Background

The importance of healthcare provider (HCP) patient communication has been thrust in the spotlight during the COVID-19 pandemic. Facing vaccine questions and concerns about vaccination in patient interactions is not a new challenge for many HCPs working in United States (US) health care settings. A large body of research suggests strategies that US providers can deploy to improve health communication and increase vaccine acceptance. Some recommendations include more time with patients during appointments [1], using motivational interviewing techniques [2], and allowing for honest discussions about vaccine concerns [3]. While evidence has shown that US-based family physicians [4] and pediatricians [5] can have a great role in increasing vaccine acceptance, especially for vaccine-hesitant parents [6,7,8], this places a heavy burden on the provider to change often strongly held beliefs.

Communication challenges have been exacerbated by the spread of false information on social media and other media outlets. This relentless misinformation coupled with an evolving information landscape submerged the public (including healthcare providers) in an overwhelming infodemic. As a result of this swirling information environment, there was an increasing demand on providers to provide up-to-date information to patients, navigate information voids, and combat resulting questions, concerns, and vaccine hesitancy [9]. Throughout the COVID-19 pandemic, the communication resources available to providers were often insufficient to address patient questions [10] in a highly fluctuating and increasingly polarized environment. The distinct challenges presented by COVID-19 vaccine attitudes and misinformation offer many considerations for continued practice, [11] and new solutions [5].

Unique environmental and policy factors in the US that persisted during COVID-19 pandemic and impacted HCP’s ability to provide patient care and education. In the US, controversies over compulsory vaccination have a complicated history, with COVID-19 as a prime example of the tension between protecting the health of the public and safeguarding the civil liberties of American citizens [12, 13]. Many state laws require vaccinations to reduce the rate of vaccine-preventable disease, such as those mandated for children to enter day care or school and federal employees to physically work within government buildings and facilitates [14]. However, US communities with varying levels of suspicion and mistrust of vaccines, persistent health care access inequities, religious exemptions, and predatory disinformation have threatened herd immunity targets for some vaccinations and resistance to vaccination mandates [15, 16]. Cultural aspects of public responses to COVID-19 in the US and increased exposure to misinformation campaigns throughout the pandemic magnified need to improve health communication strategies and strengthen the patient-provider relationship [11]. As a result of these complexities in the US context, vaccine communication can be challenging to address the myriad of concerns.

Due to high levels of institutional and government distrust, provider communication plays a key role in vaccine acceptance. In a report by WHO (2014), patient education during routine care led to the greatest increase in vaccine uptake [17]. Evidence-based education and training are crucial for clinicians to increase vaccine confidence [18], and as seen during the COVID-19 pandemic, are complemented by external factors such as vaccine availability and directing patients to trusted sources [19]. Comprehensive and consistent efforts are especially important for pregnant patients [20] and for Black Americans who consistently have lower rates of flu vaccination [21].

In an emerging body of literature, HCP experiences and perspectives are explored to assess how COVID-19 vaccine attitudes have impacted patient-provider relationships. Using a series of focus groups with HCP across the United States, the aim of this study was to capture and analyze the provider experience of patient counseling for COVID-19 vaccinations and how different aspects of the pandemic environment have impacted vaccine trust. We present our findings from these focus groups and offer recommendations for strategies to support provider health communication broadly.

Theoretical framework

Vaccine decision-making is influenced by a variety of psychosocial and environmental factors that form a complex ecosystem of factors that facilitate or create barriers to vaccine acceptance [22,23,24]. Kincaid et al. (2004) conceptualized a model of communication for social and behavior change across embedded sectors within the individual, social networks, community, and societal [25]. While there is a breadth of research describing the strategies healthcare providers can employ to encourage vaccine uptake among their patients, there is little in the way of understanding how to best support healthcare providers at the community, organizational or policy level. We borrow from Kincaid et al. (2004) and the Socioecological Model developed by Bronfenbrenner (1977) to interpose communication influences and modes at each level in the larger communication context, demonstrating support for providers needs to stem from outer levels to encourage individual-level change [25, 26]. We present a suggested Socio-ecological Model of Vaccine Communication in Fig. 1, including common messengers and messages at each level. Each level of the model illustrates messengers that have an influence within that particular level based on the narrative provider data captured in this study. Additionally, the model provides a selection of various messages observed across each level of vaccine communication.

