A qualitative study exploring the relationship between mothers’ vaccine hesitancy and health beliefs with COVID-19 vaccination intention and prevention during the early pandemic months

ABSTRACT

Vaccine hesitancy is a top ten global health threat that can negatively impact COVID-19 vaccine uptake. It is assumed that vaccine refusers hold deep, negative beliefs, while acceptors hold strong, positive beliefs. However, vaccine hesitancy exists along a continuum and is multidimensional, varying by time, place, vaccine, subgroup, and person. Guided by the Health Belief Model and vaccine hesitancy frameworks, the study purpose was to qualitatively explore maternal COVID-19 threat perceptions and willingness to accept a COVID-19 vaccine in light of their expressed vaccine hesitancy toward past school required and routinely recommended vaccines and the HPV vaccine for their children. Researchers conducted twenty-five interviews with US Midwestern mothers during the early COVID-19 pandemic months. Mothers were grouped by vaccine hesitancy categories and thematic analysis was used to analyze the data within and across categories. Results showed that prior vaccine hesitancy attitudes and behavior did not fully capture maternal acceptance of COVID-19 vaccine or perception of COVID-19 threat. Perceptions of COVID-19 threat did influence mothers’ decisions about COVID-19 protective behaviors (e.g., handwashing, mask wearing, and distancing). However, mothers were hesitant to accept the COVID-19 vaccine across vaccine hesitancy categories, primarily citing concerns about safety, efficacy, and confusion over conflicting information as barriers to immediate COVID-19 vaccine acceptance. Findings indicate that mothers cannot be grouped together based on hesitancy about, or acceptance of, other vaccines for purposes of assuming COVID-19 preventive behavior adherence or anticipated COVID-19 vaccine acceptance.

KEYWORDS:

• COVID-19 vaccine
• SARS-CoV-2
• vaccine hesitancy
• maternal
• qualitative
• threat

Introduction

With more than 451 million COVID-19 cases worldwide (as of May 2021), ensuring global access to vaccination is a priority to end the pandemic.^1,2 However, SARS-CoV-2 vaccination (hereafter referred to as COVID-19 vaccination) success will depend upon widespread immunization acceptance so that herd immunity is achieved.^1,3 Given that the World Health Organization (WHO) has identified vaccine hesitancy as a top 10 global health threat,⁴ vaccine acceptability by the general public means combatting vaccine hesitancy, which includes addressing vaccine safety, choice, and need.³

While adults may express hesitancy about vaccines for themselves, the majority of the work in vaccine hesitancy has focused on parents. In the United States, parental hesitancy toward vaccination has been prevalent and has likely increased since the H1N1 influenza pandemic of 2009.⁵ US parents are typically responsible for not only their own vaccination decisions but also those of their children. Studies show that mothers, in particular, are most often the primary decision makers for their children’s vaccination.⁶ Additionally, mothers have had increased caregiving roles in the home, taking on more of the household and childcare responsibilities, reducing their hours of work, and leaving their jobs entirely in response to the pandemic;^7,8 they are near and present to discuss the pandemic with their families. Thus, mothers’ decisions about the COVID-19 vaccine are particularly relevant to explore, especially given that COVID-19 vaccination is now available for persons 12 years of age and older and pediatric trials with younger children are under way.

Current COVID-19 vaccine intentions and hesitancy

Vaccination intentions are shown to be a good predictor of subsequent behavior,⁹ and understanding the development of COVID‐19 vaccination intentions among the public is vital because a vaccination program is the most effective strategy against the COVID‐19 outbreak.^3,10 As Wong et al. (2020, p. 2204) recommends, “Urgent investigation is warranted of the acceptability of a hypothetical COVID‐19 vaccine in order to prepare for its public availability.”^10,11

Research on COVID-19 vaccine attitudes is evolving, indicating improved acceptability in some populations and circumstances and lagging acceptability in others, demonstrating the need for interventions aimed at addressing COVID-19 vaccine hesitancy. For example, an initial survey of the adult population reported that most adults would be very or somewhat likely to accept a COVID-19 vaccine if it were proven safe and effective.¹² Those who believed that COVID-19 poses a physical threat and is a major community problem also reported higher intent.¹³ A more recent poll found that about 50% of adults now say they want the COVID-19 vaccine as soon as possible, which is up from a third of the population in December.¹⁴ Another study of the adult population reported 62% of vaccine skeptics would not get vaccinated in comparison to 15% of those supportive. Notably, although 14% self-identified as an anti-vaxxer, only 44% of these said they would not vaccinate against COVID-19.¹⁵ Although this situation has been improving, Black and Hispanic people have received less COVID-19 vaccinations than non-Hispanic White Americans, which is particularly concerning given the large race-based disparities in COVID-19 illness and death.¹⁶

