OBJECTIVES

Addressing parental/caregivers’ coronavirus disease 2019 (COVID-19) vaccine hesitancy is critical to improving vaccine uptake in children. Common concerns have been previously reported through online surveys, but qualitative data from KII and focus groups may add much-needed context. Our objective was to examine factors impacting pediatric COVID-19 vaccine decision-making in Black, Spanish-speaking, and rural white parents/caregivers to inform the content design of a mobile application to improve pediatric COVID-19 vaccine uptake.

METHODS

Parents/caregivers of children aged 2 to 17 years from groups disproportionately affected by COVID-19–related vaccine hesitancy (rural-dwelling persons of any race/ethnicity, urban Black persons, and Spanish-speaking persons) were included on the basis of their self-reported vaccine hesitancy and stratified by race/ethnicity. Those expressing vaccine acceptance or refusal participated in KII, and those expressing hesitancy in focus groups. Deidentified transcripts underwent discourse analysis and thematic analysis, both individually and as a collection. Themes were revised until coders reached consensus.

RESULTS

Overall, 36 participants completed the study: 4 vaccine acceptors and 4 refusers via KIIs, and the remaining 28 participated in focus groups. Participants from all focus groups expressed that they would listen to their doctor for information about COVID-19 vaccines. Infertility was a common concern, along with general concerns about vaccines. Vaccine decision-making was informed by the amount of information available to parents/caregivers, including scientific research; possible positive and negative long-term effects; and potential impacts of vaccination on preexisting medical conditions.

CONCLUSIONS

Parents/caregivers report numerous addressable vaccine concerns. Our results will inform specific, targeted interventions for improving COVID-19 vaccine confidence.

What’s Known on This Subject:

The coronavirus disease 2019 vaccine has shown effectiveness at limiting mortality because of the severe acute respiratory syndrome coronavirus 2 virus, but parents/caregivers have expressed hesitancy about vaccinating their children, especially among rural non-Hispanic white, both rural and urban Black, and rural and urban Spanish-speaking groups.

What This Study Adds:

This study expands on reasons for decreased vaccine uptake among rural non-Hispanic white, rural and urban Black, and rural and urban Spanish-speaking groups. This study adds knowledge about parental attitudes toward the coronavirus disease 2019 vaccine by race/ethnicity and rurality.

As of March 2023, children represented 18.0% of all coronavirus disease 2019 (COVID-19) cases and 0.15% of all COVID-19–related deaths reported since the start of the pandemic.1,2  Although the low incidence of overall pediatric mortality is reassuring, children with certain medical conditions are at increased risk of severe illness and healthy children are at risk for multisystem inflammatory syndrome in children.3,4  The messenger RNA-based COVID-19 vaccines, currently authorized for use in children aged 6 months to 17 years who lack a contraindication, have been shown to prevent both asymptomatic and symptomatic severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2) infection among children.57  However, vaccination against the SARS-CoV-2 virus lags in many states. Among children aged 6 months to 4 years, 11% have received at least 1 dose of the COVID-19 vaccine, compared with 39% of children aged 5 to 11 years and 68% of adolescents aged 12 to 17 years.1  This disparity in vaccine uptake increases in more traditionally rural states, such as Oklahoma.8 

Understanding the factors that affect parental/caregiver vaccine acceptance and causes of COVID-19 vaccine hesitancy may help pediatric health care providers improve vaccine uptake. Vaccine hesitancy is defined as the delay in accepting or refusing vaccination, despite the availability of vaccination services.9  National surveys have shown that COVID-19 vaccination intent varies by race/ethnicity, informational sources, political alignment, and parents’/caregivers’ concerns around vaccine safety and side effects.10,11  Vaccination programs and vaccine communication interventions for high-priority groups must be tailored to region- and audience-specific concerns.12  Surveys of COVID-19 vaccine hesitancy among parents/caregivers have shown that hesitancy is higher among Black persons, Hispanic persons, and rural residents.1317  Given the evidence that Hispanic persons were less likely to vaccinate than non-Hispanic white (NHW) persons and the prevalence of misinformation exclusively available in Spanish, we prioritized those whose preferred language was Spanish over Hispanic ethnicity.11,18,19  Thus, groups identified to be high priority for vaccination for this study were Black persons from rural and urban communities, those who spoke Spanish as their preferred language, and NHW persons from rural communities.

The Mobile Vaccine Uptake (MoVeUP) Application (app) (NCT05386355) was developed and is currently undergoing clinical trials testing within the Environmental Influences on Child Health Outcomes Institutional Development Award States Pediatric Clinical Trials Network (ECHO ISPCTN). This app seeks to provide parents/caregivers with personalized content about the COVID-19 vaccine from their child’s/children’s pediatric practice.20  ECHO ISPCTN is a National Institutes of Health (NIH)-funded clinical trials network with participating sites located in 18 states that increases access to clinical trial participation for families historically underrepresented in biomedical research.21  States with a site participating in the ECHO ISPCTN have high rates of COVID-19 vaccine refusal.1 

Our objective was to conduct a qualitative assessment to identify parental/caregivers’ attitudes toward COVID-19 vaccine in Black, Spanish-speaking, and rural NHW parents/caregivers and potential ways to address COVID-19 vaccine confidence in parents. The results of this study informed content design of the MoVeUP app and provided insights into vaccine communication in these vulnerable groups.

Recruitment occurred from 4 ISPCTN sites: Nemours Children’s Health in Wilmington, Delaware; the University of New Mexico School of Medicine in Albuquerque, New Mexico; the University of Oklahoma Health Sciences Center School of Medicine in Oklahoma City, Oklahoma; and the Medical University of South Carolina in Charleston, South Carolina. Eligible participants included those who were parents or legal guardians of at least 1 child aged 2 to 17 years, of which none of whom were vaccinated against COVID-19, were able to access an online conferencing platform, and self-identified as belonging to at least 1 of the following demographic and rurality groups: (1) Black (either Hispanic or non-Hispanic), (2) Spanish-speaking, (3) NHW and rural, and (4) other rural (ie, not NHW or non-Hispanic Black). Hereafter, these are referred to as “inclusion groups.” Having the inclusion group of other rural was intended to ensure representation of rural residents of American Indian, Alaska Native, Asian American, and Pacific Islander racial background. Because these racial groups have shown strong uptake of the COVID-19 vaccine, recruitment of these groups was not an active focus of this study.22,23  These sites were chosen on the basis of their patient population of >100 pediatric patients per year, their likely ability to recruit up to 20 Spanish-speaking participants, and their likely ability to recruit participants from each of the inclusion groups.

