Preventive Medicine Reports 21 (2021) 101292
Available online 5 January 2021
2211-3355/© 2020 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
Prevalence and correlates of vaccine attitudes and behaviors in a cohort of
Ross M. Gilbert
, Joshua P. Mersky
, Chien-Ti Plummer Lee
School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
Institute for Child and Family Well-being, Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee, Milwaukee, WI, United States
The US is facing a rise in vaccine hesitancy, delay, and refusal, though little is known about these outcomes in
socio-economically disadvantaged populations. This study examines the prevalence and correlates of vaccine
attitudes and behaviors in a diverse cohort of low-income mothers receiving home visiting services. Survey data
were collected from 813 recipients of evidence-based home visiting services in Wisconsin from 2013 to 2018.
Analyses were performed to describe outcome measures of vaccine attitudes and self-reported completion, and
multivariate regressions were used to test associations between vaccine-related outcomes and hypothesized
correlates. Most women (94%) reported their children were up to date on vaccines; 14.3% reported having ever
delayed vaccination. A small minority disagreed that vaccines are important (5.0%), effective (5.4%), and safe
(6.2%), though a larger proportion responded ambivalently (10.9%–21.9%). Participants with greater trust in
health care providers reported more positive overall vaccine attitudes (B =0.24; 95% CI =0.17, 0.31), a lower
likelihood of vaccine delay (OR =0.57; 95% CI =0.46, 0.73), and a greater likelihood of being up to date on
vaccines (OR =1.79, 95% CI =1.30, 2.44). Women with greater trust in a home visitor also rated vaccines more
positively (B =0.09; 95% CI =0.02, 0.15), and women who reported better mental health were more likely to
report their children were up to date (OR =1.05; 95% CI =1.02, 1.09). Compared to non-Hispanic whites,
American Indians and non-Hispanic blacks had poorer vaccine-related outcomes. More research on vaccine at-
titudes and behaviors among higher-risk populations is needed to develop tailored strategies aimed at addressing
vaccine hesitancy and underimmunization.
Routine childhood vaccination is a cost-effective preventive health
measure that will avert approximately 42,000 early deaths and 20
million cases of infectious disease while saving nearly $70 billion in
societal costs among the 2009 US birth cohort (Zhou et al., 2014).
Vaccines have an excellent safety record (Epling et al., 2014; Prevention,
2015), yet, condence in vaccine safety and efcacy is falling in the US
and worldwide, and rates of vaccine delay and refusal are rising (Glanz
et al., 2013; Robison et al., 2012).
Unfavorable attitudes about vaccine safety and efcacy represent a
threat to public health that coincides with more vaccine delay and rising
rates of underimmunization (Glanz et al., 2013; Robison et al., 2012;
McClure et al., 2017), which have subsequently been linked with out-
breaks of measles, mumps, and rubella (Addressing Vaccine Hesitancy,
2019; Williams, 2014; Glanz et al., 2013; Phadke et al., 2016).
Underimmunization is also associated with higher emergency depart-
ment utilization, more hospital admissions, increased disease morbidity,
and death (Glanz et al., 2013a, 2011b, 2010c, 2013d; McClure et al.,
2017; Haemophilus, 2008). Therefore, to improve adherence to rec-
ommended vaccine schedules, we must better understand vaccine atti-
tudes, including their variation among population subgroups and
association with alterable factors.
Research shows that parents’ vaccine decision-making is complex
and that personal beliefs and characteristics inuence vaccine attitudes
and behaviors (Ames et al., 2017). Parental trust in health care providers
is a recurring theme in the immunization literature. Health workers are
often listed as trusted sources of vaccine information (Ames et al., 2017),
and trust in doctors is more common among mothers with favorable
vaccine perceptions and those who choose to fully immunize (Williams,
2014; Benin et al., 2006; Edwards and Hackell, 2016). Conversely,
mothers who reject vaccines are more likely to report distrust in their
* Corresponding author at: 2400 E. Hartford Ave., Milwaukee, WI, 53211, United States.
E-mail address: firstname.lastname@example.org (J.P. Mersky).
