Abstract
Objective:
Public health agencies have a critical role in providing effective messaging about mitigation strategies during a public health emergency. The objectives of this study were (1) to understand perceptions of COVID-19 vaccines, including concerns about side effects, safety, and effectiveness and how these perceptions influence vaccine decision-making among US adults and (2) to learn what messages might motivate vaccine uptake.
Methods:
In April and May 2021, we conducted 14 online focus groups with non-Hispanic English-speaking and English- and Spanish-speaking Hispanic adults (N = 99) not vaccinated against COVID-19. We oversampled adults aged 18-39 years and rural residents and systematically assessed 10 test messages. Researchers used a standardized guide and an a priori codebook for focus group discussions, coding transcripts, and thematic analysis.
Results:
Vaccine hesitancy factors included fear of the unknown; long-term side effects, including infertility; and beliefs that the vaccines were developed too quickly and were not sufficiently effective. Motivating factors for receiving vaccination included the ability to safely socialize and travel. Health care providers were considered important trusted messengers. Participants were critical of most messages tested. Messages that came across as “honest” about what is not yet known about COVID-19 vaccines were perceived more positively than other messages tested. Messages were seen as ineffective if perceived as vague or lacking in data and specificity.
Conclusions:
Messages that were simple and transparent about what is unknown about vaccines relative to emerging science were viewed most favorably. Health care providers, friends, and family were considered influential in vaccination decision-making. Findings underscore the benefits of research-informed strategies for developing and disseminating effective messages addressing critical issues in a public health emergency.
Keywords
Before approval and recommendation of a COVID-19 vaccine, national polling indicated that 70% of people in the United States were willing to get vaccinated, with the other 30% hesitant or not planning to ever get vaccinated. 1 In December 2020, the first COVID-19 vaccine received Emergency Use Authorization from the US Food and Drug Administration (FDA), and by January 2021, a large-scale vaccine rollout plan was in motion. 2 Disparities in vaccine hesitancy emerged by race (eg, among Black or African American [hereinafter, African American] populations), ethnicity (among Hispanic or Latino [hereinafter, Hispanic] populations), age group (ie, those aged 18-39 y), and geography (ie, rural populations). 3 Adults leaning toward or against vaccination, also known as the “movable middle,” had concerns about the vaccines’ safety, speed of development, and short-term and long-term side effects.3,4 The Johnson & Johnson (J&J) vaccination pause in early April 2021 had the potential to further undermine vaccine confidence. 3
Early research indicated that messages about vaccine effectiveness increased the intent to vaccinate.4 -6 Studies that examined COVID-19 and influenza vaccine messaging also highlighted social norms and messenger type as vital factors for increasing vaccination intent.7 -9 At the time of this study in April 2021, only 56% of the vaccine-eligible US population had received at least 1 dose of a COVID-19 vaccine. 3 The Centers for Disease Control and Prevention (CDC) coordinated activities to create research-informed messaging to increase COVID-19 vaccination. The objectives of this study were (1) to understand perceptions of COVID-19 vaccines, including concerns about side effects, safety, and effectiveness and how these perceptions influence vaccine decision-making among US adults and (2) to learn what messages might motivate vaccine uptake.
Methods
From April 27 through May 7, 2021, we conducted 14 online focus groups among 99 adults not vaccinated against COVID-19. Each 90-minute group, conducted via Zoom (Zoom Video Communications Inc), had 6 to 8 registered participants. Groups were led by experienced moderators who used a discussion guide. We segmented groups according to those answering “probably will” or “probably will not” to a screening question about their likelihood of receiving the COVID-19 vaccine. Seven groups were “leaning toward” and 7 groups were “leaning against” vaccination. We held 4 groups with Hispanic participants only (2 English-speaking groups and 2 Spanish-speaking groups [n = 30]), 4 groups with non-Hispanic African American participants only (n = 28), and 6 groups of “general population,” which included African American, Hispanic, non-Hispanic Asian, non-Hispanic White, and multiracial participants (n = 41). The general population groups included an oversampling of younger adults (aged 18-39 y) and residents of rural areas. Most recruited participants were aged <40 years, and more rural than suburban or urban residents were recruited. Recruitment was nationwide and conducted through a contract with a professional research recruitment firm. The screening instrument and discussion guide were translated into Spanish and verified for accuracy by a bilingual researcher. The Spanish-speaking focus groups were led by a native speaker who is an experienced moderator. The study was reviewed by CDC and conducted consistent with applicable federal law and CDC policy for the protection of human subjects in research. The research was authorized under a waiver from the Paperwork Reduction Act resulting from the COVID-19 public health emergency. 10 All participants provided written consent.
