COVID-19 Vaccine Effectiveness and Barriers to Vaccination: Comparing Perceptions Based on Vaccination Status

Abstract

New York City (NYC) was the first epicenter of the COVID-19 pandemic in the USA. Despite the availability of COVID-19 vaccines by 2021, vaccination rates varied among racial and ethnic groups, further exacerbating COVID-19-related health disparities. This study explores the relationship between vaccination status and perspectives on COVID-19-related topics among racially and ethnically diverse NYC residents. The New York Community Engagement Alliance Against COVID-19 Disparities (NYCEAL) conducted focus groups with NYC residents to explore their perceptions about vaccine effectiveness and barriers to vaccination that may impact vaccine decision-making. We conducted seven focus groups between December 2021 and April 2022 in English and Spanish with individuals grouped based on vaccination status: (1) those vaccinated when vaccines first became available, (2) those vaccinated after mandates were announced, and (3) those who remained unvaccinated. Transcripts were initially analyzed using a priori and in vivo codes, and the team utilized framework analysis to examine similarities and differences across groups. Emerging themes centered on trust in science, perceived vaccine effectiveness, and the evolution of people’s COVID-19-related perspectives, experiences, and behaviors over time. Although there were distinctions between groups on concepts like trust in science and perceived vaccine effectiveness, people’s cognitive biases seemed to affect their perceptions but not necessarily their (vaccine-related) behaviors. Findings from this study may help public health professionals understand vaccine decision-making from the perspective of a diverse set of New Yorkers for use during future epidemics.

Introduction

By the winter of 2021, the United States had the highest number of reported COVID-19 cumulative deaths worldwide [1]. Black and Latino/a/x/e (Latine) groups disproportionately suffered from COVID-19 morbidity and mortality, with age-adjusted mortality for both groups far exceeding those of white Americans [1]. Literature exploring these disparities highlights that historic injustices and ongoing discriminatory health practices predispose Black and Latine communities to “skepticism about public health interventions” [2]. Survey data from 2021 underscore the relevance of these findings; minoritized respondents (including Black, Latine, and low-income people) were much less likely than white respondents to report trust in COVID-19 information from public health officials and more likely to report utilizing a “wait and see” strategy regarding the vaccine, with Black individuals expressing reluctance at a rate of five times that of their white counterparts [3, 4]. Data suggest that the legacy of discrimination and medical abuse in this country directly relates to attitudes around vaccination, even among healthcare workers; a recent study found that 11% of unvaccinated healthcare workers attributed their distrust due to racism and previously unethical treatment of minoritized populations [5]. In the United States, Hispanic and Latine communities face unique challenges shaped by immigration concerns, language barriers, and limited access to healthcare, which collectively influence their vaccine attitudes [3]. For Asian Americans, the impact of COVID-19-related discrimination and xenophobia created additional layers of hesitancy despite generally higher vaccination rates within this group [6].

Across minoritized populations, ongoing experiences of discrimination in healthcare settings, coupled with socioeconomic factors limiting access to reliable information and medical care, continue to shape vaccine perceptions and uptake [3, 7]. Data from more recent work on COVID-19 booster uptake suggest that the early disparities persist, with Black Americans still possessing the lowest rates of uptake [8]. Such complex influences underscore the need for culturally sensitive and community-specific approaches to address vaccine hesitancy and promote equitable vaccination rates among diverse populations. However, developing these approaches requires a more nuanced understanding of individuals’ perceptions of the vaccines and if and how these perceptions influence their ultimate vaccination decisions. The COVID-19 waves that New York City (the original US epicenter for the pandemic) experienced and the stubborn inequities in vaccination rates across sociodemographic groups demonstrated the need for public health practitioners and those working toward health equity to take stock of people’s perceptions of the vaccine as they developed a plan to ensure maximal vaccination uptake [9], but later data revealed that slow vaccine uptake in locations hardest hit by the first wave of the pandemic meant communities did not gain sufficient or lasting protection against future waves necessitating new approaches to promote vaccination [9]. The lagging vaccine uptake among minoritized communities likely contributed to the eventual decision of NYC policymakers to announce a series of unpopular if seemingly effective vaccine mandates in the summer/fall of 2021, limiting access to employment, education, and some recreation activities for those who chose to remain unvaccinated.

