ABSTRACT
Data are needed on the acceptability of Covid-19 vaccination among young, low-income, diverse populations. To assess this, we surveyed 18–45-year-old women on their intent to be vaccinated, experiences with Covid-19, and uptake of other vaccines. Among the 342 who completed the survey, only one-third were likely to accept the Covid-19 vaccine as soon as it was available. Less than half would accept it even if recommended by their doctor. Most (69%) wanted more information on its safety and 48% wanted proof it works. Likelihood of accepting the vaccine with a doctor’s recommendation was associated with fear of catching Covid-19 and exposure to social media as well as HPV and annual flu vaccination. This demonstrates it will be necessary to help vaccine-hesitant individuals overcome their concerns to reach herd immunity in the US. Physician recommendation and social media may play important roles.
Introduction
On December 11, 2020, Pfizer received emergency use authorization from the Food and Drug Administration to distribute a 2-dose vaccine against Covid-19. One week later, Moderna also received emergency use authorization for their vaccine. Both vaccines were developed and tested in less than 1 year. This timeline was much shorter than ever achieved in history.
Due to their rapid development as well as overall concern regarding the safety and efficacy of new vaccines, it is unknown what percentage of the population will accept one of these Covid-19 vaccines, particularly among younger individuals who may feel they have less risk of severe disease. Recent surveys published by the lay press suggest that acceptance will approach 60%.Citation1 Since these were not published in the peer reviewed literature, their results are difficult to interpret as precise details of the methodology are unpublished. Three recent studies, which were published in peer-reviewed journals, reported on respondents to online surveys. One study by Reiter et al observed that 69% of participants intended to be vaccinated.Citation2 Overall, the education level of participants was high with 27% holding a college degree or higher and an additional 21% having attended some college. Moreover, 67% of participants were white and over half were at least 50 years of age. Another study by Khubchandani and colleagues found that 52% of respondents were very likely to get vaccinated and 27% were somewhat likely. In their study, 77% had a bachelor’s degree or higher and 81% were non-Hispanic.Citation3 In a third study, almost 62% of respondents were somewhat or very likely to get vaccinated if recommended by their provider.Citation4 In this survey, 30% of the respondents had bachelor’s degrees and approximately 65% were non-Hispanic white. Thus, it is not known if the high rate of acceptability in these studies would translate to less educated, low-income populations from diverse backgrounds. The purpose of this study was to examine acceptability of the Covid-19 vaccine among a young, low-income, predominately Hispanic population.
Methods
Women 18–45 years of age receiving care in 1 of 3 reproductive clinics in south Texas were approached between November 17, 2020 and December 19, 2020. They were asked to complete an anonymous paper survey in English or Spanish. Survey completers received a gift (lunch tote, tumbler or ear buds) of their choice, worth ≤$3. Completion of the self-administered paper was considered as consent by the Institutional Review Board (IRB) to ensure confidentiality was maintained. The University of Texas Medical Branch IRB approved all study procedures.
The survey consisted of 3 pages with 33 questions. It included questions about human papillomavirus (HPV) and flu vaccination in addition to 3 questions about Covid-19 vaccination and 7 questions about personal experiences with Covid-19. Statistical analyses were conducted using SAS Statistical Software version 9.4 (Cary, NC, USA). A p-value <.05 was considered significant. Descriptive analyses included chi-square tests for bivariate analyses of categorical data. Multivariable logistic regression was used to evaluate associations between participant characteristics and whether they intend to get vaccinated against Covid-19 if a doctor recommends it. Intent was a binary (likely/unlikely) measure.
Results
A total of 357 patients presenting to women’s health clinics agreed to take the survey. Among those, 96.7% (342) returned completed surveys. Differences in those who would accept the vaccine if the doctor recommended it were observed by preferred language, by HPV vaccine uptake, and by whether respondents had received an annual flu vaccine (). In this sample, we found that only 34% were likely to accept the vaccine as soon as it became available (). However, close to 50% were likely to accept it if recommended by their doctor. Most respondents (69%) wanted to learn more about the vaccines’ safety or side-effects, followed by 48% who wanted proof that the vaccines work (Supplemental Table 1). Fewer were concerned about the number of doses, cost, how many others get it, or how many others known by the respondents who get it.
