STRENGTHS AND LIMITATIONS OF THIS STUDY

Physicians played vital roles in the COVID-19 pandemic response; in-depth interviews with primary care physicians offered first-hand knowledge of their experiences and challenges discussing COVID-19 vaccinations with families during this time.

Our interpretive qualitative approach, using multiple analysts, reflexive thematic analysis and a socioecological analytical framework, allowed us to examine physicians’ perspectives on paediatric COVID-19 vaccinations in-depth and to explore the complexity of providing vaccine recommendations to parents.

The data presented are part of a broader qualitative study examining multiple stakeholders’ perspectives on paediatric COVID-19 vaccinations; therefore, the sample size for this substudy is small. Nevertheless, we generated analytical concepts that are potentially transferable to other contexts, including future paediatric vaccine rollouts.

Most of our sample identified as white and female; interviewing a more diverse sample may have generated additional insights into how physicians approach conversations and build trust with parents.

This study was conducted as childhood COVID-19 vaccines were first approved, thus offers novel insights into physicians’ perspectives at this time. However, interviews were held prior to a surge in paediatric hospitalisations due to a viral ‘trifecta’ (COVID-19, influenza, and Respiratory Syncytial Virus (RSV) infections); therefore, some responses regarding severity of illness in childhood may look different following this development.

Introduction

Acceptance of the COVID-19 vaccine has reached relatively high levels globally (88%), but parents’ acceptance of the vaccine for their children remains comparatively low (70%).1 Vaccination rates for younger children is even lower; in Canada, only 50% of children ages 5–12 years and less than 10% of children under 5 years have received at least one dose.2 These rates are even lower in the USA (39%)3 and the UK (10%)4 for children 5–11 years old, as of May 2023. Parents’ decisions to vaccinate their children are complex, influenced by sociodemographic factors, perceived benefits and risks,5–9 access to scientific information,5 perceptions of government,9–11 social and political pressures,12 13 and balancing of individual and collective benefits of vaccination for children.12 Parents have been more reluctant to vaccinate their children than themselves against COVID-19 due to heightened risk aversion.5 6 The novelty of the vaccine and sparsity of evidence of potential long-term side effects of the vaccine were concerning for many.8 10–12 14 Given the newness of the vaccine and supporting evidence, the challenge of sourcing and weighing credible information, and the perceived politicisation of the vaccination rollout, parents reported wanting individualised advice from healthcare providers to help them understand the risks and benefits of vaccination and make this decision for their children.9 12 15

Primary care physicians represent a trusted source of information in vaccination decision-making among parents.7 9 12 15 16 However, little is known about their perspectives on COVID-19 vaccines for children, their approach to giving vaccination advice to parents, or the potential challenges they face in counselling parents to make this decision.15 17 Given their important role in parents’ vaccination decisions, understanding physicians’ perspectives and experiences may shed light on the dynamic interactions that contribute to decision-making around new vaccinations for children. Primary care physicians also have unique perspectives on the broader paediatric COVID-19 vaccination rollout given their position advising on and administering the new vaccines.15

In Canada, COVID-19 vaccines were available to the public at no cost, through a variety of methods, such as mobile outreach, mass vaccination centres (scheduled in advance through an online portal), and later in some primary care offices and pharmacies. Vaccination was prioritised for high-risk populations (eg, those in congregate settings, certain vulnerable communities18) and by age, according to Health Canada approvals. COVID-19 vaccines were first approved for adults (December 2020), followed by children aged 12–18 (May 2021), children aged 5–12 (November 2021), then children aged 6 months–5 years (July 2022)19; lower vaccination rates were seen for each successive age group,2 along with a declining willingness by parents to vaccinate their children over time.20 Over the course of the pandemic, numerous public health measures were implemented, and later lifted, in response to the approval of vaccines, the advent of new variants, epidemiological projections and public health advice.18 Canada’s public health measures were more restrictive than other G10 countries,21 and most were decentralised, with provinces enforcing their own mandates and recommendations.

