Studies note a high prevalence of pediatric coronavirus disease 2019 (COVID-19)-specific vaccine hesitancy in the United States. Our objective was to assess whether clinicians perceive a spillover effect of COVID-19 vaccine hesitancy onto other vaccines, and the impact of this spillover on their general recommendation behavior.
We conducted semistructured interviews with pediatricians in California and Colorado pediatric practices (January–March 2023). We transcribed, coded, and analyzed interviews using content analysis.
We interviewed 21 pediatricians (10 in California, 11 in Colorado). Clinicians observed some spillover effect of vaccine-favorable changes among some parents and greater hesitancy among others regarding the risks and benefits of childhood vaccination in general. This spillover was informed by 2 divergent patterns of parental trust in health systems and individual clinicians caused by the COVID-19 pandemic. Factors driving perceived changes included media coverage, greater knowledge about vaccination, and misinformation. Some clinicians felt that their approach to vaccine recommendations became more patient-centered, whereas others reported declining engagement in persuading hesitant parents about vaccination.
Clinicians described a hardening of parental views toward vaccines in both directions, which impacted their recommendation behavior. There is a need for vaccine hesitancy monitoring and better training and support for clinicians facing vaccine hesitant parents.
What’s Known on This Subject:
Vaccine hesitancy is a major public health threat. Pediatric coronavirus disease 2019-related hesitancy has been especially high since vaccination was introduced.
What This Study Adds:
Clinicians perceive a spillover effect of coronavirus disease 2019 vaccine hesitancy onto other vaccines by parents, which can have effects on their recommendation behavior.
Vaccines against infectious diseases have led to massive reductions in cases, hospitalizations, deaths, and health care costs in the 21st century.1 In 2009, routine pediatric vaccination in the United States was estimated to prevent >20 million disease cases and >40 000 deaths from 13 vaccine-preventable diseases,2,3 saving the US health care system an estimated $13.5 billion in care costs and an additional $68.8 billion in total societal costs.4
Despite the successes of vaccination, many parents choose to forgo or delay vaccines for their children. Common reasons include worries about safety and efficacy, and lack of awareness or concern for the diseases vaccines prevent.5 Studies have found decreased vaccination coverage, largely because of vaccine refusal, has led to disease outbreaks among children.6–9 In 2019, the World Health Organization named vaccine hesitancy as a top 10 threat to health.10
Although vaccines developed in response to the 2020 coronavirus disease 2019 (COVID-19) pandemic had a major impact in blunting morbidity and mortality from COVID-19,11 the pandemic spurred a backlash of vaccine hesitancy influenced in part by politicization and misinformation spread over social and traditional media.12,13 Parental reasons for hesitancy of COVID-19 vaccine included belief that the disease was not severe in children, vaccine efficacy was poor, or that the vaccine itself was harmful.14–16 Because of the high level of hesitancy and public discourse, there is concern that COVID-19 vaccine hesitancy could spill over into hesitancy for established vaccines and could alter clinician vaccine recommendation behavior. Less persistent vaccine recommendations from clinicians could have negative consequences, given that clinician recommendation has been repeatedly shown to be the strongest influencer of vaccination.17 Yet, little is known about the degree to which COVID-19 affected parental hesitancy or clinicians’ vaccine communication about routine vaccination.
In this qualitative study, we interviewed clinicians in Colorado and California to:
understand their experiences with vaccine hesitancy since the COVID-19 pandemic; and
explore how their recommendations for established vaccinations may have been impacted.
Methods
This was a supplementary qualitative study to a larger randomized clinical trial (RCT) testing the effectiveness of shifting initiation of human papillomavirus (HPV) vaccine to ages 9 to 10 years in 2 states. The interviews in this current study were not preplanned as part of the RCT, but were separate interviews conducted to assess the perceived impact of COVID-19 on parental vaccine hesitancy for routine vaccinations and discussions with clinicians. Qualitative content analysis methodology guided the project.18,19 Human subject approval was granted by a local institutional review board as an expedited review with waiver of written consent.
