Impact of the COVID-19 pandemic on social media utilization, influences related to parental vaccine decision making, and opinions on trustworthy social media vaccination campaigns: A qualitative analysis

ABSTRACT

There is a continued need for research to better understand the influence social media has on parental vaccination attitudes and behaviors, especially research capturing the effects of the COVID-19 pandemic. The goal of this study was to explore parents’ perspectives related to the impact the pandemic had on 1) social media engagement, 2) vaccine messaging on social media, and 3) factors to guide future intervention development. Between February and March 2022, 6 online, synchronous, text-based focus groups were conducted with parents of adolescents aged 11 to 17 years. Participants who all utilized social media were recruited from across the United States. Qualitative data were analyzed using content analysis. A total of 64 parents participated. Average age was 47 years, and participants were predominantly White (71.9%), female (84.3%), and engaged with social media multiple times per day (51.6%). Participants (95.3%) viewed obtaining all recommended vaccines as important or very important; however, overall vaccination rates for their adolescents were varied (50% ≥1 dose HPV; 59.4% MenACWY; 78.1% Tdap; 65.6% Flu; 81.3% COVID-19). Three themes emerged highlighting the pandemic’s impact on parent’s (1) general patterns of social media use, (2) engagement about vaccines on social media and off-line behaviors related to vaccination, and (3) perspectives for developing a credible and trustworthy social media intervention about vaccination. Participants reported fatigue from contentious vaccine-related content on social media and desired future messaging to be from recognizable health institutions/associations with links to reputable resources. Plus, providers should continue to provide strong vaccine recommendations in clinic.

KEYWORDS:

• Adolescent vaccination
• social media
• vaccine messaging
• credibility
• COVID-19 pandemic

Introduction

Vaccination has been noted as one of the greatest public health achievements and one of the most significant contributions to improved health of children in the 20^th century.^1,2 However, in 2019, the World Health Organization identified vaccine hesitancy as one of the ten leading threats to global health.³ In the United States (US), the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) currently recommends that all adolescents aged 11–12 years routinely receive four vaccines: the tetanus- diphtheria-acellular pertussis vaccine (Tdap), quadrivalent meningococcal conjugate vaccine (MenACWY), human papillomavirus (HPV) vaccine, and seasonal influenza vaccine.^4,5 For adolescents aged 16–18 years, ACIP routinely recommends the second dose of MenACWY and issued a shared clinical decision making (SCDM) recommendation for meningococcal B (MenB) vaccine. Plus, in 2023, the ACIP added the COVID-19 vaccine to the list of routinely recommended vaccines for all adolescents.⁶ However, despite strong professional guidelines and the great potential prevention benefits, US national data indicate that many adolescents do not receive recommended vaccinations.

While coverage for Tdap and the first dose of MenACWY exceed the US Healthy People 2030 goal of 80% coverage,⁷ other adolescent vaccines do not fare as well, reflecting, in part, parental vaccine hesitancy or a lack of confidence in vaccination. Data from the 2021 National Immunization Survey-Teen (NIS-Teen) showed that among adolescents aged 13–17 years, HPV vaccine series completion (61.7%) was well below the Healthy People 2030 goal of 80% series completion.⁸ Similarly, NIS-Teen data show that the recommended second dose of MenACWY is only at 60.0% coverage and MenB administration is at 31.4%.⁸ With respect to influenza vaccination, only 49.8% of adolescents aged 13–17 years received annual influenza vaccination for the 2021–2022 season,⁹ well below the Healthy People 2030 goal of 70%.⁷ The low coverage of these adolescent vaccines has significant implications for adolescent and young adult health now and in the future.

While strong healthcare provider recommendations increase vaccine acceptance among parents,^10–12 there is evidence that effective provider recommendations are underutilized, and that other influences, including social media and other online health information, also play an important role in parental vaccine decision making.¹³ Ample evidence suggests that negative messages about vaccination abound on social media,^14–19 and the COVID-19 pandemic exacerbated the negative rhetoric.²⁰ Although it is known that parents receive health information via social media and that message framing can have profound effects on parent vaccination attitudes and behaviors,^21,22 there is a continuing need for research to better understand how vaccine messaging on social media, particularly since the start of the COVID-19 pandemic, may influence parental vaccine confidence and decision making.

Previous reports indicate links between social media use, political leanings, and education level with an individual’s ability to identify misinformation, trust vaccines, trust vaccine messaging, and engage in vaccine decision making.^23,24 Additionally, vaccination status has been shown to influence social media interactions with vaccine posts (i.e., mothers posting unfavorable HPV vaccine comments were less likely to have vaccinated their daughter),²⁵ and negative messaging on media contributes to vaccine hesitancy and decisions to delay vaccination.¹⁸ Social media effects on vaccine confidence have been identified as a priority area for vaccination research in the US.²⁶ Research that directly supports evidenced-based vaccine communication/messaging interventions on social media is sorely needed.