Although Canada achieved high rates of vaccination and low rates of COVID-19-related deaths compared with other G10 countries,21 recent research has critiqued Canada’s pandemic response, including its decentralised and uncoordinated efforts,22 inadequate protection of vulnerable populations,23 24 and inequitable vaccination processes.25 These studies highlight important healthcare system shortfalls and emphasise the need for further in-depth examination into various facets of the response.26 To date, physicians’ perspectives on the Canadian vaccination rollout and the factors that may have influenced the lower vaccination rates for children have not been examined. It is important that we learn from Canada’s COVID-19 vaccination rollout to better prepare for future vaccination efforts.26 Given that vaccination rates were considerably lower for children, particularly those under 12 years of age, investigating the factors that influenced vaccine uptake for this age group is needed.

The goals of the current study were to explore primary care physicians’ perspectives on COVID-19 vaccines for children, including their experiences having vaccination conversations with and providing recommendations to parents, and their reflections on the contextual factors that shaped these experiences. By exploring primary care physicians’ perspectives, we aimed to better understand the role physicians play in parents’ COVID-19 vaccine decision-making for their children, find ways to support physicians in having vaccination conversations with families and offer suggestions for future childhood vaccination programming.

MethodsStudy design, sampling and recruitment

This research is a substudy of a larger qualitative study exploring the experiences of youth, parents and healthcare providers on COVID-19 vaccination for children under 12 years of age.12 In this study, we used interpretive qualitative inquiry to examine primary care physicians’ perspectives on COVID-19 vaccinations for children. This approach allowed us to explore the multiple interpretations and lived experiences of healthcare providers to develop an in-depth understanding of their unique and socially-constructed perspectives.27

We recruited participants from The Applied Research Group for Kids (TARGet Kids!) primary care research network and cohort study in the Greater Toronto Area (GTA), Ontario, Canada.20 From this cohort, we purposively sampled primary care physicians in the GTA, Ontario, Canada who counselled parents and provided COVID-19 vaccines to children, including family physicians, paediatricians and paediatric specialists. Eligible participants were (1) primary healthcare providers affiliated with TARGet Kids!; (2) English-speaking; and (3) willing to participate in a 60-min interview.28 We recruited participants via email and shared a letter of information and consent. Given interviews were conducted by telephone or online, we obtained verbal informed consent before each interview. A verbal consent attestation form was signed by the interviewer and emailed to participants after conducting the interviews.

Patient and public involvement

We engaged the TARGet Kids! Parent and Caregiver Team (PACT), a patient advisory committee comprising parents and caregivers,29 across multiple phases of the broader qualitative study, including protocol development, data collection, and analysis and interpretation. Overall study approach and preliminary findings were presented and discussed at multiple PACT meetings to ensure that the study design, tools and findings were informed by clinicians, parents and community members.

Data generation and analysis

We conducted semi-structured interviews with participants from May to October 2022. Interviews were conducted by telephone or via Zoom Healthcare, audio recorded, transcribed verbatim and quality checked for accuracy. Interviews were an average of 32 min in length. At the time of data collection, most public health restrictions had been lifted in Ontario (February 2022)30 and COVID-19 vaccines had been approved for children ages 5–12 (November 2021). Vaccine approvals for children aged 6 months to 5 years occurred during the study period (July 2022).

The interview guide was designed by the research team, with expertise in qualitative research. The interviews explored clinicians’ perspectives on COVID-19 vaccination recommendations for children (and variations by age groups), their understanding and sources of scientific evidence supporting COVID-19 vaccination for children, their communication strategies employed with families, and any differences they experienced counselling families for COVID-19 vaccinations versus other routine childhood immunisations.

Data analysis was guided by reflexive thematic analysis31 32 which seeks to identify interpretive themes within the data through a reflexive process. We worked with the data through multiple phases, including familiarisation with data by reading and re-reading interview transcripts, inductively coding the data to produce an initial code list, examining codes for themes, reviewing, defining and naming themes, and generating a written product synthesising the analysis and interpretation. To demonstrate rigour, we applied the Consolidated criteria for Reporting Qualitative research checklist,33 alongside other measures of quality (eg, importance of the topic, richness of description, sincerity, credibility, resonance, theoretical and practical contributions, and meaningful coherence to research objectives and scholarship).34

Interviews were conducted by three authors (KH, JW and KA) and preliminary analysis was led by two authors (KH and JW) to identify initial themes. We began by inductively analysing the data to explore participants’ perspectives without a predetermined theoretical framework. However, during analysis, we recognised that physicians’ practices are socially situated,35 and that their perspectives are shaped by not only their own beliefs, but also factors related to their social, environmental, and political contexts. Socioecological models of health acknowledge that health attitudes and behaviours do not exist in isolation, but rather are situated in and shaped by multiple, interacting layers of influence within an individual’s social system.36 We therefore used a socioecological framework to conceptualise our preliminary themes across the individual (micro-), relational (meso-) and broader contextual (macro-) level influences shaping participants’ experiences.37 Subsequent collaborative review, analysis and iterative discussion among the team (KH, JW, CJ-P and JAP) helped to define the final themes. All authors critically reviewed the themes and resultant findings for coherence.