Participants
Interviewees were pediatricians sampled from primary care pediatric practices in Colorado and California that were eligible to participate in the larger RCT. The states were chosen for participation in the study because they both have a wide variety of practice types with diverse patient populations. RCT practice eligibility requirements were employing 2+ pediatricians, serving at least 150 adolescents, and not routinely recommending HPV vaccine routinely before age 11 years. To be eligible for these supplemental interviews, clinicians had to be in practices assigned to the usual care arm (routine HPV recommendation at 11) of the trial. Colorado practices were part of a practice-based research network located throughout multiple counties in the Front Range area of Colorado. Colorado practices had a median of 13 clinicians (range: 6–23), with a median self-reported Medicaid population of 15% (range: 6%–70%). California practices were part of 2 large health systems in Southern California in western Los Angeles and Orange counties. California practices had a median of 3 clinicians (range: 2–18), with a median self-reported Medicaid population of 7% (range: <1%–>99%). Practices were asked to provide 1 clinician for these supplementary interviews. For practices with multiple sites serving different patient populations and not sharing clinicians between sites, 1 interview per site was conducted. Given the breadth of perspectives surrounding the study question, we recruited additional interviewees to ensure thematic saturation. Additional interviewees were recruited from practices not participating in the larger trial but that met trial eligibility criteria until thematic saturation around the study question was reached.20
Data Collection
Semistructured key-informant interviews were conducted between January and March 2023 by a Doctor of Philosophy-level qualitative researcher (C.T.) and 2 masters-level qualitative research assistants (D.G., E.C.). Interviews were conducted using a guide developed by the interdisciplinary research team (Supplemental File 1). The guide included questions about clinicians’ experiences with COVID-19 vaccination, parental vaccine hesitancy before and after the pandemic, and their own recommendation practices. Interviews were conducted via videoconference and lasted up to 60 minutes. Interviewees received $100 for participating.
Data Analysis
Interviews were professionally transcribed, uploaded to Atlas.ti for data management (ATLAS GMHB version 23), and analyzed using content analysis.18 A codebook including both inductive and deductive codes was iteratively developed by 3 team members (C.T., D.G., E.C.). This process involved independently reading and coding a transcript, meeting to reconcile coded transcripts and refine the codebook, and repeating until code saturation was reached.21 Once the codebook was finalized, ∼20% of transcripts were coded by the 3 team members to ensure consistency before D.G. and E.C. coded all remaining transcripts independently. Coded data were analyzed within and across all interviews to identify major themes by summarizing coded data reports, identifying connections between codes on the basis of report summaries, writing analytic memos to describe observations and record salient themes, and holding frequent meetings to discuss emerging patterns.
Results
Twenty-one clinicians were interviewed (11 Colorado, 10 California) representing 19 practices. In Colorado, we interviewed 8 clinicians from 7 control practices and 3 clinicians at 2 additional practices. In California, we interviewed 6 clinicians from 6 control practices and 4 clinicians from 4 additional practices (located within the same health systems). Clinician perception varied on the effect the pandemic had on vaccine hesitancy and uptake. Large variations among clinicians’ perceptions were noted regarding the pandemic’s intensity of effect, the duration of effect, and which vaccines were affected. The COVID-19 pandemic was perceived to both increase parental vaccine hesitancy among some parents and to decrease parental vaccine hesitancy among other parents. Clinicians perceived that the pandemic affected 3 primary domains both positively and negatively: Parental perceptions of risks and benefits, parental trust in health systems and clinicians, and clinician discussion and recommendations. Table 1 summarizes these themes and provides additional supporting quotations.