In terms of parents’ intentions for their children, a few initial studies examined parental attitudes and intentions toward the COVID-19 vaccine, but of those referenced, only one was with the US population and most applied survey methodology. Bell et al. (2020) found that parents and guardians in England reported higher acceptance for themselves (55.8%) than for their children (48.2%).¹⁷ Other global studies have reported parental intentions to vaccinate their children that range from approximately 44% – 73%.^18–20 The study by Goldman et al. (2021) on US parents found that the majority intend to vaccinate their children, although uptake was dependent upon specific factors, including being up to date on their required vaccines.²¹ Currently, at the time of writing, two recent polls report diverse results. A Kaiser Family Foundation poll found that 29% of parents of 12–15-year-old children would get their children vaccinated right away, while 32% would wait. Only 19% said they would definitely not get their child vaccinated.²² Another preliminary poll found that 1 in 4 US parents surveyed do not plan to vaccinate their children nor do they support school-required COVID-19 vaccines.²³ Mothers were more skeptical of vaccines than fathers.²³

These mixed findings suggest that 1) those who do not intend to get the COVID-19 vaccine for themselves or their children may not be anti-vaccine more generally, 2) conversely, it cannot be assumed that someone who generally holds anti-vaccine views will not get the COVID-19 vaccine, and 3) it is unclear why mothers are unwilling to accept vaccination for their children and whether their past attitudes and behaviors toward vaccines may translate to attitudes and behaviors toward the COVID-19 vaccine.

Theoretical conceptualization: the health belief model

In conceptualizing mothers’ intentions toward the COVID-19 vaccine, a model useful for understanding intentions to vaccinate against COVID-19 is the health belief model (HBM).²⁴ The premise of the HBM is that an individual must be in a state of psychological willingness to make a health behavior change to prevent disease.²⁵ Vaccine decision-making can be explained by the HBM, which conceives vaccination behaviors as an output of an individual’s perceptions about a disease and its related vaccine.²⁵ According to the HBM, people’s beliefs, which are their perceived severity of and susceptibility to the disease and their perceived benefits and risks of the vaccine, relate to health behaviors.^26,27 These constructs significantly predict intentions to vaccinate.^25,28,29

As defined in this study and others, perceived benefits are the belief that COVID‐19 vaccine uptake will reduce the risk of disease threat.¹⁰ Perceived barriers encompass beliefs that psychosocial (e.g., perceiving vaccination as dangerous), physical, or financial factors interfere with intention to get COVID‐19 vaccine.¹⁰ Perceived severity is the belief that the disease consequences are serious for oneself and others, while perceived susceptibility is the belief that there is high risk of getting the disease.^10,11 Together, these two constructs (susceptibility and severity) encompass threat, and some studies in vaccination, including COVID-19 vaccination, have reported that people who feel threatened or perceive high levels of risk of COVID‐19 disease are more likely to express higher levels of intentions to vaccinate against COVID‐19.^11,30,31

Additionally, while vaccination intentions have been the primary focus of disease prevention, threat perceptions might also affect COVID-19 preventive behavior adherence needed to delay the spread of COVID-19 before herd immunity is achieved through vaccination.³² The CDC has recommended that non-pharmaceutical interventions are imperative for delaying the spread of SARS-CoV-2,³² and several research studies have examined whether people are complying with precautionary behaviors and/or their determinants for doing so.^33–38 Some research indicates that perception of risk or susceptibility is predictive of voluntary engagement in protective behaviors during prior infectious disease outbreaks.^39,40 A Netherlands-based study of risk perceptions of the SARS outbreak in the early 2000s showed that < 3% believed susceptibility or seriousness of SARS to be high and that perceived risk was negatively associated with perceived ability to avoid SARS through protective behaviors.⁴¹

In the case of COVID-19 prevention, there are a plethora of pathways by which parents might conceptualize risk, such as employing compression bias (e.g., overestimate vaccine side effects) or ambiguity aversion (e.g., favor known risks like a disease over unknown risks like vaccine side effects).⁴² Research is still needed to understand how mothers are assessing COVID-19 threats in their own lives and how threat perception may influence the behaviors – particularly vaccination – that they are willing to take to mitigate that risk.⁴³ However, because scholars have argued that vaccine hesitancy is driven by individual factors such as beliefs about threat of disease as well as context-specific factors including time, place, and type of vaccine,^6,13,44,45 it is important to explore perception of threat along with mothers’ past vaccine intentions and behaviors as they exist along a continuum of hesitancy.