We conducted a qualitative study using focus groups and key informant interviews (KIIs) to add richer detail surrounding vaccine hesitancy that could aid development of targeted interventions for improving vaccine uptake in children, such as the MoVeUP app. The study was determined to be exempt from human subjects research review by the University of Arkansas School of Medical Sciences institutional review board, which served as the central review board for all sites.

Retrospective recruitment methods identified potentially eligible parents to contact using electronic health records to identify children of an eligible age who presented to the participating clinic for a routine care visit at least once in the last 2 years. Traditional recruitment methods focused on having participants self-identify after seeing study e-mails, flyers, or social media advertisements.

Participants participated in either a focus group or a KII on the basis of their response to the preinterview question, “How likely are you to vaccinate your child against COVID-19 within the next 3 months?” from the Rapid Acceleration of Diagnostics-Underserved Populations Diagnostic Toolbox from the NIH.24  Those that responded “Very likely” or “Fairly likely” were considered vaccine acceptors, “Not too likely” and “Not at all likely” as vaccine hesitant, and “Definitely not” as vaccine refusers. Vaccine acceptors and refusers participated in KIIs. Vaccine-hesitant participants were included in focus groups stratified by the inclusion groups capped at 10 to 12 participants. Eligible persons were put on a waiting list for invitation if other participants were unable to attend the scheduled focus group. Parents/caregivers of multiple children were able to provide a response for each child, but only the most negative response was used to determine their hesitancy status for interview designation. All interviews and focus groups were conducted virtually from August 2021 to November 2021. Although COVID-19 vaccines were not yet authorized for children aged <11 years at the time of this study, our team included the discussion of vaccinating younger children with the knowledge that they would likely be included in future vaccination efforts.

The interview guide for both focus groups and KIIs originated from the World Health Organization Strategic Advisory Group of Experts Working Group on Vaccine Hesitancy for validated questions on vaccine hesitancy, and from the COVID-19 Vaccination Communication: Applying Behavioral and Social Science to Address Vaccine Hesitancy and Foster Vaccine Confidence for demographic group-specific vaccine communication (Data Supplement 1).25,26  Focus groups and KIIs were led by a trained facilitator with assistance from a scribe who took field notes, a medical expert observer (an infectious disease physician who did not participate but was present to clarify any medical questions from participants), and up to 2 technology monitors to assist with troubleshooting technical issues. Two to 3 focus groups were conducted per inclusion group. Two KIIs, 1 involving a refuser and one involving an acceptor, were conducted per each inclusion group to ensure the comments from the vaccine hesitant were considered in their appropriate context. Because the planned intervention for the MoVeUP App trial focuses on addressing the concerns of vaccine-hesitant parents/caregivers, more vaccine-hesitant persons were interviewed in focus groups in this formative study. Vaccine acceptors and refusers were separately interviewed from the vaccine hesitant to ensure their opinions did not unduly influence the vaccine hesitant.

Audio files from interviews were deidentified and transcribed for analysis. Analysis of the focus group and KII transcripts used discourse and summative qualitative content analysis with subsequent thematic analysis.27  Codes derived from content and discourse analysis determined when the analysis should stop on the basis of when emerging patterns of response were repeated, suggesting thematic saturation.

Discourse analysis focuses on utterances that reflect what the speaker might think of a topic, centering on context and its relationship to the information shared. This method is applied to both spoken and written information. Rather than coding line by line, researchers code on the basis of developing topics and their context. An online corpus-based tool, Text Inspector, supported identification of meta-discourse among participants.28  Meta-discourse analysis identifies interactive and interactional voiced resources.29  These interactive voiced resources are propositions that help the speaker organize their speech to facilitate an audience’s understanding, whereas interactional voiced resources represent the speaker’s influence on the speech. To expand the qualitative analysis, WMatrix (v.5) examined frequencies of key words utterances and their variations, as well as idioms and multiword phrases, which when overused can signal for further investigation when reexamined during thematic analysis. Each focus group and KII underwent discourse analysis both individually and collectively.

Summative qualitative content analysis was used to code the frequency of words in particular contexts to identify patterns in content and derive themes contributing to final thematic analysis.27  Two independent coders identified themes within individual participant interviews and focus groups. All coders then met to combine themes into 5 overarching categories on the basis of the interview guide: Trust, personal choice, sources of information, vaccine decision-making, and rumors.

Overall, 285 parents/caregivers were assessed for study eligibility, with 204 qualifying. Of those who qualified, 69 were scheduled to participate in a focus group or KII. Of the 69 people scheduled, 36 parents/caregivers participated across all focus groups and KIIs. Eight parents/caregivers underwent KIIs, of which 4 were acceptors and 4 were refusers. The remaining 28 hesitant parents/caregivers participated in focus groups stratified by the inclusion group. Table 1 shows the inclusion group breakdown of participants who qualified for the study.

TABLE 1

Participants by Inclusion Group

GroupScheduledAttended Focus GroupsAttended KIIs
Blacka rural or urban 24 10 
Spanish-speakingb rural or urban 24 
NHW rural 15 11 
Otherc rural 
GroupScheduledAttended Focus GroupsAttended KIIs
Blacka rural or urban 24 10 
Spanish-speakingb rural or urban 24 
NHW rural 15 11 
Otherc rural 
a

Includes both Hispanic and non-Hispanic persons.

b

Includes any race/ethnicity that identified Spanish as their preferred language.

c

All persons not identifying as NHW or non-Hispanic Black who speak English as their preferred language.

Among reasons for not being scheduled for either focus groups or KIIs, 2 subjects were unable to be contacted, 41 were not members of an inclusion group, 43 were on the wait list but no slots were available in focus groups or KIIs, 9 chose not to join the waitlist or did not respond to the waitlist request, 26 joined after the waitlist was full, 13 qualified after the focus groups or KII occurred, and 1 declined to schedule. Of those qualified and scheduled, 33 subjects did not attend their scheduled interview or joined too late to participate. Table 2 shows the responses to the vaccine acceptability question of “How likely are you to vaccinate your child against COVID-19 in the next 3 months?” of the individuals qualified to participate in the focus groups or KIIs (as percentage of their own inclusion group).

