Persuading the “Movable Middle”: Characteristics of effective messages to promote routine and COVID-19 vaccinations for adults and children – The impact of COVID-19 on beliefs and attitudes

Abstract

Purpose

We sought to 1) explore trusted sources for vaccine information, 2) describe persuasive characteristics of trusted messages promoting routine and COVID-19 vaccines for children and adults and 3) explore how the pandemic has impacted attitudes and beliefs about routine vaccinations.

We conducted a mixed method cross-sectional study between May 3-June 14, 2021 including a survey and six focus groups among a sub-set of survey respondents. A total of 1,553 survey respondents (from which n = 33 participated in the focus groups) including adults without children under age nineteen years (n = 582) and parents with children under age nineteen years (n = 971).

Results

Primary care providers, family, and credible sources, characterized as known and well-established entities, were top sources of vaccine information.

Neutrality, honesty, and having a trusted source to rely on in sorting through volumes of sometimes conflicting information were highly valued. Trustworthy qualities about sources included: 1) expertise, 2) fact-based, 3) unbiased, and 4) having an established process for sharing information. Because of the evolving nature of the pandemic, attitudes and beliefs about COVID-19 vaccine and sources of COVID-19 information differed from typical views about routine vaccines.

Of 1,327 (85.4 %) survey respondents, 12.7 % and 9.4 % of adults and parents cited that the pandemic impacted their attitudes and beliefs. Among these respondents, 8 % of adults and 3 % of parents cited more favorable attitudes and beliefs about getting vaccinated with routine vaccines because of the pandemic.

Conclusion

Vaccine attitudes and beliefs which inform intent to vaccinate can change and differ among different vaccines. Messaging should be tailored to resonate with parents and adults to improve vaccine uptake.

1. Background

The United States is emerging from the COVID-19 pandemic in large part due to the availability of safe and effective COVID-19 vaccines [1], [2], [3]. Despite ample supply and multiple access points for vaccination services, coverage has stalled. As of September 8, 2021, 53 % of the population and 75 % of adults were fully vaccinated [4]. This is a significant feat for a large-scale mass vaccination program in adults, though far below the goal and estimated threshold of at least 90 % to reach herd immunity for the delta variant, the predominate circulating strain [5], [6], [7], [8]. Concern over the contagious delta variant place greater emphasis on increasing vaccination coverage, particularly as COVID death rates are significantly higher and increasing in states with low vaccination rates [9], [10], [11].

Building vaccine confidence—trust in the vaccine itself, in providers who administer vaccines, and in the process that leads to vaccine licensure and the recommended vaccination schedule— is central to addressing the multifaceted reasons for low coverage [12], [13], [14]. Practical issues of convenience or constraint (e.g., vaccine availability), attitudes that influence confidence (e.g., perceived risk), complacency (e.g., perceived health status), and calculation (e.g., engagement in information seeking, intention, motivation, willingness) coupled with an individual’s sense of communal responsibility, collectively influence vaccination behavior [12], [13], [14], [15]. Although related to one another, attitudes and beliefs about vaccination may differ from intent to vaccinate and actual behaviors, particularly depending on the interaction with contextual factors in a pandemic, highlighting the complexity of determinants to accepting vaccination and potential differences among COVID-19 and routine vaccines [16], [17]. Addressing hesitancy to vaccinate, refusal or delay despite available supply, through strategies that speak to attitudes and beliefs rather than behaviors, may be an important way to increase vaccination rates as some individuals will vaccinate despite still having hesitancy [18].

A key knowledge gap is whether underlying reasons for hesitancy about COVID-19 vaccines differ from known factors that influence hesitancy around routine vaccines. Further, it is unclear as to how the pandemic may have influenced attitudes and beliefs about routine vaccines. This knowledge will contribute to tailored messaging. In this two-fold study, we sought to first fill these knowledge gaps about vaccine-related beliefs and attitudes by understanding individuals’ perceptions of routine immunization, hesitancy, information seeking behaviors including trusted sources, as well as the impact of the COVID-19 pandemic on acceptability of routine immunizations across the lifespan [19]. Secondly, we tested the perceived argument strength of messages for use in immunization campaigns as message-evoked reactions are considered a critical mediating variable in the persuasion process and are strong predictors of persuasion effects such as attitude change [20], [21].