Vaccine hesitancy continuum

Given ongoing, wavering sentiment toward the COVID-19 vaccine for both adults and their children, it is important to recognize that vaccine beliefs exist along a continuum of vaccine hesitancy. The vaccine hesitancy continuum framework postulates that vaccine beliefs do not exist within a dichotomy of pro- and anti-vaccine beliefs, but more accurately exist along a continuum that ranges from mild to extreme hesitancy.^6,45,46 Hesitancy is also multidimensional, varying by time, place, vaccine, subgroup, and person.^6,45,46 Vaccine-hesitant parents may therefore accept certain vaccines for their children, refuse others, delay initiation, or accept, but feel unsure about doing so.^6,45,46 As such, a limitation to education and interventions for addressing parental vaccine hesitancy lies in treating all varieties of hesitancy the same.⁴⁴

The vaccine hesitancy literature clearly shows that mothers’ vaccination beliefs disproportionately impact child and adolescent vaccination coverage rates, with high uptake for some vaccines, typically those that are school required and routinely recommended (Measles-Mumps-Rubella, Diphtheria-Tetanus-Pertussis) and low coverage rates for non-required vaccines.⁴⁷ The continuum of hesitancy is especially evident in regard to parental decisions about non-required vaccines, which can vary according to state and district.⁴⁸ For instance, the HPV vaccine, which is recommended but not required in nearly all US states, suffers from low adolescent coverage.⁴⁸ A recent national survey found that 36% of parents reported having refused or intentionally delayed HPV vaccination for their adolescent children,¹² which is a prevalence higher than declination of other vaccines routinely recommended and required for adolescents.^48–50

The HPV vaccine is not the only vaccine that is not required for school entry in most US states. The majority of states, for example, do not require hepatitis A vaccine or meningococcal B vaccine for entry into middle school or high school. The HPV vaccine differs from the COVID-19 vaccine due to factors such as ideologies around sexual activity, confusion over marketing for males, and confusion about HPV infection.⁴⁴ However, it also shares some environmental commonalities with the COVID-19 vaccine. Like the HPV vaccine, the COVID-19 vaccine is also viewed as controversial, perceived as “new” (despite the fact that HPV vaccine has been licensed since 2006), suffers from largely unwarranted safety concerns, and can require multiple doses, depending on the manufacturer (COVID-19).⁴⁴ Therefore, there may be an advantage to studying mothers’ attitudes toward the COVID-19 vaccine, including their perceptions about threat of COVID-19, according to attitudes toward both general childhood vaccinations (defined as school required and routinely recommended, e.g., Tdap and MenACWY) and non-required vaccines (HPV). Consideration of both may be a better indicator of their beliefs and acceptance of a COVID-19 vaccine than by general childhood vaccines alone, which are typically mandated for school entry and thus may be accepted for reasons external to their beliefs. Therefore, to qualitatively explore mothers’ COVID-19 vaccine intentions, the following research questions were proposed:

(RQ1): What is the role of vaccine hesitancy in mothers’ intentions to obtain COVID-19 vaccination for themselves and their older children?

(RQ2): What are mothers’ barriers to COVID-19 vaccine acceptance within and across vaccine hesitancy categories?

(RQ3): How do mothers perceive threat of COVID-19 within and across vaccine hesitancy categories?

(RQ4): What is the role of threat in mothers’ willingness to obtain COVID-19 vaccination for themselves and family and practice COVID-19 prevention behaviors within and across vaccine hesitancy categories?

Methods

This study was situated within a larger project with the purpose of assessing Indiana mothers’ perceptions of school required and routinely recommended vaccines, the HPV vaccine, and other health behaviors for their 15–26-year-old children. Due to the timing of the interviews that corresponded with the early COVID-19 lockdown mandate in Indiana, additional questions were included to gauge Indiana mothers’ perceptions about the COVID-19 vaccine. The results of these additional interview questions are presented in this study.

Participants

For the current study, the authors conducted 25 individual interviews with US mothers between March and May 2020. The sample was obtained through a combination of volunteer and snowball sampling. The lead author initially approached mothers affiliated with a parent advisory group associated with a midwestern pediatric medical department via e-mail and invited them to participate. Additional recruitment was done through sampling from initial participants in the parent advisory group, who were asked to pass on information about the study to interested mothers who met the study inclusion criteria. Mothers were eligible to participate if they had at least one child who was 15–26 years old who lived at home or had returned home for the pandemic and resided in Indiana. The age span was supported as our population age for two reasons. First, studies show that adolescents age 15 years and older are generally as competent as adults in their ability to make medical decisions^51–53 Second, our research,⁵⁴ which is supported by others,⁵⁵ indicates parents are still influential in health decisions and management of the health of their older children.