We engaged in reflexivity, or ‘thoughtful, conscious self-awareness’, throughout all stages of research by recognising how our positionalities, including our professional and social identities, influenced the design and conduct of our study.38 Acknowledging the presence of researchers in qualitative inquiry is critical; collectively, our roles as clinicians, healthcare researchers, parents and residents of the GTA (an urban centre), as well as our multiple, intersecting identities and axes of power (eg, age, gender, race, ethnicity and education), influenced our perspectives, analytical lenses and interactions with participants.39

ResultsParticipants

We initially contacted 27 primary care physicians to participate in this study and 10 expressed interest in being interviewed. This sample included four family physicians, three paediatricians and three paediatric subspecialists; the remaining physicians did not respond. Participants’ ages ranged from 31 to 50 years. Four participants were in practice for less than 10 years and six were in practice for 10 or more years. Nearly all participants were female (n=9) and born in Canada (n=9), and most (n=7) identified as white. All participants were parents of children under 18 years of age.

Findings

Physicians’ perspectives on paediatric COVID-19 vaccinations highlighted important elements that influenced their attitudes towards the vaccine for children, their approaches to recommending the vaccine to families, and potential uptake of the vaccine among parents. These elements, operating at the individual level (the physician), the interpersonal level (their relationships with families) and the structural level (the broader context), are described (and depicted in figure 1).

Figure 1

Elements influencing physicians’ attitudes and approaches to paediatric COVID-19 vaccinations.

Individual elements

Multiple elements at the individual physician level shaped their conversations with families. Participants described their roles as clinicians to promote paediatric COVID-19 vaccines to families and discussed leveraging both their ‘physician’ and ‘parent’ social identities to foster dialogue and trust. Access to and confidence in the evidence available on the vaccines’ risks and benefits influenced physicians’ discussions and recommendations.

Physician identity and role

Participants described universally ‘pro-vaccine’ attitudes towards COVID-19 vaccinations for children, stating that they were “hugely in favour of it” (P22), and that they think “it’s very important for [children] to get vaccinations” (P23). These views were often linked to their identity as a clinician, with one participant noting: “obviously pediatricians are pro-vaccine, so I’m pro-vaccine and I think kids should get the vaccine” (P24). As part of this identity, participants expressed feeling compelled to promote COVID-19 vaccinations widely:

As a health care provider, because we’re all in this together, I just went out of my way to ask [families] if they’d had a chance to be immunized… Even if the parents weren’t my patients, I was happy just to be a health care provider in the world during the pandemic and just try to spread proper information. P25

Participants’ typically framed their support for widespread vaccination in terms of population-level benefits, with many emphasising the collective public health benefits of COVID-19 vaccinations for children over the risks or benefits for individual children:

A lot of times it’s understood that the child isn’t necessarily at very high risk of illness, but the fact that the vaccine can protect them from transmitting it to others… [it] decreases the risk for everybody else around them. P26

Participants described taking on unique roles within the pandemic response to support paediatric COVID-19 vaccinations, including volunteering in mass vaccination clinics and acting as vaccine advocates with their patients and their own personal networks. Participants also spoke about multiple identities they held, as both providers and parents. In some cases, this enabled them to empathise with parents, acknowledging that apprehension about potential side effects of the vaccine was understandable:

As a parent of under-fives, I can understand the uncertainty and knowing how a vaccine can really affect your baby, affect your sleep, affect all these other facets of your life. I can understand why some parents are a bit more hesitant. And so I think I do strongly recommend it to them but I also understand the perspective of not [wanting to vaccinate]. P30

However, some participants also highlighted a tension between their provider and parent identities. For example, one participant described recommending the vaccine confidently to patients: “As a health care provider, definitely I recommend [the COVID-19 vaccine] with certainty… I reassure them that it’s a safe vaccination” (P31); yet also acknowledged some uncertainty and caution as a parent:

I think when it comes to our own kids, there are times that you… unconsciously think, ‘Could this have any side effect long term? Could there be some uncertainty with long term effects that we just don’t know now?’ Not that I believe it by heart, or talk about it as a healthcare provider, but definitely, I think, as a parent, you have those [reservations]. I talk about it with my colleagues… I ask them, you know. ‘What did you do for your kids?’… Because I think we’re still learning about this. We still, all of us, have a bit of discomfort. P31

Knowledge and confidence in evidence

Participants described how their knowledge of the evidence supporting COVID-19 vaccination for children influenced their confidence in recommending it to parents. For example, participants noted they were comfortable discussing the mRNA technology and safety of the COVID-19 vaccine, but were less confident about the benefits or potential long-term side effects for children, given the sparse supporting evidence in these areas. Some physicians talked about ‘struggling’ with answering questions about the long-term risks or benefits for younger age groups.

What I have a bit of difficulty [with] is the long term efficacy, or the number of the boosters… I struggle at finding good reasoning or good planning for parents to help them with decision making… I still recommend that it’s quite efficient in preventing severe disease. But if they’re questioning long-term [efficacy]… I think that’s the part that I struggle [with] a little bit. P31

However, providers also emphasised that the benefits of preventing long-term risks from COVID-19 infections, ultimately, outweighed potential risks associated with the COVID-19 vaccination from their perspective:

I spent a lot of time just focusing on how the vaccine might not be perfect and it might have some side effects, but that my take on things is that COVID-19 [infection] has worse side effects… people just forget to focus on the virus itself and what we're actually looking to prevent. P25

Some physicians described challenges keeping up-to-date with emerging evidence due to time constraints, and therefore feeling less confident answering certain questions from parents. Participants also varied in their knowledge of the evidence for different age groups and, consequently, how strongly they recommended the vaccine for younger children compared with older children. Some noted they “feel less equipped to strongly recommend it” (P27) based on the low risk of disease in children, and what they perceived as less evidence supporting vaccine efficacy for younger age groups. Others, conversely, expressed that they “have no hesitation recommending [the COVID-19 vaccine], I try to recommend it to babies six months and up. I’m a strong supporter.” (P29).

Further, some participants noted that the recommendations provided by the National Advisory Committee on Immunization (NACI; a national advisory committee that provides guidance on the use of vaccines to the Government of Canada) also influenced the strength of their endorsement of COVID-19 vaccines for different age groups or risk levels. NACI guidelines were reported to have a ‘secret code’ (eg, wording that certain populations ‘should’ vs ‘may’ be vaccinated), which impacted the strength of some providers’ recommendations to parents.

Interpersonal elements

Physicians’ relationships with parents and families also shaped their COVID-19 vaccination conversations. Adapting recommendations to parents’ receptivity and establishing trust with parents represented key strategies participants employed to support families in their COVID-19 vaccination decisions.

Responsive recommendations

Participants used a variety of techniques when discussing COVID-19 vaccinations with parents, including motivational interviewing, vaccine hesitancy frameworks, addressing misinformation and sharing their personal decisions about vaccination. Most employed proactive, rather than reactive, approaches by integrating COVID-19 vaccination status as part of standard medical history discussions or raising the topic with parents during each interaction. Many also described adopting a ‘presumptive’ approach, framing their questions as ‘when’, rather than ‘if’ the child would be vaccinated:

I had read early on that presenting it just as a presumption like, ‘So when will you get the COVID vaccine?’ rather than more of a debate, is helpful. So I sort of try to make it casual and presumptive. P29

Conversely, others spoke of using ‘collaborative’, ‘non-threatening’ or ‘gentle’ approaches, focused on understanding parents’ specific concerns and providing information accordingly:

I would say, you know, ‘I understand your concerns, there’s a lot on the internet’. Then I would try to help them filter out… what’s a medically legit concern versus something that they've heard. And I would refer to literature if they really wanted it. I would refer them to official websites, or what I consider to be reputable sources of information, and then just say, ‘let me know if you have any questions’. P25

Although participants used diverse strategies, almost all spoke of being responsive to parents’ attitudes towards vaccination and their receptivity to recommendations. They described altering their approaches to ‘push’ a little with parents who were already leaning towards vaccination or with whom they had an ongoing relationship, and not push with those who expressed opposition or seemed unreceptive.