Table 1. Characteristics of reproductive-aged (18–45 year old) female respondents, stratified by likelihood of acceptance of COVID vaccine (N = 342)
Table 2. Reasons that may affect the decision to get the COVID-19 vaccine (N = 342)
Overall, we observed associations between fear of catching Covid-19 and likelihood of accepting the vaccine with a doctor’s recommendation (). We also found that social media was positively associated with the likelihood of accepting the vaccine if recommended by a doctor (42% of those who were likely to get the vaccine agreed that social media was an important influence compared to 29% of those who were unlikely to get the vaccine).
Table 3. Perceptions of Covid-19 likelihood of accepting the vaccine with doctor’s recommendation (N = 342)
In multivariable analyses, language preference was no longer associated with the likelihood of accepting the Covid-19 vaccine if a doctor recommended it (). The adjusted odds ratio (aOR) for language preference was 1.79, 95% confidence interval (CI) = 0.58,5.52 for Spanish and 2.77, 95% CI = 0.46,16.70 for English and Spanish. However, HPV vaccine uptake (aOR = 2.26, 95% CI = 1.07,4.79) and annual flu vaccine uptake (aOR = 2.78, 95% CI = 1.39, 5.58) were positively associated with likelihood of accepting the Covid-19 vaccine with a doctor’s recommendation after controlling for other potentially confounding variables.
Table 4. Multivariable analysis of likelihood of accepting the COVID-19 vaccine if doctor recommends it by characteristics (N = 342)
Discussion
This study demonstrated that the number of young low-income women in our region willing to get vaccinated against Covid-19 is suboptimal. Only about half stated they would accept the vaccine if their doctor recommended it and only one-third planned to get it as soon as it was available to them. This is much less than reported by national pollsCitation1 and falls far short of the 80+ percent needed to achieve herd immunity in the US.Citation5 Thus, vaccination of an adequate number of individuals could take a substantial amount of time. Examination of uptake rates for other available vaccines recently marketed in the US which are recommended for adults is not encouraging. The shingles vaccine, which now requires 2 doses, is recommended for individuals over age 50.Citation6 Even though shingles is a painful disease and can lead to postherpetic neuralgia, only 35% of the population over age 60 have obtained even one dose of this vaccine since its approval in 2017.Citation7 Uptake of the HPV vaccine among adults is also low. Catch-up vaccination up to age 26 was first recommended in 2006.Citation8 By 2018, only 40% of young adults 18–26 years old had obtained even one dose of the HPV vaccine series.Citation9 Based on these other recently approved vaccines, it appears it will take a significant amount of time to vaccinate a large percentage of US adults against Covid-19.
Women in this study were more likely to agree they would get vaccinated if their physician recommended it as opposed to an employer, family member or friend. This demonstrates the critical need to involve primary care physicians in vaccine distribution efforts. This is consistent with studies conducted on HPV vaccination. Due to the low uptake of the HPV vaccine in the early years after its approval, researchers investigated why some parents elected to vaccinate their child and others did not. The primary reason cited by parents was that their physician recommended it.Citation10,Citation11 The strength of the recommendation was also found to be a factor.Citation12 As a result, the CDC now recommends that physicians use every opportunity to recommend the HPV vaccine and use strong, unequivocal language.Citation13 Lessons learned during the prolonged roll out of the HPV vaccine could be instrumental in developing guidelines for physicians in how to counsel patients on the importance of Covid-19 vaccination.