TABLE 2

Survey of Vaccine Acceptability by Inclusion Group

“How Likely Are You to Vaccinate Your Child Against COVID-19 Within the Next 3 Mo?”Vaccine AcceptorsVaccine HesitantVaccine Refusers
Very LikelyFairly LikelyNot Too LikelyNot at All LikelyDefinitely Not
Blacka rural or urban 15 (42%d8 (22%) 9 (25%) 10 (28%) 9 (25%) 
Spanish-speakingb rural or urban 13 (25%) 13 (25%) 17 (33%) 3 (6%) 6 (12%) 
NHW rural 9 (24%) 3 (8%) 5 (13%) 7 (18%) 14 (37%) 
Otherc rural 10 (48%) 2 (10%) 3 (14%) 1 (5%) 5 (24%) 
“How Likely Are You to Vaccinate Your Child Against COVID-19 Within the Next 3 Mo?”Vaccine AcceptorsVaccine HesitantVaccine Refusers
Very LikelyFairly LikelyNot Too LikelyNot at All LikelyDefinitely Not
Blacka rural or urban 15 (42%d8 (22%) 9 (25%) 10 (28%) 9 (25%) 
Spanish-speakingb rural or urban 13 (25%) 13 (25%) 17 (33%) 3 (6%) 6 (12%) 
NHW rural 9 (24%) 3 (8%) 5 (13%) 7 (18%) 14 (37%) 
Otherc rural 10 (48%) 2 (10%) 3 (14%) 1 (5%) 5 (24%) 
a

Includes both Hispanic and non-Hispanic persons.

b

Includes any race/ethnicity that identified Spanish as their preferred language.

c

All persons not identifying as NHW or non-Hispanic Black who speak English as their preferred language.

d

Those endorsing that response by the total number of qualified participants in their inclusion group.

Focus groups results are summarized here as a collection of information about each inclusion group that reached thematic saturation, excluding other rural because of low focus group participation for this stratum. Overarching themes have been combined as appropriate.

Trust and Sources of Information (Table 3)

Doctors were a commonly listed source of trusted information, with more emphasis on information from family who are doctors. Participants were divided on the trustworthiness of the government and public health resources, exemplified by the statements, “So, I’ll go get my information [from] CDC.gov. Don’t totally trust it, but I want to know what they say” (NHW rural) and “Yes, [the information from the Health Department] is useful, the truth, because they are specialized, right, in that” (translated, Spanish-speaking). Social media was almost universally considered untrustworthy, except for the social media accounts of health institutions, which were seen as reliable sources. When participants turned to the Internet for information, participants identified reputable Web sites to include the Mayo Clinic, Johns Hopkins University, WebMD, and The New York Times.

TABLE 3

Themes Regarding Trust and Sources of COVID-19 Information by Inclusion Group

ThemesBlacka Rural and UrbanSpanish-Speakingb Rural or UrbanNHW Rural
Trust
“I’ll trust a medical professional over somebody who’s just getting their information off the Internet.” Black rural and urban participant 
  • Primary care

  • CDC

  • Health department

  • Government

  • God

  • Personal narratives from friends

  • Specialty health clinics

 
  • Doctor

  • President

  • News

  • Social media accounts of health institutions

  • Government

 
  • Doctor

  • Reputable Web sites

  • Self/personal experience

  • Personal research

  • Local news

  • Personal narratives from friends

  • Immediate family

  • Health department

 
Do not trust
“[Social media is] not that helpful. You end up confused if you listen to it too much.” Black rural and urban participant 
  • Pastors

  • Politicians

  • Community leaders

  • TV personalities

  • Social media

 
  • Priests

  • Social media

  • Government

 
  • Doctors and nurses

  • News Web sites

  • Social media

  • Government

  • Local health department

  • Pastors

  • Community leaders

  • Politicians pushing an agenda

  • CDC, WHO, White House

  • Other than self

 
Information sources
“There is no 1 clear answer. You search 5 sources; you get 5 different answers.” NHW rural participant 
  • Doctor

  • Primary care center

  • Personal research

  • Pharmacist

  • Google/CDC Web site

  • Not social media

  • Desire for more information

 
  • Doctor

  • TV

  • Radio

  • Internet

  • News

  • Spouse

  • Family that are doctors

 
  • Doctor

  • Friends with COVID-19 vaccine experience

  • Family

  • Medical specialists

  • Social media

  • Family members that are doctors

  • Education workers

  • Health department

  • Internet

 
ThemesBlacka Rural and UrbanSpanish-Speakingb Rural or UrbanNHW Rural
Trust
“I’ll trust a medical professional over somebody who’s just getting their information off the Internet.” Black rural and urban participant 
  • Primary care

  • CDC

  • Health department

  • Government

  • God

  • Personal narratives from friends

  • Specialty health clinics

 
  • Doctor

  • President

  • News

  • Social media accounts of health institutions

  • Government

 
  • Doctor

  • Reputable Web sites

  • Self/personal experience

  • Personal research

  • Local news

  • Personal narratives from friends

  • Immediate family

  • Health department

 
Do not trust
“[Social media is] not that helpful. You end up confused if you listen to it too much.” Black rural and urban participant 
  • Pastors

  • Politicians

  • Community leaders

  • TV personalities

  • Social media

 
  • Priests

  • Social media

  • Government

 
  • Doctors and nurses

  • News Web sites

  • Social media

  • Government

  • Local health department

  • Pastors

  • Community leaders

  • Politicians pushing an agenda

  • CDC, WHO, White House

  • Other than self

 
Information sources
“There is no 1 clear answer. You search 5 sources; you get 5 different answers.” NHW rural participant 
  • Doctor

  • Primary care center

  • Personal research

  • Pharmacist

  • Google/CDC Web site

  • Not social media

  • Desire for more information

 
  • Doctor

  • TV

  • Radio

  • Internet

  • News

  • Spouse

  • Family that are doctors

 
  • Doctor

  • Friends with COVID-19 vaccine experience

  • Family

  • Medical specialists

  • Social media

  • Family members that are doctors

  • Education workers

  • Health department

  • Internet

 

CDC, Centers for Disease Control and Prevention; WHO, World Health Organization.

a

Includes both Hispanic and non-Hispanic persons.

b

Includes any race/ethnicity that identified Spanish as their preferred language.