While research on vaccine perceptions has provided valuable insights, there are notable gaps in our understanding of the relationship between perceptions and (actual) vaccination status. Some studies have touched on this relationship, but a comprehensive examination is lacking. For instance, Dubé et al. [10] noted that vaccinated individuals tend to have more positive attitudes toward vaccines but did not explore the nuances of this relationship across different vaccines or demographic groups. Similarly, some work exploring the gender gap in COVID-19 vaccination rates characterize the data as “puzzling” because the lower overall rate among women contrasts with the bulk of established literature also framing women as more likely to consider the pandemic a serious problem and to approve of and comply with restrictive measures imposed to fight the pandemic [11]. Roat et al.’s 2022 literature review on Black Americans and effective strategies for overcoming barriers to vaccination highlights these gaps, noting that many of the strategies to increase uptake have yet to be implemented, limiting the utility of these solutions [8]. Together, these studies highlight conflicts in our existing data and suggest an insufficient understanding of how personal vaccination status and perceptions of vaccine efficacy, safety, and necessity, as well as how these perceptions might evolve based on personal vaccination experiences, shape one another. This research begins to address this gap by exploring perspectives relating to COVID-19 vaccines and possible variation by vaccination status, especially among groups of racially and ethnically diverse community members from NYC.

Methods

Setting

We engaged with a large study team of representatives from community-based organizations (CBOs) to understand racially and ethnically minoritized people’s perceptions of the vaccine and their choice to vaccinate or not across vaccination status. The CBO’s standing in the community was essential to recruiting participants and helped ensure that our research design was inclusive, relevant, and appropriate for the questions and populations of interest.

Design

We conducted virtual focus groups on Zoom in English and Spanish between December 2021 and April 2022. Moderators were experienced in conducting focus groups and utilized a semi-structured discussion guide. Focus groups lasted an average of 90 min. We audio-recorded the groups and uploaded transcripts to Dedoose for analysis [12]. This study was approved by the Program for the Protection of Human Subjects at the Icahn School of Medicine at Mount Sinai.

Participants

We recruited focus group participants from a convenience sample of individuals affiliated with or served by New York City CBOs partnering with the NYCEAL consortium. A research coordinator distributed fliers and other promotional materials to partner organizations to recruit participants. To be eligible, community members had to live in NYC, be 18 + years of age, have the ability to consent and fill out a short screening/demographic survey, have access to a computer or smart gadget to join the virtual focus group, and speak English or Spanish. In the short screening/demographic survey, participants disclosed their vaccination status and when they initiated their vaccination series. The research team divided interested and consented participants into groups by preferred language and by vaccination status, specifically (1) vaccine “early adopters,” participants who got vaccinated before September 27th, 2021; (2) “mid-adopters,” those who were vaccinated after several mandates went into effect in New York City (September 27th, 2021); and (3) “non-vaccinated,” individuals who were not vaccinated at the time of the focus groups.

Data Analysis

The research team, including physicians, social workers, and researchers with experience in qualitative data analysis, coded transcripts using a hybrid inductive/deductive coding approach that included a priori codes derived from the semi-structured interview guide and in vivo codes that emerged during analysis. The analysis included several stages, including data familiarization and blind coding in teams of two to ensure sufficient inter-coder reliability. After initial coding, the group unblinded all transcripts and reconciled codes and code applications through an iterative process to build consensus. During data familiarization and coding, the research team made notes about emerging themes, extracted excerpts, and identified relevant sub-themes. Study team members who facilitated the focus groups reviewed the emerging themes and sub-themes during this phase to support the data triangulation. We then used a framework analysis to examine similarities and differences across the groups based on vaccination status [13]. Framework analysis has been identified as a particularly useful methodology and tool for projects seeking to identify and interpret key patterns within and across groups because its organized structure is inherently comparative [14]. Working again in pairs, researchers reviewed all of the coded excerpts and sorted them into the appropriate row (group by vaccination status) and column (identified theme) of a framework grid.