Therefore, the overall goal of this study was to explore parent’s perspectives related to the impact the COVID-19 pandemic had on 1) their social media engagement, 2) vaccine messaging on social media, and 3) factors related to messaging influence (credibility and trustworthiness). In addition, we sought to garner opinions related to the development of future social media vaccine messaging interventions to increase vaccine confidence and acceptance. Data were collected in February and March of 2022, approximately 2 years after the start of the COVID-19 pandemic.

Materials and methods

Procedures and study population

A qualitative, descriptive study using an online synchronous text-based focus group methodology (6 focus groups, each 60 to 90 min, 9 to 15 participants per group) was conducted using a US national purposive sample. Members of the investigative team have a record of success using this methodology to provide robust data, particularly for topics that are sensitive or difficult to discuss face to face.^27–31 Eligibility criteria included: 1) parent or primary caregiver of an adolescent aged 11 to 17 years, 2) ability to read English, 3) access to a computer/tablet with internet access, and 4) utilization of at least one form of social media. Lastly, we sought to capture a diversity of vaccination perspectives/attitudes (vaccine cautious to vaccine confident). Therefore, participants were recruited if they had obtained at least one CDC ACIP recommended adolescent vaccine for their child. We also focused on recruiting mothers/female caregivers as they are often the primary caregiver present at health care visits, and women have been known to have higher rates of social media utilization as compared to men.³² Those who had not obtained any of adolescent vaccinations for their child were presumed to have negative attitudes toward all childhood vaccination and were thus excluded from this study.

Potential participants were recruited from an existing online US national panel of persons who have agreed to engage in research managed by InsideHeads, LLC, an experienced marketing research company. This panel provides the ability to reach quality large samples for online qualitative studies in a timely manner. Potential participants were contacted by InsideHeads and if interested they were provided additional study information. Once participants were willing to engage they were provided a copy of the informed consent and given instructions on how to attend the online focus group (e.g., date, time, login instructions). As participants joined the discussion platform they were automatically and randomly assigned pseudonyms. After participants were welcomed to the discussion, they were provided a separate link to complete the online consent and demographic survey (via Qualtrics). Once all consents were obtained, the text-based, interactive, synchronous discussion occurred with each participant on their own computer in a place of their choosing. Participants actively engaged online with the moderator (the principle investigator) and other participants by typing comments, thoughts, and beliefs, and responding to others’ posts (text-based discussions are like ‘blogs,’ participants could not view each other and no verbal exchange occurred). Investigators were able to substitute brief agreement and disagreement of typed comments as non-verbal cues during the discussions (i.e., participants used “☺” as positive feedback to others posts) and compiled detailed field notes after each discussion. All data collected remained anonymous and de-identified. InsideHeads directly remunerated their panel members (study participants) with a $75 gift card. Study protocol and procedures were approved by the University of Hawaii at Manoa Institutional Review Board June 9, 2021.

Measures

Descriptive socio-demographic quantitative data included age, gender, race/ethnicity, state/US region, level of education, employment status, health insurance status, and relationship status. We also assessed perceived level of importance for their child/children obtaining all recommended vaccines as well as their child’s vaccine status. Lastly, we collected data on rate and type of social media utilization.

A semi-structured discussion guide was utilized to collect qualitative data (Supplemental Table S1). We queried participants about their thoughts and behaviors related to social media utilization, the type of information they view or engage with related to vaccines, how they determine credibility of information and trustworthiness of sources, how they process and engage with both negative and positive information about vaccines, and their views related to social messaging influence on their decisions about vaccination for their child/children. We also elicited the COVID-19 pandemic’s influence on their social media use and content associated with vaccination.

Analysis

Quantitative data were downloaded to Microsoft Excel for management and analysis. Descriptive analyses included mean and standard deviation for the one continuous variable (age) and percentages for all nominal data. Qualitative (typed) data was downloaded from the secure discussion platform in Microsoft Word, and then was uploaded into Microsoft Excel for qualitative management (coding). Due to the nature of the data collected and goals of the study, content analysis was used to objectively engage with the data and to identify the final thematic categories.³³ The principal investigator along with two research team members, all experienced in qualitative research, independently immersed themselves in the data, reviewing each transcript along with field notes. Investigators met to discuss the emerging codes, concepts, and develop the final code book. The data were independently coded by the principal investigator and one team member. Throughout the coding process, the entire analysis team (three team members) met to assess accuracy across coders, examine relationships in the data, and refine codes. Whenever conflicting interpretations occurred discussion ensued until consensus was reached. Coded data was collapsed into broader categories and reexamination led to the development of the final themes and sub-themes.