Summary of Clinician’s Perceived Effects of the COVID-19 Pandemic on Vaccine Hesitancy and Clinician Discussion
| Theme . | Description . | Quote . |
|---|---|---|
| Positive impact on parental perceptions of risks and benefits | Increased understanding of and positive impressions of vaccines | “They saw that, again, a new vaccine was developed and how they were actively, as the studies were going on, they were able to see the impact of that decreasing hospitalization, so using that as a motivation to discuss other vaccines.” – California clinician 12 “I think, pre-COVID, parents were almost looking for any little thing they could have control over, and so they would sometimes be more hesitant for their routine vaccines. But I think it almost feels like now they can say, ‘Well, I don’t feel comfortable with the COVID vaccine ’cause that’s the new one, but the old ones, they’re fine.’” – Colorado clinician 8 |
| Increased awareness of communicable disease and value of vaccination | ||
| Improved perception of established vaccines by comparison | ||
| Negative impact on parental perceptions of risks and benefits | Increased awareness and discussions of vaccine harms | “I feel like it has affected maybe families coming into the office this y in 2022. They’re now starting to become behind on HPV or they hadn’t gotten their meningitis vaccine because it was so easy for them to run down to the pharmacy, get a flu shot, get their COVID booster, and bypass my office.” – California clinician 16 “[Parents] were on a routine ’cause it was the right thing to do…’This is the thing you do. You come for all your wells. It’s more than just vaccines. We’re checking development and growth and all these things.’ You get to ask all these questions, but now there’s telehealth and portals and all these other ways to ask these questions. You get your questions answered without coming to your appointment and your kid’s still doing fine. Typically, [with] a toddler, [they] will say, ‘Oh, they’re not in preschool yet.’ Even the schools for a couple of y were relaxed about making sure forms were signed and vaccines were done. We’ve really kind of lost traction on what the societal norms were and expectations. I think what’s really unfortunate about that is it’s not just those kids, those subset of specific children who are behind that are affected, but they’re behind because their parents lost traction and those parents are having more and more kids.” – Colorado clinician 18-2 |
| Increased perceptions of vaccine ineffectiveness | ||
| Reduced perceived need of well-child visit | ||
| Vaccine misinformation | ||
| Positive impact on parental trust in health systems and clinicians | Decreased need for discussions for those who were not hesitant previously | “I definitely have families who I think trust me more and have come to us and asked for our advice about the COVID vaccine. I think they see us as a trusted messenger, especially early on when these things are first rolling out. I had probably 5–10 conversations a d with families about whether they should get it. I was honored that they would come to me and ask me those things.” – California clinician 15 “I see [trust] improved over this past y and a half to 2 y because everybody knew someone who died of COVID…I think, now, they’ve seen that the vaccine program really has helped, that the antiviral meds and learning about treatments have helped to save lives…I think there’s more confidence now that the medical community probably did know what it was doing and did try to do the very best thing.” – Colorado clinician 8 |
| Improved relationships | ||
| Negative impact on parental trust in health systems and clinicians | Decreased trust in public health systems and personal doctors | “I can think of 1 family who stopped, they had previously been vaccinating on the routine schedule and just stopped, and cited basically big pharma. ‘They’re only out to make money. This is a conspiracy.’ Then, it made them less trustful of other vaccinations, as well, so not only the COVID vaccine, but then kinda made them step back in other routine vaccines that have been around for a long time, which is disheartening.’ – Colorado clinician 10-2 “‘Well, you just wanna push medicine and you’re in bed with the pharmaceutical companies and all clinician do is gift shots.’” – Colorado clinician 11 |
| Increased prevalence of conspiracy theories | ||
| Positive impact on clinician discussions and recommendations | Improved patient-focused vaccination approach and motivational interviewing | “I’m just, I guess, more open to conversation where parents have felt shut down from other doctors where it’s like, ‘They won’t see me if I don’t get my vaccines,’ where I’m more of, ‘Let me offer you more opportunities if you’re vaccine-hesitant to get your vaccines.’ It is something I think I’m aware about, and I think it does shape how I have conversations with parents and focusing on building the trust so they’re more likely to come back for their vaccine” – California clinician 15 “I honestly feel like I had more vaccine hesitancy and burnout from vaccine conversations before COVID. I don’t know if that’s the change in my practice…I feel like it doesn’t take so much out of me anymore because I actually don’t feel like I have [to do] it as often” – Colorado clinician 11 |
| Increased opportunities for vaccinations | ||