So I guess those are my two levels… for the families I [know]… I’ll be more pointed and saying, ‘what are your reservations about [the vaccine]?’… [but for parents where] they’re very, very harsh, like a hard no, I don’t, I don’t keep pushing because then I think, you risk getting into an argument. P23

Several physicians noted that it was only useful to encourage parents who were receptive, since strongly recommending vaccination to those staunchly opposed may risk an argument or interfere with other healthcare-seeking behaviours:

There’s some people who come in really adamantly against it, and… I don’t feel very effective at ever changing their minds… I spent a lot of time and many follow-up visits and I found it was very little yield. So if a parent comes like absolutely set against it, I usually just leave it… I don’t really push the discussion in those cases anymore… because I find that sometimes just leads to a more adversarial reaction, and they don’t come in for other things that they need to. P27

Further, participants noted that recommending vaccination too strongly to a patient/parent who is not receptive may damage trust:

My job is that, when they come to the clinic for that care, they feel that they can trust us, and I provide the care that is relevant to the issue. [So] if I see that there is hesitancy… I do mention to all that I do recommend [the vaccine], and it has good efficacy… [but] basically, if the conversation kind of ends there, I do not necessarily elaborate further on that. P31

Trust in healthcare providers

Participants spoke extensively about how parents’ trust in healthcare providers influenced their perceptions of the COVID-19 vaccine and their receptivity to recommendations. Almost all participants described trying to build trust with patients during vaccination conversations by being responsive to parents’ concerns or using multiple visits to answer questions and address fears. Notably, many physicians emphasised that the most effective strategy they used to build trust with parents was sharing their personal experiences of vaccinating their own children: “I find one of my strongest arguments is sharing that my young children have been vaccinated… I find it so compelling. It really switches things for patients, I think.” (P29). Participants underscored that sharing these personal perspectives and decisions as a parent fostered trust, and that parents were often more open to their recommendations as a result.

As a parent, I do share my personal experience about different things with them, that you know… ‘when we encountered these challenges, that’s what we did as a family.’ So I think that’s maybe led them to ask that question, because I had opened up to them. And I think it’s important. If they trust in us, and trust the team that they see, I think it does have some impact on their decision making. P31

Although trust was considered foundational to parents’ receptivity to recommendations, some participants noted that many seeking advice were already leaning towards vaccinating their children and wanted validation for their decision. In these cases, physicians felt they were not changing parents’ minds, but rather affirming and reinforcing their choice.

I feel like when parents have reached out to me is not because of a particular piece of disinformation they want me to refute… I think they are looking for some affirmation or encouragement. That’s when they’ll seek out myself as a medical professional… I think what they want is someone that they trust to give them the ‘okay’ to do it. P23

Moreover, some participants noted that parents opposed to vaccinating their children against COVID-19 may not have sought their advice at all, in favour of visiting alternative practitioners who may not promote vaccines in the same manner.

Participants also acknowledged that parents’ sense of trust may be influenced by broader, preexisting (mis)trust in the healthcare system. Physicians recognised that patients’ backgrounds, previous interactions with providers or systemic inequalities experienced within the healthcare system play a role in their level of trust and receptivity to recommendations. They also noted that perceptions of government may have influenced parents’ attitudes towards COVID-19 vaccines, given the government’s involvement in COVID-19 vaccine recommendations and mandates.

Systemic and contextual elements

Emerging COVID-19 variants, the rollout of vaccines, developments in the broader health system pandemic response and constraints on care delivery were identified as systemic and contextual elements influencing physicians’ interactions with families.

Evolving COVID-19 climate

The rapidly evolving COVID-19 pandemic climate, including novel variants and protracted timelines for paediatric vaccine approvals, shaped participants’ experiences recommending and delivering COVID-19 vaccinations for children. The emergence of COVID-19 variants with decreased severity of symptoms and rates of hospitalisation were cited as influencing parents’ vaccination decisions, as well as physicians’ approaches to discussions:

I should say that my recommendations started to change, right? Because back when even we had Delta, these strains were actually pretty nasty. You lost your smell and taste, like all those things. I was a much stronger proponent of vaccines for everybody. Whenever it came out, get it immediately. Because the strains were much worse. P28