Fig. 1
figure 1

Socio-ecological Model of Vaccine Communication

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Methods

To screen and recruit focus group participants, we collaborated with Alligator Digital, a third-party panel provider to field a survey across the United States from October 19 – November 12, 2021. Alligator Digital conducted the survey with 524 complete opt-in computer-assisted web interviews (CAWI), composed of medical professionals. The panel data were used to support a purposive sampling strategy of eligible healthcare professionals to participate, including doctors, nurses, and other medical professionals. In line with the study’s research questions, the HCP sample was designed to capture and segment the perspectives of healthcare providers most likely to counsel patients on a regular basis. Participants who reported they did not discuss vaccination with patients were ineligible and excluded from focus group discussions (FGDs). HCPs interested in participating in a FGD provided their contact information when surveyed. All FGD recruitment was conducted by the research team via email.

Based on the results from the national survey and input from an advisory group of experts in health communication, health behavior, and vaccine confidence, the following domains were identified as key areas to include in the focus group discussion guide (Appendix A): (1) best practices and strategies to discuss vaccination with patients; (2) preferred and helpful sources of information; (3) impacts of COVID-19 on the work environment; (4) perspectives on the HCP role in combating vaccine hesitancy; and (5) recommendations for supporting vaccine uptake. Through qualitative data collection and informed by our conceived model, data analysis aimed to define actionable items and communication strategies to improve vaccine acceptance among residents of the United States. This study was reviewed by the Internal Review Board at the City University of New York (CUNY) Graduate School of Public Health and Health Policy (SPH) as part of a larger mixed methods project, protocol number 2021-0330-PHHP. Findings from the full study are reported elsewhere [27, 28].

All focus group discussions (FGD) were segmented by profession and vaccination status: two groups of vaccinated physicians, two with vaccinated nurse practitioners (NP), two with vaccinated registered nurses (RN), and physician’s assistants (PA) and one with unvaccinated HCPs of various professions. Focus group size ranged from 4 to 7 participants per session depending on attendance and lasted 60–75 min. FGD were conducted until reaching thematic saturation. All participants were compensated with a $250 online gift card for their participation in the study. Focus groups were conducted by two members of the research team in December 2021 and January 2022. Before participating in the FGD, all recruited HCPs provided verbal informed consent and explicitly provided permission to be audio recorded as approved by the Internal Review Board at CUNY SPH. All groups were conducted and recorded through Zoom and audio files were transcribed for qualitative analysis.

The research team developed an initial codebook based on the interview guide domains and made iterative revisions through a first round of coding [28]. To ensure intercoder reliability, [29] at least two team members were assigned to each transcript to code and develop analytic memos of the transcripts [30]. Thematic analysis embedded within our model of Vaccination Communication of HCP. The research team met regularly to update current codes and discuss analytic approaches through an iterative approach to finalize the relevant themes as presented. Preliminary findings were sent to an advisory council for feedback following a roundtable discussion. The report was subsequently distributed to participants of the study to check for accuracy and ensure that the report reflected their experiences [31]. Six participants replied via email to confirm the report adeptly summarized their perspectives.

Results

Table 1 describes the demographics and characteristics of the 44 focus group participants. The majority of participants were doctors (34%) and physician’s assistants or nurse practitioners (34%). The majority (80%) were fully vaccinated at the time of data collection. Twenty-four US states were represented and included all regions of the country. The states with the largest representation were Indiana, North Carolina and Texas. Participants were primarily Democratic (41%), white (77%) and female (75%).

Table 1 Sociodemographic data from HCP participants
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Results at the intrapersonal and interpersonal level demonstrate the impact of COVID-19 misinformation on patient-provider communication and potential messengers and messages that can play a role in either promoting or combating misinformation. Results at the community, organizational and policy levels reveal key sources of information and recommended strategies to create an environment that supports vaccine acceptance. Table 2 summarizes the thematic analysis and provides excerpts from the FGDs for each of the themes identified.

Table 2 Qualitative Constructs and Themes
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Intrapersonal and interpersonal vaccine communication

COVID-19 misinformation has altered the patient-provider relationship

Overall, the focus group participants largely viewed their role as providing a source of scientific information and patient education during appointments. They saw themselves as trusted messengers for their patients, community, friends and family, but were quick to note communicating this information became more challenging during the COVID-19 pandemic. On the topic of COVID-19 vaccine hesitancy and refusal, most providers felt they had offered sufficient patient education and intervention in the year since the COVID-19 vaccine became widely available and that most unvaccinated individuals were no longer open to being counseled.

Providers expressed that, for the first time, some of their patients had doubts about their clinical guidance, believing that they were influenced by pharmaceutical or other institutional forces. While most providers did not face direct accusations of purposely misleading patients (especially those with long-standing relationships with their patients), providers faced patients who expressed distrust of the accuracy of information they offered.

