Table 2 describes the demographics and characteristics of the 44 focus group participants. Most participants were doctors (34%) and physician’s assistants or nurse practitioners (34%). The majority (80%) were fully vaccinated at the time of data collection. Twenty-four US states were represented and included all regions of the country. The states with the largest representation were Indiana, North Carolina and Texas. Participants were primarily Democratic (41%), white (77%) and female (75%).
Table 2
Sociodemographic data from HCP participants
| Frequency (n = 44) | Percentage |
Provider Type | | |
Doctors | 15 | 34% |
PAs & NPs | 15 | 34% |
RNs | 12 | 27% |
Other (Medical Assistant) | 1 | 2% |
Pharmacists | 1 | 2% |
COVID-19 Vaccination Status | | |
Fully vaccinated | 35 | 80% |
Unvaccinated | 9 | 20% |
Political Affiliation | | |
Democrat | 18 | 41% |
Republican | 13 | 30% |
Independent | 8 | 18% |
No preference | 5 | 11% |
Race/Ethnicity | | |
White, non-Hispanic | 34 | 77% |
Black, non-Hispanic | 6 | 14% |
Asian | 3 | 7% |
Multiple | 1 | 2% |
Gender | | |
Female | 33 | 75% |
Male | 10 | 23% |
Non-binary/gender non-conforming | 1 | 2% |
Results at the intrapersonal and interpersonal level demonstrate the impact of COVID-19 misinformation on patient-provider communication and potential messengers and messages that can play a role in either promoting or combating misinformation. Results at the community, organizational and policy levels reveal key sources of information and recommended strategies to create an environment that supports vaccine acceptance. Table 3 summarizes the thematic analysis and provides excerpts from the FGDs for each of the themes identified.
Table 3
Qualitative Constructs and Themes
Construct | Theme | Socio ecological Messengers | Illustrative Quote |
COVID-19 misinformation has altered the patient-provider relationship | Misinformation brought to appointments creates barriers to discuss science-based recommendations; providers face increasingly “dug in” perspectives. | Interpersonal | There's a lot of misinformation, even the people who got the vaccine...I can't in a few minutes visit just prove it or bring out all the data. I'm not even sure if that would help... I have that discussion with [people] that have very firm beliefs…It's almost impossible to get through. (Nurse practitioner, Illinois) |
At this point, it's almost like they're dug in, and they would be embarrassed that they've changed their mind. And I don't know how to get through to them to let them know that would be good. (Doctor, North Carolina) |
Some patients believe the information made available to providers is wrong – increasing doubt in unbiased science and medicine | Interpersonal | They trust us as their physicians. They trust that we're in good faith trying to give them the best information we can. It's just that they've been somehow misled that the information that we have as medical professionals is incorrect and they feel like… They've got access to truth that the medical professionals don't. (Doctor, North Carolina) |
It's not that they think that I have a hidden agenda and that I'm part of an evil conspiracy, it's that they think that the doctors are actually misinformed. They think we believe what we're telling them, we're just wrong and they have a better source than we do. (Doctor, North Carolina) |
A paradigm shift for some providers in how they comprehend and communicate new medical information | Intrapersonal | I’ve had patients share information that they've discovered that's contrary to what we've been taught to teach through the years. It's been sort of paradigm changing for me. To be this old in medicine and to feel like my paradigm has changed. So, it becomes harder to talk to patients when you get different information than what you had your whole life. (Unvaccinated doctor, Pennsylvania) |
I've definitely taken to heart more concerns and anecdotal stories that patients have brought either from their own vaccine stories or from loved ones. It's really easy to blow some of these things off and point to studies. Well, you got people flooding in with all these stories that you start taking [them] to heart, especially something that's been so newly released and not very well studied. You kind of internalize that. It's hard not to bring that to other patients that you interact with. (Unvaccinated doctor, Wisconsin) |
Strategies for successful vaccine communication during patient interactions | Tailoring information and recommendations to the patient’s medical history and concerns | Interpersonal and Intrapersonal | Knowing what their literacy level governs a lot on the terminology that we use… give them a chance to ask questions, and the pros and the cons that type of thing… You really have to know the background of the people, and that makes a big difference. (Nurse practitioner, Massachusetts) |
Testimonials from other patients and peers | Interpersonal | I said it in a conversation… "I just lost a patient on the vent with COVID," and the lady went down that day and got the vaccine. So, some of [their choices] are personal. (Nurse practitioner, Indiana) |