Personal Choice and Vaccine Decision-making (Table 4)

Nearly all parents/caregivers preferred for parents/caregivers to be allowed to make their own decisions about vaccinating their children over public mandates for vaccination. When discussing what parents/caregivers find important when making a vaccine decision, concerns were raised about the vaccine itself, opinions about potential positive and negative potential effects, impact of vaccination on preexisting medical conditions, and the desire for reliable information. Some participants in Spanish-speaking focus groups expressed a desire not to vaccinate their children too soon, instead preferring to wait for additional research and greater collective experience with COVID-19 vaccination. Long-term effects of the vaccine were mentioned in every inclusion group; however, none of the groups voiced specific concerns.

TABLE 4

Themes Regarding Personal Choice and Vaccine Decision-Making by Inclusion Group

ThemesBlacka Rural and UrbanSpanish-Speakingb Rural and UrbanNHW Rural
Mandates and parent/caregiver choice
“…[P]arents should have the right and ableness to be able to advocate for their kids, regardless of any government or political stance…” NHW rural participant 
  • Mandate would not influence decision

  • Others are not concerned for child like the child’s parent

 
  • Vaccination should be the parents’/caregivers’ decision

 
  • Wanted others to support parent’s/caregiver’s decision

  • Government stance would not influence decision

  • Wants transparency in vaccine education

 
Decision influences
“[What I don’t want, she understands, is for her to get sick. Rather, I want to protect her […] but I know me and my daughter are very different, and that’s what I am afraid of.]” Spanish-speaking participant 
  • Potential effect of vaccination on a preexisting medical condition

  • Child’s opinion

  • Fear of side effects

  • Benefits of vaccination (ie, ability to attend school)

  • COVID-19 deaths and spread in their region

  • Child’s difficulty wearing masks

  • Previous experience with vaccines

  • Manufacturer

  • Vaccine given by a professional at a known, trusted clinic

  • Vaccine ingredients

  • Pain of injection

 
  • Vaccine ingredients

  • Wants to wait and see

  • Decisions driven by fear

  • Desire for self-protection

  • Desire to wait for vaccine to receive full FDA approval

  • Thinks more research is needed

  • Personal medical history

  • Fear of long-term vaccination effects

 
  • Fear of vaccine side effects

  • Fear of long-term vaccination effects

  • Doctor’s advice

  • Perceived too many unknowns

  • Concern that vaccination will limit future career options

  • Research findings

  • Missing school because of the side effects

  • Manufacturer

  • Concerns about too many regulation changes

  • Perceived risk of COVID-19 disease

  • Personal medical history

  • Dislike of new vaccines

 
ThemesBlacka Rural and UrbanSpanish-Speakingb Rural and UrbanNHW Rural
Mandates and parent/caregiver choice
“…[P]arents should have the right and ableness to be able to advocate for their kids, regardless of any government or political stance…” NHW rural participant 
  • Mandate would not influence decision

  • Others are not concerned for child like the child’s parent

 
  • Vaccination should be the parents’/caregivers’ decision

 
  • Wanted others to support parent’s/caregiver’s decision

  • Government stance would not influence decision

  • Wants transparency in vaccine education

 
Decision influences
“[What I don’t want, she understands, is for her to get sick. Rather, I want to protect her […] but I know me and my daughter are very different, and that’s what I am afraid of.]” Spanish-speaking participant 
  • Potential effect of vaccination on a preexisting medical condition

  • Child’s opinion

  • Fear of side effects

  • Benefits of vaccination (ie, ability to attend school)

  • COVID-19 deaths and spread in their region

  • Child’s difficulty wearing masks

  • Previous experience with vaccines

  • Manufacturer

  • Vaccine given by a professional at a known, trusted clinic

  • Vaccine ingredients

  • Pain of injection

 
  • Vaccine ingredients

  • Wants to wait and see

  • Decisions driven by fear

  • Desire for self-protection

  • Desire to wait for vaccine to receive full FDA approval

  • Thinks more research is needed

  • Personal medical history

  • Fear of long-term vaccination effects

 
  • Fear of vaccine side effects

  • Fear of long-term vaccination effects

  • Doctor’s advice

  • Perceived too many unknowns

  • Concern that vaccination will limit future career options

  • Research findings

  • Missing school because of the side effects

  • Manufacturer

  • Concerns about too many regulation changes

  • Perceived risk of COVID-19 disease

  • Personal medical history

  • Dislike of new vaccines

 

FDA, US Food and Drug Administration.

a

Includes both Hispanic and non-Hispanic persons.

b

Includes any race/ethnicity that identified Spanish as their preferred language.

Rumors (Table 5)

The greatest number of COVID-19 vaccine rumors were relayed by the NHW rural group, followed by the Black rural and urban group. These rumors included: Claims of vaccination side effects, detrimental effects on children’s developmental processes, lack of benefit from vaccinations in general, fear of governmental interference with personal rights in mandating vaccination, and fear of religious repercussions of COVID-19 vaccination (eg, indicative of children having the “mark of the beast”).

TABLE 5

Rumors About the COVID-19 Vaccine Reported by Inclusion Groups

Blacka Rural and UrbanSpanish-Speakingb Rural and UrbanNHW Rural
• Vaccine contains a microchip or global positioning tracker
•Vaccination confers the mark of the beast.
•Risk of COVID-19 disease is unchanged by vaccination
•Government and doctors are pushing vaccination too hard
•Vaccination may cause infertility.
•Mass COVID-19 vaccination campaigns are a form of experimenting on minorities. 
  • Being vaccinated after having COVID-19 disease can be lethal.

  • COVID-19 vaccine is just like the flu vaccine.

  • Mass vaccination is an (unspecified) government conspiracy.

  • Vaccine contains a magnet

  • Government is using vaccination campaigns to spy on families

 
  • Vaccination causes COVID-19 disease.

  • It is God’s will if someone has COVID-19 disease.

  • Vaccination confers the mark of the beast

  • Natural immunity is superior to vaccine-derived immunity.

  • FDA approval of the vaccine was given too quickly.

  • Unknown effect of the vaccine on pregnancy and fertility

  • Community leaders are pushing an agenda.

  • Risk of COVID-19 disease is exaggerated, especially for children

  • Vaccination causes health problems (ie, joint inflammation, respiratory problems, growth issues).