Contents lists available at ScienceDirect
Preventive Medicine Reports
journal homepage: www.elsevier.com/locate/pmedr
Received 15 August 2020; Received in revised form 22 November 2020; Accepted 13 December 2020
Preventive Medicine Reports 21 (2021) 101292
pediatrician (Ames et al., 2017; Benin et al., 2006; Edwards and Hackell,
2016; Salmon et al., 2005). Although greater trust in pediatric health-
care providers has been linked to more positive parent vaccine percep-
tions, it is uncertain whether trust in other health and human service
providers such as home visitors inuences vaccine attitudes or
Research also shows that poorer maternal mental health correlates
with fewer visits for pediatric preventive care (Minkovitz et al., 2005;
Jhanjee et al., 2004), greater utilization of emergency care (Minkovitz
et al., 2005; Mandl et al., 1999; Sills et al., 2007), and under-
immunization (Cullen et al., 2010). One study found that infants of
mothers with more anxiety symptoms were nearly 4 times more likely to
have an incomplete vaccination status (Ozkaya et al., 2010), and
another suggested that mothers with poorer overall mental health were
3–5 times more likely to delay or refuse the routine immunization
schedule (Turner et al., 2003). Parents may also consider a child’s health
status when making immunization decisions, but maternal perceptions
of a child’s health has not been studied as a correlate of vaccine out-
comes. Likewise, access to a consistent health care location has been
identied as a predictor of up-to-date immunization status (Pati et al.,
2017), and studies have shown that underimmunized children have
lower rates of preventive care visits (Glanz et al., 2013), but it is un-
certain whether vaccine perceptions are associated with the frequency
of visits for pediatric health care.
Vaccine attitudes and behaviors have been shown to vary by socio-
economic and demographic factors. Poverty and low socioeconomic
status (SES) have been linked to greater concerns about vaccine safety,
distrust of providers (Shui et al., 2006; Wu et al., 2008; Hill et al., 2017),
and lower vaccination coverage (Hill et al., 2017; Hilderman et al.,
2011; Kruk et al., 2011; Kendrick et al., 2000; Luman et al., 2003). Some
studies suggest that low educational attainment is a barrier to vaccine
uptake (Stockwell et al., 2011; Schuller and Probst, 2013) while others
suggest that less-educated mothers have more positive vaccine percep-
tions and that their children have higher immunization rates (Kim et al.,
2007). Variation in vaccine perceptions by race and ethnicity also have
been observed. Compared to non-Hispanic whites, Hispanics and non-
Hispanic blacks have lower coverage rates and more frequent negative
attitudes toward vaccination (Luman et al., 2003; Shui et al., 2006; Wu
et al., 2008; Hill et al., 2017), though it is uncertain if these differences
hold after accounting for the confounding inuence of SES (Shui et al.,
2006, 2005; Centers for Disease Control and Prevention, 2012). Few
studies have examined the vaccine attitudes and behaviors of American
Indians, although evidence indicates that their immunization coverage
is below the national average (Woinarowicz and Howell, 2020; Hill
et al., 2018).
There remain signicant gaps in our understanding of vaccine atti-
tudes and behaviors, especially in socioeconomically disadvantaged
populations. Whereas research to date represents samples that are
whiter, more educated, and more afuent than the general population
(Ames et al., 2017; Kennedy et al., 2011), this study examines the
prevalence and correlates of vaccine attitudes and behaviors in a racially
and ethnically diverse sample of low-income mothers who received
home visiting services. Because home visiting programs often provide
prenatal and postpartum support to high-risk families with lower vac-
cine uptake, these interventions have the potential to promote adher-
ence to recommended vaccine schedules (Guide to Community
Preventive Services, 2019; Briss et al., 2000; Isaac et al., 2015). There-
fore, in addition to household demographics, ve alterable factors that
are potential intervention targets were examined as potential correlates
of vaccine attitudes: trust in health care providers, trust in home visitors,
maternal mental health, perceived child health, and frequency of pedi-
atric health care.
2.1. Study and sample design
This study analyzes data collected from a sample of 813 women with
children who enrolled in the Families and Children Thriving (FACT)
Study, a longitudinal investigation of low-income families in Wisconsin,
United States that began in 2015. All participants received home visiting
services within a statewide network of evidence-based programs,
including Early Head Start, Healthy Families America, Nurse-Family
Partnership, and Parents as Teachers. Subsidized by the federal
Maternal Infant and Early Childhood Home Visiting (MIECHV) Program,
each home visiting model provides prenatal and postpartum services to
at-risk families to enhance maternal health, parenting practices, and
infant development. More than 98% of participating households were
within 200% of the federal poverty line or were eligible for means-tested
Data from the rst two waves of the FACT Study were analyzed.
