Abstract
Amid the COVID-19 pandemic, vaccine hesitancy is believed to be among the top global health threats. U.S. Latinos have disproportionately been affected by the pandemic and have higher COVID-19 vaccine hesitancy. This study applied the Vaccine Hesitancy Determinants Matrix to understand COVID-19 vaccine hesitancy in a Latino agricultural community. Surveys were conducted with 180 adults from a Migrant Community Health Center to measure pandemic experiences and hesitancy factors across three categories: individual and group factors, vaccine/vaccination-specific factors, and contextual factors. Approximately 16% of participants reported having tested positive for COVID-19, 90% endorsed loss of income, and 47% reported their mental health was affected. Only 46% received a COVID-19 vaccine. Common individual vaccine hesitancy factors included worry about side effects, worry that vaccines cause infection, and concern that side effects would be worse than the virus. Vaccine/vaccination-specific factors included concern about how quickly COVID-19 vaccines were developed and concern about there being insufficient research on their effectiveness, potential risks, and side effects. Common contextual factors included religious beliefs and political mistrust. Logistic regression results indicated that subjects who tested positive for COVID-19, or had a coworker who tested positive were more likely to get vaccinated. The odds ratio of being vaccinated increased with age. Subjects who endorsed concern that vaccine side effects were worse than the virus were less likely to be vaccinated. Results highlight that there are health literacy gaps among Latino communities such as interpretation of vaccine efficacy and safety to gain a more accurate understanding of side effects.
Keywords
Introduction
In March 2020, the World Health Organization (WHO, 2021) declared the novel coronavirus outbreak a global pandemic. Coronavirus (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (WHO, 2021). A growing body of evidence demonstrates that racial and ethnic minority groups account for a disproportionate number of COVID-19 cases, hospitalizations, and deaths. Socio-cultural and socio-economic factors such as crowded housing, public transit, education level, household income, and foreign-born non-U.S. citizen status are essential drivers of increased COVID-19 cases in minority populations (Figueroa et al., 2020, 2021). For instance, low-income Latinos may be at a greater risk for infection because they are more likely to be essential workers (Figueroa et al., 2020, 2021). Furthermore, many low-income workers have not had the option of working from home during the pandemic and do not have jobs with paid sick leave (Chen et al., 2021; Figueroa et al., 2020).
One group of essential workers, particularly vulnerable to the pandemic, are agricultural workers responsible for producing essential crops and who are a crucial component of the economy. Research has shown that these essential workers are particularly vulnerable because, in addition to not being able to work from home, their jobs often prevent them from practicing public health measures (Corwin et al., 2021; Quandt et al., 2021). Moreover, most farm owners and managers have shown knowledge gaps and confusion over Centers for Disease Control and Prevention (CDC) guidelines and experienced financial challenges related to implementing COVID-19 infection prevention strategies (Corwin et al., 2021). Some agricultural workers migrate across state lines for seasonal work. Travel often occurs in crowded, poorly ventilated buses; housing typically consists of congregate living quarters and eating in communal settings, making social distancing impossible (Corwin et al., 2021). Latino agricultural workers may also face language and cultural barriers to implementing COVID-19 prevention strategies which place them at a greater risk. For instance, isolation during quarantine is described as a frightening experience by some, particularly when there is limited understanding of the virus (Corwin et al., 2021).
There is a strong need for widespread vaccination against COVID-19 to improve the control and prevention of the virus. To accelerate the development, manufacture, and distribution of COVID-19 vaccines, the U.S. government initiated Operation Warp Speed (Hildreth & Alcendor, 2021). The vaccine race paved the way for the novel nucleic acid vaccines designed to insert genetic instructions, mainly for the virus spike protein production, into the human cell (Baldo et al., 2021). Currently, three vaccines are authorized and recommended in the United States to prevent COVID-19: Pfizer-BioNTech, Moderna, Johnson & Johnson/Janssen (CDC, 2021). Of these, both the Pfizer-BioNTech and Moderna vaccines utilize the new technique.
Even with the vaccines available, vaccine hesitancy remains a threat. The delay in acceptance or refusal of vaccination provides obstacles to achieving optimal herd immunity percentages. So much so, in 2019, the World Health Organization identified vaccine hesitancy as one of the top 10 global threats (Lazarus et al., 2021; Succi, 2018). Significant determinants of vaccine hesitancy and refusal involve various socio-cultural, political, and personal factors. For instance, concern over “immune system overexposure,” past negative vaccine experiences, and mistrust in the vaccine industry and the health care system may deter individuals from vaccination (Succi, 2018).
