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Prevalence and correlates of vaccine attitudes and behaviors in a cohort of low-income mothers

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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 attitudes and behaviors among higher-risk populations is needed to develop tailored strategies aimed at addressing vaccine hesitancy and underimmunization.
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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
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Prevalence and correlates of vaccine attitudes and behaviors in a cohort of
low-income mothers
Ross M. Gilbert
a
, Joshua P. Mersky
b
,
*
, Chien-Ti Plummer Lee
b
a
School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
b
Institute for Child and Family Well-being, Helen Bader School of Social Welfare, University of Wisconsin-Milwaukee, Milwaukee, WI, United States
ARTICLE INFO
Keywords:
Vaccines
Immunization
Attitudes
Safety
Effectiveness
ABSTRACT
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.
1. Introduction
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, condence in vaccine safety and efcacy 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 efcacy 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 inuence 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: mersky@uwm.edu (J.P. Mersky).
Contents lists available at ScienceDirect
Preventive Medicine Reports
journal homepage: www.elsevier.com/locate/pmedr
https://doi.org/10.1016/j.pmedr.2020.101292
Received 15 August 2020; Received in revised form 22 November 2020; Accepted 13 December 2020
Preventive Medicine Reports 21 (2021) 101292
2
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 inuences vaccine attitudes or
behaviors.
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
35 times more likely to delay or refuse the routine immunization
schedule (Turner et al., 2003). Parents may also consider a childs health
status when making immunization decisions, but maternal perceptions
of a childs health has not been studied as a correlate of vaccine out-
comes. Likewise, access to a consistent health care location has been
identied 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 inuence 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 signicant 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 afuent 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. Methods
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
benets.
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
human subjects.
3. Measures
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 childs 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 315); 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. Childs health was measured from participantsratings of
their childs overall health on a scale from (1) poor to (5) excellent.
Participants reported the number of child health care visits (range 024) 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 doctors
ofce 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
2168), 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
3
sample was 0.81.
Demographic factors are analyzed as potential correlates, including
mothers age at baseline (range 1850) and childs age at study wave 2
(range 16). Using baseline data, mothers race/ethnicity was categorized
as Hispanic or one of four non-Hispanic groups: whites, blacks, Amer-
ican Indians, and other race/ethnicity. Mothers 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 specication 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, 19982017).
4. Results
Sample demographics are shown in Table 1. Out of 813 women,
44.9% self-identied 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. Childrens 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 childs 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 childs 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 childs 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 childs 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 childs 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
Table 1
Study Variables (N =813).
Range M (SD) or %
Correlates
Childs health 15 4.4 (0.8)
Number of child health care visits 024 2.5 (2.4)
Health care provider trust 15 4.4 (0.8)
Home visitor trust 15 4.5 (0.7)
Mothers mental health 2168 46.5 (8.9)
Childs age 16 1.9 (1.0)
Mothers age 1850 28.3 (6.0)
Mothers race/ethnicity
Non-Hispanic White 01 44.9%
American Indian 01 7.1%
African American 01 18.7%
Hispanic 01 24.6%
Other 01 4.7%
Mothers education 16 3.4 (1.1)
Outcomes
Vaccines important for childs health
1
15 4.3 (1.0)
Disagree/Strongly disagree 01 5.0%
Somewhat agree and disagree 01 10.9%
Agree/Strongly agree 01 84.0%
Vaccines effective
1
15 4.2 (1.0)
Disagree/Strongly disagree 01 5.4%
Somewhat agree and disagree 01 14.5%
Agree/Strongly agree 01 80.0%
Vaccines safe 15 4.0 (1.0)
Disagree/Strongly disagree 01 6.2%
Somewhat agree/disagree 01 22.0%
Agree/Strongly agree 01 71.9%
Vaccine attitudes, total score 315 12.5 (2.7)
Vaccines delayed 01 14.3%
Vaccines up to date 01 94.0%
1
Item percentages do not sum to 100% due to rounding error.
Table 2
Correlates of Vaccine Attitudes.