Previously published literature informed the development of the focus group discussion guide, which covered experiences with COVID-19; views on vaccine safety, side effects, and effectiveness; trusted sources of information; and message testing. We included questions about the pause in distribution of the J&J vaccine to assess how the pause affected participants’ views. Respondents were instructed to answer for themselves or to consider how others close to them (ie, family and friends) might respond.
We systematically assessed 10 test messages developed by the research team. We divided the 10 test messages into 2 sets (set A and set B) of 5 messages; focus groups reviewed 1 set in randomized order (Table 1). The messages were read to participants by the moderator and shared on their computer screen. We asked participants a series of questions about believability, clarity, motivation, and general feedback for each message. We asked participants to select the message that most encouraged them to get vaccinated against COVID-19. Participants were allowed to choose more than 1 best message.
Ten test messages systematically assessed among 99 participants in 14 online focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021 a
The 10 test messages were divided into 2 sets (set A and set B) of 5 messages; each focus group reviewed 1 set in randomized order.
We used a grounded theory approach 11 with an iterative and inductive process to code transcripts using NVivo version 1.7.1 (QSR International).12,13 Code families included uptake motivators; hesitancy factors; perceptions of safety, side effects, and effectiveness; sources of information; and message testing. To assess coding concordance, reconcile discrepancies, and validate the codebook, a team of 4 researchers initially coded the same transcripts independently. We calculated Cohen κ, which accounts for chance within coding, for the initial 2 transcripts to assess intercoder reliability. The mean Cohen κ across transcripts and coders was 0.84 (range: 0.76-0.91). Following the establishment of high intercoder reliability, researchers independently coded the remaining transcripts. We used a selective coding approach to further the analysis. After thematic coding, analysis identified differences and similarities between segmented groups. 14
Results
Of the 99 focus group participants, most (65.6%; n = 65) were aged 26-39 years and had some college (28.3%; n = 28) or a bachelor’s degree (39.4%; n = 39). More than half (58.5%; n = 58) were female. Participants were almost evenly divided between residing in urban (35.4%; n = 35), suburban (29.2%; n = 29), and rural (35.4%; n = 35) areas. More than one-third (36.4%; n = 36) were non-Hispanic African American, fewer than one-third were Hispanic (31.3%; n = 31), and about one-quarter were non-Hispanic White (26.3%; n = 26) (Table 2).
Characteristics of participants (n = 99) in 14 online focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021
Vaccine Hesitancy Factors
COVID-19 vaccines were generally perceived as unsafe across focus groups due to risks for short-term and long-term side effects, the speed with which the vaccines were developed, the lack of long-term studies, and the absence of full FDA approval (Table 3). Protection against COVID-19 infection was noted as a benefit of vaccines, but it was not perceived as outweighing perceived risks.
Illustrative quotes from participants (n = 99) in 14 online focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021 a
Abbreviation: FDA, US Food and Drug Administration.
Groups were segmented according to participants answering “probably will” or “probably will not” to a screening question about their likelihood of receiving the COVID-19 vaccine. Seven groups were “leaning toward” and 7 groups were “leaning against” vaccination. Four groups had Hispanic participants (2 English-speaking groups and 2 Spanish-speaking groups), 4 groups were entirely African American participants, and 6 groups were “general population.” The general population groups included participants of any race and ethnicity and an oversampling of younger adults (aged 18-39 y) and residents of rural areas.
Common concerns about short-term side effects included arm soreness at the injection site and influenza-like symptoms, which were commonly associated with the second dose and occasionally referred to in focus groups as “baby COVID.” Interruption of daily life and loss of income were discussed as secondary negative consequences of vaccination in one-third of focus groups.
Concerns about long-term, unknown side effects due to the newness of the vaccines were more concerning than short-term side effects. Concerns about male sterility were expressed by a few participants. The potential impacts on women’s fertility, pregnancy health (including risks for miscarriage and birth defects), and menstrual cycle were specific long-term side effects of concern across all focus groups, races and ethnicity, and vaccine leaning. For example, a participant in the general population group leaning toward vaccination said, I have a 15-year-old daughter, so I am a little more sketch about her getting the vaccine because, I mean, she’s 15. I hope she’s not thinking about children right now, but you know, later in life, is that going to affect her fertility?