Data collection

Once participants were recruited, eligible participants contacted the lead researcher to schedule a phone interview. All interviews were conducted by the lead author and principal investigator virtually by phone. The lead author was selected for her ability to establish rapport with participants by relating to them on a personal level (as a mother with young adult children), which allowed for encouragement of open answers about family health and vaccination.

As part of the original interview guide about family health issues and vaccination, participants were asked a series of open-ended questions about their attitudes, beliefs, and acceptance of school required and routinely recommended vaccines and the HPV vaccine. The original questionnaire also asked when each type of vaccine (school required and routinely recommended and HPV) was accepted and the reason for hesitancy. As the study corresponded with the onset of the pandemic, the participants’ natural responses included frequent mention of COVID-19. Therefore, we set aside our preconceived directions for the interview and for this study utilized emergent design principles inherent in qualitative research to adapt our interview guide to also include questions that further explored mothers’ perceptions about willingness to obtain the COVID-19 vaccine for themselves and their families, perceptions of health beliefs about COVID-19 vaccination (e.g., benefits, barriers, and threat), and belief in and uptake of COVID-19 preventive behaviors. These final questions used for the current study were situated around the context of understanding the role of vaccine hesitancy in mothers’ intentions to vaccinate (RQ1), the barriers to COVID-19 vaccination within and across vaccine hesitancy categories (RQ2), perceptions of COVID-19 preventive behaviors within and across vaccine hesitancy categories (RQ3), and the role of threat in COVID-19 vaccination and prevention within and across vaccine hesitancy categories (RQ4). Due to overwhelming resistance to COVID-19 vaccination, there was little mention of vaccine benefits, thus results did not include discussion of benefits.

Interviews were audio-recorded and transcribed verbatim by the lead author. All identifying information was removed to protect personal identities. Interviews lasted approximately 30 minutes. Participants received a 20 USD gift card for their participation. The study received human subject approval from the principal investigator’s university as exempt status (pro00041072), with participant written informed consent waived.

Data analysis

Based upon participants’ interview responses as to their decisions about school required and routinely recommended vaccines and the HPV vaccine for their children and their hesitancy about these vaccines, the researchers first grouped participants into one of four vaccine hesitancy categories for purposes of exploring comparisons and potential variation in the four research questions about health beliefs, vaccine hesitancy, intentions toward COVID-19 vaccine, and COVID-19 prevention behaviors. The four categories of participants included: 1) opposing of all school required and routinely recommended and HPV vaccines, 2) accepting of all school required and routinely recommended and HPV vaccines (e.g., on schedule and/or immediately upon referral), 3) accepting of school required and routinely recommended vaccines/hesitant accepting of HPV and 4) accepting of school required and routinely recommended vaccines/not accepting of HPV vaccine. The whole of mothers’ responses for multiple children were used, as decisional responses did not differ for children of qualifying age (See Table 1).

Table 1. Demographics of participants and operational definitions

Demographics	N	(%)
Education
Some college	2	(8.0%)
Bachelor’s degree	17	(68.0%)
Graduate degree	6	(24.0%)
Age
29–39	3	(12.0%)
40–49	15	(60.0%)
50–59	7	(28.0%)
Race
White	21	(84.0%)
Black	3	(12.0%)
Asian	1	(4.0%)
Children
Female	30	(49.0%)
Male	31	(51.0%)
Adolescents (high school)	18	(30.0%)
Older Children (college +)	43	(70.0%)
Hesitancy Categories
Opposed to all vaccines – Refused school required and routinely recommended and HPV vaccines for children	2	(8.0%)
Accepting of all vaccines – Accepted school required and routinely recommended and HPV vaccines for children on schedule and/or immediately upon referral	8	(32.0%)
Accepting of school required and routinely recommended/hesitant accepting of HPV – Accepted required but delayed (e.g. not on schedule or immediately upon referral) HPV vaccine for children	8	(32.0%)
Accepting of school required and routinely recommended/not accepting of HPV – Accepted required vaccines for children on schedule but declined HPV vaccine for children	7	(28.0%)

Following participant placement into vaccine hesitancy categories, the researchers then applied thematic content analysis using an established qualitative approach to identify themes and patterns within and across vaccine hesitancy categories^56,57 The analysis approach was driven by the researcher’s theoretical or analytic interest in the area and identified themes that were strongly related to the questions asked of the participants and the research questions posed for the study.