Important Effective Safe Total Score
B (95% CI) B (95% CI) B (95% CI) B (95% CI)
Childs health
score
0.07 (0.01,
0.15)
0.06 (0.02,
0.13)
0.03 (0.05,
0.10)
0.06 (0.02,
0.13)
N of health care
visits
0.03 (0.05,
0.10)
0.03 (0.05,
0.10)
0.00 (0.07,
0.07)
0.02 (0.05,
0.09)
Health care
provider trust
0.21 (0.14,
0.28)**
0.21 (0.14,
0.28)**
0.25 (0.17,
0.32)**
0.24 (0.17,
0.31)**
Home visitor
trust
0.07 (0.00,
0.13)
0.07 (0.00,
0.13)*
0.10 (0.04,
0.17)**
0.09 (0.02,
0.15)*
Mothers
mental health
score
0.03 (0.04,
0.10)
0.04 (0.04,
0.11)
0.07 (0.01,
0.14)
0.06 (0.02,
0.13)
Childs age 0.02 (0.04,
0.09)
0.01
(0.07,
0.06)
0.02 (0.04,
0.08)
0.01 (0.05,
0.07)
Mothers age 0.02 (0.04,
0.09)
0.06 (0.00,
0.13)
0.04 (0.02,
0.10)
0.05 (0.01,
0.11)
Mothers race/
ethnicity
American
Indian
0.08
(0.14,
0.01)*
0.10
(0.16,
0.03)**
0.08
(0.14,
0.02)*
0.09
(0.16,
0.03)**
African
American
0.05
(0.12, 0.03)
0.11
(0.18,
0.03)**
0.03
(0.09,
0.04)
0.06
(0.13,
0.00)
Hispanic 0.05 (0.02,
0.13)
0.03 (0.05,
0.11)
0.02 (0.05,
0.10)
0.03 (0.04,
0.11)
Other 0.06 (0.00,
0.11)*
0.01 (0.05,
0.07)
0.06 (0.01,
0.12)*
0.05 (0.01,
0.10)
Mothers
education
0.02
(0.09, 0.05)
0.03 (0.04,
0.10)
0.06
(0.13,
0.01)
0.02
(0.09,
0.05)
Sample size 813 811 810 808
Note. B =standardized beta. CI =condence intervals. *p <.05 **p <.01.
R.M. Gilbert et al.
Preventive Medicine Reports 21 (2021) 101292
4
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 childs 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).
5. Discussion
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 childs
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, conrming 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 condence
may be especially vital to promoting vaccine acceptance in these
populations.
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 specic 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 modiable correlate of
vaccine uptake in our study. Although mental health scores were not
signicantly 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 modiable barrier to accessing adequate preventive
pediatric care (Minkovitz et al., Feb, 2005; Jhanjee et al., 2004).
Most demographic indicators were not signicantly 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 childs 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).
6. Limitations
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.
7. Conclusions
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
Table 3
Correlates of Vaccine Delay and Adherence.
Vaccines Delayed Vaccines Up to Date
OR (95% CI) OR (95% CI)
Childs 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)
Mothers mental health score 0.99 (0.96, 1.01) 1.05 (1.02, 1.09)**
Childs age 0.98 (0.81, 1.19) 1.49 (1.00, 2.21)*
Mothers age 0.97 (0.94, 1.01) 1.01 (0.96, 1.06)
Mothers race/ethnicity
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)
Mothers education 1.12 (0.93, 1.36) 0.88 (0.65, 1.19)
Sample size 810 796
Note. OR =odds ratio; CI =condence intervals. *p <.05 **p <.01.
R.M. Gilbert et al.
Preventive Medicine Reports 21 (2021) 101292
5
hesitancy and delay were also prevalent, presenting a signicant 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
analysis.
Declaration of Competing Interest
The authors declare that they have no known competing nancial
interests or personal relationships that could have appeared to inuence
the work reported in this paper.
Acknowledgments
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
this study.
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R.M. Gilbert et al.
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BACKGROUND: Although several predictors of COVID-19 vaccine hesitancy have been identified, the role of physical health and, particularly, mental health, is poorly understood. METHODS: We used individual-level data from a pandemic-focused investigation (COVID Survey), a prospective cohort study nested within the UK Understanding Society (Main Survey) project. In the week immediately following the announcement of successful testing of the first efficacious inoculation (Oxford University/AstraZeneca, November/December 2020), data on vaccine intentionality were collected in 12,035 individuals aged 16-95 years. Pre-pandemic, study members had responded to enquiries about diagnoses of mental and physical health, including the completion of the 12-item General Health Questionnaire for symptoms of psychological distress (anxiety and depression). Peri-pandemic, individuals indicated whether they or someone in their household was shielding; that is, people judged by the UK National Health Service as being particularly clinically vulnerable who were therefore requested to remain at home. Intention to take up vaccination for COVID-19 was also self-reported. RESULTS: In an analytical sample of 11,955 people (6741 women), 15.4% indicated that they were vaccine-hesitant. Relative to their disease-free counterparts, shielding was associated with a 24% lower risk of being hesitant (odds ratio; 95% confidence interval: 0.76; 0.59, 0.96), after adjustment for a range of covariates which included age, education, and ethnicity. Corresponding results for cardiometabolic disease were 22% (0.78; 0.64, 0.95), and for respiratory disease were 26% (0.74; 0.59, 0.93). Having a pre-pandemic diagnosis of anxiety or depression, or a high score on the distress symptom scale, were all unrelated to the willingness to vaccine-hesitancy. CONCLUSIONS: People with a physical condition were more likely to take up the potential offer of a COVID-19 vaccination. These effects were not apparent for indices of mental health.Key messagesIn understanding predictors of COVID-19 vaccine hesitancy, the role of physical and mental health has not been well-examined despite both groups seemingly experiencing an elevated risk of the disease.In a large UK cohort study, people with a pre-pandemic physical condition were more likely to take up the theoretical offer of vaccination.There were no apparent effects for indices of pre-pandemic mental health.
