Exploring Why Adult Mexican Males Do Not Get Vaccinated: Implications for COVID-19 Preventive Actions

Abstract

Vaccination is the single most important preventive medicine action worldwide. However, there are inequalities in the procurement of vaccines particularly among US ethnic and racial minority males when compared to the rest of the US population. This study explored the reasons given by adult Mexican-origin males residing in Texas, for obtaining or not, immunizations. This was a cross-sectional, exploratory study with a sample of convenience of 401 adult males (age range 18–79) who were invited to participate in the study while waiting their turn to receive administrative services at the Mexican Consulate in Austin Texas. Data was collected in Spanish with a seven-item multiple choice questionnaire, using electronic tablets. The majority of respondents received their last vaccination longer than 5 years earlier. A higher percentage of individuals in the older age groups received a vaccine in the last year, as opposed to their younger counterparts who obtained their last immunization 3 to 5 years earlier. Among the reasons given for not getting vaccinated were lack of time or money, feared injections and side effects, insufficient information, interest or motivation. Others did not get vaccines because they perceived themselves to be healthy and did not feel sick. Findings from this study have important implications for future preventive medicine and vaccination practices that reach socially excluded groups in times of COVID-19. Recommendations are made to facilitate access to vaccines to the target group of this study and other socially disadvantaged populations in the global health context.

Keywords

vaccines males Mexican preventive medicine COVID-19

Introduction

According to the Center for Disease Control’s Advisory Committee on Immunization Practices, vaccination is one of the safest and most recommended preventive care measures available to preserve health among both, children and adults. Immunizations are an essential component of preventive medicine (Orenstein & Ahmed, 2017). Access to vaccines, however, varies across the U.S. population. For instance, there is an abundance of research and data suggesting that Hispanic groups have the lowest rates of vaccination compared to most other race/ethnic groups residing in the United States (Cruz-Hevert et al., 2013). The U.S. Department of Health and Human Services Office of Minority Health reported that Hispanic adults were 30% less likely to have received influenza flu shot, hepatitis, or pneumonia vaccinations compared to non-Hispanic whites within the last 12 months (USDHHS-OMH, n.d.).

Disparities in vaccination rates are even greater among Mexican migrant populations for measles, flu, and pertussis (BPT). A 2014 study concluded that Mexican immigrants are highly underserved and the type of work they do (mostly construction, agriculture, services) places this group at the greatest risk for infectious diseases. The study found that, less than one-fifth of mobile Mexican migrants received an influenza vaccination in the previous year. This is a substantially low rate compared to the overall rates found among adults living in the United States (42%) and Mexico (44%) (Ejebe et al., 2014; Hughes et al., 2018). A 2015 study conducted by the American Public Health Association found evidence supporting similar findings: that is, when compared with other ethnic groups (non-Hispanic Whites, Asians, and Blacks), Hispanics had the lowest vaccination coverage for influenza and pneumococcus (Hughes et al., 2018).

Similarly, access to affordable health care is more difficult for immigrants, especially if they are undocumented (Derose et al., 2007). Due to the nature of their jobs (high risk), the context of poverty in which they live, and the low wages they receive, males are at greater risk for communicable diseases and work-related injuries (Moyce & Schenker, 2017). Furthermore, preventive medicine information is less available to limited English speaking immigrants, especially men (DuBard & Gizlice, 2008).

Adult immunization practices are a topic that in spite of its importance have not received sufficient and systematized attention from public health researchers and health officials. For instance, there is a scarcity of literature reporting specifically on vaccination practices by gender and ethnic differences. Although it is known that lower class individuals and adult males in general of all racial/ethnic groups receive less preventive health care than higher SES males, so in this regard Mexican-origin males may not be too different from other males regardless of race or ethnic origin.