Results

Socio-demographics and social media utilization

A total of 64 parents/caregivers of adolescents aged 11 to 17 years participated (see Table 1). The average age was 47.1 years and the majority (84.3%) identified as female. The racial/ethnic demographics were 71.9% White, 12.5% Black, 6.3% Asian, and 7.8% identified as another race or more than one race. Approximately one-third (34.4%) identified as Hispanic. Participants were primarily college educated (76.6%), employed full time (71.8%), married/partnered (84.3%), and had private health insurance (65.6%). Most viewed having their child/children receive all recommended vaccines as “very important” (60.9%) or “important” (34.4%); however, when queried specifically, in this purposely diverse sample of vaccine acceptors, only 50% had obtained HPV, 59.4% MenACWY, and 78.1% Tdap vaccines for their adolescent. Interestingly, 81.3% indicated their adolescent received the COVID-19 vaccine and 65.6% noted obtaining the Flu vaccine.

Table 1. Sociodemographic characteristics of the sample (N = 64).

Sociodemographic Characteristic	N (%)
Age in years	Mean (SD)
	47.1 (7.9)
Gender
Female	54 (84.3)
Male	10 (15.6)
Race
White	46 (71.9)
Black	8 (12.5)
Asian	4 (6.3)
Other/Multiple	5(7.8)
Missing	1 (1.6)
Hispanic ethnicity
Yes	22 (34.4)
No	40 (62.5)
Missing	2 (3.1)
United States Region
Northeast	20 (31.2)
Midwest	7 (11.0)
Southeast	22 (34.3)
Southwest	7 (11.0)
West	8 (12.5)
Type of Insurance
Private	42 (65.6)
Public	19 (29.7)
None	2 (3.1)
Missing	1 (1.6)
Education
High School graduate	5 (7.8)
Some college	9 (14.1)
College graduate or higher	49 (76.6)
Missing	1 (1.6)
Employment status
Full time employed	46 (71.8)
Full time caregiver	8 (12.5)
Full time student	1 (1.6)
Part time employed	8 (12.5)
Retired	1 (1.6)
Relationship Status
Married/Partnered	54 (84.3)
Single/Divorced/Separated	9 (14.1)
Missing	1 (1.6)
How important is it your child (children) receive all recommended vaccines?
Very Important	39 (60.9)
Important	22 (34.4)
Not Important	2 (3.1)
Missing	1 (1.6)
Which vaccines has/have your child (children) age 11–17 received? Flu (every year or periodically)
Yes	42 (65.6)
No	22 (34.4)
≥ 1 HPV dose
Yes	32 (50.0)
No	32 (50.0)
MenACWY
Yes	38 (59.4)
No	26 (40.6)
Tdap
Yes	50 (78.1)
No	14 (21.9)
COVID-19
Yes	52 (81.3)
No	12 (18.8)
Social Media Use
Multiple times per day	33 (51.6)
Daily	23 (35.9)
Weekly	8 (12.5)
>Weekly or never	0 (0)

The rate of social media use was high among participants. Over half (51.6%) indicated engaging with social media multiple times per day and 35.9% indicated daily use (Table 1). Figure 1 highlights the rate of social media use across platforms. The majority (76.5%) indicated daily Facebook use, 50% indicated daily Instagram use, followed by TikTok (25%) and Twitter (23.4%). Figure 2 highlights the preferred sources for health care information and health care providers were overwhelmingly (87.5%) the preferred source of information. Other top ranked preferred sources included: websites (42.2%) and friends and family (35.9%). Conversely, social media (76.6%), church leaders (89.1%), and television advertisements (75%) were predominantly noted as “never/not a top choice.”

Figure 1. Frequency of social media use across platforms (N = 64).

Figure 2. Preferred sources for health care information ranked (N = 64).

HCP = health care provider.

Qualitative analysis

Three common themes emerged from the qualitative data: (1) the pandemic’s impact on parent’s general patterns of social media use; (2) the pandemic’s impact on parental engagement about vaccines on social media as well as off-line behaviors related to vaccination; and (3) perspectives for developing a credible and trustworthy social media intervention about vaccination in the wake of the COVID-19 pandemic. See Table 2 for illustrative quotes by theme.

Table 2. Illustrative quotes.