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Background: Childhood vaccination is an effective way to prevent serious childhood illnesses, but many children do not receive all the recommended vaccines. There are various reasons for this; some parents lack access because of poor quality health services, long distances or lack of money. Other parents may not trust vaccines or the healthcare workers who provide them, or they may not see the need for vaccination due to a lack of information or misinformation about how vaccinations work and the diseases they can prevent.Communication with parents about childhood vaccinations is one way of addressing these issues. Communication can take place at healthcare facilities, at home or in the community. Communication can be two-way, for example face-to-face discussions between parents and healthcare providers, or one-way, for instance via text messages, posters or radio programmes. Some types of communication enable parents to actively discuss vaccines and their benefits and harms, as well as diseases they can prevent. Other communication types simply give information about vaccination issues or when and where vaccines are available. People involved in vaccine programmes need to understand how parents experience different types of communication about vaccination and how this influences their decision to vaccinate. Objectives: The specific objectives of the review were to identify, appraise and synthesise qualitative studies exploring: parents' and informal caregivers' views and experiences regarding communication about childhood vaccinations and the manner in which it is communicated; and the influence that vaccination communication has on parents' and informal caregivers' decisions regarding childhood vaccination. Search methods: We searched MEDLINE (OvidSP), MEDLINE In-process and Other Non-Index Citations (Ovid SP), Embase (Ovid), CINAHL (EbscoHOST), and Anthropology Plus (EbscoHost) databases for eligible studies from inception to 30 August 2016. We developed search strategies for each database, using guidelines developed by the Cochrane Qualitative Research Methods Group for searching for qualitative evidence as well as modified versions of the search developed for three related reviews of effectiveness. There were no date or geographic restrictions for the search. Selection criteria: We included studies that utilised qualitative methods for data collection and analysis; focused on the views and experiences of parents and informal caregivers regarding information about vaccination for children aged up to six years; and were from any setting globally where information about childhood vaccinations was communicated or distributed. Data collection and analysis: We used maximum variation purposive sampling for data synthesis, using a three-step sampling frame. We conducted a thematic analysis using a constant comparison strategy for data extraction and synthesis. We assessed our confidence in the findings using the GRADE-CERQual approach. High confidence suggests that it is highly likely that the review finding is a reasonable representation of the phenomenon of interest, while very low confidence indicates that it is not clear whether the review finding is a reasonable representation of it. Using a matrix model, we then integrated our findings with those from other Cochrane reviews that assessed the effects of different communication strategies on parents' knowledge, attitudes and behaviour about childhood vaccination. Main results: We included 38 studies, mostly from high-income countries, many of which explored mothers' perceptions of vaccine communication. Some focused on the MMR (measles, mumps, rubella) vaccine.In general, parents wanted more information than they were getting (high confidence in the evidence). Lack of information led to worry and regret about vaccination decisions among some parents (moderate confidence).Parents wanted balanced information about vaccination benefits and harms (high confidence), presented clearly and simply (moderate confidence) and tailored to their situation (low confidence in the evidence). Parents wanted vaccination information to be available at a wider variety of locations, including outside health services (low confidence) and in good time before each vaccination appointment (moderate confidence).Parents viewed health workers as an important source of information and had specific expectations of their interactions with them (high confidence). Poor communication and negative relationships with health workers sometimes impacted on vaccination decisions (moderate confidence).Parents generally found it difficult to know which vaccination information source to trust and challenging to find information they felt was unbiased and balanced (high confidence).The amount of information parents wanted and the sources they felt could be trusted appeared to be linked to acceptance of vaccination, with parents who were more hesitant wanting more information (low to moderate confidence).Our synthesis and comparison of the qualitative evidence shows that most of the trial interventions addressed at least one or two key aspects of communication, including the provision of information prior to the vaccination appointment and tailoring information to parents' needs. None of the interventions appeared to respond to negative media stories or address parental perceptions of health worker motives. Authors' conclusions: We have high or moderate confidence in the evidence contributing to several review findings. Further research, especially in rural and low- to middle-income country settings, could strengthen evidence for the findings where we had low or very low confidence. Planners should consider the timing for making vaccination information available to parents, the settings where information is available, the provision of impartial and clear information tailored to parental needs, and parents' perceptions of health workers and the information provided.
