have been shown to play a crucial role in guiding vaccine decision-making. Proximity of communication also played an important role, as several participants recalled that they perceived localized messaging to be more informative, and truthful:

I believe that truth is in the actions, not the information that comes out of somebody’s mouth. I felt there was a lot of talk from the [federal] government and no real action, whereas the real boots on the ground was coming from the health authorities and from the provincial government. (British Columbia, Man)

The discrepancies between communications and tangible government action highlights a critical gap that may undermine vaccine promotion strategies.

There was a common sentiment among participants that relatability and inclusivity of communication delivery had a significantly positive impact on how they experienced receiving information on the COVID-19 vaccines:

In my own country, the president made it like it was a war. Everything was related to war. It was a battle. … In Canada, it was much more friendly, I guess. I thought it was a better way to do it, to reach other populations, just to make it easier for people to understand and not make it something negative. (Quebec, Woman)

It seems like [Chief Public Health Officer] became a part of our family for a little while there. We were seeing her every day, and you know what, we’re visible minorities and seeing a face like that, again, I’m not trying to get into socio political and all that stuff, but it makes it easier for people like me or my family or my parents especially, when they see someone like them, educated, intelligent. (Ontario, Man)

Many participants additionally described experiencing confusion with who or what to trust when making vaccine-related decisions:

There were people supporting it, there were people against it. It was very confusing. I didn’t even know who to believe. (Ontario, Man)

Perceptions and experiences with trust in communications from practitioners and decision-makers fed into eventual motivations to act on receiving the COVID-19 vaccine that were grounded in personal assessments of overall risk:

It was just the thing where I was trusting the scientists and public health officials that these vaccines would work the way they said they would. … It was about maybe 50% that I understood the risk, and 50% my trust in them. (Ontario, Man)

I have no idea if what you’re telling me is from a biased opinion. Are you telling me something because you’ve actually done your research on it or because you are being compensated by a vaccine brand? It’s a risk—I don’t know you. (Alberta, Man)

Behaviours

Participants who described active information seeking behaviors for COVID-19 vaccines were driven by general vaccine acceptance and understanding risks of the COVID-19 disease. In contrast, participants who described passive information seeking behaviors were driven by diminishing frequency of communications and overall pandemic fatigue. How vaccines were conceptualized prior to the COVID-19 pandemic also exerted an influential force on information seeking behaviors.

Information seeking behaviours.

Active information seeking behaviors were accepted and described frequently among participants that also commented on their overall or general acceptances of vaccines:

I was looking for other sources … But we take them all the time. We get vaccines when we’re born. (Ontario, Man)

I read both sides, but I still think it’s a worthwhile thing, like the flu shot. (Manitoba, Man)

Participants who understood the risk of contracting the COVID-19 disease, through educational backgrounds or health-related professions, also described active information seeking behaviors:

I do work for the provincial health entity… So, it was easier for me to get more direct information than a lot of the public and general society. (Alberta, Woman)

Passive information seeking behaviors, however, were associated with diminishing frequency of vaccine communications on COVID-19 booster vaccines among several participants:

I would imagine a lot of people just don’t think too much about it. I’m surprised there isn’t more stronger messaging and a wider attempt to try to get people to continue taking their boosters. (Ontario, Man)

Overall pandemic fatigue also hindered participants’ willingness and drive to seek COVID-19 vaccine information:

I don’t know if my views have really changed—I think I’ve reached overload. So, where before I used to like, oh yeah, grab that headline and go deeper into it, figure out what they’re saying. Now I kind of like, oh, more COVID stuff and I flip through it. (Nova Scotia, Woman)

Many participants either directly or indirectly commented on how previous conceptualizations of the necessity of vaccines more broadly had the potential to impact information seeking behaviors regarding the COVID-19 vaccines:

There’s this drive to reinforce what you already believe with whatever information you can get without the will to actually change what you think based on the information there is. (Ontario, Man)

I’m seeing it similarly to the flu shot where there are people who believe in it, and they research and they get it every year and they see the results. (Ontario, Woman)

Unanswered questions

Despite that interviews for the current study were conducted at a time when COVID-19 vaccine booster doses and the bivalent vaccine were readily available – long after initial vaccine communications began – participants described lingering discomfort with COVID-19 vaccines:

I felt like my fears haven’t been acknowledged. It was just, this is how it is, this is what we’ve said. I don’t feel like I’ve ever became comfortable with it. (Alberta, Woman)

I still haven’t got [my daughter’s] COVID vaccine because I’m still hesitant about the effects for younger generations. (Alberta, Woman)

This discomfort was rooted in outstanding, unanswered questions, that had the potential to negatively impact future decisions about novel and routine vaccines. Nearly all participants were concerned about what long-term side effects of COVID-19 vaccines should be expected:

That was really the big question. … Are there any long-term effects, from a vaccine perspective? It doesn’t really exist still. It’s too new. (Nova Scotia, Woman)

That was one of my hesitancies, was not knowing what the side effects would be. Also, as an individual who has a medical history, I didn’t know whether it was going to impact the medication that I was taking. (Ontario, Man)

More specific questions from participants focused on COVID-19 vaccine safety (e.g., vaccination during pregnancy, receipt of numerous vaccines at one time), effectiveness (e.g., duration of immunity, impact of infection), necessity (e.g., need for continuous boosters), and availability (e.g., when or where to receive vaccines, eligibility requirements):

How can we know that a vaccine is safe and effective if there is no five-year perspective on what is actually happening? (Ontario, Man)

I would say that I’m still skeptical in terms of the efficacy of the vaccine, so I find myself questioning other vaccines even after the pandemic. (Ontario, Woman)

I think that we still don’t have enough information to continue receiving boosters. We don’t know about if they are necessary. I think we need to get educated first before we take part in multiple boosters … even other vaccines. (Ontario, Woman)

My perception of vaccines had always been that you take it, you have a very solid immunity. The fact that you had to take two rounds of COVID-19, I was questioning the effectiveness. Then we had to take it yearly—everyone? I started to ask more questions. (Ontario, Man)

For many participants, their experience with vaccine communication challenges in the COVID-19 pandemic served to springboard their inquisition into vaccines generally:

Well now, I want to see a complete ingredient breakdown on what’s in the vaccine. I want to see the mechanism of how it works. I want to see diagrams. I want to be informed like I would be if I was sitting in a lecture theatre. And understanding the mechanism of how this pharmaceutical works. I want to know where it was researched. I want to know the money behind it. I want to know who’s making the money. There’s a whole lot of unknowns that I’m asking about now for all vaccines. (British Columbia, Man)

People are beginning to doubt vaccines they used to take before. What I’m noticing is that people are beginning to question everything now. Vaccines that I know people would normally take without any hesitation or anything because they trusted the process. But now, what I’m noticing is that people are more critical all around. (Manitoba, Woman)

Discussion

We conducted a qualitative description study to explore how experiences with vaccine-related information and communication challenges (e.g., mis- and dis-information) during the COVID-19 pandemic could impact motivations (i.e., desire for action) and behaviors (i.e., uptake) among adults in the general public who live in Canada to receive future novel and routine vaccines. Facilitators and barriers to address and manage these challenges could be conceptualized by the Information-Motivation-Behavior Model. Our findings indicated that information and communication challenges in the context of COVID-19 vaccines were connected to a general inaccessibility of information required to conduct often unclear assessments of validity and accuracy (highlighting the onus on individuals to build personal health information literacy), as well as trust in health communications from practitioners and decision-makers (underpinning the value in providing evidence-based information on vaccines in a transparent manner through established public communication channels with authoritative health figures). Participants in our sample also described information seeking behaviors they employed during the COVID-19 pandemic, suggesting that outstanding unanswered questions relating to the safety, effectiveness, and availability of, as well as the differences between, COVID-19 vaccines, had negatively impacted future vaccine uptake (demonstrating that it is critical to continue working to share true and correct information on vaccines complementary to organizational information advocacy given the cumulative impact of these factors on behaviour change). These results deepen our understanding of the mechanisms by which COVID-19 vaccine hesitancy may predict future vaccine uptake that have been suggested through earlier quantitative research in this area.^45–47

Our study identified that online resources for health information were frequently accessed among participants in our sample to mitigate communication challenges during the COVID-19 pandemic. That public citizens now have easily accessible, online health information begs the question of whether unencumbered personal access to information on vaccines is helping or hurting vaccine motivations. Answering this question depends on the source of information that is accessed, the quality of the information, and individual health information literacy.⁴⁸ In the early stages of the COVID-19 pandemic, Hernándex-Garcia and Giménez-Júlvez conducted an infodemiological study of 80 websites, finding that websites of official public health organizations compared to digital media (e.g., online news sources) were 4.39 times more likely to recommend wearing a mask.⁴⁹ Pullan and Dey furthered this line of inquiry during the period when COVID-19 vaccines were being developed by analyzing search patterns in Google Trends. They reported that spikes in search patterns for COVID-19 vaccines occurred in parallel to spikes in search patterns for well-known antivaccine search words, such as “autism” and “mercury.”⁵⁰ Despite available tools for self-measuring health literacy (e.g., Rapid Estimate of Adult Literacy in Medicine (REALM,⁵¹ Test of Functional Health Literacy in Adults (TOFHLA,⁵² and the eHealth Literacy Scale (eHEALS⁵³), most adults – not only those with basic or below basic health information literacy (estimated at 36% in the United States⁵⁴ – use low-quality websites when searching for health information.^55,56 Further, even if health information seekers discern reputable from disreputable sources, they may not engage with high-quality information if low-quality information is easier to understand and/or more engaging.⁵⁷ While the World Health Organization (WHO) convened the Tech Task Force on COVID-19 with companies in the social media and tech industry to identify strategies to limit the circulation of fake news and harmful contents,⁵⁸ participants in our study suggested that more action is needed to sufficiently manage the existing and pervasive infodemic. Encouraging quality-improvement processes such as fact-checking or peer-review to monitor online information (i.e., infoveillance) must accompany the provision of consistent, clear, and comprehensive information to promote development of health information literacy capacities thereby enabling consumers to draw valid conclusions that positively impact future vaccine behaviors.