| Negative impact on clinician discussions and recommendations | Vaccine discussion fatigue (parent and clinician) | “Adding a COVID vaccine to the normal vaccine discussion in rooms, all of a sudden, parents are like, ‘Wait, we’re supposed to get these 3 vaccines today, and you want me to do another vaccine?’… It was [previously] just accepted because it hasn’t changed in so long. All of a sudden, your 6-mo-old is eligible for the COVID vaccine, and then you start to question all the vaccines that you’re getting.” – California clinician 11 “We even start to talk about it and they’re like, ‘No.’ They’ll get offended if you even suggest it. You can just see in their posture that they just start to tighten up. Yeah. They’re not open to it. I think it’s changed. I guess the way to answer your question is the thing that’s changed is that, now, in the past 6 mo, I don’t spend a lot of time on it. ’Cause I used to spend 10 min trying to tell them, per encounter, trying to convince them of why I think they need to do it. I’ve learned, I’ve adapted, it never works. If they’re against it, they’re against. Tucker Carlson’s told them it’s all a government conspiracy. Nothing you will do will convince them.” – Colorado clinician 6 |
| Reduced appetite to persuade hesitant parents | ||
| Too many vaccines for parents caused increase in requests for delayed or alternate vaccine schedules |
| Theme . | Description . | Quote . |
|---|---|---|
| Positive impact on parental perceptions of risks and benefits | Increased understanding of and positive impressions of vaccines | “They saw that, again, a new vaccine was developed and how they were actively, as the studies were going on, they were able to see the impact of that decreasing hospitalization, so using that as a motivation to discuss other vaccines.” – California clinician 12 “I think, pre-COVID, parents were almost looking for any little thing they could have control over, and so they would sometimes be more hesitant for their routine vaccines. But I think it almost feels like now they can say, ‘Well, I don’t feel comfortable with the COVID vaccine ’cause that’s the new one, but the old ones, they’re fine.’” – Colorado clinician 8 |
| Increased awareness of communicable disease and value of vaccination | ||
| Improved perception of established vaccines by comparison | ||
| Negative impact on parental perceptions of risks and benefits | Increased awareness and discussions of vaccine harms | “I feel like it has affected maybe families coming into the office this y in 2022. They’re now starting to become behind on HPV or they hadn’t gotten their meningitis vaccine because it was so easy for them to run down to the pharmacy, get a flu shot, get their COVID booster, and bypass my office.” – California clinician 16 “[Parents] were on a routine ’cause it was the right thing to do…’This is the thing you do. You come for all your wells. It’s more than just vaccines. We’re checking development and growth and all these things.’ You get to ask all these questions, but now there’s telehealth and portals and all these other ways to ask these questions. You get your questions answered without coming to your appointment and your kid’s still doing fine. Typically, [with] a toddler, [they] will say, ‘Oh, they’re not in preschool yet.’ Even the schools for a couple of y were relaxed about making sure forms were signed and vaccines were done. We’ve really kind of lost traction on what the societal norms were and expectations. I think what’s really unfortunate about that is it’s not just those kids, those subset of specific children who are behind that are affected, but they’re behind because their parents lost traction and those parents are having more and more kids.” – Colorado clinician 18-2 |
| Increased perceptions of vaccine ineffectiveness | ||
| Reduced perceived need of well-child visit | ||
| Vaccine misinformation | ||
| Positive impact on parental trust in health systems and clinicians | Decreased need for discussions for those who were not hesitant previously | “I definitely have families who I think trust me more and have come to us and asked for our advice about the COVID vaccine. I think they see us as a trusted messenger, especially early on when these things are first rolling out. I had probably 5–10 conversations a d with families about whether they should get it. I was honored that they would come to me and ask me those things.” – California clinician 15 “I see [trust] improved over this past y and a half to 2 y because everybody knew someone who died of COVID…I think, now, they’ve seen that the vaccine program really has helped, that the antiviral meds and learning about treatments have helped to save lives…I think there’s more confidence now that the medical community probably did know what it was doing and did try to do the very best thing.” – Colorado clinician 8 |
| Improved relationships | ||
| Negative impact on parental trust in health systems and clinicians | Decreased trust in public health systems and personal doctors | “I can think of 1 family who stopped, they had previously been vaccinating on the routine schedule and just stopped, and cited basically big pharma. ‘They’re only out to make money. This is a conspiracy.’ Then, it made them less trustful of other vaccinations, as well, so not only the COVID vaccine, but then kinda made them step back in other routine vaccines that have been around for a long time, which is disheartening.’ – Colorado clinician 10-2 “‘Well, you just wanna push medicine and you’re in bed with the pharmaceutical companies and all clinician do is gift shots.’” – Colorado clinician 11 |
| Increased prevalence of conspiracy theories | ||
