The dynamics of trust and communication in COVID-19 vaccine decision making: A qualitative inquiry

Figures & data

Figure 1. Study timeline.

Table 1. Sample characteristics (n = 30)

Risk exposure	Risk level 1: highest risk, included units such as housekeeping staff, front desk clerks, and greeters who interact with patients in indoor public spaces with limited protective equipment	5 (16.7%)
	Risk level 2: units who provide patient care with direct medical contact with patients in clinical spaces with protective equipment	8 (26.7%)
	Risk level 3: education, research, and administrative units that work alongside clinicians with opportunity for physical distancing	11 (36.7%)
	Risk level 4: lowest risk, included units such as groundskeeping staff who work primarily outdoors	6 (20%)
Vaccination status	Vaccinated	19 (63.3%)
	Not vaccinated	11 (36.7%)
Race/ethnicity	White American	17 (56.7%)
	Black or African American	7 (23.3%)
	Hispanic American	3 (10%)
	Indian American	1 (3.3%)
	Multiple races/ethnicities	2 (6.7%)
Gender	Female	14 (46.7%)
	Male	16 (20%)
Age	Range 29–73

Table 2. Decision-making factors associated with vaccine decisions

Category	Topic definition	Exemplar quote
Emotional response	Participants describe a response of fear, being scared of potential side effects of the vaccine.	“The reason why I think that is because I had COVID and some people that got the vaccine caught COVID and I’m just scared that I might catch it again if I get the vaccine.” (Participant 5, risk level 1, non-vaccinated)
	Participants describe initial feelings of guilt connected to a perception that they are receiving the vaccine before other people who need it.	“I was in the first wave of the first weekend and you almost feel a little guilty because you know that there are people who are sicker who wouldn’t survive this if they got it, but I also believe that by me being in the position I’m in that if people saw me get it that they would hopefully be encouraged to get it.” (Participant 28, risk level 1, vaccinated)
	Participants describe feeling distressed when thinking about the vaccine as a potentially mandatory action and in response to conversations with coworkers who are vocal and assertive about getting the vaccine.	“My emotions have been up and down and pretty high with how my department, people in my department are handling the whole vaccine thing.” (Participant 30, risk level 2, non-vaccinated)
	Participants described an initial response of excitement or relief when hearing about the availability of the vaccine.	“When I got the news that they were kind of opening [vaccine eligibility criteria] to more than the front line COVID, I was relieved.” (Participant 14, risk level 3, vaccinated) “..so I was grateful to be part of [the vaccine process] and it was exciting. I would be fibbing if I said it wasn’t, because it was in the air, here we go, COVID your days are numbered.” (Participant 22, risk level 1, vaccinated)
Understanding	Participants frequently describe their understanding of the response efficacy of the vaccine.	“We’ll see long term how long my immunity will remain what it is. I think it’s greater than 95% effective after the second dose, but for how long and will we need a booster” (Participant 17, risk level 2, vaccinated).
	Participants describe how their understanding of the process of development and distribution affected their decision to get vaccinated.	“March to July I was kind of anti-vaccine. I have specifically done drug research in the past. I understand why there is a process that there is and why there are tests that there are and it made me very uncomfortable that a lot of that was being bypassed and grouped together and just basically all the things they did to make it available quicker.” (Participant 29, risk level 2, non-vaccinated)
	Participants describe how their understanding influences a cost-benefit analysis.	“Being in the healthcare field and I’m always kind of bringing junk home every now and then, that’s a choice for me that I make for me and my children to get the flu vaccine and I’m not opposed to vaccines… I would say I was willing to take it with the COVID vaccine relatively quickly just because of me being directly exposed with patient care. I think I weighed the risks and benefits and there was more benefit to getting the vaccine than not….It’s better than being dead” (Participant 16, risk level 2, vaccinated).
Personal values	The choice to vaccinate was also connected to the value of public service. When the participant values public service they enact the service behavior to improve the health of the community.	“It’s kind of like not just for the greater good of helping eradicate this disease, it not just benefits me, the more people get vaccinated, everybody is better off. I know that there are people that legitimately cannot get vaccinated, for whatever reason, but the more people that get vaccinated almost prevents those people that can’t, for medical reasons, not get vaccinated.” (Participant 14, risk level 3, vaccinated)