According to Braun and Clarke’s thematic content analysis approach (2006; 2019),^56,57 the researchers first conducted multiple-transcript readings that were discussed among the research team. From the first readings, researchers developed initial impressions of the data by coding distinct ideas followed by the identification of emergent themes as guided by HBM and the study’s research questions. The coded transcripts were discussed among the research team in an iterative manner for agreement on the code meanings. Emergent patterns and themes across the codes were discussed and reviewed by the researchers to confirm that the codes reflected study topics. Importantly, initial analysis began after 15 interviews were conducted, and members of the team met repeatedly to discuss these emerging codes and findings. Concurrently, the lead author proceeded with interviews and continued testing and refining the emerging codes and themes until interviews produced no new information or insight, suggesting saturation. While no major disagreements on coding or themes emerged among the team members, the lead author made final decisions on the organization of the themes and subthemes. Consistent and close readings of the transcripts allowed for fidelity to the thematic analysis method and the data. The lead author then returned to the transcripts to identify exemplar quotes and proceeded to compile the findings, all organized by the four vaccine hesitancy categories. The findings presented from the data for each research question contain responses from all 25 participants.

Findings

Sample

The sample consisted of 25 mothers, primarily from the greater Indianapolis metro area, aged 36–58 years, with the majority having a bachelor’s degree or higher (92%) and identifying as White (84%). Mothers had 61 children in total, 51% male and 49% female. Thirty percent of children were in high school, and 70% were young adults, college age or older. Percentage of respondents in vaccination hesitancy categories were roughly even, with the exception of those opposed to all vaccines (8%). (Table 1)

RQ1: What is the role of vaccine hesitancy in mothers’ intentions to obtain COVID-19 vaccination for themselves and their older children?

Overall, across all vaccine hesitancy categories, only four mothers out of the 25 were willing to immediately accept a COVID-19 vaccine for themselves and their children upon availability. The four who would accept included two mothers out of the 8 who had accepted all vaccines for their children as well as one mother out of the 7 who had not vaccinated her child for HPV. Additionally, one mother out of the 8 who had initially delayed the HPV vaccine for her child was also willing to accept COVID-19 vaccine for herself and her children.

The other 21 mothers across all hesitancy categories indicated that they would reject (n = 4) or delay (n = 10) COVID-19 vaccination or were unsure (n = 7) about getting the vaccine. Mothers who were hesitant or believed they would refuse included 13 of the 16 mothers who had eventually accepted all vaccines for their children, including the HPV vaccine, which many participants also perceived as new. For instance, participant 1, who vaccinated her daughter against HPV immediately upon provider recommendation said, “I mean to be quite honest, I don’t know if I would be first in line for you know when it first comes out.” Similarly, participant 2, who immediately accepted the HPV vaccine for her children and who felt she had “never been alive during a time when such an important vaccine has been screamed for” still said: “I will probably wait. Is the cure worse than the actual virus itself?” Participant 3, who hesitantly accepted the HPV vaccine for her adolescent daughter said, “I would listen to doctor, but yeah I would have to be really hard core change my opinion to get the COVID vaccine.”

Six out of seven mothers who had refused the HPV vaccine but accepted school required and routinely recommended vaccines were also unwilling to immediately accept the COVID-19 vaccine for themselves and their children as well as both mothers who had not chosen to give any vaccines to their children. Of the two who had not accepted any vaccines for her children, one would not recommend it to her young adult child, saying, “Would it push me to get a vaccine? I don’t know if it would prompt me to let go of everything I feel or think I know and say let me go ahead and get this vaccine” (Participant 4). The other mother (Participant 5) was unsure about getting it for herself or recommending it to most of her adult children but does hope that her adult son with cancer will get it.

RQ2: What are mothers’ barriers to COVID-19 vaccine acceptance within and across vaccine hesitancy categories?

Across all vaccine hesitancy categories, mothers reported safety, skepticism about efficacy, feeling rushed, and confusion about contradictory and changing COVID-19 information as barriers to COVID-19 vaccine acceptance.

The most prevalent barrier to the COVID-19 vaccine for mothers across all hesitancy categories was safety; they did not want to gamble with the outcome of such a new vaccine. Instead, they wanted to wait to see how others do with it and wanted more data before deciding to get it. Some mothers were influenced by their spouses or stated that their spouses agreed to wait. As Participant 6, who had not accepted the HPV vaccine for her young adult children said, “Husband wants to wait to see how other people are who get it. He likes to have a little more research.” Participant 7, who hesitantly accepted the HPV vaccine for her children, said she and her family would be willing to get the vaccine only if there are clear data supporting its safety, and she hopes others feel the same: “If there is really good data on the vaccine, then I hope we all go euphoric for it (vaccine), but I’d want to see the data.”