2. Methods

This cross-sectional, mixed-methods study used survey informed-responses to select eight messages to test in focus groups, quantify changes in attitudes and beliefs, and characterize sources of information by vaccine hesitancy type. Eligible adults, eighteen years of age and older without children and parents, adults with children younger than eighteen years of age, from Maryland, Delaware, Pennsylvania, New Jersey, and New York were asked to complete a confidential survey on trusted messengers and messages about routine and COVID-19 immunization. Upon completion, those who elected to participate in focus groups were stratified by adult or parent into one of six focus groups (three adult, three parent) of no more than eight participants, to evaluate vaccine messages. We used message receivers’ cognitive responses to test argument strength (one that has elicited predominantly favorable or positive thoughts) by focusing on intrinsic message features and valence, or thoughts grouped in terms of whether they are favorable, unfavorable, or neutral toward the advocated position (vaccination) [20]. The Children’s Hospital of Philadelphia (CHOP) Institutional Review Board determined the study exempt.

2.1. Survey

The survey, conducted May 3–28, 2021, was developed and administered by CHOP using the Research Electronic Data Capture (REDCap) instrument and distributed to participants through a Prodege survey panel. All data were stored in a secure server. A sample of 2000 responses (20 % adults and 80 % parents) was requested of Prodege to complete separate surveys on 1) sources of vaccine information, 2) COVID-19 vaccination intent and 3) the impact of the pandemic on attitudes and beliefs about vaccination.

In order to stratify respondents by vaccine confidence status: hesitant, somewhat hesitant, or not hesitant, the Betsch, et al. 5C scale [15] on confidence, complacency, constraints, calculation, and collective responsibility was used for adults without children and the Opel et al. Parental Attitude about Child Vaccines (PACV) validated short scale was used for parents [22], [23], [24].

Summary statistics, Pearson’s Chi-squared (Χ²) test for any comparison with all cell sizes over ten participants, and Fisher’s exact test for any comparison with any cell sizes ten and below were calculated using Stata/BE 17.0.

2.2. Focus groups

Focus groups of up to eight individuals per group were conducted between June 7–15, 2021 to 1) further explore findings in the surveys about sources of trusted information, 2) test the appeal of persuasive vaccine messages drawn from top reasons for vaccination drawn from survey responses (Table 1 ), and 3) explore changes in attitudes and beliefs about routine vaccination due to the pandemic. All participants who completed the survey were eligible to participate in focus groups. Those who elected to do so were asked to compete a seven-question screener survey including a question to rank the eight messages (SUPPLEMENTAL MATERIAL 1). The top four to six messages from the screener survey were compared to focus group responses and used in 60-minute focus group discussions. Two members of the research team independently coded results including characterization between pre-screen and focus group responses and an inter-rater reliability score was calculated for each focus group (SUPPLEMENTAL MATERIAL 2). Participants were asked to react to messages in the positive and the negative within the context of convincing others to accept vaccination as well as who would be the most trusted source to deliver messages. In addition to the moderator and note taker, all sessions were recorded and transcribed. Participants were informed prior to each focus group that the responses were confidential and that by participating they consented to be a part of the study. No personal identifiers were collected and participants were given gift cards for participation.

Table 1.

Reasons for and against COVID-19 vaccination based on adult and parent survey respondents.