Categories	Illustrative Quotations
Theme 1: Pandemic’s impact on parents’ general patterns of social media use
Types of posts	Most pics of me, my family, cats, or food :). (F, 53) I post humorous things. The world needs some happiness and good news right now. Pretty food I don’t post health information on social media. I post pictures of family, events, vacations. Inspirational quotes. (M, 49) Factual information from the CDC. Recommendations to protect against serious illnesses. (M, 55) I post information I find that talks about the pros and cons of vaccines. I want to give the correct information I find. There are a lot of things I find that are totally not true. (M, 55) I post about major lifetime events such as graduations. I try not to be political. (F, 53) Lighthearted things and family, I don’t want to be part of ugliness. I avoid engagement since nobody knows how to act right anymore. (F, 43)
Motivations to post or repost	Important issues that have fact and meaning (F, 55) If it’s something that’s worth repeating, something informative, or humorous (M, 39) Things that inspire people. Things that bring joy. (M, 49) If I feel passionate about the topic or want to share information with others (F, 51) If I feel I can contribute to a discussion, I will post. If I have a question and want advice, I will post. (F, 59) I want to help my Facebook friends. I want to share any important or helpful info. (F, 52)
Pandemic effect on level of engagement
Same	[in terms of engaging more] No, I post in waves and always have. (F, 45) Remained about the same as before (F, 43)
More	I would say more because of being stuck inside so much. (F, 55) More, it was a way to stay connected with others when we couldn’t do so in person. (F, 48) Well, I had more time to be on social media, so I would say it increased. I was also trying to stay connected with friends. (F, 54)
Less	My contact on FB [Facebook] became less and less. Initially I took to social media more to lessen the isolation of the pandemic. I found myself agitated with much of the ignorance. (F, 49) Less on most days. I get fed up with the ignorance. (F, 43) Less. Too much negativity now. (M, 49) Yes. A lot less engagement. People are just so opinionated (F, 53) Oddly less. Groups have fractured. (M, 63) Much less. I’m done with the constant panic and fear, my anxiety. Not just the pandemic but EVERYTHING is negative. (F, 43)
Passive engagement	Less interaction, more observing (F, 34) I’m more on social media but posting less. Nowadays you seriously have to watch what you post. (F, 39) More engagement due to more free time and WFH … Def don’t post as much about anything. Just scrolling and liking. (F, 43) I read more than I advise in health matters. (M, 42)
Engagement with health or vaccine discussions	I do not. It can lead to fights. (M, 39) No, I don’t. It’s an individual’s choice when it comes to health. (M, 49) With friends and family. COVID vaccines are important. (M, 55) I was unintelligent and post only once in my life on my views on healthcare and was instantly sent hostile messages for a week or so. I stay away from anything with my personal opinion of any merit anymore. (F, 42) Yes, I engage a lot about health on social media. (M, 55) No. I don’t trust the “Facebook” doctors. Everyone seems to have become experts on infectious diseases on social media. … I read, but I only use information that makes sense to me. So I take everything with a grain of salt. (F, 41) Not anymore [discuss health]. I feel face to face conversations are best. (F, 43) YES. I discuss health especially when I disagree with someone. I only respond to those I know. (F, 54)
Theme 2: Pandemic’s impact on parental engagement about vaccines on social media and off-line behaviors related to vaccination
Type of information seen about vaccines
Mixed/neutral	Lots of things. Some say you shouldn’t get them and that they don’t work. Others think they are the best thing that was ever invented. Mainly regarding COVID vaccine. I generally see a mix of both negative and positive. (F, 38) A mixed bag of positive and negative. It seems to be aligned with political beliefs. (F, 53) Very polarized opinions. There are a group of hard-core believer and then there are groups of people that are hard core nonbelievers of vaccines. And then arguments ensue. (F, 41)
Negative	About how healthy young people are suddenly dying of heart problems. mostly in fb [Facebook] groups of people that are anti-vaccine. (F, 53) They inject you with microchips. Will mutate your body. Will turn you into zombies. It depends on political affiliation. (M, 49) I always see studies trying to prove vaccines cause autism. (F, 48) That you can’t spread the virus [in reference to COVID]. [Getting a vaccine] It’s a way to see who will do as the government TELLS them. (F, 39) That they are putting things into them to track you. (F, 34) Individuals expressing concern about particular vaccines (side effects, lack of research, bizarre mutations, etc.). (F, 59)
Positive	I see mostly positive information about vaccines, and believe in that. Do not do further research. (F, 52) That the vaccines were helping to lower the COVID cases. (F, 43) Mom groups that say their kids suffered no side effects. (F, 53) News from CDC or WHO. (F, 34) Prevents long term dangerous illnesses such as HPV vaccine prevents cancer. I am afraid of cancer so I listened more. (F, 53) It helps save lives and protects you and the health of others around you. (F,41)