 
Blacka Rural and UrbanSpanish-Speakingb Rural and UrbanNHW Rural
• Vaccine contains a microchip or global positioning tracker
•Vaccination confers the mark of the beast.
•Risk of COVID-19 disease is unchanged by vaccination
•Government and doctors are pushing vaccination too hard
•Vaccination may cause infertility.
•Mass COVID-19 vaccination campaigns are a form of experimenting on minorities. 
  • Being vaccinated after having COVID-19 disease can be lethal.

  • COVID-19 vaccine is just like the flu vaccine.

  • Mass vaccination is an (unspecified) government conspiracy.

  • Vaccine contains a magnet

  • Government is using vaccination campaigns to spy on families

 
  • Vaccination causes COVID-19 disease.

  • It is God’s will if someone has COVID-19 disease.

  • Vaccination confers the mark of the beast

  • Natural immunity is superior to vaccine-derived immunity.

  • FDA approval of the vaccine was given too quickly.

  • Unknown effect of the vaccine on pregnancy and fertility

  • Community leaders are pushing an agenda.

  • Risk of COVID-19 disease is exaggerated, especially for children

  • Vaccination causes health problems (ie, joint inflammation, respiratory problems, growth issues).

 

FDA, US Food and Drug Administration.

a

Includes both Hispanic and non-Hispanic persons.

b

Includes any race/ethnicity that identified Spanish as their preferred language.

Table 6 includes the themes found in vaccine acceptor and refuser KIIs. Data were not presented by inclusion group, because there was only 1 participant for each inclusion group interviewed. Unlike among the vaccine-hesitant inclusion groups, themes raised among acceptors (and, separately, among refusers) did not differ greatly by inclusion group stratum. Refusers reported a sentiment of having access to a large number of sources of COVID-19 vaccine information, but few sources that they considered to be trustworthy. Refusers doubted the credibility of sources perceived to be overly positive about the vaccine. Among all refuser participants, the concerns seemed similar, with a focus on perceived low vaccine efficacy and perceived risk of both short- and long-term vaccination side effects.

TABLE 6

Themes Reported by Vaccine Acceptors and Refusers

ThemesVaccine AcceptorsVaccine Refusers
Trust 
  • Doctors and nurses

  • Pediatrician

  • Government

  • Health department

  • CDC/FDA

  • Family members who are doctors

  • Local news

  • More cautious plans of action

  • Tribal leadership

  • Vaccine manufacturer

  • Their own research

 
  • Doctors

  • Statistics

  • Religious Web sites with vaccine alternatives and accommodation information

  • Personal narratives from friends

  • Libraries

  • God

  • Opinions of friends and family

  • Pastor

  • Personal intuition

 
Do not trust 
  • Nonmedical people

  • Social media

  • Internet

  • News

  • Government

 
  • Doctors and nurses

  • Pastors

  • Health department

  • Government

  • Social media

  • Internet

  • News

  • People perceived to be too strongly in favor of vaccination

  • Politicians

  • Sources that disagree with personal viewpoint

 
Mandates and personal choice 
  • Desire for vaccination decision to be a personal choice, but hesitant about hurting others

  • Leaders view it as necessary, but parents/caregivers would like to wait and see

 
  • Belief that others will try to exert influence to change parents’/caregivers’ mind

  • Desire for vaccination decision to be a personal choice, but believe parents/caregivers should do a lot of research

  • Desire not to advise others

  • Would abide by a mandate

 
Information sources 
  • Pediatrician/doctor

  • Personal discussion with someone who vaccinated their child

  • CDC/FDA Web site

  • Family members who are doctors

  • Internet

  • News

  • Vaccine manufacturer

 
  • Physicians

  • Prefers to not use any external information

  • Licensed physician focused on compassion, not what they are supposed to do

  • Historical accounts of other vaccines

  • Vaccine clinic

  • News

  • Other parents/caregivers that vaccinated their children

  • CDC Web site

  • Holistic doctors

  • Family members

 
Decision influences 
  • Wants full FDA approval before vaccinating

  • Perceived vaccine safety (ie, side effects, possible long-term effects)

  • Desire to protect family members

  • Personal experience with COVID-19 disease

  • Child’s opinion of vaccination versus keeping the child safe

  • Desire for more information

  • Risk/benefit analysis

  • Wants to avoid making a decision driven by fear

  • Wants to wait and see other’s experience before vaccinating

  • Personal medical history

 
  • Perceived vaccine safety (ie, side effects, possible long-term effects)

  • Perceived newness of COVID-19 vaccine

  • Potential impact on work/school opportunities

  • Other parents’/caregivers’ opinion

  • Wants to avoid making a decision through fear and propaganda

  • Understanding of vaccine history

  • Vaccine development process

  • Vaccine ingredients

  • Wants to wait and see other’s experience before vaccinating

  • The health of others after receiving COVID-19 vaccine

  • Personal medical history

  • Possibility of an allergic reaction

  • Perception of vaccine integrity

  • Perception of whether enough research has been done

 
Reported rumors 
  • Misinformation leads to vaccine refusal

  • Vaccine causes autism

  • Vaccine contains a GPS chip

  • Vaccine contains a microchip

  • Vaccine is experimental

  • Vaccine is another strain of COVID-19 that will make you sicker

  • Vaccination is a form of government control

  • Vaccine has not been fully approved

 
  • The vaccine needs more time for research.

  • Natural immunity is superior to vaccine-induced immunity.

  • Each person has a unique reaction to different viruses.

  • Physicians in the community support vaccination.

  • It is God’s will if someone has COVID-19 disease.

  • Vaccine contains fetal tissue

  • Incorrect COVID-19 case counts are reported

  • Repeated vaccination is replacing cures to make money.

  • Vaccine causes autism

  • Other natural treatments for COVID-19 disease are superior to the vaccine.

  • Vaccines in general harm healthy people.

  • Vaccination is a trap.

  • Vaccine development process skipped safety measures

  • COVID-19 disease course is more severe among the vaccinated

  • Vaccination causes paralysis.

  • Vaccination spreads the SARS-CoV-2 virus.