	Adults (N = 563)					Parents (N = 883)
	Not Vaccinated (n = 154, 27.4 %)		Vaccinated (n = 409, 72.6 %)		Χ2 p-value	Not Vaccinated (n = 352, 39.9 %)		Vaccinated (n = 531, 60.1 %)		Χ2 p-value
Reasons why to get a COVID-19 vaccine:	Count	Percentage	Count	Percentage		Count	Percentage	Count	Percentage
I want to protect my child/myself/my family/ (e.g., It would be the best way to avoid getting seriously ill from COVID-19. I have a chronic health condition, so it is important to receive a COVID-19 vaccine. It would allow me to feel safe around other people)	27	5 %	291	52 %	< 0.001*	72	8 %	319	36 %	< 0.001*
I want to protect my community.	25	4 %	217	39 %	< 0.001*	51	6 %	219	25 %	< 0.001*
My family and friends have gotten the vaccine and are well.	19	3 %	142	25 %	< 0.001*	45	5 %	164	19 %	< 0.001*
I am required to get the vaccine for my employment.	8	1 %	18	3 %	0.689	21	2 %	29	3 %	0.751
I want the freedom to go to a restaurant or bar. Life will not go back to normal until most people are vaccinated.	24	4 %	197	35 %	< 0.001*	42	5 %	148	17 %	< 0.001*
My doctor/pastor/elders wanted me to get the vaccine.	12	2 %	85	15 %	< 0.001*	16	2 %	82	9 %	< 0.001*
The vaccine is carefully tested and found to be safe.	41	7 %	214	38 %	< 0.001*	69	8 %	226	26 %	< 0.001*
I trust my doctor and the recommendation to get vaccinated.	29	5 %	220	39 %	< 0.001*	84	10 %	271	31 %	< 0.001*
Not applicable - I do not plan to get the vaccine.	52	9 %	–	–	< 0.001*	140	16 %	16	2 %	< 0.001*
Reasons why not to get a COVID-19 vaccine:	Count	Percentage	Count	Percentage	Χ2 p-value	Count	Percentage	Count	Percentage	Χ2 p-value
I have had a COVID-19 infection, so am likely have antibodies to the disease.	12	2 %	5	1 %	< 0.001*	30	3 %	18	2 %	0.001*
I am in a low-risk group for getting seriously ill from COVID-19.	14	2 %	11	2 %	0.001*	43	5 %	73	8 %	0.509
The COVID-19 outbreak is not as serious as some people say it is.	12	2 %	5	1 %	< 0.001*	30	3 %	20	2 %	0.003*
The vaccine was developed too quickly. I don’t trust the COVID-19 vaccine development process.	57	10 %	43	8 %	< 0.001*	143	16 %	59	7 %	< 0.001*
The vaccine was not tested on people like me.	13	2 %	16	3 %	0.030*	22	2 %	18	2 %	0.045*
I am concerned about side effects from the vaccine.	65	12 %	55	10 %	< 0.001*	148	17 %	121	14 %	< 0.001*
I don’t think vaccines work well.	12	2 %	6	1 %	< 0.001*	33	4 %	6	1 %	< 0.001*
I am concerned about getting infected with COVID-19 from the vaccine.	18	3 %	12	2 %	< 0.001*	46	5 %	20	2 %	< 0.001*
I have other problems to worry about in life than the vaccine.	17	3 %	8	1 %	< 0.001*	16	2 %	14	2 %	0.125
I don’t have time to get vaccinated.	6	1 %	2	0 %	0.002*	7	1 %	8	1 %	0.587
Nobody I know has gotten the vaccine.	7	1 %	5	1 %	0.015*	13	1 %	15	2 %	0.471
Not applicable - I plan to get the vaccine.	21	4 %	273	48 %	< 0.001*	43	5 %	248	28 %	< 0.001*

^*denotes significant p-value.

Content analysis was performed on the interview notes. Recordings were used as reference sources to aid in analysis. Deductive thematic analysis used a priori codes based on four main outcome measures: (1) Trusted sources of information (2) Characteristics of persuasive messages (i.e., convincing believable, important, confident, and comfortable) (3) Advice to others in a vaccination campaign and (4) differences in attitudes and beliefs about routine vaccination and changes in these attitudes and beliefs in the context of the pandemic. Data on this last outcome also came from the survey. Emergent themes not well-captured by these characteristics were addressed by an inductive approach.