Wave 1 recruitment activities occurred at least two weeks after the birth
of a child associated with a home visiting service episode, at which time
a baseline survey was administered to English- and Spanish-speaking
mothers. For this analysis, baseline surveys supply data on maternal
demographics and perceived trust with home visitors. Wave 2 surveys,
which were collected about one year after the baseline assessment,
provide data on vaccine-related outcomes and multiple correlates,
described below. All participants provided informed consent prior to
voluntary study enrollment and received a $40 incentive for completing
Wave 1 and a $20 incentive for completing Wave 2 surveys. No families
were denied services for declining to participate. Study protocols were
approved by a university Institutional Review Board before engaging
An original three-item measure of attitudes toward childhood vac-
cines was used to assess the degree to which respondents perceived
childhood vaccines to be (1) important for my child’s health; (2) effec-
tive; and (3) safe. Participants rated their level of agreement with each
statement on a scale from (1) strongly agree to (5) strongly disagree.
Development of the measure was informed by a review of extant liter-
ature prior to study Wave 2 (Larson et al., 2015; Opel et al., 2013), and
item content validity was assessed by a panel of experts. A total vaccine
attitudes score was computed by summing the items (range 3–15); in-
ternal consistency reliability was 0.92. Participants also reported if they
had ever delayed vaccinating their child out of safety concerns (yes =1),
and if their child had received all vaccines that are recommended for
children up to his/her age (yes =1). No electronic health record data
was used to reinforce this self-reported vaccination data.
At study wave 1, participants reported their level of home visitor trust
on a single item: “My home visitor and I trust each other.” Response
options ranged from (1) strongly disagree to (5) strongly agree. Four
hypothesized correlates of vaccine hesitancy and delay were assessed at
study wave 2. Child’s health was measured from participants’ ratings of
their child’s overall health on a scale from (1) poor to (5) excellent.
Participants reported the number of child health care visits (range 0–24) in
response to the following question: “In the past six months, not counting
emergency room visits, how many times did your child go to a doctor’s
ofce or clinic to get health care?” Health care provider trust was assessed
based on responses to a single item: “Overall, how much do you trust
your regular doctor or health care provider?” Responses ranged from (1)
not at all to (5) completely. Finally, global mental health was assessed
using a four-item subscale of the PROMIS® Global-10 (Hays et al.,
2009). Raw scores were converted to T-scores and summed (range
21–68), with higher values signifying better mental health. Research
indicates that the subscale has good internal consistency reliability and
construct validity (Hays et al., 2009). Internal reliability in the present
R.M. Gilbert et al.
Preventive Medicine Reports 21 (2021) 101292
sample was 0.81.
Demographic factors are analyzed as potential correlates, including
mother’s age at baseline (range 18–50) and child’s age at study wave 2
(range 1–6). Using baseline data, mother’s race/ethnicity was categorized
as Hispanic or one of four non-Hispanic groups: whites, blacks, Amer-
ican Indians, and other race/ethnicity. Mother’s education was coded as
an ordinal variable ranging from (1) less than high school to (6) four-
year college degree.
3.1. Statistical analysis
A descriptive analysis was used to calculate the means and pro-
portions for all study measures. Multivariate regressions were conducted
to test associations between outcomes and their hypothesized correlates
while controlling for covariates. Multiple linear regression along with
robust maximum-likelihood estimation was used to estimate associa-
tions with perceived vaccine importance, effectiveness, safety, and a
total vaccine attitudes score, and logistic regression was used to model
associations with dichotomous self-reported outcomes: vaccines delayed
and vaccines up to date. The same model specication was used for each
regression, with all variables entered simultaneously. Listwise deletion
was used to exclude a small proportion of cases with missing data for
study outcomes (0.0% to 2.1%). All descriptive analyses were performed
using SPSS 25 (Corp, 2017), and regression models were performed
using Mplus 8.4 (Muthen, 1998–2017).
Sample demographics are shown in Table 1. Out of 813 women,
44.9% self-identied as non-Hispanic white, 24.6% Hispanic, 18.7%
African American, 7.1% American Indian, and 4.7% as other race/
ethnicity. Mothers ranged in age from 18 to 50 with a mean of
28.3 years. Children’s ages ranged from 1 to 6 with a mean of 1.9 years.