The speed of vaccine development was a topic of discussion across all focus groups, races and ethnicity, and vaccine leanings, with participants expressing beliefs that the vaccines were understudied, “too new,” and “experimental.” The pause in the J&J vaccine was commonly cited as confirmation of participants’ concerns about vaccine safety and speed of development.
When asked what they knew about the COVID-19 vaccine trials, most participants reported very little knowledge. Participants were aware that all 3 vaccines had undergone testing and trials before FDA’s Emergency Use Authorization, but only a handful of participants were able to provide any details. Similarly, other than the J&J pause, few participants were aware of any vaccine safety monitoring practices.
Perceived susceptibility to COVID-19, existing precautions, and having natural antibodies against COVID-19 due to previous infection also influenced participants’ vaccine hesitancy. In 11 focus groups, participants expressed that their risk of becoming sick with COVID-19, particularly with severe or fatal illness, was very low. This belief was especially prevalent among participants who perceived themselves as “young and healthy” and those who knew people who had COVID-19 but did not get sick themselves. Another common theme was the reasoning that their current safety precautions, including wearing face masks, frequently washing hands, and practicing social distancing, were sufficient to protect them from COVID-19. For example, a participant in the general population group leaning toward vaccination said, I’m younger, no health issues, no medications, so it’s not something urgent, but it’s something I lean towards, just for others.
Underlying participants’ hesitation to vaccinate were beliefs that COVID-19 vaccines were not effective enough to outweigh safety concerns. Effectiveness was universally important when considering getting a COVID-19 vaccine, with participants frequently indicating that 90% to 100% effectiveness at preventing disease would be a motivating range to get vaccinated. Participants generally defined vaccine effectiveness as long-term protection against the disease it was developed to address, ranging from complete protection to reducing the risks of the disease (eg, minimizing symptoms, preventing transmission, reducing side effects). The potential need for booster doses was also described as a characteristic of an ineffective vaccine. Regarding perception of effectiveness, 1 African American participant leaning against vaccination said, To hear someone’s got the vaccine and then, yes, you can still get COVID, that’s not effective to me.
Vaccine Uptake Motivating Factors
Participants in all focus groups discussed relaxation of prevention guidelines, such as wearing face masks and practicing social distancing, and vaccine information as potentially motivating them to receive the vaccine. Safely socializing and getting together with friends and family outside the home, including eating in restaurants, watching movies, and seeing live music, were the most commonly cited motivating factors for vaccine uptake, particularly with respect to protecting others, including older family members. The ability to travel was also described as motivating, although most participants noted that they would vaccinate to travel only if required. In 3 focus groups, participants said they would get vaccinated if it were required for school or work.
In half the focus groups, including 3 of the 4 Hispanic groups, participants discussed hearing about the vaccination experiences of family, friends, and others as influential in their vaccination decision-making, citing trust, personal connection, and relatability. When close contacts shared positive experiences, including minimal side effects, participants were more motivated to get vaccinated. A Spanish-speaking Hispanic participant leaning toward vaccination said, It is important, in my opinion, for me personally, for my family, that we are guided by close people and close friends who already got the vaccine because they are the best source to see if we’re interested or not interested in getting the vaccine.
Sources of Information
Participants cited the positive experiences of family and friends not only as motivating vaccination but also as trusted sources of information and advice. Other groups seen as trusted sources of vaccine information were physicians and medical professionals. But medical professionals were sometimes found to both persuade and dissuade vaccination: participants in 5 focus groups (3 Hispanic, 2 general population) talked about how their physician or a friend who was a medical professional was unvaccinated or recommended against vaccination.
Most participants agreed that they do not seek information from nor trust social media for vaccine-related information. Some participants said they do not have to search for COVID-19 vaccine information because it appears unprompted on social media feeds, streaming television, and the radio. Some participants recognized that what they see on their social media feeds likely will reinforce what they already believe about the vaccine. Misinformation that was often stated as truth by participants when explaining their hesitation came from word-of-mouth and social media sources. One frequently mentioned misunderstanding was infertility resulting from the vaccine. Other themes of misinformation were sometimes recognized as such but other times appeared to be believed by participants. This misinformation included ideas that the vaccine has a tracking device, alters DNA, and infects the recipient with the virus. In several groups, participants said they heard about someone dying within a week after receiving the vaccine. For factual information, participants said they would look at scholarly articles and/or the news media. Some participants described feeling overwhelmed with information about the vaccine, leading to confusion. A Spanish-speaking Hispanic participant leaning against vaccination said, I feel that the worst source of information we can use is social media about health because social media and online all you’re gonna find is you find some false and trustworthy information, but you also find a lot of fake information and you have no way of knowing which is the correct one.