3. Results

Survey. Among 1,553 individuals who completed our survey, 582(37.5 %) were adults without children and 971(62.5 %) were parents. Most adults (n = 409, 72.6 %) and parents (n = 531, 60.1 %) reported already having received a COVID-19 vaccine.

For both adults and parents, the top reasons for getting vaccinated related to 1) protecting self, family, and community; 2) trust in their healthcare provider; and 3) freedom and autonomy (p < 0.001 for each) (Table 1). Vaccinated individuals reported these as reasons to receive COVID-19 vaccines proportionately more than unvaccinated individuals (Table 1). Regardless of COVID-19 vaccination status, both adults and parents reported concerns about the side effects from the vaccine, however vaccinated individuals selected this reason less than those were unvaccinated (p < 0.001) (Table 1).

Of those 1,327(85.4 % of total sample) individuals who answered the question, 12.7 % and 9.4 % of adults and parents, respectively, cited that the pandemic impacted their attitudes and beliefs. Within this subset of respondents, 8 % of adults and 3 % of parents, respectively, changed their minds in the positive direction, and 2 % of adults and 3 % of parents changed their minds in the negative direction (Table 2 ). Adult and parent survey respondents, who could select multiple options, cited healthcare providers (75 % and 74 %, respectively), news outlets (74 %,52 %), family members (53 %, 48 %), and health service organizations (53 %, 42 %) as top key sources of information (Table 3 ). SUPPLEMENTAL MATERIAL 3–4 provide additional stratification by vaccine hesitancy status.

Table 2.

Respondents who affirmed that the COVID-19 pandemic changed their attitudes or beliefs about getting vaccinated with routine vaccines, Adults (N = 526) and Parent (N = 801) responses.

Responses Citing Change	Positive Direction About Routine Vaccines	Negative Direction Against Routine Vaccines
Adults, n = 67 – 11.5 %	n = 42 (8 % ) 42/526 = 8 %	n = 12 (2 %) 12/526 = 2 %
67/582 = 11.5 % (total) 67/526 = 12.7 % (subset) 42/526 = 8 % 12/526 = 2 %	•“I didn’t always get the flu shot, will do so now.” “It made me more likely to get vaccinated.” “I realized that my husband and I probably should get whatever vaccinations or boosters are recommended for our age group, like a tetanus booster. I had never given the issue much thought before COVID.” “I never used to get the flu shot, but this made me get a better understanding that it isn’t just about protecting me, it is about others as well.” “More inclined to seek out getting Shingles and Pneumonia shots which I have neglected to get.” “made it more real” “I feel I believe more in vaccines.” “In the past, I have not opted for all shots, such as the flu shot. With Covid, I am reconsidering.”	•“Less trusting” “More reluctant to get vaccines.”
Parents, n = 75 (7 %)	n = 24 (3 %)	n = 21 (3 %)
75/971 = 7 % (total) 75/801 = 9.4 % (subset) 24/801 = 3 % 21/801 = 3 %	•“Its change my beliefs and attitudes that my children need to get vaccinated” “It makes me want to get more to keep them healthy.” I make sure my kids are up to date on all there vaccines.”	•“I'm less trusting of vaccines after seeing how quickly the COVID vaccine was rushed through.” “I don’t believe as much as I used to.” “It makes me wonder if all the vaccines they get are essential.”

Source Notes: Four adult and four parent responses each were discarded because they referenced COVID-19 rather than routine vaccinations. Eight adult and eighteen parent responses were not counted since they were unclear or neutral, and six parent responses were discarded because they were rubbish responses (e.g., asdfasdfasdf). Denominator is those who answered question.

Table 3.

Vaccine information sources for adult and parent survey respondents.