	When participants described valuing individual choice, the value was not uniformly connected to vaccinating or not vaccinating. Participants communicated to others the importance of each individual making a decision for his or her self.	“I encourage everyone, all my friends, family, coworkers, people close to me or just in small groups, I just tell them, go on your convictions. Ultimately, that is it. If this is for you, if you feel like this is going to help you and your family and friends, I definitely think you should do it. If not, then don’t.” (Participant 21, risk level 1, non-vaccinated)
	Participants talked about getting the vaccine as a responsibility of leaders: they value transformational leadership that models the way. Participants described this not only in formal leadership roles but also as faith and opinion leaders.	“I was in the first wave of the first weekend and you almost feel a little guilty (emotional response) because there are people who are sicker who wouldn’t survive this if they got it, but I also believe that by me being in the position I’m in that if people saw me get it that they would hopefully be encouraged to get it” (Participant 28, risk level 1, vaccinated)
	Choosing to vaccinate was connected to the value of protecting the vulnerable. Participants describe vaccinating to protect people who cannot protect themselves.	“I also felt somewhat of a responsibility because I’ve got my spouse who is older than I am and has more conditions that could increase complications from COVID so I also felt a responsibility at home. I mean to me this is a great gift and it’s a responsibility all in one.” (Participant 15, risk level 3, vaccinated)
	Participants describe valuing a holistic approach to overall healthcare. This is an underlying value that drives a complete approach to healthcare.	“Putting foreign things in my body is just not something I want to do, I’m not a health nut, but I do believe that we have a lot more control of our health than we think..I’m not opposed to medicine. I just feel like unless you really need it, just don’t.” (Participant 9, risk level 3, non-vaccinated)
Culture	Participants who talked about the race/ethnic layers of culture described the historical abuse and events of violations of research ethics in the African American community.	“We all know that people of color are hit more adversely, and part of that is health disparities and then the other piece of that is, distrust of the medical establishment. I went to [historically black college or university]…I understand completely why people would feel a certain way, not just about Henrietta Lacks, but also with the Tuskegee study. Then a lot of people don’t know that the father of obstetrics practiced on slave women.” (Participant 3, risk level 2, vaccinated)
	Participants describe faith and ontological beliefs as they provide underlying value shared by a culture.	“I’m a Christian. The ultimate healer is Jesus Christ. Why is this [COVID] important when He knows the answer to everything?” (Participant 11, risk level 4, non-vaccinated)
	Participants described family of origin culture, as values shared within a family and the norms established by a family. Participants described how their families interacted with the medical system when they were children and how that affects their perceptions of the medical systems as adults.	“Vaccination was a normal part of what they did for me. I grew up with this being normal.” (Participant 15, risk level 3, vaccinated) “I grew up overseas and in some pretty exotic areas so it was a condition of traveling to those areas you had to have certain vaccinations so I even recall from a very young age needing to get those shots and never really questioned the need for it and accepted it was a part of what one needed to do to go to certain areas of the countries or the world.” (Participant 18, risk level 3, vaccinated)
	Participants described their organizational culture and its values that emerge from their membership in a research university. This is a more superficial shared identity than family of origin or race/ethnic culture.	“Well, I’m sure I [talked to coworkers], but I had no idea that I was going to be among the first 10 until about an hour before that. But, you know, we all were talking about it, and overall, everybody that I work with couldn’t wait to get it.” (Participant 22, risk level 1, vaccinated)
Social norms	Participants described social norms of their household, their workplace, their circle of friends, or churches affected their decision. These contemporary norms apply only to the COVID vaccine. Seeing other people get the vaccine made them think it was safe.	“So I know a lot of my friends got it and then when I actually volunteered and I saw all these doctors and nurses and researchers lining up to get the vaccine I’m like well if all these people are getting it there should be no fear for me kind of thing.” (Participant 10, risk level 3, vaccinated)