A participant in the general population group leaning against vaccination said, I don’t go on social media for anything I’m looking for to be absolutely true. But I see it anyways unwillingly.
In 11 focus groups, participants expressed distrust of the US government, including the president, state and local representatives, CDC, and FDA. Government distrust expressed by African American participants was rooted in a history of discrimination and abuse. Across all focus group populations, participants believed that government representatives and institutions were motivated by political agendas and financial incentives, a concern affecting distrust of pharmaceutical companies, too. Distrust in government institutions was also driven by inconsistent and conflicting messaging about COVID-19. Many participants felt “pressured” by the government to get vaccinated, which made them suspicious.
Seven focus groups, including 5 of 7 leaning against vaccination, expressed resistance to the notion of government-mandated vaccination. Opposition to mandated vaccination was voiced in 3 African American groups, 3 Hispanic groups, and 1 general population group.
Message Testing
Participants were critical of most messages tested and found most of them not to be motivating. Of the 10 messages, participants noted message 1 was the most likely to motivate them to get vaccinated (Table 4). Messages that came across as honest relative to emerging science were perceived more positively than messages that came across as not honest. Messages perceived as honest included message 5, which gave simple statements of fact without being perceived as “overpromising,” and message 1, which showed honesty about what is unknown. About message 5, an African American participant leaning against vaccination said, [T]his statement is not promising anything. It’s saying you can start to do some things. . . . To me it’s honest. . . . It can protect you from getting sick, but it didn’t say it prevents it.
Another African American participant leaning against vaccination said this about message 1: Seems more honest. They’re being transparent and acknowledging both sides, the good and the bad, not trying to force you to get it.
Participants described several messages as ineffective because they were vague or lacked data and specificity. Participants stated that many of the messages were missing specific information, perhaps left out intentionally, making them less persuasive. Some suggestions for improving the messages involved adding detail. For example, in message 2, participants suggested providing specific information about the demographic groups involved in safety testing. For message 6, they suggested including information on how the vaccines build immunity. About message 6, a Spanish-speaking Hispanic participant leaning against vaccination said: I’d want to know how is it building my immunity. Like what is being built exactly or how exactly is it building my immunity to prevent this severe illness? And then what is the severe illness?
When participants were asked to select the message that most encouraged them to get vaccinated against COVID-19, message 1 performed best across all focus groups (Table 4). By focus group stratification, 32.1% (9 of 28) of participants in the African American groups, 16.7% (5 of 30) in the Spanish-speaking and English-speaking Hispanic groups, and 22.0% (9 of 41) of participants in the general population groups chose message 1 as the most motivating message; 16.7% (5 of 30) of participants in Hispanic groups also selected message 2.
Results of poll on 10 test messages among participants (n = 94) in 14 focus groups designed to examine COVID-19 vaccine hesitancy and motivation among US adults, April 27–May 7, 2021
The 10 test messages were divided into 2 sets (set A and set B) of 5 messages; each focus group reviewed 1 set in randomized order. Percentages reflect the number of participants who reviewed and voted on a set; for set A (messages 1-5), the denominator was 51; for set B (messages 6-10), the denominator was 43.
Discussion
Overall, during the period of initial COVID-19 vaccine rollout, participants expressed low levels of confidence in the safety and effectiveness of available COVID-19 vaccines (ie, J&J, Pfizer/BioNTech, and Moderna). These focus groups identified the specific components of these generalized concerns and provided feedback on 10 test messages.
Many respondents believed that COVID-19 prevention measures, such as wearing face masks, were sufficient to protect against illness. These beliefs indicate a need for increased messaging about COVID-19 susceptibility, severity, and long-term consequences, particularly directed toward people who consider themselves “young and healthy.”15,16 Pointing toward protecting others, as did message 1, which tested best, may therefore resonate as it has in other studies.17 -20 Also, messages that contrast the risks of unknown, potentially adverse consequences of infection with known, benign consequences of vaccination may be useful and warrant further testing.