Vaccine Information Source	Adult (n = 582)		Parent (n = 971)
	Count	Percentage	Count	Percentage
Personal
My colleague or supervisors	67	12 %	113	12 %
My employer	63	11 %	93	10 %
Family Members	308	53 %	470	48 %
Friends	182	31 %	310	32 %
Social Influencer	36	6 %	117	12 %
Other	188	32 %	215	22 %
Health Care and Government
My doctor/health care provider	438	75 %	719	74 %
Local government	204	35 %	222	23 %
Federal government	330	57 %	342	35 %
Other	19	3 %	20	2 %
Media
News Media	429	74 %	509	52 %
Social Media	120	21 %	291	30 %
Other	45	8 %	96	10 %
Community
Church or religious group	42	7 %	76	8 %
Community organizations	61	10 %	133	14 %
Health service delivery organization	311	53 %	406	42 %
Child's school	10	2 %	327	34 %
Other	91	16 %	62	6 %

Focus Groups. Six focus groups (n = 33 of 18 adults, 15 parents) with adults without children or parents were conducted (SUPPLEMENTAL MATERIAL 2). Findings from adults and parents were similar between both sets of data. Differences are described within each following section.

3.1. MEASURE 1: Trusted sources of information

Top sources of information—providers, family members, and credible news outlets— aligned with survey results for both adults and parents. Notably, neutrality, honesty, and having a trusted source to rely on in sorting through volumes of sometimes conflicting information were highly valued, as well as a general preference for face-to-face conversations that allows for engagement to answer questions. Hearing consistent information from different sources (external consistency) was also important.

“It would be concerning if the CDC said one thing and my state health department said another. I would take that to my internist and say I’m getting two different messages…she’s a good referee on things like that.”

“You can go online and find an opinion to support anything.”

Qualities that were valued for trustworthiness of sources included: 1) being viewed as an expert, 2) presenting fact-based information, 3) appearing unbiased and 4) having an established process for sharing information. Credible sources, particularly electronic ones, were characterized as known and well-established entities. While family members were cited as top sources of information, informants differentiated that they may not always be credible. Conversely, social media was consistently ranked as a bottom source of information. As corroborated in survey responses (10 % of adults and 14 % of parents), participants shied away from local community groups (e.g., church or religious group, YMCA), citing the trust in these sources as familiar entities in the community, however lacking health expertise to be credible.

“I look at actual science research [through PubMed].”

“It’s important to have a conversation.”

“[In social media, they can] post whatever they want, and it’s not regulated.”

“There is just so much out there. It’s hard. I think people are just [bombarded] with poor information by people who can just put anything out there.”

Notable differences between trusted sources for adults and parents varied because adults see either a diverse range of providers or none at all unlike children who see providers often and usually a primary care provider like a pediatrician. Many adults also have comorbid conditions, citing specialists as more trusted sources of information because of their familiarity with their own patient history to make a personalized and informed decision. In the same vein, parents overwhelmingly cited trust in their pediatric provider and the importance of a shared clinical decision-making process. Parents also cited the school system as a trusted, helpful, and useful source of information. These responses from focus group participants aligned with survey responses of top sources of information (Table 3).

Significant distinctions were made for sources for COVID-19. Unlike for sources about routine vaccines and vaccine-preventable diseases, individual providers were not the preferred sources for the pandemic due to the speed in which the pandemic was unfolding, the rapidly evolving information, and the availability of information particularly regarding access to vaccination appointments, and where to get vaccinated. Instead, respondents sought information more from news outlets and of state and local health department websites to receive near real-time information.

3.2. MEASURE 2: Testing appeal - characteristics of convincing messages

One routine immunization message and four to six COVID-19 vaccine messages were tested in each focus group. Four main characteristics of messages were described as convincing, including: 1) relatable and relevant content, 2) values-aligned messaging, 3) influenced by past experience, and 4) short, simple, and clear format. Participants recommended ways to improve messages to be more convincing (Table 4 ). Recommendations included: 1) be more directive; 2) include details; 3) provide audience-targeted context; 4) paint a clear, realistic, and complete picture; and 5) target the independence of decision-making.