A group of unvaccinated and/or “late adopting” providers (defined as being vaccinated after November 2021) indicated that they experienced a shift in perception of their own role in vaccine promotion. They expressed distrust stemming from their belief that vaccine mandates were implemented without comprehensive scientific evidence to support them, such as a lack of consideration for natural immunity in vaccine policy development. Importantly, these providers shared many of their patients’ COVID-19 vaccine concerns and reported that information provided by patients led them to question some key aspects of their medical training.

Provider’s strategies for vaccine communication during patient interactions

The providers offered several strategies for promoting vaccine acceptance among patients. The most common strategy was to tailor information to each patient’s medical history and concerns related to the COVID-19 vaccine and to avoid generic guidance. In their view, this approach facilitated provider trust and mitigated any institutional mistrust. This communication strategy was echoed as effective and meaningful in subsequent in-depth interviews and focus groups with patients in the parent study reported elsewhere [21].

A few providers touted “scare tactics” that appeal to patient fear, stating that patients have responded to other vaccine recommendations which cautioned of severe disease outcomes. One provider suggested this is an underused patient education tactic for the COVID-19 vaccine, citing the success of anti-smoking campaigns that highlighted severely impacted former smokers with chronic illness and disability. Providers also found that testimonials from recent adopters had an impact on their patients. Providers described the sharing of personal anecdotes, family stories, and introductions to other recently vaccinated patients as helpful for individuals still uncertain of their vaccination decision. Details about the unknown and prolonged effects of long-COVID would be an example of this communication strategy.

When discussing successful strategies for patient communication, many providers acknowledged that addressing vaccine hesitancy often takes multiple appointments with the same patient, and adequate appointment time - both circumstances that many patients and providers cannot independently facilitate or control. Those who saw patients on a regular basis due to the type of care they provided (i.e., maternal, and prenatal health care; care for chronic conditions) noted that the ability to have multiple touchpoints with the same patient facilitated a trusting dialogue around medical recommendations, including vaccination.

Community, organizational and policy messengers

Information sources that support provider vaccine communication

Many providers discussed the pressure to stay up to date in an evolving information environment, especially during the first year of the pandemic. They had mixed opinions on whether they had adequate resources to answer patient questions about the COVID-19 vaccination but generally agreed about their main sources of vaccine information during the pandemic. Participants cited the Centers for Disease Control and Prevention (CDC) and professional organizations like the American College of Obstetricians and Gynecologists (ACOG) as helpful. Other helpful resources included local and state health departments whose regular updates mitigated pressure on healthcare providers to stay up to date.

Several providers also indicated workplace communication digests and regular team meetings led by department heads as the most helpful resources to stay current on COVID-19 information. Some of these communications from employers also included patient-facing resources, which many providers reported as necessary to facilitate conversations with new information.

Provider’s recommendations to support vaccine acceptance outside the clinical setting

Providers described the challenge of addressing COVID-19 vaccine questions and concerns in an environment that often left them unsupported to reduce barriers to vaccination. This discussion led to some clear guidance for policy and institutional practices to address providers’ barriers to vaccine counseling. Firstly, many providers recommended all vaccinations be provided free of charge to the patient. Providers highlight patient financial concerns surrounding the COVID-19 as well as previous vaccinations. Despite the national provision that vaccines be available free of charge, there continued to be confusion among patients about the financial cost of vaccination. This has implications for both communication strategies and ready access to vaccines.

Some providers suggested continuing to offer vaccinations outside of the medical office or hospital environments (i.e., at mobile units, or pharmacies) to prevent cold supply chain challenges and other barriers in small doctors’ offices. Many providers hoped that the lessons learned during the COVID-19 vaccine rollout will inform future vaccination availability.

Providers indicated a strong need for a more centralized, unified vaccine communication response from regional and federal agencies to address the ongoing challenges that they face addressing oft-conflicting vaccine messages from health officials, and government representatives. While they recommend the policies and messaging come from a centralized effort, there is additional importance of engaging local messengers. They underscored the need for local, diverse and neutral messengers from trusted community leaders to combat further politicization and polarization. Some acknowledged this could involve collaboration between other sectors that may not be traditionally involved in public health campaigns (e.g., community leaders, faith leaders).