Views on negative information’s credibility/trustworthiness	I felt as though most of the information may have been disinformation and not credible. (F, 38) I didn’t necessarily believe the [negative] information was credible, but I was concerned enough about it – because it involved my child – to ask her pediatrician. The doctor said there is no medical proof and that the benefits were great. That was enough. (F, 57) I ignored most of it. (F, 51) No I did not view the negative information as trustworthy. It was based on opinions and not facts. (F, 51) I can’t think of a single negative comment that I would consider credible. (F, 45) I didn’t view negative as trustworthy or not, because I didn’t know the facts. It was more food for thought. (F, 34)
Views on positive information’s credibility/trustworthiness	Yes [positive information] viewed as trustworthy. Because based on trials and statistics. (F, 53) Yes, credible because it came from the CDC. (F, 38) If it came from a proven and reliable source. (F, 41) I mean, I’m biased toward it because I agree with it. But, I still always check sources, and think about motivations behind the publications. (F, 42) Positive information seems to be more transparent and fact-checked. Negative seems to be more conspiracy and other theories. (M, 63) I felt the positive information was trustworthy because it was based on scientific research. (F, 51)
Perceived impact on vaccine behaviors for children
No change	No change in getting vaccines, I always did get them for my family (F, 52) No, I still feel that routine vaccinations are important. I want to do everything I can to prevent my family from getting any disease or illness. (F, 48) No. I have always believed in vaccines all along. My kids are all up to date with recommended immunizations. COVID or no COVID, we stand with vaccines. (F, 41)
More likely to seek vaccines	Yes. I actually also made sure my son got the flu and HPV vaccines. (F, 48) Yes, and rightly so. We are moving down the line in terms of who is next and that is also the children. (F, 39) Yeah for the flu vaccine it did. Before I was not a fan of them getting the flu vax. How? I saw how COVID was ravaging through people so quickly. (F, 47)
Less likely to seek vaccines	Somewhat. I never had any doubts prior. Some doubts have creeped in. people always say they know someone who has had complications or side effects. (M, 49) Yes, I don’t trust the government at all now. If you don’t go along with the vaccine and mask mandate, you are targeted. (M, 55)
Theme 3: Perspectives for developing a credible and trustworthy social media intervention regarding vaccination in the wake of COVID-19 pandemic
Sources for trustworthy/credible information	It would have to come from an official government source. Like a post from the CDC. (M, 49) I would say the WHO, FDA, some doctors. I don’t know what to think about the CDC at this moment. (F, 38) If it is a credible article such as the CDC or FDA published article, then I think it is trustworthy. (F, 51) If it’s from a place like the CDC, I would consider it trustworthy, but more often than that, I don’t trust things I see on social media. (F, 45) I usually don’t trust anything on social media, because a lot of people repost things without thinking about how true they are. (F, 34) Endorsements from public health authorities (R91. Diane. G1)
Validation, wanting links to reputable resources to learn more	I will google it and see what else I find to either validate or invalidate it. (F, 53) Referenced data that I can interpret myself. (F, 45) Proven facts and where I can verify them (M, 42) If it’s somewhat in layman’s terms. Relatable. Also, if they can point us toward more information that supports their claims or statements. (F, 42) I always encourage people to do RESEARCH, numbers talk. (F, 39) I doubt all and research its credibility on my own. (F, 45) I went into the sources and read the information, then cross-referenced them with my research. (F, 51)
Influence of message delivery type Storytelling/narrative messages Data driven messages	Seeing other parents, I know, like myself, also made the decision to vaccinate their children made me feel good about my decision to do so with my own child. (F, 51) Seeing how many people (plural) have a vaccine and it didn’t help them. (F, 39) It influences me when it is from someone I trust. (M, 55) A social media post has the best chance of influencing me if it’s just facts. I don’t appreciate people or companies trying to scare me into doing something. (F, 45) I think that infographic, images, and videos can assist with information distribution, but I still look at the source. Anyone can create an infographic and spread misinformation. (F, 38) No, they’re probably good for clarifying information or giving more insight, but I wouldn’t say it affects my decision. (F, 51) All of that helps me understand the information, but I would still consider the source to determine credibility. (F, 59)
Posts by personal healthcare providers	I would trust it for sure coming from my health care provider. That’s my first source. (F, 38) My child’s doctor is on social media and I don’t follow them or engage in any way. (F, 48) I would rather engage with my health care provider in a private setting. Everything that is said on social media is not private. (M, 55) MMMM, I don’t know. I feel like healthcare still needs to be tailored to the individual. So posts by my doctor about what’s good for everyone may not be great. I’d rather have a one on one. I’d still maybe follow them just to see what their visit specials and things are, new staff, etc. (F, 51) If our pediatrician started posting on social media. I would think it was a bit weird (F, 45)