Results

Demographics

A total of 44 individuals participated in one of the 7 focus groups. Table 1 summarizes the demographic characteristics of participants across the three groups. The team identified three key themes during analysis: (1) the evolution of COVID-19-related perspectives, experiences, and behaviors over time; (2) perceived vaccine effectiveness and barriers to uptake, including the impact of breakthrough infections and new variants; and (3) trust in science.

Table 1.

Characteristics of focus group participants

Participant Characteristics	N=44
Age, mean (sd)	32 (±11)
Female sex, n (%)	22 (50%)
Black, non-Hispanic, n (%)	21 (48%)
Latine, n (%)	18 (41%)
Other, non-Hispanic, n (%)	5 (11%)
Spanish Primary Language, n (%)	12 (27%)

Using a framework analysis allowed the team to assess the similarities and differences between groups regarding how participants discussed themes. Figure 1 displays selected excerpts from the more comprehensive framework analysis grid. These exemplar quotes help illustrate some of the main themes and sub-themes. The narrative below summarizes all of the themes and contains additional excerpts pulled from the completed framework analysis grid (available upon request). The additional excerpts (not visible in the paired-down visual available in Fig. 1) are woven throughout the results section, adding depth and nuance to exploring each theme and/or sub-theme.

Fig. 1.

Excerpt from framework grid

Theme 1: Evolution of COVID-19-Related Perspectives, Experiences, and Behaviors Over Time

Ongoing Concerns About COVID-19

As demonstrated in Fig. 1, many early adopters expressed that COVID-19 is still a threat to themselves and their loved ones, with several participants in this group citing the Omicron variant as a reason to continue masking and taking necessary precautions to prevent infection. Additionally, some participants cited unvaccinated individuals as the reason for COVID-19 continuing to be a big problem.

Early Vaccinators, FV3: “I just think COVID is still a big problem because I think there’s still a lot of people who haven’t even received their first dose of the vaccine.”

Early Vaccinators, FV4: It’s definitely a problem still with the new variant…So it’s definitely a problem for—especially for people who won’t get vaccinated because they’re the ones that have ended up in the hospitals, overcrowding the hospitals. And that’s the problem.

Participants in the early adopter group frequently and explicitly linked their ongoing concerns about COVID-19 to the continued emergence of variants and socially irresponsible behaviors of others. While participants in all three groups agreed fairly uniformly that COVID-19 continued to be a problem (particularly because of the variants), participants in the mid-adopter and non-vaccinated groups were more likely to suggest some confusion as to the reason(s) or maintain some possible link to vaccine ineffectiveness.

Non-Vaccinator Group, FG6: FEMALE VOICE 1: Okay. It’s still a threat. More principles should be taken. People should still take precautions…Yes, it’s still a major problem. I’m still - - [vaccine] not effective because people are still wearing masks. Yes, I think it’s effective. Cases have drastically decreased. It’s effective to some point.

COVID-19 Fatigue and Pandemic to Endemic Transition

As noted in the first sub-theme, while most participants (regardless of their vaccination status) recognized that COVID-19 still threatened individual and public health, some also felt that people are adapting to living with it, partially due to ongoing vaccination efforts. Participants also described sentiments regarding COVID-19 fatigue, indicating that their vaccination status tempered their fatigue and that the vaccine allowed them to get back to living life in their “new normal” context.

Early Vaccinators, MV1: For me, what I think about COVID is that people are getting used to it now, it’s not like before when COVID was new and everybody was afraid of dying, I think, all I can say people are adapting. So the vaccination process going on around the world so people are getting the vaccines and their lives are now better.

Similarly, those who received the vaccine after enforcement of the mandates had varying perspectives about COVID-19 over time, acknowledging that COVID-19 is still a threat as evidenced by ongoing safety precautions, but that the threat is not as significant due to increased access to vaccines.

Mid-Point Vaccinator Group, FV3: “I feel like COVID is a big thing, but not a big thing. It’s a big thing because we still have to follow precautions, you know, take steps, measures to be all right and all that. But I feel like it’s not a big thing because of the US government, actually New York has made, made it possible to have the vaccine, you know…I do feel like it’s kind of just like 50/50.”