 
ThemesVaccine AcceptorsVaccine Refusers
Trust 
  • Doctors and nurses

  • Pediatrician

  • Government

  • Health department

  • CDC/FDA

  • Family members who are doctors

  • Local news

  • More cautious plans of action

  • Tribal leadership

  • Vaccine manufacturer

  • Their own research

 
  • Doctors

  • Statistics

  • Religious Web sites with vaccine alternatives and accommodation information

  • Personal narratives from friends

  • Libraries

  • God

  • Opinions of friends and family

  • Pastor

  • Personal intuition

 
Do not trust 
  • Nonmedical people

  • Social media

  • Internet

  • News

  • Government

 
  • Doctors and nurses

  • Pastors

  • Health department

  • Government

  • Social media

  • Internet

  • News

  • People perceived to be too strongly in favor of vaccination

  • Politicians

  • Sources that disagree with personal viewpoint

 
Mandates and personal choice 
  • Desire for vaccination decision to be a personal choice, but hesitant about hurting others

  • Leaders view it as necessary, but parents/caregivers would like to wait and see

 
  • Belief that others will try to exert influence to change parents’/caregivers’ mind

  • Desire for vaccination decision to be a personal choice, but believe parents/caregivers should do a lot of research

  • Desire not to advise others

  • Would abide by a mandate

 
Information sources 
  • Pediatrician/doctor

  • Personal discussion with someone who vaccinated their child

  • CDC/FDA Web site

  • Family members who are doctors

  • Internet

  • News

  • Vaccine manufacturer

 
  • Physicians

  • Prefers to not use any external information

  • Licensed physician focused on compassion, not what they are supposed to do

  • Historical accounts of other vaccines

  • Vaccine clinic

  • News

  • Other parents/caregivers that vaccinated their children

  • CDC Web site

  • Holistic doctors

  • Family members

 
Decision influences 
  • Wants full FDA approval before vaccinating

  • Perceived vaccine safety (ie, side effects, possible long-term effects)

  • Desire to protect family members

  • Personal experience with COVID-19 disease

  • Child’s opinion of vaccination versus keeping the child safe

  • Desire for more information

  • Risk/benefit analysis

  • Wants to avoid making a decision driven by fear

  • Wants to wait and see other’s experience before vaccinating

  • Personal medical history

 
  • Perceived vaccine safety (ie, side effects, possible long-term effects)

  • Perceived newness of COVID-19 vaccine

  • Potential impact on work/school opportunities

  • Other parents’/caregivers’ opinion

  • Wants to avoid making a decision through fear and propaganda

  • Understanding of vaccine history

  • Vaccine development process

  • Vaccine ingredients

  • Wants to wait and see other’s experience before vaccinating

  • The health of others after receiving COVID-19 vaccine

  • Personal medical history

  • Possibility of an allergic reaction

  • Perception of vaccine integrity

  • Perception of whether enough research has been done

 
Reported rumors 
  • Misinformation leads to vaccine refusal

  • Vaccine causes autism

  • Vaccine contains a GPS chip

  • Vaccine contains a microchip

  • Vaccine is experimental

  • Vaccine is another strain of COVID-19 that will make you sicker

  • Vaccination is a form of government control

  • Vaccine has not been fully approved

 
  • The vaccine needs more time for research.

  • Natural immunity is superior to vaccine-induced immunity.

  • Each person has a unique reaction to different viruses.

  • Physicians in the community support vaccination.

  • It is God’s will if someone has COVID-19 disease.

  • Vaccine contains fetal tissue

  • Incorrect COVID-19 case counts are reported

  • Repeated vaccination is replacing cures to make money.

  • Vaccine causes autism

  • Other natural treatments for COVID-19 disease are superior to the vaccine.

  • Vaccines in general harm healthy people.

  • Vaccination is a trap.

  • Vaccine development process skipped safety measures

  • COVID-19 disease course is more severe among the vaccinated

  • Vaccination causes paralysis.

  • Vaccination spreads the SARS-CoV-2 virus.

 

CDC, Centers for Disease Control and Prevention; FDA, US Food and Drug Administration; GPS, global positioning.

COVID-19 vaccine hesitancy encompasses multifactorial concerns among parents/caregivers. Because of the relative newness of the COVID-19 vaccine and the relatively low vaccine uptake in younger children, it is important to build vaccine confidence in parents/caregivers while addressing common causes of vaccine hesitancy. Groups of high priority who have been previously identified as harboring increased vaccine hesitancy need to have their concerns clearly identified for future efforts to address them to build vaccine confidence.30 

This data support previous literature on parent’s opinions on COVID-19 vaccinations for children. Wigle et al (2023) interviewed 20 parents in the Toronto area of varying levels of COVID-19 vaccine hesitancy, and similarly identified concerns about vaccine newness, overpoliticization, concerns about social pressure, and possible benefits.31  Our findings differed in that vaccination mandates were universally unpopular, with 1 participant explaining that “nobody cares about the child like a parent.” This finding supports the NIH suggestion that mandates are not helpful for reducing COVID-19 vaccine hesitancy.25 

Rajeh et al (2023) interviewed 50 parents in Saudi Arabia about COVID-19 vaccination, and also found that vaccine-hesitant parents/caregivers reported doctors to be a reputable and trustworthy information source, which also matches the quantitative survey in Szilagyi et al (2021).11,32  However, our work shows that some NHW rural participants had concerns about the trustworthiness of the motives of those promoting COVID-19 vaccination. Although this duality seems self-contradictory, it could suggest that vaccine hesitant and refusers were willing to listen to doctors but evaluated whether to trust them on the basis of other factors. Goulding et al (2022) conducted focus groups with 67 primarily female and Hispanic parents from central Massachusetts and had similar findings of desiring more information and themes of confusion and frustration with the messaging around COVID-19 vaccines.33 

All vaccine-hesitant inclusion groups had participants who shared rumors about the vaccine related more to government and pharmaceutical influence than about the vaccine itself. Concerns included fear that the true purpose of COVID-19 vaccination campaigns were to “trap” participants, apprehension about an overarching government conspiracy, and worry that the vaccination was not developed to protect individuals but as a new way to make money. These concerns were not captured on previous surveys on COVID-19 vaccine hesitancy.10,11  Social media was generally considered an untrustworthy information source, and many of the rumors reported by participants were widely disseminated on social media.34 

Overall, vaccine-hesitant, Black parents/caregivers expressed attitudes, beliefs, and opinions more aligned with vaccine acceptors, whereas vaccine-hesitant NHW rural parents/caregivers’ attitudes, beliefs, and opinions tended to be more aligned with vaccine refusers. Many times, vaccine acceptors and refusers expressed similar attitudes, beliefs, and opinions about vaccinating their children, such as trusting their physician; a desire for more information about vaccine side effects, both short and long term; and being wary of making decisions on the basis of fear.