I asked her if she would go in and speak with a woman who received her first [dose]. They just had a conversation and found out that they went to the same college. They actually exchanged numbers and became friends right there. I thanked her for making her feel comfortable and telling her that you didn’t have any side effects. So, sometimes I use that method. (Registered nurse, Texas) |
Time, multiple appointments, patience and empathy | Intrapersonal (with organizational barriers due to health care access, appointment-making policies, etc.) | It's an ongoing conversation. I tell them [to] think about what we talked about, and we can discuss it again. If you change your mind or if you want to discuss this further, we can always address it out at a later time… so they don't feel pressured. (Nurse practitioner, New York) |
Information resources that support provider vaccine communication | Local and frequent updates | Community, Organizational and Policy | Our local public health department disseminates our information a couple times a week… and they recap the new CDC guidelines and what the State of Iowa's Department of Public Health recommends. (Nurse practitioner, Iowa) |
Resources and materials provided by employers | Organizational | I work for a huge hospital so the epidemiologist at the hospital would send out daily updates, and they were translating the information that was in the media and on the CDC website. It was very simple to follow, it also included instructions for patients on what to tell them… regarding vaccines, side effects, protocols, and step-by-step approach on how to navigate the world of COVID. I found that very helpful. (Nurse practitioner, Utah) |
An increased need for patient-facing materials to navigate new COVID-19 information | Community and Organizational | I would like to really have a resource to provide to families and patients…in a format that's really easy to follow... A lot of us don't have a ton of time to explain to families, but to give them an opportunity to…do a little bit of research on their own without maybe digging through the CDC website. (Nurse practitioner, Texas) |
Environmental and policy level recommendations to support vaccine acceptance outside the clinical setting | Removing financial barriers to vaccination | Policy | …I am in a pediatric private practice…we do have a lot of parents asking the same thing, “is it covered by insurance?”... (Nurse practitioner, Indiana) |
A need for a more centralized and unified response to COVID-19 vaccinations | Organizational and Policy | Other countries are doing a much - I don't want to say a better - but a different job of [communicating] this is just for the good of the population, and… try to get people to get more into that community mentality. (Nurse practitioner, Indiana) |
Multiple outlets for information and vaccination | Community, Organizational and Policy | We've gone to COVID clinics… at different churches. So, I think as far as culture is concerned some people they really look at their priests, their minister, their pastor, for guidance… If you could get him… on board to endorse the vaccines, I think you will get more participants. I really do. (Registered nurse, Texas) |
Who speaks to the different groups? Maybe our current administration doesn't speak to everybody but somebody speaks to everybody. Somebody reaches. Every person out there has somebody they respect or that they know and trust. And, maybe we need to move away from the national speakers that everybody's seen on TV all the time. Maybe regionally, they need to look for people of different race, color, interests, backgrounds and find somebody to speak locally or regionally to those that are hesitant. I mean, that's the only thing I can think of is to better reach individuals. (Doctor, Nebraska) |
Intrapersonal and Interpersonal Vaccine Communication
Covid-19 Misinformation Has Altered The Patient-provider Relationship
Overall, the focus group participants largely viewed their role as providing a source of scientific information and patient education during appointments. They saw themselves as trusted messengers for their patients, community, friends and family, but were quick to note communicating this information became more challenging during the COVID-19 pandemic. On the topic of COVID-19 vaccine hesitancy and refusal, most providers felt they had offered sufficient patient education and intervention in the year since the COVID-19 vaccine became widely available and that most unvaccinated individuals were no longer open to being counseled.
Providers expressed that, for the first time, some of their patients had doubts about their clinical guidance, believing that they were influenced by pharmaceutical or other institutional forces. While most providers did not face direct accusations of purposely misleading patients (especially those with long-standing relationships with their patients), providers faced patients who expressed distrust of the accuracy of information they offered.