| Positive impact on clinician discussions and recommendations | Improved patient-focused vaccination approach and motivational interviewing | “I’m just, I guess, more open to conversation where parents have felt shut down from other doctors where it’s like, ‘They won’t see me if I don’t get my vaccines,’ where I’m more of, ‘Let me offer you more opportunities if you’re vaccine-hesitant to get your vaccines.’ It is something I think I’m aware about, and I think it does shape how I have conversations with parents and focusing on building the trust so they’re more likely to come back for their vaccine” – California clinician 15 “I honestly feel like I had more vaccine hesitancy and burnout from vaccine conversations before COVID. I don’t know if that’s the change in my practice…I feel like it doesn’t take so much out of me anymore because I actually don’t feel like I have [to do] it as often” – Colorado clinician 11 |
| Increased opportunities for vaccinations | ||
| Negative impact on clinician discussions and recommendations | Vaccine discussion fatigue (parent and clinician) | “Adding a COVID vaccine to the normal vaccine discussion in rooms, all of a sudden, parents are like, ‘Wait, we’re supposed to get these 3 vaccines today, and you want me to do another vaccine?’… It was [previously] just accepted because it hasn’t changed in so long. All of a sudden, your 6-mo-old is eligible for the COVID vaccine, and then you start to question all the vaccines that you’re getting.” – California clinician 11 “We even start to talk about it and they’re like, ‘No.’ They’ll get offended if you even suggest it. You can just see in their posture that they just start to tighten up. Yeah. They’re not open to it. I think it’s changed. I guess the way to answer your question is the thing that’s changed is that, now, in the past 6 mo, I don’t spend a lot of time on it. ’Cause I used to spend 10 min trying to tell them, per encounter, trying to convince them of why I think they need to do it. I’ve learned, I’ve adapted, it never works. If they’re against it, they’re against. Tucker Carlson’s told them it’s all a government conspiracy. Nothing you will do will convince them.” – Colorado clinician 6 |
| Reduced appetite to persuade hesitant parents | ||
| Too many vaccines for parents caused increase in requests for delayed or alternate vaccine schedules |
Impact on Parental Views on Vaccine Risks and Benefits
Positive Impact
Overall, interviewees across both states reported that the COVID-19 pandemic altered parents’ perceptions of the risks and benefits of vaccines and the diseases they prevent. Clinicians reported that the COVID-19 vaccine was by far the greatest focus of vaccine hesitancy for patients, centering around a deep mistrust of the COVID-19 vaccine. For example, interviewees experienced having parents question whether the COVID-19 vaccine was effective (or even harmful) given its rapid and recent development, express concern about COVID-19–related conspiracy theories, and question whether COVID-19 was a serious enough disease to warrant vaccination.
Hesitancy around other vaccines was less common and the effect of the pandemic was more polarizing among interviewees’ experiences. For example, interviewees reported that vaccine hesitancy was reduced for parents who gained a better understanding of the function and value of vaccines “because the pandemic made people realize that there are infectious diseases out there that we can protect their kids from” (Colorado clinician 07). Many clinicians stated that the newness of the COVID-19 vaccine and uncertainty around messenger RNA technology boosted some parents’ confidence in established vaccines by comparison, making them more accepting of vaccines they might have previously refused. Particularly when it came to influenza vaccine, parents who were unwilling to get their children COVID-19 vaccines but wished to protect their children from diseases sometimes were more amendable to the influenza vaccine, because it was seen as the “lesser evil” (Colorado clinician 18-1) between the 2. Vaccines previously viewed by some parents as “new vaccines,” like the HPV vaccine, were also no longer perceived as novel. As 1 clinician explained:
“I think it's new versus older 'cause certainly HPV is not an old vaccine in my career, but I think the newness of COVID and the type of science around how it was developed, it's very different than HPV, and so HPV feels a little bit older [with] a lot more data and outcomes information that you can give a family.” (Colorado clinician 10-1)
Negative Impact
In contrast, other interviewees felt the COVID-19 pandemic generated more vaccine hesitancy among parents by altering their perceptions of vaccine risks and benefits. Although clinicians across both states reported that a majority of their practice population was generally accepting of vaccines, some described seeing an escalation of hesitancy (for either all or some vaccines, particularly HPV and influenza) among parents who were already worried about vaccines before the COVID-19 pandemic. All clinicians discussed how the COVID-19 pandemic reduced well-child visits. During pandemic years with stricter public health mandates (eg, masking, social distancing), many families skipped well-child visits and the routine vaccines they might have otherwise accepted without any observable consequences. One clinician postulated (Colorado clinician 18-2) this could have long-term effects on the “social contract” of well-child visits. Particularly when coupled with increased influenza vaccine availability at pharmacies and telehealth for acute health-related questions, these circumstances could reduce the perceived need of these visits and affect standard vaccinations typically done at these visits for both children who skipped well-child visits during the COVID-19 pandemic and their younger siblings.