Table 4.

Characteristics of Convincing Messages that Motivate and Recommendations for Improvement.

Convincing (+)

Not convincing (-) and Recommendations from Informants:

1. Relatable, Relevant Priorities and Benefits • “I can relate to this message. I want to keep myself healthy. I don’t want to get sick.” • “It reflects my motivation [to] protect my older relatives.” • “I find this message convincing because I do have trust in healthcare. But there are those in the community who do not have trust in healthcare so I don’t think they would find it convincing.” 2. Resonates with Values • “This is me. I am a person getting the vaccine who really cares about others.” 3. Touches Past Experience • “It’s effective because I got a serious case of COVID and was in the hospital, one step away from the respirator. My wife also got COVID. Now keeping up with routine shots is more pertinent…we have had several friends who have died from COVID. It’s a lot more meaningful. Prior to this I have never gotten a flu shot. Now I’m at a point where I think differently.” 4. Messages Have Clarity • “Messages should say one of the reasons I got the shot… but it’s not the only reason.” • “It covers several reasons in one sentence. I like it because it’s the bottom line for me… it covers self-care, concern for my family, concern for my community. It’s all inclusive. It’s concise…in a short number of words.” 5. Mandates • “[Getting vaccinated to go to school:] it’s a no brainer.” “I don’t want to grief of what happens if you do not get the vaccinations.”

1. Be directive. • “The statement doesn’t mean anything to me. It doesn’t say go get a shot. It just says the shot protects.” 2. Get directly to the message. • “Get rid of ‘I have gotten caught up…I fumble on those words. Go directly to I get my regular shots.” 3. Include details, beyond the “basics” and explained. • “How can getting a vaccine make a positive difference. I want more information about the seriousness of the disease itself and the potential affects the virus can have.” • “The messages should talk about protecting all around you, beyond family, you should also say co-workers, neighbors…everyone has others they care about.” 4. Provide targeted context. • “I am a diabetic and the risk factors for diabetics are higher so the message means more to me rather than if I didn’t have those underlying factors.” 5. Paint a clear, realistic and complete picture. • “You still have to wear a mask, so I think it gives false hope that everything is fine [if you get a COVID-19 shot].” • “We’ve still got a long way to go, with variants, so vaccination is not the end of the end.” • “This [message] doesn’t resonate because you cannot totally go back to normal life. I want things to go ack to normal. I got my COVID shot but others did not…I think it’s premature to assume it’s safe to be in a bar [and resume normal life activities].” 6. Respect for Autonomy and Shared Decision-Making. • “You need to have your own reason [for getting the shot]. Not just because everyone else got it.” • “I got it because it was best for me, not because hundreds of millions of people got it. One friend who works in a lab convinced me it just didn’t come out of no where…its been worked on for years. I got it [COVID shot].” • “Something like because my doctor advised me to and ‘I agreed with him.’ or something where it shows we have used our critical thinking to look at what our doctor told us to do and if it’s reasonable and plausible we follow it.”

The most amount of dissonance and discussion revolved around the concept of herd immunity. Some informants resonated with messages about protecting family and others, while these messages clashed with the concept of autonomy and individuality and the fallacy in logic around broad vaccination, because many in their family units (i.e., their children) are not yet within a recommended age group for vaccination.

Among adults, respondents noted that some messages may imply judgement and that messages based on a false premise will be difficult to target strategies to use to persuade vaccine uptake.

“Implies that people who are not routinely vaccinated in some way they don’t care about other people.”.

“If I know the COVID vaccine would keep me safe then I would take it. It only helps with the symptoms. It doesn’t help with getting it.”

Participants were also asked what advice they would give others in a vaccination campaign. Four pieces of advice, common to both adults and parents, included advising individuals to 1) weigh risks and benefits, 2) make an informed and choice through a trusted process, 3) speak with your doctor, and 4) listen to a personal story from someone they trust (Table 5 ).