Table 1 shows that 5.0% of respondents disagreed that vaccines are
important for their child’s health, while 5.4% disagreed that vaccines
are effective, and 6.2% disagreed that vaccines are safe. The proportion
who responded somewhat agree and disagree to the vaccine hesitancy
items was as follows: (1) important for child’s health =10.9%; (2)
effective =14.5%; (3) safe =21.9%. 14.3% of parents had delayed
vaccinating their child and 94.0% of sample children were up to date on
all recommended vaccines.
Multivariate analyses (Table 2) showed that participants who re-
ported greater trust in their health care provider rated vaccines as more
important for their child’s health (B =0.21; 95% CI =0.14, 0.28), more
effective (B =0.21; 95% CI =0.14, 0.28), and safer (B =0.25; 95%
CI =0.17, 0.32), and they reported more positive vaccine attitudes
overall (B =0.24; 95% CI =0.17, 0.31). As shown in Table 3, greater
trust in health care providers was associated with a reduced likelihood of
vaccine delay (OR =0.57; 95% CI =0.46, 0.73) and an increased like-
lihood of being up to date on vaccines (OR =1.79, 95% CI =1.20, 2.44).
Respondents who reported greater trust in their home visitor also rated
vaccines as more effective (B =0.07; 95% CI =0.00. 0.13) safer
(B =0.10; 95% CI =0.04, 0.17), and more positively overall (B =0.09;
95% CI =0.02, 0.15).
Racial/ethnic differences in vaccine attitudes were observed (see
Tables 2 and 3). Compared to non-Hispanic whites, American Indians
rated vaccines as less important for their child’s health (B = − 0.08; 95%
CI = − 0.14, −0.01), less effective (B = − 0.10; 95% CI = − 0.16, −0.03),
and less safe (B = − 0.08; 95% CI = − 0.14, −0.02), and their vaccine
attitudes were less positive overall (B = − 0.09; 95% CI = − 0.16, −0.03).
American Indians were also less likely to report that their child’s vac-
cines were up to date (OR =0.30; 95% CI =0.12, 0.76). Vaccines were
rated as less effective by blacks than whites (B = − 0.11; 95%
CI = − 0.18, −0.03), and blacks were more likely than whites to report
that they had delayed vaccination (OR =1.84; 95% CI =1.10, 3.06).
Few other correlates were consistently associated with study
Study Variables (N =813).
Range M (SD) or %
Child’s health 1–5 4.4 (0.8)
Number of child health care visits 0–24 2.5 (2.4)
Health care provider trust 1–5 4.4 (0.8)
Home visitor trust 1–5 4.5 (0.7)
Mother’s mental health 21–68 46.5 (8.9)
Child’s age 1–6 1.9 (1.0)
Mother’s age 18–50 28.3 (6.0)
Non-Hispanic White 0–1 44.9%
American Indian 0–1 7.1%
African American 0–1 18.7%
Hispanic 0–1 24.6%
Other 0–1 4.7%
Mother’s education 1–6 3.4 (1.1)
Vaccines important for child’s health
1–5 4.3 (1.0)
Disagree/Strongly disagree 0–1 5.0%
Somewhat agree and disagree 0–1 10.9%
Agree/Strongly agree 0–1 84.0%
1–5 4.2 (1.0)
Disagree/Strongly disagree 0–1 5.4%
Somewhat agree and disagree 0–1 14.5%
Agree/Strongly agree 0–1 80.0%
Vaccines safe 1–5 4.0 (1.0)
Disagree/Strongly disagree 0–1 6.2%
Somewhat agree/disagree 0–1 22.0%
Agree/Strongly agree 0–1 71.9%
Vaccine attitudes, total score 3–15 12.5 (2.7)
Vaccines delayed 0–1 14.3%
Vaccines up to date 0–1 94.0%
Item percentages do not sum to 100% due to rounding error.
Correlates of Vaccine Attitudes.
Important Effective Safe Total Score
B (95% CI) B (95% CI) B (95% CI) B (95% CI)
N of health care
Child’s age 0.02 (−0.04,
Mother’s age 0.02 (−0.04,
Hispanic 0.05 (−0.02,
Other 0.06 (0.00,
Sample size 813 811 810 808
Note. B =standardized beta. CI =condence intervals. *p <.05 **p <.01.