Misinformation spread by social and traditional media about the risks of the COVID-19 disease and vaccine also negatively affected parents’ calculations around other vaccines. As parents heard about health risks that could arise from COVID-19 vaccine, some parents generalized these concerns to other vaccines. As 1 interviewee explained:
“In social media and among parenting circles, it's become more common to assert that the risks of the [COVID-19] vaccine were worse than the disease. When you weigh risk/benefits, you don't wanna vaccinate. Parents are trying to extrapolate that to other vaccines. If they don't see anybody who's sick with measles, then clearly there's no risk for getting sick with measles, and therefore any risk [from measles vaccine] is unacceptable.” [California clinician 13]
This trend was partly because of the fact that vaccines predating COVID-19 “are a victim of their own success; when you don't see diseases as a parent, you often just don't worry about it and so you're less likely to vaccinate” (California clinician 13).
Trust in Health Systems and Clinicians
Clinicians described how the pandemic contributed to changes in parents’ trust in the health care system and in individual clinicians. Interviewees reported that changes in systemic or clinician-level trust were also polarizing; they felt that parents tended to solidify and intensify their prepandemic views and that the number of “convertible” parents with vaccine-questioning or vaccine-hesitant positions had declined, whereas the number of nonconvertible hesitant parents had increased.
Positive Impact
Interviewees reported that, for parents who had gained a better understanding of how vaccines function, and what can happen when they are not available, trust in the science of vaccines and in their clinicians increased. One clinician stated these parents now responded to discussions about routine vaccination by saying, “We want everything. We trust science and we trust you and we chose you for a reason” (Colorado clinician 11). Some interviewees even reported that the increased knowledge and trust in vaccines made discussions easier with parents who were previously uncertain:
“I think it's actually helped bring about some easier discussions, especially with those families who were previously not sure of whether to vaccinate. I'm not talking about the full antivaxxers, but the families who had some hesitation about some of these vaccines…they were able to see the impact of that decreasing hospitalization, so using that as a motivation to discuss other vaccines.” (California clinician 12)
Negative Impact
On the other hand, interviewees felt that the COVID-19 pandemic reinforced existing suspicions about vaccination for parents who were already hesitant, and ultimately diminished their trust in the medical profession. Although interviewees felt that hesitancy used to be vaccine specific (eg, measles, mumps, and rubella vaccine over concerns for autism), they reported that COVID-19 led to an increase in more generalized distrust in national medical experts, health organizations, and vaccine recommendations. One source of this distrust was misinformation from social and traditional media. Interviewees stated that they constantly had to combat misinformation ranging from misunderstandings about how vaccines work to conspiracy theories around messenger RNA technology:
“Some [parents] would accuse us of injecting 5G chips in their children. They would say that we were part of some government conspiracy and we were secretly getting kickbacks from the government. I mean they had false beliefs that we were certainly not gonna be able to change…” (Colorado clinician 06)
Some interviewees whose patient population had lost trust in medical institutions saw this distrust turn into questioning the clinician’s clinical judgment. Feelings that the pandemic was overblown led to distrust of the government and its COVID-19 response, distrust in the COVID-19 vaccine, and eventually bleeding into a degradation of the clinician–parent relationship because of clinician support of the vaccine. For example, some lamented the repeated public health warnings about potential “twin/triple-demics” that, in some parents’ minds, did not come to pass, adding unnecessary governmental mandates and harming long-term trust in health care and individual clinicians.
Clinician Discussion and Recommendation Around Vaccination
Perceived effects of the pandemic on parents’ understanding of vaccine risks, benefits, and trust brought about reported changes in clinician’s behavior.
Positive Impact
Some interviewees described altering their approach to vaccine discussions and recommendations to account for pandemic-related changes in parent perceptions. These changes were sometimes constructive. Many reported switching recommendation approaches to ones that focused on the clinician–parent relationship, including utilizing motivational interviewing approaches. Interviewees felt that emphasizing emotional appeals, “meeting parents where they are,” and offering more opportunities to receive vaccines were received positively during the COVID-19 pandemic:
“Parents have felt shut down from other doctors where it's like, ‘They won't see me if I don't get my vaccines,’ where I'm more of, ‘Let me offer you more opportunities if you're vaccine-hesitant to get your vaccines.’ It is something I think I'm aware about, and I think it does shape how I have conversations with parents and focusing on building the trust so they're more likely to come back for their vaccine” (California clinician 15)
Negative Impact
Although clinicians who experienced positive changes described feeling satisfied with their work, some of those who saw greater increases in vaccine hesitancy discussed how their willingness to engage in vaccine discussions with hesitant parents had waned. For instance, some clinicians reported that constantly hearing about vaccinations in the media (especially conservative news sources, according to some clinicians) made many vaccine-hesitant parents experience “vaccine fatigue” and become less receptive to having those conversations, and, ultimately, interviewees felt unable to convince them.