M = Male; F = Female (Gender, Age in Years).

Pandemic’s impact on parents’ general patterns of social media use

Most participants stated that their social media habits changed over the course of the pandemic. The slight majority said they used social media less now than at the start of the pandemic. Participants who used it less expressed exasperation with negativity and polarization. One said, “I’m done with the constant panic and fear … Not just the pandemic but EVERYTHING is negative” [female (F), age 43]. Those who reported using social media more often indicated that it was because they had more free time or because “it was a way to stay connected with others when we couldn’t do so in person” (F, age 48). A subgroup discussed their experience with both the impulse to stay connected, as well as the frustration with bitter disagreements: “My contact on FB [Facebook] became less and less. Initially I took to social media more to lessen the isolation of the pandemic. I found myself agitated with much of the ignorance [related to vaccine and health topics],” said one participant (F, age 49). The frustration with the negativity encountered online led many to use social media more passively (only reading or browsing but not posting or making comments to posts).

By far, most participants said they only used social media for lighthearted purposes: posting pictures of family and friends, pets, food, or fun memes. One said “I post humorous things. The world needs some happiness and good news right now. And [to see] pretty food I’ve made or am eating lol” (F, age 43). Most were wary about getting involved with “the ugliness” (F, age 43) surrounding contentious issues and wanted to avoid fights or persecution for their beliefs. “Social media has become a landmine field of dissention and bickering, so I am limiting my time there. I seldom repost [or] comment and if I do it’s something very inoffensive. Never political or vulgar,” explained a participant (F, age 56). However, if the content was uplifting or funny, then people were highly motivated to post or repost.

Pandemic’s impact on parental engagement about vaccines on social media and off-line behaviors related to vaccination

Just as the pandemic affected general social media behaviors, it also affected people’s online and offline engagement, attitudes, and behaviors related to vaccination. When asked about routine adolescent vaccines, participants repetitively brought the conversation back to discussing COVID-19 vaccines and the associated rhetoric.

The negative information people saw related to vaccines (largely COVID-19 vaccine related) ranged from what they described as conspiracy theories to concerns about side effects. Participants identified what they believed to be misinformation, which included: the link between vaccines and autism, the belief vaccines are fatal, and that the COVID-19 vaccine is not actually a vaccine. A few also noted viewing messages that they felt misconstrued incidence and severity of common side effects or rare adverse events. For example, one said “[I have seen] how healthy young people are suddenly dying of heart problems [post-vaccine]. Mostly in FB [Facebook] groups of people that are anti-vaccine” (F, age 53) in reference to rare incidents of myocarditis and pericarditis following COVID-19 vaccine administration. However, most participants noted that they did not view negative information as credible or trustworthy. Negative vaccine information was often described as opinionated, irrational, and not based on facts and participants were skeptical of the sources that disseminated negative information. As a result, many participants said they ignored the negative information. Still, some did relay that at least some of the negative vaccine information caused concern or gave them pause: “I didn’t view negative [information] as trustworthy or not because I didn’t know the facts. It was more food for thought,” (F, age 34) and “I didn’t necessarily believe the [negative] information was credible, but I was concerned enough about it – because it involved my child – to ask her pediatrician” (F, age 56).

The positive vaccine information participants viewed on social media was described as more straightforward in its messages. Participants noted that they read how the COVID-19 vaccines were helping lower the number of new infections, that if a vaccinated person was infected with COVID-19 the illness was more likely to be mild, and that vaccines protect oneself and the people around them. Participants described the positive information as credible and trustworthy. A crucial part of why participants found the positive information credible was the source and the neutrality of its presentation.

Engaging in discussions about vaccination (of any type, including routine and school required vaccines) online was described as political and almost taboo, and again participants noted concerns related to hostility, persecution, and simple futility. One described how they were “instantly sent hostile messages for a week or so” (F, age 42) after posting their views on vaccination. As a result, they said they have ceased to post their vaccine opinion. One stated, that they did not post on “[all matters] of any merit anymore” (F, age 42). Only a small minority were willing to discuss health and vaccines online.

Participants noted that their choices for obtaining routinely recommended vaccines for their adolescent were largely unchanged from the beginning of the pandemic. One stated, “I have always believed in vaccines all along. My kids are all up to date with recommended immunizations. COVID or no COVID, we stand with vaccines” (F, age 41). A few did note how the online rhetoric changed their minds about obtaining routinely recommended vaccines for their adolescent; however, the numbers of participants who were more likely to vaccinate and/or less likely to vaccinate were nearly equal. Participants who were more likely to vaccinate expressed concern for their family’s safety: “[COVID-19] made me make sure [my] kid is safe” [male (M), age 43] thereby increasing uptake for all routinely recommended vaccines for their adolescent, including HPV and influenza. Those who said they were now less likely to obtain routine vaccinations expressed a myriad of concerns related to side effects, government distrust, perceived lack of vaccine efficacy, and vaccine development. One said, “I never had any doubts prior. Some doubts have creeped in. People always say they know someone who has had complications or side effects” (M, age 49).

Perspectives for developing a credible and trustworthy social media intervention regarding vaccination in the wake of COVID-19 pandemic

Participants’ discussions about future social media vaccine interventions focused on their viewpoints related to how they determine if information they view on social media is credible and from a trustworthy source. Nearly all participants expressed that information obtained from social media was credible if it included data and statistics and was “information from scientists and researchers” (F, age 51), or “information universally accepted […] by experts” (M, age 49). Trustworthy sources included the CDC, World Health Organization, US Food and Drug Administration (FDA), a health care provider, or a local health system/center or health department. For a source to be considered trustworthy, one stated “It would have to come from an official government source. Like a post from the CDC” (M, age 49).