Additionally, participants noted that the advent of COVID-19 vaccines and widespread vaccine coverage in adults in Ontario led to a “very different pandemic” (P28). They observed waning motivation from parents who were less concerned about their children experiencing severe illness or hospitalisation due to COVID-19 and, amidst substantial increases in community spread, felt they had acquired ‘natural immunity’ from exposure to milder virus variants. Participants also noted that delayed approvals for vaccines for children under 5 years old “sen[t] a message” to parents on the vaccine’s safety, efficacy, and importance—“it’s almost like they don’t care, versus they’re actually trying to make sure it’s super safe” (P24). Further, once approved, paediatric vaccines did not target the most recent COVID-19 variants, which one participant deemed as offering little value to protect children.

Given this evolving environment, many participants described a shift in their position on paediatric vaccines, from firm recommendations that all children ‘must’ be vaccinated to a more open and tailored approach. Going forward, physicians outlined the importance of increased flexibility and adaptability in their tactics and recommendations to accommodate developments in knowledge and the health system landscape:

I’m prepared to change my recommendations and how strongly I encourage vaccine based on the climate of what’s going on. P28

Health system pandemic response

The health system’s response to the pandemic also influenced physicians’ experiences counselling parents on COVID-19 vaccination. Although some participants commended the child-friendly nature of some mass vaccination centres, many viewed the delivery of COVID-19 vaccinations for children in these spaces, rather than in primary care facilities, as an obstacle to providing information and administering vaccines. To participants, this represented a missed opportunity to leverage established relationships and trust, and to offer counselling and delivery of vaccinations during routine visits. Additionally, they highlighted that this may have offered a less personalised approach to COVID-19 vaccinations, potentially limiting uptake among children and families:

As a provider, one could consider the concept of the ‘medical home’ where, you know, this is where you go for all of your child’s health care, it’s a hub. So having COVID-19 vaccine[s] in primary care offices may have been smoother for parents and for kids… [than] going to a mass centre… The family doctor knows you… [so] they may have a more personalized approach. P22

Participants also criticised the online vaccination booking portal (administered by Ontario’s Ministry of Health), citing logistical challenges that may have posed unnecessary barriers to families seeking COVID-19 vaccines. Given these concerns, some physicians helped patients book vaccination appointments, particularly to support accessibility of services for equity-deserving populations:

The [booking] system is a bit clunky… Early in the pandemic, [I] would spend the time after hours booking patients myself… for really marginalized families… but the system is too cumbersome for me to do that for every family. And so I find that there’s a group of parents who say, ‘Yeah, I’ll vaccinate my kids.’ But there’s no way they're going to be able to figure out where and how to get them an appointment. P27

National and provincial government vaccination mandates also impacted physicians’ experiences. Some participants discussed that the perceived politicised nature of COVID-19 vaccines introduced unique challenges in attending to parents’ concerns: “there’s a lot of stuff that comes up in conversation that doesn’t happen for other vaccines” (P27). At the same time, some participants indicated that lifting government vaccination mandates over time undermined their motivation to recommend the vaccine:

It’s just hard now we’re past the mandate of having a vaccine… the will for me to make sure all my patients are vaccinated has gone down a little bit because there’s nothing backing me up. If I ask them and they say no, there’s no consequence… there’s no political will to enforce it. So I still ask, but there’s not really much to do if they say no. P23

Constraints in care delivery

Healthcare practice constraints also shaped providers’ discussions with parents on COVID-19 vaccines. Participants noted that shifting to virtual care may have circumscribed opportunities for parents to discuss COVID-19 vaccinations for their children. Many also conveyed having limited time for lengthy conversations with parents during health visits due to competing demands and time pressures:

There’s just not a lot of time… in family medicine, like everything is so stretched and strained, and there’s so many, it seems, all of a sudden, there’s so many bigger problems, so much more collateral damage from the pandemic and short staffing, and everything else… I just find it’s hard to have these [conversations]. P27

Additionally, broader health system challenges, such as shortages of healthcare providers, frustration and burnout among primary care physicians amidst the pandemic were highlighted as underlying forces shaping participants’ capacity to deliver information and COVID-19 vaccines to families:

And when things are really bad and I was a frustrated health care worker and frustrated that the world was closed and that my patients were getting sick and that everything was challenging, I felt frustrated. But I was just trying to not impart that feeling of frustration to the families because it wasn’t very helpful, it wasn’t constructive, or I could tell it wouldn’t be constructive. P25

Amidst changes in the health system landscape and the broader COVID-19 climate, participants adjusted the strength of their recommendations, but demonstrated a sustained commitment to providing COVID-19 vaccinations to protect children against severe illness.