Table 5.

Recommendations from Focus Groups on Advice to Adults and Parents for Vaccination Campaign, (n = 33).

Advice to Adults	Advice to Parents
1. Weigh benefits and risks
•“You have to weigh the options, side effects versus dying, it’s definitely better to get the vaccine.” •“Include a statistic, it would help [for parents who think getting COVID and getting sick is not common].	•“I’d rather have my kid get a vaccine then die of COVID…know that kids are getting sick from it even though it may not be as many as adults…most of what is out there publicly is that kids don’t get this, but they do.”
2. Empower yourself with a trusted process to make an informed choice. Talk to people you trust most, listen to the experts, and pay attention the source of information and seek trusted sources.
•“Find and develop a relationship with a physician you can trust, have an honest conversation, before you make a decision, give yourself time to think about it, discuss with those closes to you and then decide. Do your own research” •“See if it’s a credible source before you even start reading it. Before even reading the article and because there is an overwhelming amount, I don’t want to be wasting my time put out by 12 people who are the only 12 people who believe in that. Every day it’s a challenge to try to only pay attention to what I consider reputable sources.”	•”Trust yourself and do as much research as you can. Do a pros and cons list and just be honest with yourself and your family and do what’s best for your family overall and own it.” •“Listen to the experts, not the Facebook warriors. I have some great friends and I love them, but I’ve tuned them out. You have to do your own gut check and tune everyone else out.”
3. Make a tailored decision together with your doctor. Trust your doctor.
•“A person needs to evaluate their own risk factors. It’s not the same for everyone. You need to understand how it can benefit you and at what risk do you stand normally. What is your baseline risk.” •“Do not let people, I mean social media and friends, not CDC [not non-public health professionals] influence your decision. Make a decision for yourself. You have to do what’s best for you at the end of the day.”	•“Your doctor went to medical school for a reason. They are practicing based on their expertise. You have to trust your doctor, that’s what they are there for. They have the experience that we don’t.” •“Take all your questions and go to your doctor who you trust to separate the fact from the fiction. There is a lot of noise out there. Go with all your questions, specific questions and have them [your doctor] answer it.”
4. Share a personal story
“Everyone has a different reason for taking the vaccine. I explain to them why I took it.”	•“If you’re interested in knowing my experience, I would offer my experience with my children. And separate advice for COVID than advice for MMR, something that has decades of experience versus something like COVID that is brand new. If you want some trusted source [for COVID] here are some of the sources I trust.”

“You have to weigh the option, side effects versus dying, it’s definitely better to get the vaccine.”.

“See if it’s a credible source before you even start reading it. Before even reading the article and because there is an overwhelming amount, I don’t want to be wasting my time put out by 12 people who are the only 12 people who believe in that. Every day it’s a challenge to try to only pay attention to what I consider reputable sources.”.

3.3. MEASURE 3: Impact of the pandemic on attitudes and beliefs

The focus groups explored reasons why a proportion (12.7 % and 9.4 % of adults and parents, respectively, who responded to that question) of survey participants changed their attitudes and beliefs about routine vaccinations because of the pandemic. Many cited the relevance of the disease in terms of immediate impact in death and disability.

“MMR is not prevalent so what am I protecting my children against. You don’t see cases of those diseases.”

Attitudes and beliefs about COVID-19 vaccine differed from views about routine vaccinations, given the rapid speed vaccine candidates were produced and introduced into the public.

“If you are targeting someone on the fence, they need to be reassured that these [COVID-19 vaccines are safe.”

Participants noted trusted sources of information were especially important for COVID-19 information because of the overwhelming amount of available information. Participants yearned for a “single source of truth” and cited most often, either their state health department, CDC, or their provider as that single source. Participants also felt a gap in long-term information about COVID-19 disease and vaccine safety.