Skepticism that the COVID-19 vaccine would be effective in preventing disease was expressed alongside concerns for safety across categories. As participant 8, who had accepted all vaccines for her children stated, “I will probably wait. Is the cure worse than the actual virus itself? I might be a little concerned that if it is rushed that there may be some long-term ramification.”

Mothers across categories felt rushed to make a decision and felt such a shortened time was a barrier to acceptance. The majority of mothers wanted time to look for and weigh vaccine information carefully. For example, participant 9, an African American mother who had accepted all school required and routinely recommended vaccines and the HPV vaccine for her children, said, “I’m a researcher and in God we trust, and all others must show data … I’m saying I would want some evidence of effectiveness, you know, not 38% effectiveness.” Participant 10, who had not accepted the HPV vaccine for her children also said, “What will be talked about (in family) when it (vaccine) comes is how safe is it? Will we wait until they know how effective it is?”

Confusion over what COVID-19 information to believe was also mentioned as a barrier to vaccine uptake by mothers in all hesitancy categories because it affected belief in the vaccine’s importance and efficacy. As Participant 11, who accepted all school required and routinely recommended and HPV vaccines for her children said, “There is just information coming from everywhere. Disinformation is rampant.” Participant 12, who did not accept the HPV vaccine for her child, also explained that information continuously changed as the pandemic changed, making it hard to know what to think about the need for a vaccine: “The whole pandemic is fluid, is constantly changing. New information finally comes out. The right and wrong thing is hard to pinpoint.”

Participant 4, who had not accepted any vaccines for her child, demonstrated that she was somewhat vigilant about monitoring conflicting information, and the location of such conflicting information about COVID-19 supported her belief that a vaccine was likely unnecessary for her: I was reading something, might have been a newspaper, something it was an op-ed and it was talking about how many cases of people who get the flu versus diagnosis with COVID in comparison. It is so staggering with more who die and get the flu. Point of the article is why COVID? Why framed, why getting the attention because the flu is far worse … So much when you expose yourself to so many opinions, it’s hard to arrive at conclusions.

RQ3: How do mothers perceive threat of COVID-19 within and across vaccine hesitancy categories?

Most mothers in this sample across all hesitancy categories (n = 21) perceived COVID-19 as a significant, serious threat. For instance, participant 7, who delayed but eventually accepted the HPV vaccine for her children, stated that preventive behaviors are crucial given “this particular virus is beyond the scope of anything we have seen.” Mothers who saw COVID-19 as a high threat also included six of seven mothers who had not yet accepted the HPV vaccine for their children due to perceived lack of need for it.

On the other hand, there were both participants who had not accepted any vaccines for their children (participants 4 and 5) and those who had accepted the HPV vaccine, albeit hesitantly (participants 13 and 14), who did not see COVID-19 as a serious threat to their family. Participant 13, who delayed the HPV vaccine but eventually accepted, explained that “when it comes to us and our family, our risk level is low. And even if we get it, the stats are so high that we will recover.” This mother felt that the closing of businesses is setting a precedent of fear:“Every once in a while, there is a virus that comes around and for the economy to shut down every time this happens is setting a dangerous precedent.” Participant 14, who delayed the HPV vaccine because she was not sure her children needed it, did not fear the virus for her family and was frustrated with stay-at-home orders, stating,“So, I have been annoyed about all of these restrictions because I don’t feel they are very helpful generally. Kids not being able to go to (the) park, I think is ridiculous because that is a place for building health immunities and stuff like that.” This mother did believe, as some others did, that her parents in their 70s and 80s should get the vaccine.

Participants who had not accepted any vaccines for their children expressed low COVID-19 perceived threat, whether due to distrust of government messaging about the pandemic’s seriousness or due to other priorities that precluded focus on COVID-19. As participant 4 stated, “I don’t trust the government. The degree they will lie. The only truth I believe is that people have germs and germs can spread.” Participant 5, who has an adult son with cancer, said her son’s cancer takes precedence over the threat of COVID-19: “This COVID will only last a year and everyone will go on their merry way, not like some cancers … ”

RQ4: What is the role of threat in mothers’ willingness to obtain COVID-19 vaccination for themselves and family and practice COVID-19 prevention behaviors within and across vaccine hesitancy categories?

Among the respondents, perception of COVID-19 threat did not entirely align with mothers’ willingness to accept an anticipated COVID-19 vaccine for themselves and their family primarily because 21 out of 25 mothers were unwilling to immediately accept it, regardless of perceived threat. Of the four mothers who would accept, each saw COVID-19 as a high threat, but so too did 17 other mothers who were hesitant or unwilling to accept.