Our methods did not focus on traditional organization by race and ethnicity, a social construct. Instead, our approach focused on including participants at risk for nonvaccination on the basis of the intersectionality of race/ethnicity, rurality, and English versus Spanish language preference. Previous work has shown that the association between race/ethnicity and vaccine hesitancy can be explained by differences in socioeconomic status among racial and ethnic groups.11 

This study has the following limitations. This study involved a convenience sample from 4 states and, thus, findings may not generalize to beyond participants of similar backgrounds. This study only enrolled participants who have an Internet connection and a device capable of accessing a video conferencing platform, which could have limited the possible participants to those with greater technological literacy and access. The SARS-CoV-2 virus and COVID-19 vaccine were considered a sensitive subject by some individuals approached for recruitment, and participant self-selection could have resulted in a narrow view of concerns. The COVID-19 pandemic was evolving at the same time as the study. New US Food and Drug Administration vaccine authorizations, Centers for Disease Control and Prevention vaccine recommendations, and SARS-CoV-2 variant strains arising during study conduct could have made opinions about the vaccines shift frequently, even within the same participant.

Parents/caregivers reported a variety of attitudes, beliefs, opinions, and potentially addressable concerns about the COVID-19 vaccine. These results will inform interventions for addressing COVID-19 vaccine hesitancy and may also help guide pediatric providers in their discussion about the COVID-19 vaccination with patients and families.

We thank Phyllis Nader, BSE, for her assistance with this project. We also thank all site coordinators for their excellent work, especially Timothy Walsh, for coordinating Zoom events and liaising with the transcription company. This work would not have been possible without the efforts of DeAnn Hubberd and the many members of the Data Coordinating & Operations Center, as well as Jaime Baldner, who co-led the data management, provided oversight of participant recruitment and quality assurance, and ensured the deidentification of all transcripts. We thank Heather Young for assisting with focus groups and KIIs. Lastly, we thank all the participants.

Mx Honcoop participated in study design, data acquisition, data analysis and interpretation, and drafting and revising of the manuscript; Dr Roberts participated in study design, manuscript drafting, and critically revising of the manuscript; Dr Davis participated in study design, and data analysis and interpretation, and provided critical revisions to the manuscript; Dr Pope and Ms Dawley participated in study design, data acquisition, and data analysis and interpretation, and provided critical revisions to the manuscript; Drs McCulloh, Fu, and Darden participated in study design and data interpretation, and provided critical revisions to the manuscript; Dr Garza participated in study design, and data analysis and interpretation, co-led the data management, and provided critical revisions to the manuscript; Dr Greer participated in data analysis and data interpretation, and provided critical revision to the manuscript; Dr Snowden participated in study design, data acquisition, and data analysis and interpretation, and provided critical revisions to the manuscript; Dr Young participated in study design and data acquisition, and provided critical revisions to the manuscript; Dr Dehority participated in acquisition and interpretation of data, and provided critical revisions to the manuscript; Drs Enlow, Watts, Queen, Costello, and Alamarat provided interpretation of the study data and critical revisions to the manuscript; and all authors approved of the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Research reported in this publication was supported by the Institutional Development Award Program States Pediatric Clinical Trials Network of the National Institutes of Health under award U24OD024957, UG1OD024943, UG1OD024947, UG1OD024951, UG1OD024953, UG1OD024956, UG1OD024958, UG1OD024959, and UG1OD030016. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

COMPANION PAPERS: Companions to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-062927 and www.pediatrics.org/cgi/doi/10.1542/peds.2023-063169.

app

application

COVID-19

coronavirus disease 2019

ECHO ISPCTN

Environmental Influences on Child Health Outcomes Institutional Development Award States Pediatric Clinical Trials Network