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Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.
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This is the protocol for a review and there is no abstract. The objectives are as follows: The specific objectives of the review are to identify, appraise and synthesise qualitative studies exploring: • Parents’ and informal caregivers’ views and experiences regarding communication about childhood vaccinations and the manner in which it is communicated • The influence that vaccination communication has on parents’ and informal caregivers’ decisions regarding childhood vaccination
Article
Objectives The objective of this study was to compare immunization rates of American Indian (AI) and White children in North Dakota and identify disparities in immunization rates by race. Study design The study design was to assess immunization coverage rates by race using immunization information system (IIS) data. Methods Data from the North Dakota Immunization Information System (NDIIS) for children aged 19–35 months during quarter four of 2014, 2015, 2016, 2017 and 2018 were used to assess and compare immunization coverage rates for AI and White children. NDIIS data were also analyzed for timeliness of vaccine administration, Vaccines for Children (VFC) status, and the number of doses still needed to be considered up to date (UTD) with routinely recommended immunizations. Results In quarter four of 2018 (Q4 2018), only 60% of AI children were UTD with the complete 4:3:1:3:3:1:4 vaccine series compared with 74.5% of White children of the same age. Fewer VFC-eligible AI children (59.1%) are UTD than VFC-eligible White children (68.7%). AI children were also more likely to be delayed at each immunization milestone, leading to fewer AI children to be UTD by 19 to 35 months of age. Conclusions This study shows that there is a racial disparity in immunization coverage rates between AI and White children in North Dakota. Public health and private healthcare providers should work to identify and address barriers to vaccination and should implement strategies to increase immunization rates for AI children.
Article
Purpose: Vaccines represent one of the most important aspects of pediatric preventive care. However, parents are increasingly questioning the safety of and need for vaccines, and as a result, vaccination rates have fallen to dangerously low levels in certain communities. The effects of vaccine hesitancy are widespread. Community pediatricians who interact regularly with vaccine-hesitant parents report higher levels of burnout and lower levels of job satisfaction. Not surprisingly, vaccine hesitancy has also had direct influence on vaccination rates, which in turn are linked to increased emergency department use, morbidity, and mortality. Methods: Literature from 1999 to 2017 regarding vaccines and vaccine hesitancy was reviewed. Findings: Few evidence-based strategies exist to guide providers in their discussions with vaccines-hesitant parents. Recent research has shown a presumptive approach (ie, the provider uses language that presumes the caregiver will vaccinate his or her child) is associated with higher vaccination uptake. Motivational interviewing is a promising technique for more hesitant parents. Implications: At the community level, evidence-based communication strategies to address vaccine hesitancy are needed. The practice of dismissing families from pediatric practices who refuse to vaccinate is common, although widely criticized. Other controversial and rapidly evolving topics include statewide vaccination mandates and school exemption policies. Electronic interventions, such as text-messaging services and social media, have recently emerged as effective methods of communication and may become more important in coming years.