In contrast, adherence to COVID-19 protective behaviors did generally align with perception of threat: Those who perceived high COVID-19 threat willingly practiced preventive behaviors, while those who perceived low COVID-19 threat did not. Participants who saw COVID-19 as high threat all mentioned wiping down objects, limiting visits with others, monitoring children under-shared custodial arrangements, social distancing, and cleaning. Preventive measures meant having difficult discussions and decisions with family, including the need to keep an adult son at college to protect a newborn grandchild (participant 15, accepting of all vaccines). Participants described keeping their adolescents home from church and school activities (participant 16, hesitant HPV); keeping daughters separated from boyfriends (participant 17, accepting of all vaccines); and keeping children away from grandparents (participant 18, hesitant HPV). One African American mother (participant 12, not accepting HPV) felt that COVID-19’s severe impact on minorities made prevention especially critical to her household. As she explained, “I’m just you know a little, not necessarily afraid, but just want to take every precaution that we can so that none of us catch it.”

These mothers who perceived high COVID-19 threat were sensitive about practicing preventive behaviors to protect others, especially the elderly. For example, participant 18 (hesitant HPV) said,“My 15-year-old wants to see boyfriend and grandparents. I have to keep saying ‘How would you feel if others get it’?” Participant 19 (hesitant HPV) was especially vigilant for her elderly parents’ sake: “Parents are 76 and 77 and we clean everything. My thinking is you are not going to get COVID-19 because of me.”

The four mothers who perceived COVID-19 as a low threat to their family were not convinced that stay at home orders, social distancing, and/or mask wearing were necessary. Participant 13 (hesitant HPV) does not wear face masks and said she will not, in the future, go into a store that requires it. Participant 14 (hesitant HPV) does not feel that precautionary measures are effective, stating that “it (prevention) is more about what makes people feel better than what is effective.” Participant 4 (opposed all vaccines), who compared the threat of COVID-19 as being no more “serious than the flu” if her family should get it, was unsure about the need to wear face masks in public but did try to practice increased handwashing and cleanliness.

Discussion

The study purpose was to investigate the role of health beliefs and prior vaccine hesitancy in US mothers’ intentions to vaccinate against COVID-19 and engage in COVID-19 preventive behaviors. The study was contextualized around upcoming vaccines for COVID-19 prevention that received much media attention, making this a novel opportunity to examine mothers’ cognitive and emotional processes that impacted anticipated vaccine decision making for their families during the early pandemic months. This was especially important given the positioning of the vaccine within a social media environment laden with contradictory information and anti-vaccine sentiment.⁵⁸ This exploratory study identified that conflicting COVID-19 information was a primary barrier to mothers’ initial acceptance of the anticipated COVID-19 vaccine.

Our findings also showed that mothers’ prior vaccine attitudes and behaviors influence but did not fully capture their willingness to accept COVID-19 vaccine or perception of COVID-19 threat. Perception of threat did generally align with self-reported adherence to preventive behaviors during the pandemic. The findings are novel for considering 1) prior vaccine behavior as an antecedent to willingness to obtain a COVID-19 vaccine as defined within a vaccine hesitancy continuum that included school required and routinely recommended vaccines and the HPV vaccine and 2) the role of the HBM constructs of threat and barriers on mothers’ COVID-19 vaccine intentions and uptake of nonpharmaceutical preventive behaviors before the vaccine was available. Implications of each finding are discussed.

Implications for role of vaccine hesitancy

First, our exploratory results indicate that mothers’ prior vaccine behaviors and attitudes may not provide needed direction for understanding mothers’ COVID-19 vaccine intentions, at least in the initial pandemic phase. Most mothers across all vaccine hesitancy categories were unwilling to immediately accept the COVID-19 vaccine due to safety concerns. Safety concerns have also been cited as a primary barrier to the HPV vaccine, which is also perceived as new by mothers, even though it has been approved since 2006.⁵⁹ Findings confirm the vaccine hesitancy continuum ideology,^6,45,46 showing that although parents may have accepted other or even all vaccines for their children, they may not be willing to accept this vaccine. This is because vaccine hesitancy is a set of beliefs and processes that are affected by contextual factors, which ultimately affect vaccine behavior.⁶⁰ In regard to the COVID-19 vaccine, findings suggest that 1) there may be some overall initial resistance to maternal acceptance of a COVID-19 vaccine for themselves and their family and 2) positive maternal attitudes and behaviors toward prior school required and routinely recommended vaccines and the HPV vaccine may not be a good indicator of willingness to accept a COVID-19 vaccine but may suggest that additional information on safety may prove reassuring.