For the participants in the non-vaccinated group, however, this movement from pandemic to endemic appeared to have little to do with the vaccine, with many still doubting the effectiveness or utility against variants and instead endorsing a longer-term “wait-and-see” approach regarding vaccine safety and suggesting that other non-pharmaceutical approaches provided them with as much surety as they needed to return to more normal daily life activities. Participants in all three groups did however suggest a shared understanding of COVID-19 as “here to stay.”

Non-Vaccinator Group, FG6 MV1: For me I can say that it should be—it shouldn’t be mandatory because after vaccination, I think it was not stated that you will no longer get COVID or because people who were vaccinated are just like us, they keep that social distancing like us, they wear mask like us. So I don’t know what is the need of vaccination when you are still, you are still doing what people who are not vaccinated are doing. So I think it should be what your decide because we are the same in—again, we all wear mask{s} and we all keep that social distancing and we all protect ourselves. So it should be your choice.

Theme 2: Vaccine Effectiveness

Vaccine Effective at Preventing Severe Disease, Including Against New Variants

Participants in the early adopter group spoke about their own fears of getting really sick and their hope that the vaccine would prevent severe cases of COVID-19. This was particularly prominent among people in the group who self-reported other health conditions/comorbidities that might put them at increased risk. Participants cited data and shared their personal observations of witnessing quicker recoveries and fewer and milder symptoms among people who had contracted COVID-19 after getting vaccinated.

Early Vaccinator Group, FG1: “And from what I see they’re saying the ones who are hospitalized now more so, are people that aren’t vaccinated. So it, it shows in the numbers and who’s getting sick at this point. I mean people—you can still get it and you’re, you’re vaccinated but you more than likely won’t end up in the hospital or on a ventilator and that—the, the data has been shown.”

Although most early adopters strongly believed in the vaccine’s effectiveness, some were still concerned about side effects and potential long-term effects. In contrast to the early adopters, the mid-adopter participants specifically noted the role of emerging variants and their perception of vaccine effectiveness, noting that there are limitations to its utility.

Mid Group, FG7: “So I think the vaccine—the vaccine is doing what it should do, but the vaccine wasn’t engineered for an evolving species or for an evolving strain of the virus.”

Other participants in both the mid-adopter and nonvaccinated groups also voiced contradictory views about the vaccine lowering the chance of getting the virus while also increasing the risk of infection. Participants from these groups used both publicly available data and personal anecdotes to explain their positioning.

Mid Group, MV4: Yeah. - - I, I think that, you know, getting vaccinated, it is not done. You’ll still, you’ll, you’ll still be exposed and you, you’ll go out and you’ll meet up with people. So, yeah, you can, you can get the, the, the virus as well. And so far, I’ve seen some studies that show the—those people who have been fully vaccinated and they have like taken the booster shot, they, they are, they are maybe contracting the virus at a higher rate than the, the unvaccinated people. But then I think getting the vaccine, it still lowers the chances of getting the virus.

Non-Vaccinated, FG6: “I don’t think the vaccines are effective due to the different jabs and the fact that people could still contract it. Yes, I do think the vaccines are effective because despite the risk one is facing towards the COVID-19 vaccine, the virus effects are less severe. I also don’t fancy the vaccine. I see it to be not effective since people have chances of getting COVID.”

Breakthrough Infections, Variants, Ongoing Restrictions, and the Need for Multiple Doses Undermine Perceived Vaccine Effectiveness

Across the three groups of participants—although not as prominently among the early adopters—concerns about vaccine effectiveness came through comments made about breakthrough infections, variants, ongoing restrictions, and the need for multiple vaccination doses/boosters. Among the mid-adopters, several participants went further, believing the vaccine was simply ineffective or even considering the vaccine to be potentially harmful.

Mid Group, MV4: “…after she [my grandmother] receiving a booster shot, she began, you know, getting ill. She was like taken to hospital, and, yeah, she was like taken back home and she was always being treated at home, then it got worse, she was like taken back to the hospital again, and now it got worse and worse, and then unfortunately she passed away. So I, I don’t believe that the vaccine worked for her because the whole of 2020 she didn’t get the vaccine and she made it. Now 2021, I think the vaccines cost her life.”