Article
Introduction: Low-income child populations remain under-vaccinated. Our objective was to determine differences in the relative importance of maternal health literacy and socio-demographic characteristics that often change during early childhood on up-to-date (UTD) immunization status among a low-income population. Methods: We performed secondary data analysis of a longitudinal prospective cohort study of 744 Medicaid-eligible mother-infant dyads recruited at the time of the infant's birth from an inner-city hospital in the United States and surveyed every 6 months for 24 months. Our primary outcome was infant UTD status at 24 months abstracted from a citywide registry. We assessed maternal health literacy with the Test of Functional Health Literacy in Adults (short version). We collected socio-demographic information via surveys at birth and every 6 months. We compared predictors of UTD status at 3, 7, and 24 months. Results: The cohort consisted of primarily African-American (81.5%) mothers with adequate health literacy (73.9%). Immunizations were UTD among 56.7% of infants at 24 months of age. Maternal health literacy was not a significant predictor of UTD immunization status. Instead, adjusted results showed that significant predictors of not-UTD status at 24 months were lack of a consistent health care location or "medical home" (OR 0.17, 95%CI 0.18-0.37), inadequate prenatal care (OR 0.48, 95%CI 0.25-0.95), and prior not-UTD status (OR 0.31, 95%CI 0.20-0.47). Notably, all upper confidence limits are less than 1.0 for these variables. Health care location type (e.g., hospital-affiliate, community-based, none) was a significant predictor of vaccine status at age 3 months, 7 months, and 24 months. Conclusions: Investing in efforts to support early establishment of a medical home to obtain comprehensive coordinated preventive care, including providing recommended vaccines on schedule, is a prudent strategy to improve vaccination status at the population level.
Article
Objective Little is known about how families' experiences with immunization visits within the medical home may affect children's immunization status. We assessed the association between families' negative immunization experiences within the medical home and underimmunization. Methods We surveyed parents ( n=392) of children aged 2–36 months about immunization experiences at community health centers, hospital-based clinics, private practices, and community-based organizations in New York City. We used Chi-square tests and odds ratios (ORs) to assess the relationship between medical home elements and parental immunization experience ratings. We used multivariable analysis to determine the association between negative experiences during immunization visits and underimmunization, controlling for insurance, maternal education, and receipt of benefits from the Special Supplemental Nutrition Program for Women, Infants, and Children. Results The majority of children were of Latino race/ethnicity and had Medicaid and a medical home. One-sixth (16.9%) of families reported a previous negative immunization experience, primarily related to the child's reaction, waiting time, and attitudes of medical and office staff. Parents' negative immunization experiences were associated with the absence of four components of the medical home: continuity of care, family-centered care, compassionate care, and comprehensive care. In addition, children in families who reported a negative experience were more likely to have been underimmunized (adjusted OR=2.00; 95% confidence interval 1.12, 3.58). Conclusions In a community in New York City, underimmunization of young children was associated with negative immunization experiences. Strategies to improve family experiences with immunization visits within the medical home (particularly around support for the family), medical and ancillary staff attitudes, and reduced waiting time may lead to improved immunization delivery.
Article
Importance Parents hesitant to vaccinate their children may delay routine immunizations or seek exemptions from state vaccine mandates. Recent outbreaks of vaccine-preventable diseases in the United States have drawn attention to this phenomenon. Improved understanding of the association between vaccine refusal and the epidemiology of these diseases is needed.Objective To review the published literature to evaluate the association between vaccine delay, refusal, or exemption and the epidemiology of measles and pertussis, 2 vaccine-preventable diseases with recent US outbreaks.Evidence Review Search of PubMed through November 30, 2015, for reports of US measles outbreaks that have occurred since measles was declared eliminated in the United States (after January 1, 2000), endemic and epidemic pertussis since the lowest point in US pertussis incidence (after January 1, 1977), and for studies that assessed disease risk in the context of vaccine delay or exemption.Findings We identified 18 published measles studies (9 annual summaries and 9 outbreak reports), which described 1416 measles cases (individual age range, 2 weeks-84 years; 178 cases younger than 12 months) and more than half (56.8%) had no history of measles vaccination. Of the 970 measles cases with detailed vaccination data, 574 cases were unvaccinated despite being vaccine eligible and 405 (70.6%) of these had nonmedical exemptions (eg, exemptions for religious or philosophical reasons, as opposed to medical contraindications; 41.8% of total). Among 32 reports of pertussis outbreaks, which included 10 609 individuals for whom vaccination status was reported (age range, 10 days-87 years), the 5 largest statewide epidemics had substantial proportions (range, 24%-45%) of unvaccinated or undervaccinated individuals. However, several pertussis outbreaks also occurred in highly vaccinated populations, indicating waning immunity. Nine reports (describing 12 outbreaks) provided detailed vaccination data on unimmunized cases; among 8 of these outbreaks from 59% through 93% of unvaccinated individuals were intentionally unvaccinated.Conclusions and Relevance A substantial proportion of the US measles cases in the era after elimination were intentionally unvaccinated. The phenomenon of vaccine refusal was associated with an increased risk for measles among people who refuse vaccines and among fully vaccinated individuals. Although pertussis resurgence has been attributed to waning immunity and other factors, vaccine refusal was still associated with an increased risk for pertussis in some populations.