Additionally, interviewees felt that the COVID-19 pandemic made vaccine hesitancy a “mainstream” topic, leading to more frequent questioning of once-routine vaccinations. The introduction of a new vaccine about which there is limited evidence made parents begin to rethink their previous acceptance of established vaccines as the status quo. As a result, these interviewees described experiencing “vaccine discussion fatigue.” Spending more time addressing vaccine hesitancy at the expense of other well-child topics left many interviewees feeling too “burned out” to try persuading parents to vaccinate who expressed hesitation. As described by 1 clinician:
“There were times during the pandemic where if a patient didn't want something like flu or COVID [vaccines] where I didn't have a quick like, ‘The school's gonna want this’-type answer, I might have been like, ‘Next time. I just don't have capacity today for this conversation.’” (Colorado clinician 18-2)
Pediatricians reported that, for many vaccine-hesitant parents, concerns related to the number of vaccines that are safe to administer at 1 time. Adding the COVID-19 vaccine could make this issue more salient. A common solution among many interviewees was to offer delayed or alternate vaccine schedules, tailoring their recommendation to try to maximize the chances that parents might eventually vaccinate at some point.
Discussion
Though a high level of hesitancy toward the COVID-19 vaccine has been well documented,12,16 effects on other vaccines and clinician behavior changes as a result have not been as well explored. Our sample of primary care clinicians confirmed the high hesitancy around COVID-19 vaccine they have experienced, stemming from lack of concern about COVID-19 disease and lack of trust in efficacy or safety of COVID-19 vaccine. These views were often shared by social and traditional media consumed by parents. Parental views on COVID-19 vaccination appeared to shape some parents’ perceptions about other vaccines. However, this effect was varied: The pandemic shifted parental perceptions of the risks and benefits of other vaccinations and the diseases they protect in 1 of 2 directions, either increasing or decreasing parental trust in the medical establishment and their own clinicians. These changes were shown to potentially affect how clinicians discuss vaccines with their parents, both positively (ie, increasing compliance) and negatively (ie, increasing overall discussion time). In some cases, it changed the approach or the clinicians’ rigor when recommending routine vaccines.
Recent national and statewide surveys of parents have highlighted the continued parental support for vaccination.22–24 However, some surveys have found increased concern about vaccine side effects23 or decreased trust in vaccine information.24 A survey of Israeli parents found that parents who had already vaccinated or intended to vaccinate their children for COVID-19 had an increased intention in future influenza vaccination; however, those who did not vaccinate for COVID-19 were much less likely to be accepting of influenza vaccine.25 The variation in perceptions from our interviewees underscores these differences in vaccination attitudes. Most clinicians felt there was little overall change in hesitancy in the majority of their parents but did see changes in certain parents which stood out. Some clinicians offered nuanced reasons for the perceived increase in vaccine hesitancy among some parents, for both specific vaccines and vaccination generally, including changes in parental perception in disease risk, increased public discourse in vaccine harms, and a decrease in public trust in national medical leaders and guidelines. Some clinicians described the opposite effect in some of their populations, because increased vaccination discussions on news media also increased parental understanding of the benefit of vaccines and increase trust in their clinician. These changes to hesitancy were sometimes seen by the same clinician when thinking about different patients at their practice.
Taken as a whole, clinicians described a polarization and hardening in existing views on vaccines, similar to findings by Higgins et al.24 Although many clinicians added the caveat that this affected a small portion of their patients overall, it was perceived to reduce the number of the “movable middle” of parents who may be hesitant but ultimately vaccinate. Those clinicians describing higher levels of hesitancy ranging from longer discussions to combative parents were at times overwhelmed with dealing with this increased demand along with other needs of primary care. Some reported not trying as hard to convince parents, opting instead to accept delayed or alternate schedules, or failing to bring up skipped vaccines at the next visit. Together, these findings point to a potential for undervaccination, which could lead to resurgences in vaccine-preventable diseases,8,26 as well as increased clinician stress and possible burnout.