We also observed that women who had not been vaccinated against HPV or did not get an annual flu shot were less likely than those who did to state they would accept the Covid-19 vaccine if recommended by their doctor. This suggests that women who fail to obtain other recommended vaccines are less likely to obtain this one. Vaccine hesitancy is a significant problem in the US with 1 in 15 parents refusing to vaccinate their children against any diseasesCitation14 and 20% refusing to vaccinate their child against the flu.Citation15 Worldwide, the World Health Organization lists vaccine hesitancy as one of the top ten threats to global health.Citation16 Since mandatory Covid-19 vaccination is unlikely to be a viable option, strategies need to be implemented to address vaccine hesitancy or it will not be possible to achieve herd immunity.
It is reassuring that women influenced by social media were more likely to accept the vaccine if their doctor recommended it. Prior studies have similarly demonstrated that social media can have an impact on parents’ attitudes toward vaccinating their children.Citation17 However, this impact is not always positive. A systemic review found that social media lowered HPV vaccination rates in some populations due to exposure to negative, anti-vaccine content.Citation18 With regards to the Covid vaccines, there is concern that incorrect information could spread across the web by those in the anti-vaccine movement and increase vaccine hesitancy. One strategy suggested to combat this negative effect is to have healthcare providers and agencies use social media to communicate with their patients. This could have a positive effect as healthcare providers could address vaccine myths and decrease fears.Citation19
One strength of this study is that it included low-income women who often do not participate in internet surveys or polls. Furthermore, we had a diverse population which allowed us to examine differences by race/ethnicity and preferred language. There were also several weaknesses. All women resided in south Texas, so it is not known if our findings are generalizable to low-income women living in different geographical regions. Furthermore, we do not know if women who reported they were willing to be vaccinated will agree when it is offered. Prior studies on intent to vaccinate have shown that while intent is not a complete predictor of action, both intent and action are significantly correlated.Citation20,Citation21 In addition, we do not know the actual refusal rate as our institutional review board required that front desk personnel distribute the surveys and they did not track refusals. Furthermore, this survey represents only a snapshot in time. As more information on the vaccines is disseminated, it is possible that attitudes will change. It would be of value to re-survey these women in the future to see what percentage did receive the vaccine.
Overall, we found that only half of the young women included in this survey are willing to be vaccinated against Covid-19, even if their physician recommends it. Although suboptimal, intent was higher if their physician recommended it as compared to others. This demonstrates the importance of educating physicians on how to counsel patients about the need to obtain this potentially life-saving vaccine. To reach herd immunity, it will be critical to help vaccine-hesitant individuals overcome their concerns about the vaccine’s safety and efficacy. This is essential to protect individuals from this deadly infection who are not able to be vaccinated due to a medical condition.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Supplemental Material
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Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2021.1918994.
References
- Funk C, Tyson A. Intent to get a COVID-19 vaccine rises to 60% as confidence in research and development process increases. Pew Research Center Science & Society; 2020 Dec 3 [accessed 2021 Jan 23]. https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/ .
- Reiter PL, Pennell ML, Katz ML. Acceptability of a COVID-19 vaccine among adults in the United States: how many people would get vaccinated? Vaccine. 2020;38(42):6500–07. doi:10.1016/j.vaccine.2020.08.043.
- Khubchandani J, Sharma S, Price JH, Wiblishauser MJ, Sharma M, Webb FJ. COVID-19 vaccination hesitancy in the United States: a rapid national assessment. J Community Health. 2021 Jan 3;46:1–8. Epub ahead of print. doi:10.1007/s10900-020-00958-x.
- Head KJ, Kasting ML, Sturm LA, Hartsock JA, Zimet GD. A national survey assessing SARS-CoV-2 vaccination intentions: implications for future public health communication efforts. Sci Commun. 2020;42(5):698–723. doi:10.1177/1075547020960463.
- McNeil DG Jr. How much herd immunity is enough? The New York Times. 2020 Dec 24 [accessed 2021 Jan 23]. https://www.nytimes.com/2020/12/24/health/herd-immunity-covid-coronavirus.html .
- Dooling KL, Guo A, Patel M, Lee GM, Moore K, Belongia EA, Harpaz R. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018;67(3):103–08. doi:10.15585/mmwr.mm6703a5.