Second, findings showed that mothers’ attitudes and behaviors toward prior vaccines also did not entirely influence their perceptions of COVID-19 threat. Although the majority of mothers perceived COVID-19 as a severe threat to their families, there were some mothers not accepting of any vaccines for their children as well as mothers who had accepted or hesitantly accepted all school required and routinely recommended vaccines and the HPV vaccine for their children who did not perceive COVID-19 as a high threat. Health professionals, therefore, should not assume that mothers will see COVID-19 as a threat that justifies vaccination just because they have been accepting of other vaccines in the past. However, although past vaccine hesitancy alone did not seem to drive mothers’ perceptions of COVID-19 threat in the early pandemic months, there is value to continued exploration of hesitancy beliefs as they exist alongside health beliefs. This is because sound health decisions depend on accurate perceptions (e.g., health beliefs) of the costs and benefits of choices for oneself and for society, yet emotions like threat often drive these perceptions, sometimes more so than factual information.⁶¹ Future research should further investigate the directional relationships among health beliefs, threat, and preventive COVID-19 behaviors and vaccination intentions.

Threat implications for COVID-19 vaccine intentions and prevention

Third, when analyzing the role of threat in mothers’ COVID-19 prevention perception and practices, we found that threat perception did not have a primary influence on mothers’ intentions to vaccinate themselves and their older children. Rather, the concern with safety was vocalized as a strong barrier to vaccine acceptance for most mothers in all vaccine categories. Typically, the literature indicates that when individuals perceive heightened threat risk, they are more favorable toward interventions that will mitigate the threat.^62,63 Fridman and colleagues (2021) found that in relation to COVID-19, heightened threat of COVID-19 did not equate to more positive attitudes toward a vaccine and greater likelihood to get vaccinated.⁶² In a commentary about psychological determinants of vaccine hesitancy, Brewer et al. (2017) also questioned whether feelings such as risk and threat actually motivate vaccine acceptance.⁴⁴ The current study’s findings similarly suggest that the association between threat salience and COVID-19 vaccination intent may not be straight forward. Taken together, the results cast some doubt on the direct role of threat perception alone in COVID-19 vaccination intentions and imply that as a new infectious disease, mothers’ COVID-19 threat perceptions and vaccination interest are likely to be somewhat unstable and influenced by such factors as information source, family/friend perceptions, and evolving COVID-19 experiences.

However, although perceived threat did not seem to influence mothers’ willingness to get a COVID-19 vaccine, it did generally seem to influence mothers’ self-reported preventive behaviors (e.g., mothers with high perceived COVID-19 threat practiced preventive behaviors; low perceived threat did not practice). This finding showing that mothers’ threat perceptions were important to decisions about uptake of preventive behaviors represents one of a minimal number of qualitative examinations of how parents may conceptualize risk and be motivated to enact nonpharmaceutical interventions until a vaccine becomes available during a global infectious disease pandemic.

Limitations

The qualitative study nature and the small sample size drawn from one specific US state of primarily educated mothers, which are shown to affect higher predispositions toward vaccine acceptance, limit generalizability of the findings to other locations and populations. Although our final sample of mothers represented a diverse range of attitudes and behaviors toward vaccination, future studies should obtain representation from differing backgrounds for comparison. Additionally, while the current study focused on COVID-19 disease threat and vaccination, the original study – and method for grouping participants into vaccine hesitancy categories -prioritized vaccines required for school entry and the HPV vaccine in particular. Therefore, the grouping of participants into vaccine hesitancy categories should be viewed in that light. Additionally, some vaccine hesitancy categories also had small and uneven numbers of participants. A final limitation is recognizing that the study represented a snapshot of mothers’ perceptions and decisions about a theoretical vaccine during the early pandemic months. Although capturing a snapshot of vaccine attitudes during the early pandemic months surrounded by conflicting information is valuable, results may differ if asked about vaccines that were developed, approved, and made available as the pandemic evolved.

Conclusion

Given the novelty of the global COVID-19 pandemic and its unrelenting impact on health and well-being, there may be many ways to analyze and intervene to promote mothers’ COVID-19 vaccine uptake. This exploratory study considered vaccination history along with health beliefs as determinants to understanding COVID-19 vaccination and preventive behaviors. As results demonstrate that there is a broad continuum of vaccine beliefs, the whole continuum of vaccine hesitancy must be considered when communicating and planning maternal COVID-19 vaccination interventions.

Disclosure of potential conflict of interest

The authors declare the following financial interests/personal relationships, which may be considered as potential competing interests: GZ has received consultant fees from Merck & Co., Inc. and from Moderna for work on HPV vaccination and COVID-19 vaccination, respectively. He has also received research funding from Merck, administered through his university.