We found that how participants perceived, experienced, and were motivated to act on COVID-19 vaccine information was grounded within trust in the practitioners and decision-makers who were delivering health communications. Without accessible and accurate information, public citizens often turn to authoritative sources (e.g., decision-makers) that provide health information such as scientists and governmental figures.⁵⁹ The credibility of such sources is comprised of expertise and trustworthiness – the extent to which the source can provide accurate information and the extent that one is willing to provide accurate information, respectively. Perceived trustworthiness is considered more important than expertise among public citizens regarding persuasion and the correction of misinformation.^60,61 During the COVID-19 pandemic, trust was cited as one of many core determinants of compliance to vaccinate and rejection of conspiracy theories.^62,63 Devine and colleagues meta-analyzed 67 studies on trust published within the COVID-19 pandemic, suggesting that vaccination policies were perceived as more trustworthy when driven by public health authorities than governments, whereas compliance measures were perceived as more trustworthy when delivered by (trusted) governments.⁶⁴ While trust is expected to have general consequences (such as increasing vaccination uptake), these results suggest that the effect of trust on motivation for behavior change is at least in part conditional on who is being trusted.⁶⁵ Despite no consensus among existing literature on the merits of trust, studies from the Ebola epidemic corroborate ours and other reports focused on the COVID-19 pandemic, illustrating a double-edged nature of trust^66,67; trust can increase noncompliance if communication from trusted sources encourage noncompliance and/or the community is not complying more broadly.⁶⁸ It is therefore imperative that further examinations of trust proactively reduce susceptibility to common issues of endogeneity (e.g., is increased vaccine uptake related to that less severe vaccination compliance measures are required in higher trusting countries). Undoubtedly, the dynamics between trust, who is being trusted, and subsequent motivations to act, require greater theorizing and investigation within and surrounding periods of public health crises. Longitudinal mixed-methods studies combining the breadth of cross-sectional survey data with in-depth qualitative analyses to track the same individuals over time should be used to broaden data sources and data collection methods.

Perhaps the most important finding from our work is that outstanding, unanswered questions from the COVID-19 pandemic may exert a negative influence on future vaccine-related decisions. This result underscores that to better predict vaccine uptake for future routine and novel vaccines, public health must potentiate strategies to monitor public opinions by gathering information on concerns and reasons for hesitancy toward COVID-19 (or earlier, novel) vaccines including and beyond responses related to safety, effectiveness, necessity, and availability.⁶⁹ Further exploration into past vaccine experiences should precede communication efforts for future vaccines that are targeted to information needs and concerns to address underlying reasons for vaccine hesitancy among sub-populations with historically low vaccine uptake⁷⁰; enhancing vaccine uptake among these sub-populations may require overcoming barriers of mistrust in the system as a whole.^71,72 Tailoring of messages will also be important to address communication inequalities that may lead to further enhance existing disparities across sub-populations in their ability to comply with recommended preventive behaviors such as receiving vaccines.⁷³ Given the complexity of vaccine hesitancy and the limited evidence available on how it can be addressed, interventions should be carefully tailored according to the target population, their reasons for hesitancy, as well as the specific context, and rigorously evaluated to determine effectiveness.^74,75 Successful work on messaging around HIV prevention among diverse populations (e.g., men who have sex with men, users of intravenous drugs, those at risk of occupational exposure) emphasizes the potential benefit of this targeted approach.^76–80

It is important to note that COVID-19 vaccine hesitancy can associate with hesitancy toward other routine and novel vaccines. It is thus imperative to investigate the mechanisms underpinning the association between COVID-19 vaccine hesitancy future routine and novel vaccine uptake. Further studies on this topic may employ community-based participatory research methods to explore contextually responsive strategies, approaches, and interventions to increase broader vaccine uptake.