A group of unvaccinated and/or “late adopting” providers (defined as being vaccinated after November 2021) indicated that they experienced a shift in perception of their own role in vaccine promotion. They expressed distrust stemming from their belief that vaccine mandates were implemented without comprehensive scientific evidence to support them, such as a lack of consideration for natural immunity in vaccine policy development. Importantly, these providers shared many of their patients’ COVID-19 vaccine concerns and reported that information provided by patients led them to question some key aspects of their medical training.
Strategies For Successful Vaccine Communication During Patient Interactions
The providers offered several strategies for promoting vaccine acceptance among patients. The most common strategy was to tailor information to each patient’s medical history and concerns related to the COVID-19 vaccine and to avoid generic guidance. In their view, this approach facilitated provider trust and mitigated any institutional mistrust. This communication strategy was echoed as effective and meaningful in subsequent in-depth interviews and focus groups with patients in the parent study reported elsewhere.21
A few providers touted “scare tactics,” stating that patients have responded to other vaccine recommendations which cautioned of severe disease outcomes. One provider suggested this is an underused patient education tactic for the COVID-19 vaccine, citing the success of anti-smoking campaigns that highlighted severely impacted former smokers with chronic illness and disability. Providers also found that testimonials from recent adopters had an impact on their patients. Providers described the sharing of personal anecdotes, family stories, and introductions to other recently vaccinated patients as helpful for individuals still uncertain of their vaccination decision. Details about the unknown and prolonged effects of long COVID would be an example of this communication strategy.
When discussing successful strategies for patient communication, many providers acknowledged that addressing vaccine hesitancy often takes multiple appointments with the same patient, and adequate appointment time - both circumstances that many patients and providers cannot independently facilitate or control. Those who saw patients on a regular basis due to the type of care they provided (i.e., maternal, and prenatal health care; care for chronic conditions) noted that the ability to have multiple touchpoints with the same patient facilitated a trusting dialogue around medical recommendations, including vaccination.
Community, Organizational and Policy Messengers:
Information Sources That Support Provider Vaccine Communication
Many providers discussed the pressure to stay up to date in an evolving information environment, especially during the first year of the pandemic. They had mixed opinions on whether they had adequate resources to answer patient questions about the COVID-19 vaccination but generally agreed about their main sources of vaccine information during the pandemic. Participants cited the Centers for Disease Control and Prevention (CDC) and professional organizations like the American College of Obstetricians and Gynecologists (ACOG) as helpful. Other helpful resources included local and state health departments whose regular updates mitigated pressure on healthcare providers to stay up to date.
Several providers also indicated workplace communication digests and regular team meetings led by department heads as the most helpful resources to stay current on COVID-19 information. Some of these communications from employers also included patient-facing resources, which many providers reported as necessary to facilitate conversations with new information.
Recommendations To Support Vaccine Acceptance Outside The Clinical Setting
Providers described the challenge of addressing COVID-19 vaccine questions and concerns in an environment that often left them unsupported to reduce barriers to vaccination broadly. This discussion led to some clear guidance for policy and institutional practices that may bolster recommendations and communication from providers. Firstly, many providers recommended all vaccinations be provided free of charge to the patient. They cited their patient's financial concerns when considering other vaccinations prior to the pandemic and noted this continued to be true for the COVID-19 vaccine. Despite the national provision that vaccines be available free of charge, there continued to be confusion among patients. This has implications for both communication strategies and ready access to vaccines.
Some providers suggested continuing to offer vaccinations outside of the medical office or hospital environments (i.e., at mobile units, or pharmacies) to prevent cold supply chain challenges and other barriers in small doctors’ offices. Many providers hoped that the lessons learned during the COVID-19 vaccine rollout will inform future vaccination availability.
Providers indicated a strong need for a more centralized, unified response from regional and federal agencies to address the ongoing challenges that they face. While they recommend the policies and messaging come from a centralized effort, the messengers and actions need to be localized. They underscored the need for local, diverse and neutral messengers to combat further politicization and polarization. Some acknowledged this could involve collaboration between other sectors that may not be traditionally involved in public health campaigns (e.g., community leaders, faith leaders).