Those who were not yet vaccinated felt that the need to continue wearing masks and practicing social distancing, coupled with changing guidelines that recommended future boosters, meant that the vaccine was not doing its job.

Non-Vaccinated, FV4: …in Facebook I have heard testimonies of people who have got the vaccine, who have believed in the vaccine and uhm they say “I got sick, I’m not feeling well, I got COVID, I got other illnesses, a relative died”. And so I started watching videos on YouTube of different doctors saying that the vaccines are not as effective as others like to claim…

Theme 3: Trust in Science

The final theme, trust in science, demonstrated the most diversity of perspectives depending on vaccination status and sometimes even despite vaccination status. Among early adopters of the vaccine, trust in science was evident, and participants discussed their decision to get the vaccine based on such trust. As noted in Fig. 1, participants cited trust in Dr. Fauci as a member of the scientific and medical community, seeing him as a credible messenger.

Early Vaccinator Group, FV2: “I just continued to watch Fauci and, and push out the other nonsense, bleaching your arm and all kinds of other weird little things…I definitely followed the scientists and when it was my, my time I, I was—I was ready.”

In contrast, the discussion with the “mid-adopter” group reflected a greater variety in opinion. Overall, the group expressed much more skepticism about the vaccine and concerns about the science behind the vaccine than the early adopters. While some felt that the vaccine was a good option, this was dampened by a sense that none of the options were exceptionally good. This was felt within the context of a general agreement that the vaccine timeline felt rushed and participants shared they were concerned that they may not be receiving all of the information about what the vaccine contains or what they were being asked to put into their bodies. Some of this may have been a result of misinformation circulating online.

Mid Vaccinator Group, FV3: “For me, I won’t say I totally believe in it because I remember before I took the vaccine, you know, I was having just like the mind, you know, should I, should I—what’s in the vaccine? What am I taking into my body? Like the fear of, you know, having to put something that should not be in my body or, you know, reacts to it, like I’ve been seeing in social media and all that.”

For a small but vocal minority of the mid-adopters, there appeared to be regret and worry that they made the wrong choice in getting the vaccine. For one person, this was perhaps exacerbated by fears that they could not trust science, given concerns about racial discrimination and bias.

Mid Vaccinator Group, MV4: “I first trust the rumors before I get the, the correct information. So the rumors has it that the Black community is the one being targeted and they want to exterminate it—to exterminate us, and so they are hesitant and probably reluctant. They don’t want to get the vaccine because they feel like they’re the first ones to take it. If they are being forced to take it, they are, they are the lab, the lab rats, and they don’t want to get experimented on.”.

Those not yet vaccinated were very vocal about their distrust of science. While some expressed concern because the vaccines were developed too quickly, more of the discussion centered around concerns about changing, conflicting, and/or a lack of information from the scientific community.

Non Vaccinated, FV5: “..one day, they tell us one thing and the next day, they say something else. And this is not a charlatan speaking, right?, this is Mr. Dr. Fauci saying this.”

In this group, there were also more personal anecdotes that were cited, including one in which the participant cited that their friend, who is a doctor, shared concerns about the vaccine and another that was drawing on fears.

Non-Vaccinated Group, MV2: “My close friend is a doctor. And he has been telling me that we should wait because the vaccines that are being released so quickly and they can—he can’t trust it, yeah.

Non-Vaccinated Group, MV1: “I heard the story of a girl. Her father had to vaccinate her for school and, what happened? She almost died…So I don’t think it’s necessary. I don’t think they should be doing that. That that is not right.

Finally, a central theme to this discussion was around political motives with one participant sharing a sense of exasperation at accusations they felt were targeting the nonvaccinated community.

Non-Vaccinated Group, FV4: “They like to accuse people like us who are simply skeptic, uhm they like to accuse us of being of denying science and uhm of creating a political theater a political stage for this this problem. But I say that they are they are accusing us of something they are responsible for.”