Discussion

We discuss our findings in the context of this model, focusing specifically on solutions to mitigate the negative impacts of misinformation, or evolving or confusing information on the patient-provider relationship and suggestions to create a stronger communication infrastructure that anchors patient-provider relationships. The results of this study highlight the impact of the confusing and often chaotic information environment surrounding COVID-19 and COVID-19 vaccination on patient-provider communication and demonstrate the strain caused when HCPs are not supported to respond adequately to patient concerns during clinical interactions. The impacts of misinformation specifically on the patient-provider dyad during the pandemic may be indicative of a new chapter of vaccine sentiments influencing how HCPs approach conversations about vaccination [32] While HCPs can play an important interpersonal role in providing consistent and empathetic messaging for their patients, policies and procedures must strengthen organizational and community communication channels to better provide consistent evidence-based health information. Our findings are situated in the socioecological model to show that HCPs counsel patients within a complex communication environment and can be helped or hindered by community, organizational, and policy factors. Viewing patient-provider communication this way demonstrates, for example, that HCPs cannot be the sole combatant to pervasive and predatory misinformation as the public is exposed through various means.

One of the most salient findings from our analysis was the provider recommendation for tailored interpersonal communication strategies that “meet patients where they are at.” This includes the empathetic recognition of patient questions and concerns but also the personalization of their advice to each patient’s medical needs – key strategies echoed in motivational interviewing and other tailored approaches [33, 34]. Providers generally agreed that vaccine acceptance requires an iterative and multi-phased process for many patients [17, 35]. The inclusion of anecdotes and personal perspectives has been demonstrated to be particularly effective in combating anti-vaccine misinformation [36].

Our findings echo current COVID-19 communication literature describing HCPs as the most effective messengers to present tailored messaging to their patients [37,38,39]. However, to ensure the sustainability of such approaches on a community-level and prevent provider burnout, other resources are needed to support broader efforts to address vaccine trust.

To provide the best evidence-based communication approaches, providers require support to navigate changing medical advice while fielding patient’s questions and concerns. For example, our participants agreed that guidance condensed into digests at a regular cadence (i.e., weekly) was the easiest way to consume new information. Digests were most helpful when they came from local organizational-level messengers like a regional health department or an employer. Having hyper-local data snapshots, news and guidance mitigated the pressures felt by providers to be consistently up-to-date and helped them tailor their information to their patients given the regional nature of the pandemic experience. Unlike many web pages or e-newsletters, these channels should flow two ways to include feedback from the providers on the use and usefulness of the resources provided. While we found communication resources are most effective and impactful when tailored at the community-level, national policy and advocacy must support the collection and dissemination of up-to-date, evidence-based information that all can access and use.

Furthermore, our findings indicate that providers seek resources to combat misinformation and overcome entrenched myths and misconceptions beyond currently available educational materials and resources. Bonnevie et al. (2021) have called for the development of partnerships to monitor and track sources of vaccine misinformation and responses to such campaigns through existing monitoring systems in our health infrastructure [40]. Based on our findings, we recommend that communication and response infrastructure is set up between private organizations tracking and combating misinformation, clinical facilities providing patient education, and government actors with the resources and capital to ensure the sustainability of the collaborative before the next pandemic.

The decline in government subsidies for COVID-19 vaccines and testing may impact the acceptability and uptake of vaccination and other mitigation measures [41]. Our focus group participants believed removing financial barriers to vaccination would increase patient uptake, citing that prohibitive cost to patients would thwart any effective communication efforts. Affordable vaccinations and availability at convenient locations removes logistical barriers for vaccine willing patients. As a policy-level intervention to encourage vaccine acceptance, free or low-cost vaccination in the US must be sustained, regardless of income, insurance, or legal status.

The polarized and politicized information environment during the COVID-19 pandemic had a significant impact on vaccine trust and literacy [42,43,44,45,46]. Our participants agreed the lack of a unified response from different US federal, state, and local agencies greatly contributed to community fragmentation over COVID-19 preventative measures, including vaccination. Future efforts should be made to ensure a coordinated and unified policy-level response to limit regional and community dissension and enhance public trust and the adoption of public health measures in future emergencies.

While participants spanned the United States, the limited sample size prevents generalized conclusions or assessments of correlations in our results. Although attempts were made to recruit for racial and ethnic diversity, the final sample of participants was largely white and concentrated on the coastal regions of the US. These focus groups offer a preliminary understanding of barriers and facilitators HCPs face when promoting vaccine acceptance. This study highlights the need for further research on perspectives of vaccine trust and acceptance from marginalized and rural populations.

Conclusion

HCPs faced various unique challenges throughout the COVID-19 pandemic, including unprecedented volumes of mis- and disinformation, often rendering pre-pandemic strategies to tackle vaccine hesitancy ineffective. There is a need to recognize provider perspectives in the creation of vaccine communication programs to mitigate HCP challenges and provide sufficient, up-to-date data to address patient concerns. Most important, HCPs require the support of policies and a communication infrastructure that builds patient trust in health care institutions and the science behind vaccination.