Another interesting finding is the impact on the perceived benefit around annual well-child visits and vaccinations. The acute disruption the pandemic had on well-child visits and immunizations27–29 may have residual effects of some parents no longer seeing the value of preventive health visits for healthy children, particularly over a certain age. Further research is needed to explore parents’ overall views on preventive care.
Our study has many strengths. Our sample included a variety of practices across 2 states with differing practice policies, payer mixes, and patient populations, though may be weighed more heavily toward relatively affluent populations. Our data are in line with other work around pandemic impacts on vaccination. There were also several limitations. Interviewees described their own perceptions of parental and clinician behaviors, but we did not assess vaccine receipt and cannot speak to whether perceived differences in hesitancy affected actual vaccination decisions. We did not have access to patient race/ethnicity information, although we did not have hypotheses for why race/ethnicity would modify the impact of the pandemic on hesitancy. We lacked baseline vaccination and hesitancy data, which may impact the lens through which clinicians view changes in vaccine hesitancy. Additionally, these perceptions could be affected by recall, recency, and negativity bias; in fact, several clinicians mentioned that they were talking about a sometimes-small subset of their population. However, particularly with negative impacts, these perceptions (even from a small subset) sometimes appeared to affect clinician behavior. Future research should assess the broader prevalence of these views and their potential impact on vaccination behavior. Future research should also include a broader sampling of lower socioeconomic classes, because those populations may face disproportionate challenges associated with vaccine hesitancy.30
Public Health Implications
Findings from our interviews, along with the literature, highlight need for increased national focus on surveillance and etiologies of vaccine hesitancy. Given the investments made in creating and testing effective vaccines, there should be corresponding investment into vaccine implementation, focused on overcoming the barriers from parental vaccine hesitancy. Similar to national efforts to monitor infectious pathogens, ongoing national efforts should be underway to track rates and causes of hesitancy overall and for different vaccines because hesitancy varies by vaccine.31,32 These interviews add clinicians’ perspectives on changes to vaccine hesitancy, and highlight how clinicians may react to these changes in practice. The data presented here underline how hesitancy varies in response to events, such as pandemics, and how hesitancy toward 1 vaccine can affect trust in others. Our findings suggest that, if another pandemic occurs, public education and clinician conversations will need to emphasize that the effectiveness or safety profile of a new vaccine does not alter the known vaccine effectiveness and safety profile of existing vaccines.
Our data also illustrate the struggles clinicians are experiencing in dealing with parental concerns about new and established vaccines, creating burnout and reduction in effort to change the minds of hesitant parents. It is not known how widespread these effects on clinician behavior might be, but if common, this could further exacerbate the problem of vaccine hesitancy. National efforts to combat disinformation with messages specifically designed to address etiologies of hesitancy, as well as training for clinicians in methods to communicate with vaccine-hesitant parents, are needed to maximize the benefits of vaccines and maintain the morale of clinicians.
Conclusions
In this qualitative study, clinicians described a hardening of parental views toward vaccines in both directions among different subsets of patients, which has created a novel stress for clinicians in discussing childhood vaccinations with parents. Our data suggest the need for ongoing national monitoring of hesitancy for different vaccines and what is driving hesitancy, and the need to better train and support clinicians addressing vaccine hesitancy.
Mr Gurfinkel drafted the initial manuscript, critically reviewed and revised the manuscript, assisted with interview guide development, and collected and analyzed data; Dr Tietbohl critically reviewed and revised the manuscript, served as methodological lead for the project, lead interview guide development, and oversaw data collection and analysis; Ms Clark critically reviewed and revised the manuscript, assisted with interview guide development, and collected and analyzed data; Ms Saville and Ms Albertin critically reviewed and revised the manuscript, assisted with interview guide development, and managed the project; Dr O’Leary critically reviewed and revised the manuscript, assisted with interview guide development, and was involved in study conceptualization and design; Drs Szilagyi and Kempe critically reviewed and revised the manuscript, assisted with interview guide development, and lead study conceptualization and design; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
This study is registered at ClinicalTrials.gov, NCT04722822, https://clinicaltrials.gov/ct2/show/NCT04722822. Deidentified data (interview transcripts) presented in this manuscript will be granted upon reasonable request (sound methodological reasoning required). Data will be distributed by a secure file transfer protocol site. Access requests will be reviewed until April 2028. Please submit requests to the corresponding author ([email protected]).
FUNDING: Funded by National Institute of Health (NIH). Funding for this project was granted by the National Cancer Institute under grant 1R01CA240649.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.
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