In addition, focus group participants identified potential motivating factors related to lifestyle changes, including socializing and traveling, so messaging should focus on these benefits of vaccination. Focusing messages on vaccine side effects, safety testing, and long-term outcomes may also motivate vaccine uptake. These lessons are relevant not only for promoting COVID-19 vaccination, including boosters, but also for other future novel vaccines.
Message 7, which explained and normalized side effects, also performed well in this study. Ultimately, participants weighed the perceived risks of short-term and long-term vaccine side effects versus their effectiveness and the threat of COVID-19. Other studies published since our study was conducted also found that adding information on side effects may be effective in messaging. 21 For the benefits of vaccination to outweigh the potential risks, participants desired low risk for side effects; complete, long-term protection against COVID-19 infection; and prevention of transmission. In this respect, the availability of data on the long-term effects of the COVID-19 vaccine may alleviate some concerns. More evidence on the safety and effectiveness of the vaccine is available now than it was when our study was conducted.22 -24
Hearing about the vaccination experiences of friends and family was key to decision-making about vaccine uptake among our focus group participants. Our findings demonstrate that the positive experiences of friends and family were influential in allaying fears about potential side effects and their severity. These findings validate the need to create positive social norms and enlist informed, key opinion leaders in communities to minimize sensational media accounts of rare outcomes. In addition, although social media was not a “go-to” source of information among our study participants, it was potentially influencing beliefs through exposure.
The message that performed best was endorsed because it appeared to be honest and transparent about what is known and unknown about vaccines. This finding may confirm what other studies have suggested, that acknowledging uncertainty may be effective in communicating about COVID-19 vaccines.21,25,26 In addition, balanced messages have been perceived as more trustworthy than persuasive messages among people with a negative or neutral prior belief about the message content.27,28 This finding may indicate that using transparent messaging and acknowledging uncertainty may be even more effective than other messages tested among those who are skeptical or lean against vaccination.26,29 -31
Limitations
Our study had several potential limitations. First, the sample represents a convenience sample of adults across the United States who agreed to be included in the online panel recruitment approach and participate in this particular study. Second, although we oversampled rural residents to ensure representation, we did not analyze their data separately; this study limitation warrants additional research. Third, we used a certain set of test messages; use of different messages might have yielded different findings. Lastly, our results represent the views of the focus group participants and are not necessarily generalizable to other groups.
Conclusions
Although communication programs tailored toward vaccine-hesitant populations are key to increasing COVID-19 vaccine uptake, these programs can be challenging to develop because of the wide range of demographic and individual factors that contribute to vaccine hesitancy and perceived barriers to vaccination.31 -34 Successful immunization programs and public health strategies require coordinated communication that uses various strategies to be effective in increasing vaccine confidence and uptake in vaccine-hesitant populations.
The use of focus groups was effective in elucidating the attitudes and beliefs of groups in the “movable middle” to inform future message development to promote COVID-19 vaccination. Findings underscore the role of health care providers serving as trusted sources of information along with friends and family. The role of health care providers is especially important for pediatric vaccination or any new vaccine in the future. Loss frames (eg, missing work, loss of income) or messaging focused on one’s positive effect on others (eg, keeping grandparents safe) may be effective. Research has shown mixed results on the notion of personal versus community benefit messaging in motivating COVID-19 vaccine, sometimes further driven by underlying worldviews or perceived risk.35 -37 Messages that focus on facts rather than persuasion and messages that acknowledge a person’s right to choose to be vaccinated might be more effective for some people than for others in facilitating individual decision-making. Findings underscore the benefits of research-informed strategies for message development and dissemination. Future research with a larger, nationally representative sample would allow for refinement and updating messages for rapidly changing pandemic situations.
Footnotes
Acknowledgements
The authors acknowledge all individuals who are making difficult decisions about their health during the COVID-19 pandemic. We thank the Vaccine Task Force Communications leaders, especially Betsy Mitchell, PhD, MA, Allison Maiuri, MPH, CHES, and Janine Cory, MPH, at the Centers for Disease Control and Prevention (CDC), who were instrumental in providing support in guiding this research. The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of CDC. Use of trade names and commercial sources is for identification only and does not imply endorsement by the US Department of Health and Human Services.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by CDC’s Vaccine Task Force (contract no. 75D30121C10149).