The barriers for vaccination access among minority group males are complex and strongly related to traditional gender roles (Ferris et al., 2009; Gutiérrez-Robledo et al., 2017; Johnson et al., 2008; Williams et al., 2014). Some of the reasons adult patients do not receive vaccines, as reported by clinicians, include resistance due to cost, needle opposition -“If I don’t have to get the shot [for work] then I don’t want it”-, unwillingness to miss work, pain avoidance, and lack of knowledge about adult vaccines. Additionally, clinicians mentioned more hesitance coming from male adult Hispanic patients than from other groups (Wexler, 2009). In general, the health system seems to exclude males as there is a significant focus on immunizations for pregnant women and their newborn children. Further, the lack of knowledge or misinformation parents hold regarding vaccines not only affects their own heath, but it can also turn into a barrier that prevents children from receiving vaccination (Damnjanovic et al., 2018)

In the last couple of months, the entire world has dedicated considerable effort directed at the development of a vaccine against the deadly Coronavirus that has damaged not only the physical health of the inhabitants of all nations, but also wounded the global social and economic structure. As has been reported elsewhere, the SARS-CoV-2 (COVID-19) is highly contagious and even lethal in high-risk population groups (Wang et al., 2020). Currently, controlling the spread of the epidemic and reducing mortality is a global priority (Wang et al., 2020). Vulnerable groups are significantly more exposed to being infected mostly due to the social determinants of health that surround their daily life (inadequate housing, poor diet, low wages, overcrowded conditions, impossibility to stop working or to isolate at home, and discrimination, among others ). Some of the conditions associated with clinical complications are reported among individuals with primary basic diseases, especially those with chronic illness such as hypertension, diabetes, coronary heart disease and cancer. The Mexican-origin population has a higher prevalence rate for all the health factors that place them at greater risk than the U.S. general population (Aguayo-Mazzucato et al., 2019; Caballero, 2011). Thus, increased is the reason why Latino communities throughout the country are reporting high rates of COVID-19 infection and deaths (Rodriguez-Diaz et al., 2020).

Among Mexican-origin men there are prevailing cultural and gender-oriented beliefs that might deter them and their families from obtaining preventive health care such as immunizations (DeKeijzer, 2003). In many traditional Mexicans families, especially those originating in rural communities, family life is oriented around male dominance where men lead their family by example (Caballero, 2011; Salgado de Snyder et al., 2005). The leading role of the head of household in matters of health is of utmost importance to assure the well-being of all members of the family (Sobralske, 2006). Furthermore, as vaccination schemes vary by age and health status and the composition of Mexican households include ample age-ranges, it is essential to invest health promotion resources in health literacy campaigns that emphasize the preventive role of immunizations that are directed at adult males (Baker et al., 2020).

The Coronavirus pandemic has disproportionately affected the population groups that are already disadvantaged and will continue to do so, unless efficient strategies of health literacy are implemented for them (CDC, 2020). The development and availability of adequate treatments and a vaccine for COVID-19 is on its way, but we need to prepare the path by designing strategies of distribution and administration of medication and vaccines to underprivileged groups in order to truly help closing the gap of health inequality. The purpose of this study was to explore reasons given by Mexican-origin males for obtaining vaccines or avoiding getting vaccinated. Findings will help health service providers develop strategies to facilitate Mexican-origin men access immunization programs for themselves and their family members.

Method

This cross-sectional, exploratory study was conducted with a sample of convenience comprised by 401 adult males with ranging from 18 to 79 years with a mean age of 40 years (SD = 43.1). Most of the respondents were in the age group of 30 to 49 years.

Procedure

Participants were approached while waiting their turn to receive administrative services at the Mexican Consulate in Austin Texas (birth or death certificates, repatriation, passport, automobile temporary export permit, and notarized services, among others). Data was collected in Spanish using electronic tablets by six bilingual females affiliated with the organization Migrant Clinicians Network (MCN) who coordinate the services provided by the Ventanilla de Salud at the Mexican Consulate in Austin. This study was conducted in May 2019 and was previously approved by MCN’s IRB. After we explained the purpose of the study and assured participants that their responses would remain confidential, as no identifying information would be collected, men were asked for their verbal consent to answer a brief survey of seven questions. Also, we clarified that their participation was voluntary and that their answers would not affect the services offered by the Mexican Consulate. It must be noted that we did not ask country of birth, however, we can safely assume that most of the participants were first-generation immigrants, as most of the services provided by the Consulate are directed to Mexican nationals.