Discussion

Vaccine Perception Commonalities Regardless of Vaccination Status

News and media from the height of the COVID-19 pandemic in the United States often bluntly categorized people as staunchly pro or anti-vaccine [15]. While using the framework grid allowed the research team to identify some pronounced differences of opinion about vaccine effectiveness and utility, it is also important to acknowledge that participants shared many similar perspectives, regardless of their vaccination status. For example, as we explored the idea of COVID-19-related perspectives evolving, our data illustrated that participants across all three groups consistently shared sentiments about experiencing COVID-19-related fatigue and the possibility of as-yet-unknown long-term side effects. A year and a half into the pandemic, other researchers recognized this phenomenon, noting that people were exhausted by a constant news cycle that required them to mentally sift through politics, misinformation, and need-to-know facts about protecting themselves [16]. Our analysis highlights the ubiquitous nature of fatigue with little regard for vaccination status or vaccine decision-making timelines.

Confirmation Bias Among the Groups

We found further commonality between groups regarding how they filtered data and information about COVID-19 and vaccinations, suggesting mindsponge theory and confirmation bias. Confirmation bias is often defined as when “strong initial views are resistant to change because they influence the way that subsequent information is interpreted.” Recent work by Casigliani et. al. [17] and previous work by Blumenthal-Barby and Krieger [18] specifically address the role of bias in medical decision-making, highlighting how heuristics¹ and biases can affect some of the skills (such as probability estimation and information synthesis) central to clinical decision-making by both providers and patients [19]. This also aligns with findings from other publications focused on COVID-19 vaccination, including a July 2021 vaccine monitor brief noting that “nearly half of the most vaccine-hesitant group say nothing would make them more likely to get vaccinated”[20]. In our analysis, the framework model similarly illuminated how people grouped by vaccination status tended to interpret new information (whether data-based or anecdotal) as evidence to confirm their pre-existing beliefs. The graphic visual representation of themes in the framework grid allowed our research team to more deeply explore the linkages between the major themes and sub-themes [19].

Among the early adopters, most participants maintained their overall hope and belief in the vaccines and an enduring trust in science, even in the face of breakthrough infections and variants (Themes 1, 2, and 3). Many of the early adopters cited observing downward trends in the numbers of people being hospitalized or getting severely ill from COVID-19 as evidence that the vaccines were effective, despite also sharing personal anecdotes about breakthrough infections. The participants from the unvaccinated group cited many of the same factors when describing their continued reluctance to accept the vaccine. The evolution of participants’ views thus seemed to largely extend along the continuum from their original positioning, with early adopters maintaining a generally positive opinion and unvaccinated participants a more negative opinion.

Participants in the mid-adopter group showed more diversity of opinion, which also lends itself to the theoretical underpinning around mindsponge theory and cognitive bias. The evolution of opinion of the mid-adopters may have again varied by the individual’s original position as generally proor anti-vaccine. During the coding and thematic process, the study team was able to identify, from the mid-adopters’ comments, different motivators behind their decisions for getting the vaccine. For example, some mid-adopters spoke about getting the vaccine on their own accord (regardless of the mandate enactment) for varying reasons; these participants had a nuanced but generally positive opinion about the vaccine and science in general. In contrast, people in the mid-adopter group who got vaccinated because of the mandate maintained their original, more negative views of the vaccine.

Similarly, using framework analysis and grouping by vaccination status among participants who mostly identified as either Black or Latine allowed for a more thorough exploration of the concept of trust. Most studies identify trust as a key component linked to vaccination acceptance [21, 22]. However, recently, the oversampling of Black and Latina participants allows for a deeper understanding of how trust between health institutions and minority communities/populations is built and maintained [23]. Many of the participants in our groups demonstrated a high level of trust in public health professionals and science, highlighting that it is possible to build and maintain trust with communities of color. But framed in the context of mindsponge theory and confirmation bias, our study findings also suggest that trust is not enough and that trust can be undermined by repeated data filtered through an individual’s biased lens (Fig. 2).

Fig. 2.

Factors influencing COVID-19 vaccination uptake and receptivity

This is not to say that individuals in each group universally refused to acknowledge any evidence contradicting their underlying (and likely original) position on the vaccine. Rather, participants in each group often voiced a somewhat nuanced stance; early adopters noted concerns about long-term side effects, and mid-adopters and unvaccinated group members indicated in some instances that they believed the vaccine prevented more serious illness. Like the recent work by Casigliani et al. [17], this may reflect the fact that an array of cognitive biases and heuristics are involved in vaccine decision-making; to characterize it as simply the result of a single assessment likely over-simplifies a complex internal process. Using skilled moderators in this context and the ability of participants to respond in their chosen language helped minimize the likelihood of groupthink and minimize the possibility of one voice dominating the conversation.