Participants had mixed beliefs related to following or obtaining vaccine information from a primary health care provider (PCP) on social media. While nearly all participants viewed PCPs as trustworthy, “[My PCP] is my first source [of information]” (F, age 38), only a few noted that they would follow or engage with their PCP on social media. They described that following their PCP on social media felt too intrusive into their personal lives or “weird” (F, age 38) to engage directly with their PCP on social media. But, on the whole participants were supportive of following a professional healthcare organization’s or their health clinic/health center’s social media page and/or a highly visible public figure who may also be a respected health care provider. One stated, “I would prefer [information] from a public site. Not a clinicians private account” (M, age 49).

Despite the majority consensus that credible information was scientific and originated from a reputable medical source, the degree of confidence participants described in their ability to discern credible information ranged from low to high. Plus, while infographics, videos, and other visual aids assist in the accessibility of the information participants noted these visual aids did not influence credibility as they could depict misinformation. Participants who rated their ability to distinguish credible information as low or moderate acknowledged the difficulty in sorting through the abundance of information and misinformation on social media. This led to skepticism for all information, “I usually don’t trust anything on social media because a lot of people repost things without thinking about how true they are” (F, age 34). In general, participants felt that if social media posts contained a link to the source for the information this was helpful because they could then independently check the source and determine if it was legitimate. Many participants used the term doing their “own research” (F, age 31) to describe the ways in which they would try to determine credibility and independently verify what they had learned on social media. Participants clearly noted that any future vaccine campaign should share links to where they could go to learn more and validate what they have read about vaccines online.

Lastly, health messages that participants said influenced them most were a mix of anecdotes/storytelling (narrative messages) and scientific results (non-narrative messages), but these messages needed to adhere to the above criteria for credibility/trustworthiness. For example, one said, “The messages that are scientifically based promote a sense of motivation” (F, age 49), while another said, “I saw personal stories of people dying of the disease [related to COVID-19], [and] I made a decision that I would do whatever it took to prevent that from happening to me” (F, age 48). The storytelling was powerful, but participants always returned to the importance of social media interventions/campaigns providing links to original sources of information so they could read and learn more independently.

Discussion

Much of the research related to the influence of social media on routinely recommended adolescent vaccination was conducted before the COVID-19 pandemic. The public health measures that were implemented to mitigate the spread of COVID-19 such as stay-at-home orders, quarantines, and the closure of businesses and public centers may have led many people to spend more time at home using social media.³⁴ Furthermore, the COVID-19 pandemic fueled the public conversation around public health, viruses, and vaccinations. One might expect the social media behaviors and vaccine attitudes/behaviors to shift as a result of these significant lifestyle changes. Timing of this study captured the pandemic’s impact on general patterns of social media use and engagement about vaccines on social media. Plus, the study helped to provide insights for designing new interventions about vaccination that would be credible and trustworthy in the post-pandemic period.

A combined 87% of participants indicated they use social media “multiple times per day” or “daily.” Most participants stated that their social media habits changed over the course of the pandemic, with a slight majority noting less use. The negativity and hostility of social media were the predominate reasons motivating participants to reduce their social media engagement. When queried about the type of posts they share or engage with, the majority stated they almost exclusively make lighthearted posts, such as jokes, pictures of family, or recipes. Participants were wary of getting involved in any discussions about health or vaccines for fear of judgment and verbal attacks or wanting to avoid futile arguments. Interestingly, some participants noted a more passive engagement, that is, viewing but not posting or commenting. However, whether or not passive engagement has increased as a result COVID-19, the majority of participants in this study were not interested in making posts or participating in discussions online related to health and/or vaccines.

Similar to this study, recent reports have also documented the proliferation of negative information and misinformation on social media about vaccines, particularly on Facebook.^14,18,35 Others have described how the significant proliferation of anti-vaccine sentiment on social media has increased hesitancy, potentially leading parents opting out of vaccinations for themselves or their children.^14,36–39 In our sample, most viewed the positive messaging about vaccines to be credible, but not the negative messaging. This is important to note as other reports have found that negative messages are more likely to have more ‘likes’ or views.¹⁹ Taken together, this may indicate that negative messages about vaccination on social media, while not necessarily believed, may be sufficient to confuse and cast doubt for parents as they make vaccine decisions. In this study many described this skepticism and wanted to be provided with links to reputable resources so that they can independently learn more, form their own conclusions, and then seek the advice of their PCP.