Instrument

The survey was designed especially for this study and had six multiple-choice, close-ended questions. Two of the questions included an open response option, listed as “other” to allow participants to respond freely with their own answers.

Results

The descriptive findings of this study will be presented in the same order as the questions were asked in the survey. Answers to the first question (How long ago since you had a vaccine administered?) suggested that the majority of respondents (n = 160; 40%) had received their last vaccination longer than 5 years earlier. Another 27.5% (n = 99) reported having been vaccinated on average, about 3 years earlier, and lastly 35.5% (n = 142) of the men reported a vaccination within the last year. Given the fact that immunization schedules (routine and catchup vaccination) vary depending on age, Table 1 presents the percentage of respondents indicating that they received any type of vaccination in the last 5 years, broken down by age group. In general, getting vaccinated in the last 5 years, regardless of age, is low among this group of participants. The most interesting findings as shown in the table is that a higher percentage of individuals in the older groups (40 and older) had received a vaccine in the previous year, when compared to their younger counterparts.

Table 1.

Percent of Men Getting any Type of Vaccination by Age Group.

Age group	Within the last year %	Three years ago %	Five years or longer %
18–29	24.6	33.3	42.0
30–39	27.4	31.0	41.5
40–49	44.5	17.1	38.2
50–59	36.3	25.0	38.6
60 and older	45.0	15.0	40.0

The individuals responding having received a vaccine 3 years before, or in the year previous to the survey, were asked to identify the main reason (from a list of six) for getting a vaccine. Most of the respondents (62%) chose the most socially desirable answer which was to take care of their own health. However, more than one-fourth of the respondents referred “other reasons” (27.5%) for getting vaccinated, such as injuries (37.9%) that required the application of the tetanus vaccine; that the vaccine was offered and administered by a clinician (30.3%); and that the vaccine was a mandatory procedure to complete immigration- or school-related applications (24.2%).

Those individuals reporting not having received a vaccine in the last 5 years were asked the motive for this. One-fourth (24%) of the participants responded that they did not have time to get vaccines. A smaller proportion (16.8%) feared injections or side effects of vaccines. It is interesting to note that more than half of the participants (58.8%) indicated not getting vaccines because they were healthy, they felt well, and they were not sick. Others acknowledged that they did not have sufficient, information, interest, or motivation to get vaccines (29.8%).

In an open-ended question, participants were asked the reasons they have heard from other Mexican men as to why they do not get vaccinated. The most prevalent answer was fear of needles or side effects of the vaccine, followed by being lazy or irresponsible or not caring about the issue, as well as lack of time to get vaccinated because they had to work. One- fourth of the participants reported not having heard anything as to why the men they know, do not get vaccines.

The last item of the survey was an open-ended question, specifically asking, “How can we make it easier for men, such as yourself, to get vaccinated?”. Participants responded they needed to be convinced with more accurate information regarding the importance of vaccines through health campaigns/fairs, social media, TV or radio. They also mentioned that if immunizations were easily accessible to them; for example, without interrupting their work, with locations near their work or home, and not having to pay for a vaccine, they would probably be more open to getting vaccinated. Another important finding of the study is that almost all respondents (97.2%) answered “yes” when asked if they believed that getting vaccinated was as important for men, as it is for women and children. This suggests that the men are not anti-vaccinations, but because of their working class status accessibility and cost are barriers to positive health care practices.