Strengths and Limitations

The study’s strengths include NYCEAL’s collaboration with community-based organizations to recruit participants with varying vaccination statuses and perspectives. The majority of participants in these groups also self-identified as members of historically marginalized communities that were hardest hit by the COVID-19 pandemic in New York City. The multidisciplinary and multi-lingual research team helped facilitate conversations and aided during the triangulation process.

However, we acknowledge that many of us contributing to this research project received the COVID-19 vaccine early on and were part of ongoing efforts to improve constituent trust in science and provide more access to vaccine education and vaccines. This may have influenced research design decisions, including final analyses. Several other limitations exist in this study. Although this study provides insights into the experiences and decision-making processes of participants from diverse communities in New York City, transferability to the general population (particularly in rural or less diverse areas of the country) may be limited. Future studies should consider combining multiple qualitative methods to triangulate findings and better capture population diversity [24].

Additionally, the study team made the executive decision for the study design to group mid-adopters as any participant who had received the vaccine since the mandates were enacted. This means that those who received the vaccine strictly because of the mandates were in the same discussions as those who chose to get the vaccine regardless of the mandate, and differentiating between the groups was only possible through our qualitative content analysis. Looking at transcripts for these two distinct categories of mid-adopters enabled us to better distinguish between them and give us a better understanding of a spectrum of pre-existing beliefs in the middle. Using diffusion theory, we may have been able to distinguish, within this group, between an early and late majority, which could have further implications for addressing confirmation biases [25].

Participants in these focus groups were also already connected to community-based organizations/social services in New York City, which may indicate a general willingness to engage with service providers or medical professionals. The research team tasked with analyzing these data was primarily composed of clinicians and public health–trained researchers with their own beliefs about science and vaccines. Although we utilized trained and experienced moderators, it is also possible that focus group dynamics and the complex interplay of social and psychological factors altered how individuals expressed their views in this setting. A group discussion always presents the possibility that a dominant personality can skew a discussion and lead to “groupthink” [26]. Cognitive bias and the availability heuristic may also cause participants to overemphasize recent or easily recalled experiences, altering the group’s perception or discussion of the topic [27, 28].

Implications for Practice/Future Research

As with all research, the intent and biases of the research team make a nuanced exploration of charged health-related topics potentially more difficult. Public policies, such as vaccine mandates, aimed at improving or protecting health at the population level often present a dichotomous choice—yes or no—with one option framed as being right. These data suggest that the relationship between some of the core concepts required for an individual to endorse a public health policy/mandate, such as trust in science and vaccine effectiveness, may be paradoxically both incredibly nuanced and yet somewhat inflexible based on the individual’s original positioning and heuristic lens. Future public health messaging campaigns and policy decisions should thus consider the role of confirmation bias and help people recognize their own beliefs and integrate new information at odds with their cognitive schema. New approaches could draw on successful campaigns like “Man Therapy,” which specifically addressed cognitive biases relating to mental health stigma using humor and relatable stories to normalize help-seeking behaviors and framing mental health as aligned with masculine stereotypes, countering biases framing seeking help as a sign of weakness [29].

Conclusion

Our study found both similarities and differences when exploring perceptions about vaccine effectiveness and barriers to vaccination among groups of individuals characterized as either early adopters or mid-adopters of the vaccine or as non-vaccinated. The differences, however, largely relied on the individuals’ foundational beliefs relating to vaccine effectiveness and overall trust in science. Collaboration with our community partners allowed us to purposefully sample mostly Black and Latine individuals. Our subsequent analysis allowed us to add nuance and context to previously reported general findings around public health vaccine messaging and mandates, the role of building and maintaining trust, and the need to explore actionable ways to address confirmation bias in healthcare decision-making.

Data Availability

The dataset used in this study is available upon reasonable request from the corresponding author.