Discussion

This study highlights a range of important elements that shaped primary care physicians’ experiences of supporting families with COVID-19 vaccination decisions for their children. Our findings illustrate that physicians’ practices are socially situated, influenced by their individual, interpersonal and systemic environments.35 Specifically, we found that physicians’ conduct was shaped by (1) their individual experiences, knowledge and perceptions (regarding evidence related to COVID-19 vaccinations for children, and their roles in promoting the vaccine); (2) their interpersonal relationships with families (including levels of trust and responsiveness to parents’ attitudes, concerns and receptivity); and (3) the broader global pandemic context (such as new variants, decreased severity of COVID-19 infections, introduction of public health measures and system-level constraints). Socioecological models have been employed to explain microlevel, mesolevel and macrolevel influences on COVID-19 vaccination attitudes among the public40 41 and parents37; this study extends our understanding of vaccination decision-making by illuminating the multilevel influences on physicians’ attitudes towards paediatric COVID-19 vaccinations.

Tension between physicians’ perceptions of their roles in promoting vaccinations and the difficulties they sometimes face maintaining confidence in their recommendations due to the new and ever-shifting nature of evidence for COVID-19 vaccines is highlighted in this work. Physicians’ sense of responsibility as ‘role models’ of COVID-19 vaccinations and contributing to population health has been echoed elsewhere.42 At the same time, researchers in other jurisdictions have also found that physicians feel pressure in staying abreast of COVID-19 evidence,15 43 and that they are often ‘ambassadors’ of COVID-19 vaccines, but rarely given guidance on how to approach conversations with parents.44 Moreover, studies in other countries have shown that healthcare providers have varying attitudes towards COVID-19 vaccines,45–47 which may create dissonance when advising patients on vaccination48 and influence their communication with patients46; giving providers timely, tailored, transparent information about vaccine risks and benefits may increase their capacity to counsel patients appropriately and confidently.42 47–49 Similar to research on physicians providing COVID-19 vaccination counselling to adults16 43 44 and parents of adolescents,17 our findings reiterate that physicians require support in obtaining, synthesising and communicating evidence to parents of younger children to inform their vaccination decisions. Physicians in our study varied in their confidence answering parents’ questions and recommending the vaccine for children under 12 years of age. These findings extend current scholarship to include physicians’ perspectives recommending COVID-19 vaccines to parents of children under 12, and highlight the inter-related nature of physicians’ individual perspectives and their approach to relating with parents and families.

Physicians’ relationships with parents and their influence on paediatric COVID-19 vaccination conversations were discussed at length during interviews. Physicians’ efforts to tailor strategies to parents’ individual concerns and to use multiple visits to encourage vaccination have been discussed by other researchers.43 However, physicians in our study also described a ‘dichotomised’ approach of gauging parents’ receptivity to vaccination recommendations and deciding when to ‘push’ or ‘back off’. While previous research has found that primary care physicians frequently lack confidence in responding to patients’ personal objections to COVID-19 vaccinations,50 and are less willing to recommend the vaccine to unreceptive parents,17 our findings add that physicians may also intentionally choose to cease recommending vaccinations to maintain trust. Trust was described by participants as foundational to parents’ receptivity to vaccine recommendations. They portrayed leveraging their role as parents as their most useful strategy for building trust and reassuring parents in their decisions, as described elsewhere.15 Previous research has shown that shared racial or ethnic identity (race/ethnicity concordance) between providers and patients can facilitate patient trust,51 representing a potential avenue for future research on COVID-19 vaccinations, given many countries experienced racial and ethnic disparities in vaccination uptake due to mistrust.52 In this study, having a shared 'parent’ identity seemed to enable both trust and confidence from parents, as well as empathy and understanding from physicians, further highlighting the inter-related nature of individual and interpersonal elements in vaccination recommendations.