Discussion

Findings of this study suggest that Mexican adult men believe vaccinations are important for their health. However, because they have limited knowledge in regard to the benefits of vaccines, frequency, cost, and where to get them, our respondents do not engage in vaccination behaviors or prioritize this as a preventive health practice. Results from our study showed that almost one-half of the respondents had not received a vaccine in the last 5 years, in spite of their belief that vaccines are equally important from a health perspective for children, women and males. This suggests a conflict between beliefs and actual behaviors, perhaps due to a combination of absence of information, cost, lack of time to get vaccinated, and the erroneous belief that they themselves did not need a vaccine because they did not feel sick, as reported by some of the participants.

Other findings show that a higher proportion of respondents aged 40 and older, when compared with the younger groups, reported being vaccinated within the last year. This could be related to experiencing chronic health problems associated with older age. In the Hispanic general population, men aged 40 and older, when compared to younger age groups, are more likely to have been diagnosed with a chronic condition such as high blood pressure, obesity or diabetes. This group regularly visits their health care facility, where they may also receive vaccine information and receive treatment that includes a vaccination (Caballero, 2011).

When compared to older males, younger participants reported a larger gap of time since obtaining their most recent vaccination. Our findings also suggest that younger males are less likely to pay attention to their health or to get vaccines, simply because they do not feel ill, and perceive themselves as “healthy” individuals. The younger participants erroneously believe that vaccines are equivalent to “medication”, to be administered only in case of a medical intervention for illness, not as a preventive measure. It is interesting to note that the reason why almost 40% of those getting a vaccine in the last year was to prevent tetanus, due to accidental injuries at work (e.g., wounds, cuts, hits, crashes, perforations, etc.).

The last question of the survey asked participants what they thought could be done to facilitate the vaccination of Mexican adult men. More than one-half of the respondents expressed a need for more information regarding vaccines. Some specific suggestions were to design health campaigns to promote health and encourage people to get vaccinated, more education on vaccines, such as the purpose of specific vaccines and when different vaccines are called for, information about places where people can go to get vaccines and information about the cost and/or insurance coverage.

Among the limitations of the study is that data was collected by female interviewers, and it is possible that the participants may have answered differently if the surveyors were males. Also, our survey was very short due to the context in which data was collected (waiting room) and precluded us from collecting personal information that could have provided some important insights to our findings. For instance, it would have been important to know the participants’ level of education, income, marital status, and health insurance, as some of these factors could have been related to, or even determined, the participants’ responses. Nevertheless, our findings have important implications for future research on the topic of cultural issues related to vaccination practices and for the development of interventions, particularly health promotion programs aimed at vulnerable groups.

Recommendations and Future Directions

Based on the findings of this study, we offer several recommendations. First, the development of strategies to design culturally relevant resources and material for at-risk populations that would allow these groups to become more informed about vaccination and empower them to make more proactive health choices. Along with this, the implementation of information dissemination via outlets that would reach Latino groups, such as social media and Spanish-language television and radio stations that could reach a greater number of people. Likewise, it is important to reframe the narrative of vaccination campaigns focusing on men as providers of their families and therefore prioritizing their acceptance of vaccinations as preventive for everyone in their family. Very often, Mexican men are the only, or the main providers for their families, so it is important to discuss the financial impact that a health-related incident (that could have been prevented with a vaccine) could have on the well-being of their family members.

At the health care provider level, it is important to establish a collaborative relationship between employers and health clinics to promote preventive healthcare practices in the workplace. The employers’ support can motivate workers to take action in reaching out for help and to better manage their health. Also, the coordination between mobile clinics and employers to bring vaccinations to worksites, such as construction sites and farms would make vaccinations readily available for these high-risk groups. Also, the Ventanillas de Salud (VdeS) in the Mexican Consulates must continue and reinforce their important work¹ but also serve as a launching pad for more detail studies on this and other important public health topics affecting Mexican-origin population.