Strengths and limitations

There are strengths and limitations of our study to consider. First, we recruited participants from a representative sample of adults living in Canada who had participated in a related cross-sectional survey study on knowledge, beliefs, and behaviors toward vaccination for COVID-19 in which individuals consented to be contacted for future research.³³ We have reported our previous work that recruited from this sample, including a longitudinal study design^81,82 with near-perfect participant retention to assess COVID-19 booster dose and bivalent vaccine hesitancy.³⁴ Although eligibility criteria for the present study were broad (i.e., English or French speaking adults able to provide informed consent), the majority of participants held a post-secondary degree, were employed full-time, or self-reported an annual income of $100,000 or more; among the working age population in Canada over 65% have a post-secondary degree and over 80% are employed full-time.⁸³ These demographic factors as well as sociocultural factors (e.g., linguistic, or cognitive barriers) are reported determinants of vaccine hesitancy.^{9–84–85,86} Our findings may have been different among participants of lower socioeconomic status given that these populations in Canada were more severely impacted by the COVID-19 pandemic.^87–89 Further research from a more expansive sampling frame that provides in-depth understanding on experiences and perspectives of individuals who commonly face added barriers in times of crisis is needed. Second, the semi-structured interview guide was developed and informed by our nationally representative cross-sectional survey of adults in Canada,³³ in-depth narratives on the COVID-19 pandemic,^90–92 existing literature on the association of communication in the COVID-19 pandemic with intentions and behaviors toward future vaccines,^35–38 and grounded in intersectionality theory.⁹³ The interview guide was co-designed with experts in vaccinology, public health policy, citizen engagement, and qualitative research, and pilot tested with eligible public citizens to ensure that questions were clear and comprehensive. Nevertheless, our study may also have been influenced by response bias and social desirability bias. It is possible that participants were unable to accurately recall intentions and behaviors throughout the pandemic or did not feel able to disclose more risky intentions or behaviors to the research team. Interviews were conducted from December 2023 through February 2024 long after lockdown measures had been lifted and cases of COVID-19 were not monitored and publicly reported daily. Transferring the results of this study to other populations or periods of health crisis must be made cautiously. Finally, we conducted virtual interviews to allow participants from various geographical regions the opportunity to offer important insights and share perspectives.^94,95 As over 93% of Canadians have access to high-speed internet, we were confident that recruiting participants via e-mail and social media advertisements would reach a broad and representative sample. It is imperative for future studies to conduct community-based work to elucidate information and communication challenges experienced by individuals in geographically and demographically diverse regions across Canada.

Conclusions

Understanding vaccine hesitancy is imperative to ensure health of the current and future populations. Continuously mobilizing new knowledge on vaccine communication surrounding health crises directly benefits theory, future research, and the audience for whom the communication was intended. Our understanding of what constitutes effective vaccine communication is constantly updated, uncovered, and refined. The current study explored the impacts of vaccine communication on Canadian adults in the COVID-19 pandemic that emphasized how understanding the way individuals receive, perceive, and seek out information in particular social contexts considering personal risk profiles must shape our actions in future health crises to develop more useful and effective vaccine communications.

Biography

Dr. Jeanna Parsons Leigh, Ph.D. is a Sociologist and Associate Professor in the Faculty of Health at Dalhousie University. She has a cross-appointment in the Department of Critical Care Medicine, Faculty of Medicine and is a member of the Policy, Programs, and Implementation group (PPI) at the Canadian Centre of Vaccinology. She also leads the Advocacy, Health Literacy and Knowledge Transfer team within Sepsis Canada–a Canadian Institutes of Health Research (CIHR) funded national network. Her program of research is broadly focused on optimizing the delivery of health services and public health interventions for improved public (citizen, patient, family caregiver) healthcare provider and system outcomes. Specific projects currently being led by Dr. Parsons Leigh include: improving public and health system responses to the COVID-19 pandemic, documenting levels of public awareness and understandings of Sepsis in Canada for improved public health literacy, improving transitions in care for survivors of critical illness, and developing evidence informed interventions to improve equity, diversity and inclusion in medical specialties. Dr. Parsons Leigh provides mentorship to students conducting applied health services, mixed methods, and qualitative research projects. She draws from a variety of research methods in her work including institutional ethnography, grounded theory, and narrative inquiry.

Funding Statement

Dr. Parsons Leigh obtained funding for this work from the Canadian Immunization Research Network (Institute of Population and Public Health, #464928).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Authors’ contributions

All those designated as authors have met all ICMJE criteria for authorship.

SJM and JPL made substantial contributions to the conception and design of the work and drafted the work, approved the submitted version, and agreed both to be personally accountable for each author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriate investigated, resolved, and the resolution documented in the literature.

Availability of data and materials

The datasets generated and analyzed are not publicly available as we did not secure direct permission from the survey respondents to share the de-identified dataset with the general public. Requests for the data can be directed to the institutional research ethics boards overseeing the conduct of the study via the corresponding author, Dr Jeanna Parsons Leigh.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2448052