- Terlizzi EP, Black LI. Shingles vaccination among adults aged 60 and over: United States, 2018. NCHS Data Brief, no 370. Hyattsville (MD): National Center for Health Statistics; 2020.
- Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR–2):1–24. PMID: 17380109.
- Boersma P, Black LI. Human papillomavirus vaccination among adults aged 18−26, 2013−2018. NCHS Data Brief, no 354. Hyattsville (MD): National Center for Health Statistics; 2020. PMID: 32487295.
- Dorell C, Yankey D, Kennedy A, Stokley S. Factors that influence parental vaccination decisions for adolescents, 13 to 17 years old: National Immunization Survey-Teen, 2010. Clin Pediatr (Phila). 2013;52(2):162–70. doi:10.1177/0009922812468208.
- Gargano LM, Herbert NL, Painter JE, Sales JM, Morfaw C, Rask K, Murray D, DiClemente RJ, Hughes JM. Impact of a physician recommendation and parental immunization attitudes on receipt or intention to receive adolescent vaccines. Hum Vaccin Immunother. 2013;9(12):2627–33. doi:10.4161/hv.25823.
- Gilkey MB, Calo WA, Moss JL, Shah PD, Marciniak MW, Brewer NT. Provider communication and HPV vaccination: the impact of recommendation quality. Vaccine. 2016;34(9):1187–92. doi:10.1016/j.vaccine.2016.01.023.
- Centers for Disease Control and Prevention. For healthcare professionals: five ways to boost your HPV vaccination rates. [ accessed 2021 Jan 23]. https://www.cdc.gov/hpv/hcp/boosting-vacc-rates.html .
- Kempe A, Saville AW, Albertin C, Zimet G, Breck A, Helmkamp L, Vangala S, Dickinson LM, Rand C, Humiston S, et al. Parental hesitancy about routine childhood and influenza vaccinations: a national survey. Pediatrics. 2020;146(1):e20193852. doi:10.1542/peds.2019-3852.
- Santibanez TA, Nguyen KH, Greby SM, Fisher A, Scanlon P, Bhatt A, Srivastav A, Singleton JA. Parental vaccine hesitancy and childhood influenza vaccination. Pediatrics. 2020;146(6):e2020007609. doi:10.1542/peds.2020-007609.
- World Health Organization. Ten threats to Global Health in 2019 [accessed 2021 Jan 23]. https://www.who.int/emergencies/ten-threats-to-global-healthin-2019 .
- Melovic B, Jaksic Stojanovic A, Vulic TB, Dudic B, Benova E. The impact of online media on parents’ attitudes toward vaccination of children-social marketing and public health. Int J Environ Res Public Health. 2020;17(16):5816. doi:10.3390/ijerph17165816.
- Ortiz RR, Smith A, Coyne-Beasley T. A systematic literature review to examine the potential for social media to impact HPV vaccine uptake and awareness, knowledge, and attitudes about HPV and HPV vaccination. Hum Vaccin Immunother. 2019;15(7–8):1465–75. doi:10.1080/21645515.2019.1581543.
- Puri N, Coomes EA, Haghbayan H, Gunaratne K. Social media and vaccine hesitancy: new updates for the era of COVID-19 and globalized infectious diseases. Hum Vaccin Immunother. 2020;16(11):2586–93. doi:10.1080/21645515.2020.1780846.
- Liao Q, Cowling BJ, Lam WWT, Fielding R. Factors affecting intention to receive and self-reported receipt of 2009 pandemic (H1N1) vaccine in Hong Kong: a longitudinal study. PLoS ONE. 2011;6(3):e17713. doi:10.1371/journal.pone.0017713.
- Walling EB, Benzoni N, Dornfeld J, Bhandari R, Sisk BA, Garbutt J, Colditz G. Interventions to improve HPV vaccine uptake: a systematic review. Pediatrics. 2016;138(1):e20153863. doi:10.1542/peds.2015-3863.