Parents, while generally supportive about routine vaccines, were conflicted about vaccinating their children with COVID-19 vaccines, citing the lack of data on long-term safety.

“Given there is not a lot of long-term testing, I worry about fertility issues”

“They don’t know much about it [the vaccine]. Why take a chance of putting something in your children, that can do more damage than can help.”

4. Discussion

In this study of vaccine attitudes and beliefs among adults without children and parents during the COVID-19 pandemic, we found a population in flux. Adults and parents have found trusted sources of information, and developed processes for decision making around vaccination, yet still expressed conflicting emotions, attitudes, and beliefs, both between and within individuals on the decision to vaccinate themselves and their family members with the COVID-19 vaccines. Moreover, although it may be assumed that those who are “hesitant” or vaccine deniers are not movable, we suspect this is not entirely the case. It is keenly important to continue to address all those in the community as a target audience, not the vocal vaccine deniers, since data shows that those whose attitudes and beliefs are vaccine hesitant still will receive vaccines [17], [25].

The pandemic and the nations’ response have not only been rapid and fluid, but confusing, particularly in messaging about the vaccine and the critical role vaccination plays in controlling the pandemic. This theme came across strongly in our study, with informants developing their own processes to sift through information, often using a trusted advisor, such as a health care provider or the local health department, to help. We found that while HCPs continue to be rated as among the most trusted sources of health information for adults and parents, they were not considered as up-to-date for information on the COVID-19 vaccine as news outlets and state departments of health at the time the study was conducted.

While communications should be clear, we found that clarity alone may not be compelling unless the message resonates in experience or context (e.g., having immunocompromised grandparents or a near-death experience with COVID-19). Our findings echo other research in that individuals want to 1) understand overall risk–benefit to themselves and be reassured that 2) symptoms after vaccination (e.g., fever, chills), are “normal”. Therefore, the lack of long-term safety poses challenges in messaging. Statistics and relative proportional risk may be helpful in reassuring individuals about the benefits relative to the risks of vaccination.

The recognition that some may be resistant to accepting new information means counter beliefs must extend beyond simply providing corrective information. Messages designed for individuals prone to reactance can minimize controlling language to emphasize individual’s independence in adopting behavioral recommendations [26].

4.1. Limitations

This study has several limitations. First, demographic data were not collected by Prodege, limiting the ability to stratify vaccine hesitancy status by sociodemographic factors, which have previously shown to be highly predictive of vaccine hesitancy [27], [28], limiting the analysis. Future studies can use predictive modeling to further characterize associations between specific sociodemographic characteristics and vaccine attitudes and beliefs by vaccine confidence status. Second, many of the survey respondents shared their views on COVID-19 when asked about routine immunization. When obvious, these responses were excluded from analysis, thus, responses about routine vaccination may be inflated. Lastly, as the nature of the pandemic changes, views and attitudes about vaccines and vaccinations are evolving; particularly, there has been a rise in COVID-19 vaccine initiation and acceptance as increased cases of COVID-19 are flooding hospitals in certain regions of the countries [29], [30]. Moreover, impending, emergency use authorization or licensure of vaccination for children under age 12 is expected. Recently, an additional dose of COVID-19 vaccine was recommended for immunocompromised populations [31], [32].

5. Conclusion

We recognize that attitudes and beliefs are vaccine specific. However, the nature of attitudes and beliefs are malleable, influenced by trust placed in information sources, content and tone of messaging, and perceptions of the current environment, such as unanticipated events like the pandemic. COVID-19 increased positive attitudes about vaccines overall, however time will tell whether these changes are temporal or more rooted in longer lasting change.

Funding statement

Dr. Kornides was supported by an award from the National Institute of Child Health and Human Development and Office of Women’s Research [5K12HD085848-04]. This study was funded by an internal grant from Children’s Hospital of Philadelphia’s Office of External Affairs.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary material

The following are the Supplementary data to this article:

Data availability

The data that has been used is confidential.