Counselling parents during an evolving pandemic posed particular contextual challenges for participants. Restricted access to in-person physician visits and the introduction of virtual care disrupted many physicians’ usual practices and interactions with families.53 54 Time and resource constraints, and the implementation of mass vaccination clinics, may have limited opportunities for providers to counsel parents. Physicians also took on new responsibilities to encourage vaccination in paediatric populations, exposing shortcomings in the provincial and national pandemic response.26 Additionally, frontline healthcare providers in Ontario often felt responsible for communicating rapidly shifting COVID-19 policy changes to their patients, adding further complexity—and sometimes confusion—to their vaccination recommendations.55 Research in other countries has also described operational barriers faced by providers,56 as well as broader contextual challenges, such as the politicisation of COVID-19 vaccines,57 polarisation of media, shifts in public perceptions of virus-related and vaccine-related risks, and increases in vaccination misinformation58 that influenced physicians’ interactions with patients. Our findings add to this body of work, illustrating the integral role of contextual and health system factors related to the pandemic response on physicians’ roles, recommendations and interactions with families.

Understanding that physicians’ recommendations are influenced by individual, interpersonal and structural elements has implications for clinical practice and future paediatric vaccination rollouts. Given the central role of trust in vaccination decisions,59–61 participants suggested that new paediatric vaccinations should be offered in primary care offices where trusting relationships and opportunistic counselling opportunities already exist. However, participants also described primary care constraints that might hinder their ability to rapidly deliver widespread immunisations; therefore, while primary care providers may be well suited to provide new vaccinations, targeted support to effectively incorporate new paediatric vaccinations into their existing practices is needed.62 Additionally, our findings suggest that physicians may only be effective sources of vaccination information and recommendations if trusting relationships are already established; parents who are mistrusting of the healthcare system or providers, or who do not have access to (or choose to not access) primary care, may not seek or heed advice from healthcare providers, a finding that has been reiterated elsewhere.63 Other trusted avenues of vaccination information must therefore be identified and incorporated into future vaccination programming to avoid exacerbating existing health inequities. Lastly, finding ways to support physicians in remaining knowledgeable about emerging information and conveying evidence to parents is important. Given the interpersonal nature of vaccination recommendations, incorporating the perspectives of parents, children and other providers in this endeavour may help to optimise communication methods for future vaccination programming.

Strengths, limitations and future directions

Our interpretive qualitative approach allowed us to examine physicians’ perspectives on paediatric COVID-19 vaccinations in-depth and to explore the complexity of providing vaccine recommendations to parents. Employing multiple analysts and adopting a reflexive approach to data analysis was a methodological strength. Recruiting and interviewing physicians during the pandemic were challenging due to physicians’ time constraints, but we were able to garner a range of physician roles and perspectives. These data are part of a broader study examining a range of stakeholder perspectives on paediatric COVID-19 vaccination, therefore, the sample size for this substudy is small; nevertheless, we generated a rich empirical dataset and produced analytical concepts that are potentially transferable to other contexts, including future paediatric vaccine rollouts in Canada and internationally. Most of our sample identified as white and female, and all were parents of children under 18 years of age; interviewing a more diverse sample may have generated additional insights into ways shared social identity impact how physicians approach conversations and build trust with parents. This study was conducted in Canada’s largest city; therefore, the experiences portrayed here might differ across other jurisdictions. This study was also conducted prior to a surge in paediatric hospitalisations in the fall of 2022 due to a viral ‘trifecta’—COVID-19, influenza and RSV infections—resulting in severe illness in some children and a significant burden on the Ontario healthcare system. The comments of some providers regarding the severity of illness in childhood might look different following this development. Future research should examine if the perspectives voiced here remain consistent over time, explore the perspectives of youth regarding COVID-19 vaccination, and bring the perspectives of parents, healthcare providers and youth into interaction through further qualitative inquiry.

Conclusions

Our findings underscore the multifaceted nature of influences on primary care physicians’ experiences when supporting families with COVID-19 vaccination for their children. Understanding how they approach vaccination decision-making holds important implications for health policies and services to better support both parents and providers in making decisions around new paediatric vaccinations.

Data availability statement

No data are available. The datasets generated and analysed in the current study are not publicly available due to participant confidentiality.

Ethics statementsPatient consent for publication

Not applicable.

Ethics approval

This study was approved by the Research Ethics Boards of Unity Health Toronto, the Hospital for Sick Children and the University of Toronto. Participants gave informed consent to participate in the study before taking part.