There is also the need for additional research to understand beliefs, attitudes and behaviors toward vaccinations among Mexican-origin, working-age men. This is not irrelevant since men’s decisions often carry much weight within nuclear Mexican families; being informed about preventive health care may determine whether or not to get a vaccine for themselves, and more importantly, vaccinations for their children.

The findings of this study are of critical importance during the current pandemic and the worldwide spread of COVID-19. It is imperative to implement studies aimed at the development of innovative strategies to successfully deliver immunizations to everyone, especially vulnerable populations such immigrant families, with limited financial and linguistic resources and a health care system that is constrained in resources to reach everyone. Experiencing the current COVID-19 pandemic is perhaps the strongest reasons for public health and social sciences researchers to work together with private and public governmental agencies to reach out to the high-risk groups, when the COVID-19 vaccine becomes available. Seeing the devastation that the COVID-19 pandemic has left behind in our health, social, and economic systems forces us to recognize that we as public health and social scientist, have a moral responsibility toward others, which must extend beyond territorial boundaries. Governmental efforts to protect residents and citizens within their country should also contribute to the responsibility to think globally and thus, contribute to global efforts to fight coronavirus. As has been reported by the United Nations (2020), the COVID-19 pandemic has disproportionately affected disadvantaged, vulnerable populations. Such disparities must stop, and efforts should concentrate in researching the ways in which treatments and vaccines can be developed, accessed, and distributed globally in a fair and equitable way.

Among the lessons we continue learning from this pandemic is that vaccines, but particularly COVID-19 immunizations, must be considered a global public good. In other words, access to preventive medicine and vaccinations is for everyone, regardless of their nationality, racial or ethnic background, legal status, gender and age. As Kaul and Faust (2001) have suggested, additional efforts will be required, but it is imperative that many public goods switch from being national public goods to being global public goods, keeping in mind that the best way to ensure our own well-being is to be concerned about others, and implement actions toward improving everyone’s well-being.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Author Biographies

V. Nelly Salgado de Snyder holds a doctorate in Social Welfare from the University of California Los Angeles, and a BA and MA in Clinical Psychology from the Autonomus University of Morelos and UNAM, respectively. She is currently the coordinator of the Global Health Program at the National Institute of Public Health in Mexico. Her research interest include: global health, social determinants of health and the intersection of health sciences and social and behavioral sciences in the study of inequities among vulnerable groups.

Deliana Garcia holds a BS and MA from the University of Texas at Austin. She is the director of International Projects and Emerging Issues for Migrant Clinicians Network. Deliana’s research interests include continuity of care, international health, migration and infectious and chronic diseases.

Roxana Pineda has a master’s in Public Health with a specialty in Community Nutrition from the Autonomous University of Nuevo Leon in Mexico. She currently works for Migrant Clinician Network and is assigned to the Consulate of Mexico in Austin as coordinator of the Ventanilla de Salud. Her research interests include disease prevention, chronic degenerative diseases, and health behavior.

Jessica Calderon holds a BA in Spanish literature and Psychology from Texas State University. She currently supports the Migrant Clinician Network’s International Projects and Emerging Issues. Jessica’s research interests are mental health, trauma, neuroscience, cognitive science, and sociocultural psychology.

Dania Diaz graduated from The University of Texas at Austin in May of 2019 with a Bachelor of Science degree in Human Development and Family Sciences. She currently works with an e-commerce company in Austin. She holds great interest in cognitive behavioral therapy and is still finding ways to dive more into the field.

Alondra Morales graduated from The University of Texas at Austin in 2019 with a Bachelor of Science in Human Development and Family Sciences and Bachelor of Arts in Health and Society. Currently, she is exploring career options in case management. Alondra’s research interests include autism spectrum disorder, child welfare, migrant and immigrant health.

Brenda Perez graduated from the University of Texas at Austin in 2019 with a bachelor’s in social work. Currently, she is a community health worker for Austin Public Health, Neighborhood Services Unit. Brenda’s. Area of interest: identifying social determinants of health and making basic health services more equitable for underserved communities.

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