R.M. Gilbert et al.
Preventive Medicine Reports 21 (2021) 101292
outcomes. Children were more likely to be up to date on vaccines if they
were older (OR =1.49; 95% CI =1.00, 2.21) and if their mothers re-
ported more positive mental health scores (OR =1.05; 95% CI =1.02,
1.09). Compared to non-Hispanic whites, American Indians were less
likely to report that their child’s vaccines were up to date (OR =0.30;
95% CI =0.12, 0.76), and blacks were more likely to report that they
had delayed vaccination (OR =1.84; 95% CI =1.10, 3.06).
This study examined the prevalence and correlates of vaccine atti-
tudes and behaviors in a racially and ethnically diverse sample of low-
income mothers. Overall, 94% of sample women reported that their
children were up to date on recommended vaccines, which is higher
than both national estimates (70.4%) and Wisconsin state estimates
(69.2%) (Hill et al., 2018). The high rate of reported vaccine adherence
may be partly due to the use of self-report data rather than medical
records, though it also may be related to receiving home visiting services
that aim to enhance maternal and child health outcomes, including
adherence to well child visit schedules.
Despite this nding, many caregivers (14%) reported that they had
delayed vaccination at least one time. Moreover, a substantial minority
of caregivers disagreed that vaccines are important for their child’s
health (5.0%), effective (5.4%), and safe (6.2%). An even higher per-
centage responded ambivalently, indicating that they somewhat agreed
and disagreed that vaccines are important (10.9%), effective (14.5%),
and safe (21.9%). The results underscore that vaccine hesitancy is
common, even among this highly immunized population, which could
lead to future vaccine delay or refusal.
Results from a multivariate analysis showed that respondents who
reported greater trust in their health care provider were more likely to
agree that vaccines are important, effective, and safe. These caregivers
were less likely to have delayed vaccines and more likely to report being
up to date on vaccines, conrming that greater trust in healthcare pro-
viders is associated with reduced vaccine hesitancy (Williams, 2014;
Ames et al., 2017; Benin et al., 2006; Edwards and Hackell, 2016;
Salmon et al., 2005). Because socioeconomically disadvantaged groups
tend to have more distrust in healthcare providers (Shui et al., 2006; Wu
et al., 2008; Hill et al., 2017), interventions to increase their condence
may be especially vital to promoting vaccine acceptance in these
We also discovered that mothers who reported greater trust in their
home visitor were more likely to agree that vaccines are effective and
safe, and they reported lower vaccine hesitancy overall. These novel
results have important public health implications given that the federal
MIECHV Program alone supports services for about 300,000 low-income
families per year (Thrive, 2018), and many more receive home visits
from non-MIECHV providers that deliver prenatal and postpartum in-
home care. Our ndings are notable because most home visiting pro-
grams do not vaccinate children and many do not focus on vaccine at-
titudes as an intervention target (Kendrick et al., 2000; Isaac et al.,
2015). It is plausible that home visiting programs with intentional
vaccine promotion or administration could be effective in reducing
vaccine hesitancy and improving immunization in low-income families
(Guide to Community Preventive Services, 2019; Briss et al., 2000; Isaac
et al., 2015). Given the time limitations of most pediatrician visits,
adequately addressing vaccine misinformation comes at the expense of
other important anticipatory guidance (Kempe et al., 2015; Olson et al.,
2004), and as such, interventions to address hesitancy in other settings
are key to curbing the rise in vaccine hesitancy (McClure et al., 2017).
Future work should investigate specic vaccine protocols in home
visiting and other similar programs such as prenatal care coordination
and community health worker interventions.
Maternal mental health status was the nal modiable correlate of
vaccine uptake in our study. Although mental health scores were not
signicantly correlated with vaccine attitudes, mothers with better self-
rated mental health were more likely to report that their child was up to
date on vaccines. This nding is consistent with the limited research
linking mental health disturbance with underimmunization (Cullen
et al., 2010), and it further supports prior claims that poor maternal
mental health is a modiable barrier to accessing adequate preventive
pediatric care (Minkovitz et al., Feb, 2005; Jhanjee et al., 2004).