Additionally, vaccine hesitancy may coexist with vaccine uptake, whereby a recommendation from PCPs strongly predicts the decision to vaccinate, but media exposure to vaccine negative messages results in persistent vaccine hesitancy.¹⁸ This may explain why participants preferred to discuss vaccination and clear up misinformation with their PCP, but some may retain lingering concerns about their decision to vaccinate even when provided evidence-based information. Determining what is legitimate health information on social media presents a significant challenge for parents/caregivers as negative messaging (including mis- or dis-information) is both more prevalent and spreads more quickly than positive messaging.^35,38,40

Nearly all (95%) participants in this study viewed having their children up to date on all routinely recommended adolescent vaccines as “very important” or “important,” yet this did not align with the reported adolescent vaccination rates (i.e., only 50% reported ≥ 1 HPV vaccine dose and 59.4% reported obtaining the MenACWY). It is possible that accurate recall of vaccines administered may have been influenced by the salience of the vaccine (e.g., COVID-19 vaccination experiences may have been more memorable than routine vaccination for MenACWY). Also, during the pandemic, routine adolescent vaccination rates declined and besides the potential effect of negative rhetoric on social media, other barriers to accessing health care existed.^41–43 For example, many offices around the US were closed at various times, there was an increase in virtual health care, people may have feared returning to health care settings (due to risk of exposure), and with the shift to online learning for students many schools loosened vaccine requirements.^44,45

In this study, the majority indicated that they were pro-vaccine prior to the pandemic and have remained pro-vaccine. However, a noteworthy minority did change their attitudes about vaccination over the course of the pandemic, with the number of those who were more likely to vaccinate equaling the number who became less likely to vaccinate. So, while our sample indicates there was little net change in the number of parents willing to obtain routine vaccines for their children, the myriad effects of the pandemic did have an influence on parental vaccine decision making and should be explored further.

Finally, although the discussion questions were designed to investigate parents’ attitudes and behaviors regarding all routinely recommended adolescent vaccines, it was difficult for participants not to discuss the COVID-19 vaccine in particular. Participants described being inundated with messaging (negative and positive) about COVID-19 vaccines and this led to an information overload. Therefore, a common discussion point was the desire “do their own research,” which, with ongoing probing, meant participants wanted to learn more independently and be provided with links to credible sources of information. To identify credible social media messages, they focused on the sources of information, preferring posts from recognizable health organizations/leaders, and they viewed messaging from non-health experts with skepticism. As a result, participants overwhelming agreed that a social media intervention/campaign to promote vaccination should have (1) messaging delivered by recognizable health experts/organizations, (2) direct links to credible websites so that parents can read/learn more about vaccination for their child, and (3) messaging to promote off-line discussion with their child’s PCP. Similar to many studies, participants in this study continued to recognize that a health care provider recommendation was one of the most powerful influences in their decision making.

The results of this study must be viewed in terms of its limitations. While the sample size was robust for a qualitative study and included participants across all US regions, the sampling method was one of convenience and there could be some bias as it was drawn from a national panel of potential research participants. The sample also lacked racial/ethnic and other socioeconomic diversity and the majority of the participants indicated that they were from the Northeast US region. Differences from state to state and differences between the US and other countries were not captured. Due to the nature of qualitative design the results cannot be generalized beyond this sample, plus text-based discussions (while noted to improve discourse on sensitive topics due to the anonymity)^27–31 are limited as verbal and visual cues are not available. The sample did, however, include participants that had a high level of social media utilization and gave voice to parents/primary caregivers who reported a diverse range of vaccine uptake behaviors for their adolescent children. Finally, insights for future social-media vaccine interventions were garnered.

Conclusion

This study captured the influence the COVID-19 pandemic has exerted on social media utilization and the subsequent online public discourse and behaviors surrounding vaccination. Additionally, opinions related to the development of credible and trustworthy social media campaigns to increase vaccine confidence and reduce hesitancy in parental decision making for their adolescents were elucidated. Participants reported a wide range of vaccine behaviors with the majority reporting adolescent vaccination rates well below the Healthy People 2030 goals. Participants described being fatigued from the multiplicity of contentious vaccine-related content on social media and were overwhelmed by the abundance of vaccine information (primarily negative) on social media. The overwhelming majority of participants preferred not to get involved in online discussions related to vaccination because of the expected hostility. Future social media messaging interventions should include posts from recognizable health institutions (e.g., CDC, state or local health departments), professional health associations (e.g. American Academy of Pediatrics, Society of Adolescent Health and Medicine, or National School Nursing Association) or from nationally recognized health care providers with links to resources so that the parent/caregiver can learn more about vaccinations from reputable sources. Providers should ask patients about the types of messaging they have viewed on social media, have additional resources readily available, and continue to provide strong clear recommendations for all routinely recommended adolescent vaccines.

Disclosure statement

GZ has served as an external advisory board member for Moderna and Pfizer, and as a consultant to Merck. He also has received investigator initiated research funding from Merck administered through Indiana University. HF has received investigator-initiated research funding from Merck administered through the University of Hawaii at Manoa, GG and GZ are also funded on this grant. KO, AM, have nothing to disclose.

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2311476.

Additional information

Funding

This work was supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharp & Dohme Corp.