KII

key informant interviews

MoVeUP

Mobile Vaccine Uptake

NHW

non-Hispanic white

NIH

National Institutes of Health

SARS-CoV-2

severe acute respiratory syndrome coronavirus 2 virus

1
American Academy of Pediatrics
.
Children and COVID-19: state-level data report
. Available at: https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/. Accessed March 17, 2023
2
Centers for Disease Control and Prevention
.
Provisional COVID-19 deaths: focus on ages 0-18 years
. Available at: https://data.cdc.gov/NCHS/Provisional-COVID-19-Deaths-Focus-on-Ages-0-18-Yea/nr4s-juj3. Accessed March 17, 2023
3
Fowlkes
AL
,
Yoon
SK
,
Lutrick
K
, et al
.
Effectiveness of 2-Dose BNT162b2 (Pfizer BioNTech) mRNA vaccine in preventing SARS-CoV-2 infection among children aged 5–11 years and adolescents aged 12–15 years–PROTECT Cohort, July 2021–February 2022
.
MMWR Morb Mortal Wkly Rep
.
2022
;
71
(
11
):
422
428
4
Payne
AB
,
Gilani
Z
,
Godfred-Cato
S
, et al
.
Incidence of multisystem inflammatory syndrome in children among US persons infected with SARS-CoV-2
.
JAMA Network Open
.
2021
;
4
(
6
):
e2116420
5
Committee on Infectious Diseases
.
COVID-19 vaccines in children and adolescents
.
Pediatrics
.
2022
;
149
(
1
):
e2021054332
6
Woodworth
KR
,
Moulia
D
,
Collins
JP
, et al
.
The Advisory Committee on Immunization Practices’ interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine in children aged 5–11 Years–United States, November 2021
.
MMWR Morb Mortal Wkly Rep
.
2021
;
70
(
45
):
1579
1583
7
Fleming-Dutra
KE
,
Wallace
M
,
Moulia
DL
, et al
.
Interim recommendations of the Advisory Committee on Immunization Practices for use of Moderna and Pfizer-BioNTech COVID-19 vaccines in children aged 6 months–5 years–United States, June 2022
.
MMWR Morb Mortal Wkly Rep
.
2022
;
71
(
26
):
859
868
8
Murthy
BP
,
Sterrett
N
,
Weller
D
, et al
.
Disparities in COVID-19 vaccination coverage between urban and rural counties–United States, December 14, 2020–April 10, 2021
.
MMWR Morb Mortal Wkly Rep
.
2021
;
70
(
20
):
759
764
9
Macdonald
NE
.
SAGE Working Group on Vaccine Hesitancy
.
Vaccine hesitancy: definition, scope, and determinants
.
Vaccine
.
2015
;
33
(
34
):
4161
4164
10
Ruiz
JB
,
Bell
RA
.
Predictors of intention to vaccinate against COVID-19: results of a nationwide survey
.
Vaccine
.
2021
;
39
(
7
)
1080
1086
11
Szilagyi
PG
,
Shah
MD
,
Delgado
JR
, et al
.
Parents’ intentions and perceptions about COVID-19 vaccination for their children: results from a national survey
.
Pediatrics
.
2021
;
148
(
4
):
e2021052335
12
US Department of Health and Human Services
;
Centers for Disease Control and Prevention
.
Health communication playbook: resources to help you create effective materials
. Available at: https://www.cdc.gov/nceh/clearwriting/docs/health-comm-playbook-508.pdf. Accessed May 10, 2023
13
Khubchandani
J
,
Sharma
S
,
Price
JH
,
Wiblishauser
MJ
,
Sharma
M
,
Webb
FJ
.
COVID-19 vaccination hesitancy in the United States: a rapid national assessment
.
J Community Health
.
2021
;
46
(
2
):
270
277
14
Valier
MR E-EL
,
Mu
Y
, et al
.
Racial and ethnic differences in COVID-19 vaccination coverage among children and adolescents aged 5–17 years and parental intent to vaccinate Their children–National Immunization Survey–Child COVID Module, United States, December 2020–September 2022
.
MMWR Morb Mortal Wkly Rep
.
2023
;
72
(
1
):
1
8
15
UnidosUS
. Health issues and priorities–Latino voters in the 2020 electorate.
2021
16
Sanchez
GR
,
Peña
JM
. Skepticism and mistrust challenge COVID vaccine uptake for Latinos. Brookings. 2022. Available at: https://www.brookings.edu/articles/skepticism-and-mistrust-challenge-covid-vaccine-uptake-for-latinos/. Accessed May 10,
2023
17
COVID Collaborative
.
Survey on coronavirus vaccine hesitancy in Black and Latinx communities
. Available at: https://www.covidcollaborative.us/resources/coronavirus-vaccine-hesitancy-in-black-and-latinx-communities. Accessed March 23, 2023
18
Sanchez
GR
,
Bennett
C
. Why Spanish-language mis- and disinformation is a huge issue in 2022.
2022
. Accessed March 23, 2023
19
Silesky
MD
,
Panchal
D
,
Fields
M
, et al
.
A multifaceted campaign to combat COVID-19 misinformation in the Hispanic community
.
J Community Health
.
2023
;
48
(
2
):
286
294
20
Mcculloh
RJ
,
Darden
PM
,
Snowden
J
, et al
.
Improving pediatric COVID-19 vaccine uptake using an mHealth tool (MoVeUp): study protocol for a randomized, controlled trial
.
Trials
.
2022
;
23
(
911
)
21
Snowden
J
,
Darden
P
,
Palumbo
P
,
Saul
P
,
Lee
J
.
The Institutional Development Award States Pediatric Clinical Trials Network: building research capacity among the rural and medically underserved
.
Curr Opin Pediatr
.
2018
;
30
(
2
):
297
302
22
Ta Park
VM
,
Dougan
M
,
Meyer
OL
, et al
.
Vaccine willingness: findings from the COVI-19 effects on the mental and physical health of Asian Americans and Pacific Islanders survey study (COMPASS)
.
Prev Med Rep
.
2021
;
23
:
101480
23
Foxworth
R
,
Redvers
N
,
Moreno
MA
,
Lopez-Carmen
VA
,
Sanchez
GR
,
Shultz
JM
.
COVID-19 vaccination in American Indians and Alaska Natives–lessons from effective community responses
.
N Engl J Med
.
2021
;
385
(
26
):
2403
2406
24
RADx-UP
.
Data toolkit
. Available at: https://myhome.radx-up.org/cdcc-resources/data-toolkit/. Accessed February 2, 2023
25
Chou
W
,
Burgdorf
C
,
Gaysynsky
A
,
Hunter
C
.
COVID-19 Vaccination Communication: Applying Behavioral and Social Science to Address Vaccine Hesitancy and Foster Vaccine Confidence
.
Bethesda, MD
:
National Institutes of Health
;
2020
26
World Health Organization
.
Report of the SAGE WHO Working Group on Vaccine Hesitancy
. Available at: https://www.who.int/immunization/sage/meetings/2014/october/1_Report_WORKING_GROUP_vaccine_hesitancy_final.pdf. Accessed December 30, 2022
27
Hsieh
HF
,
Shannon
SE
.
Three approaches to qualitative content analysis
.
Qual Health Res
.
2005
;
15
(
9
):
1277
1288
28
Hyland
K
.
Metadiscourse: what is it and where is it going?
J Pragmatics
.
2017
;
2017
(
113
):
16
29
29
Hyland
K
,
Jiang
FK
.
“In this paper we suggest”: changing patterns of disciplinary metadiscourse
.
Engl Specif Purposes
.
2018
;
2018
(
51
):
18
30
30
Larson
HJ
,
Gakidou
E
,
Murray
CJL
.
The vaccine-hesitant moment
.
N Engl J Med
.
2022
;
387
(
1
):
58
65
31
Wigle
J
,
Hodwitz
K
,
Juando-Prats
C
, et al
.
Parents’ perspectives on SARS-CoV-2 vaccinations for children: a qualitative analysis
.
CMAJ
.
2023
;
195
(
7
):
E259
E266
32
Rajeh
MT
,
Farsi
DJ
,
Farsi
NJ
,
Mosli
HH
,
Mosli
MH
.
Are parents’ willing to vaccinate their children against COVID-19? A qualitative study based on the Health Belief Model
.
Hum Vaccin Immunother
.
2023
;
19
(
1
):
2177068
33
Goulding
M
,
Ryan
GW
,
Minkah
P
, et al
.
Parental perceptions of the COVID-19 vaccine for 5- to 11-year-old children: focus group findings from Worcester, Massachusetts
.
Hum Vaccin Immunother
.
2022
;
18
(
6
):
2120721
34
Lohiniva
A-L
,
Pensola
A
,
Hyökki
S
,
Sivelä
J
,
Härmä
V
,
Tammi
T
.
Identifying factors influencing COVID-19 vaccine uptake in Finland–a qualitative study using social media data
.
Front Public Health
.
2023
;
11
:
1138800

Supplementary data