Most demographic indicators were not signicantly correlated with
vaccine attitudes, delay, and adherence. The most notable exception is
that, compared to non-Hispanic whites, American Indians rated vaccines
as less important for their child’s health, less effective, and less safe, and
they were less likely to be up to date on vaccines. These results highlight
the need for more extensive study of vaccine attitudes and behaviors
among American Indians, especially given the pronounced health dis-
parities they experience (Arias et al., 2014; Cobb et al., 2014). Non-
Hispanic blacks also were less likely than non-Hispanic whites to
believe that vaccines are effective and were more likely to delay vac-
cines. Taken together, the results add to the literature on diverse and
low-SES populations that are underrepresented in literature despite
evidence that they are more vaccine-hesitant (Shui et al., 2006; Wu
et al., 2008; Hill et al., 2017; Hilderman et al., 2011; Kruk et al., 2011;
Kendrick et al., 2000).
Findings should be interpreted considering the cross-sectional-
design, which limits our ability to infer causal association. Measures
of vaccine delay and adherence, frequency of pediatric visits, and all
hypothesized correlates were based on self-report data, which have
known limitations such as response bias and social desirability bias. In
addition, the measure of parent attitudes toward childhood vaccines
warrants further psychometric testing. Given the complexity of vaccine
decision-making, omitted variable bias is another limitation; salient
correlates of vaccine hesitancy were absent from our measurement plan,
including barriers to immunization access such as proximity of vaccine
administration sites, transportation access, and insurance status. Finally,
generalizability of the ndings is limited by the non-representative
sample comprising low-income households receiving home visiting
services in a single Midwest state. It is uncertain to what degree our
ndings apply to the general population and to other low-income sub-
groups in the US.
This study described the prevalence and correlates of vaccine atti-
tudes and behaviors in a racially and ethnically diverse group of low-
income families receiving home visiting services. The results indicated
that, although reported child vaccination rates were high, vaccine
Correlates of Vaccine Delay and Adherence.
Vaccines Delayed Vaccines Up to Date
OR (95% CI) OR (95% CI)
Child’s health score 1.04 (0.78, 1.38) 1.16 (0.77, 1.73)
N of child health care visits 1.01 (0.92, 1.11) 1.20 (0.96, 1.51)
Health care provider trust 0.57 (0.46, 0.73)** 1.79 (1.30, 2.44)**
Home visitor trust 1.16 (0.83, 1.63) 1.02 (0.71, 1.46)
Mother’s mental health score 0.99 (0.96, 1.01) 1.05 (1.02, 1.09)**
Child’s age 0.98 (0.81, 1.19) 1.49 (1.00, 2.21)*
Mother’s age 0.97 (0.94, 1.01) 1.01 (0.96, 1.06)
American Indian 1.75 (0.86, 3.54) 0.30 (0.12, 0.76)*
African American 1.84 (1.10, 3.06)* 0.83 (0.38, 1.80)
Hispanic 0.70 (0.38, 1.29) 1.08 (0.44, 2.64)
Other 1.59 (0.63, 4.03) 1.04 (0.21, 5.12)
Mother’s education 1.12 (0.93, 1.36) 0.88 (0.65, 1.19)
Sample size 810 796
Note. OR =odds ratio; CI =condence intervals. *p <.05 **p <.01.
R.M. Gilbert et al.
Preventive Medicine Reports 21 (2021) 101292
hesitancy and delay were also prevalent, presenting a signicant threat
to community health. Consistent with past research, greater trust in
health care providers was associated with more positive vaccine atti-
tudes and behaviors. The ndings also uniquely showed that maternal
trust in a home visitor was a correlate of positive vaccine attitudes,
suggesting that home visiting programs are a promising outlet for future
vaccination interventions. Within this low-income sample, greater vac-
cine hesitancy and lower vaccine adherence was observed among
American Indian and African American participants, emphasizing the
need to target further research and intervention resources toward these
disadvantaged and underserved populations.
CRediT authorship contribution statement
Ross M. Gilbert: Conceptualization, Writing - original draft. Joshua
P. Mersky: Conceptualization, Project administration, Writing - original
draft. Chien-Ti Plummer Lee: Data curation, Methodology, Formal
Declaration of Competing Interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
This work was supported by funding from the Maternal, Infant, and
Early Childhood Home Visiting Grant Program, U.S. Department of
Health and Human Services, Health Resources and Services Adminis-
tration (Awards: X10MC311790100, X10MC295120100).
Financial Interest Statement: All authors declare that there were no
nancial relationships with organizations that might have an interest in
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