While vaccine hesitancy generally refers to a delay in acceptance or refusal of vaccines, this phenomenon is complex and context specific (World Health Organization, 2014). Several frameworks consider vaccine hesitancy as a decision-making process (i.e., how or why people accept, refuse, or delay vaccines) that is influenced by various contextual factors and leads to a variety of behavioral outcomes (Peretti-Watel et al., 2015). These behavioral outcomes (e.g., to accept, refuse, or delay vaccines) are important from a public health perspective. This study aims to better understand some of the factors associated with COVID-19 vaccine hesitancy among Latinos living in agricultural communities. The study utilizes the Vaccine Hesitancy Determinants Matrix (VH Matrix; MacDonald & SAGE Working Group on Vaccine Hesitancy, 2015) as a guiding conceptual model for grouping vaccine hesitancy factors. The VH Matrix groups hesitancy factors into three categories: (1) individual and group factors, (2) vaccine/vaccination-specific factors, and (3) contextual factors. Individual and group factors arise from personal perceptions of the vaccine or influences of the social/peer environment. Examples include, personal, family, or community members’ experience with vaccination, beliefs/attitudes about health and prevention, knowledge/awareness, and risk/benefits of a particular vaccine. The second category, vaccine/vaccinations-specific factors, is directly related to a particular vaccine. These factors include the introduction of a new vaccine, cost, and the knowledge base regarding the recommended vaccine. The third category, contextual factors, arises due to historic, socio-cultural, environmental, health system, economic or political factors. These include things like communication and the media environment, historical influences, and religious or cultural factors.
This study explored these three categories of factors utilizing phone surveys that were conducted with Latino adults receiving primary care services at a Migrant Health/Community Health Center in an agricultural community. By understanding the population’s beliefs regarding vaccinations, future vaccination programs can address their unique concerns and potentially curb the disproportionate morbidity and mortality rates among Latino farmworkers.
Method
Data Collection and Measures
This study was approved by The Florida State University Institutional Review Board. During an eight-week period in the Summer 2021, adult patients receiving primary care services at a Migrant Health/Community Health Center were invited to complete a phone survey. The health center provided a weekly list of names and phone numbers of adult patients seen by a medical provider for a primary care office visit (non-COVID-19 related). Patients were randomly selected from the list and were contacted by phone and invited to complete a brief phone survey. The survey was a revised/abbreviated version of the Pogue et al. (2020) COVID-19 Vaccine Survey, which aimed to measure multiple factors related to the impact of COVID-19 and participants’ opinions (and hesitancy) about COVID-19 vaccines. Participants were also asked about their COVID-19 experiences and their current vaccination status or future intentions to become vaccinated. Survey questions were divided into six different sets of items: (1) COVID-19 Experiences set (i.e., self or close contacts testing positive); (2) Vaccination Beliefs set (i.e., individual and group hesitancy factors such as beliefs about vaccine risks and side effects, concern about vaccination cost); (3) Contextual Factors (i.e., policies related to public health measures like mask wearing and social distancing, hand hygiene); (4) Vaccine/Vaccination-specific Factors (i.e., confidence in vaccination development and effectiveness, cost); (5) Vaccine History set (i.e., vaccination status for recommended adult vaccines including the influenza vaccine); (6) Demographic Characteristics set (i.e., age, gender, ethnicity, marital status, level of education, and agriculture-worker status). Subjects were given the option to complete the survey in either English or Spanish.
Sample
Participants were recruited during an 8-week period from a Migrant Health/Community Health Center serving a predominantly Spanish-speaking, migrant, farm-working population located in a rural area of southwest Florida. A total of 326 patients were contacted and invited to complete the phone survey. Of those invited, 186 agreed to participate (57%) and 140 declined (43%). At least three attempts were made to reach an additional 117 patients via phone who never answered. Of the 186 who agreed to participate, 180 completed the survey in its entirety. Only their responses were included in our analyses. The primary reason given by those who declined to participate was lack of time.
Data Analysis
Descriptive statistical analyses were performed to describe the following: (1) demographic characteristics of the participants; (2) COVID-19 experiences endorsed by subjects and its impact; (3) vaccination status; (4) potential barriers for receiving COVID-19 vaccines (including vaccination concerns); and (5) reasons for vaccine refusal or vaccine indecision. Means, SDs, and ranges were calculated for continuous variables. Frequencies and percentages were presented for categorical variables. Chi-square tests (or Fisher’s exact test) were applied to check whether misinformation, vaccination beliefs, and rushed pace of testing for the new COVID-19 vaccines impact vaccine hesitancy, and if there was a relationship between trust and/or use of public health measures and vaccine uptake. Logistic regression was performed to identify significant predictors for the binary (yes/no) outcome of Covid-19 Vaccine Uptake. Model selection was conducted by forward method among several sets of independent variables. Independent variable sets correspond to each of the six sets of items included in the COVID-19 Vaccine Survey: COVID-19 Experiences, Vaccination Beliefs (individual hesitancy factors), Contextual Factors (trust in, and use of, public health measures), Vaccine/Vaccination-Specific Factors, Vaccine History, Demographic Characteristics. A best model candidate with all significant factors at the significant level of .05 was selected by the forward method. In addition, two more factors were embedded (testing positive for COVID-19 or not, and immediate family members testing positive or not) from the above variable list into this model candidate based on the literature review and our research interest, to form our final model. The significance for all variables in the model candidate were retained in the latter model, except for one factor (immediate family tested positive or not) slightly reduced as marginal significant, while the latter model achieved lower Akaike information criterion (AIC) and higher area under curve (AUC) than the model candidate selected by forward method. Therefore, the latter model (best model candidate from forward selection plus two factors) was determined as our final model, driven by research interest. All analyses were conducted using SAS Version 9.4 (Cary, NC, USA).
Results
The majority (92.2%) of participants were of Latino ethnicity. The mean age of participants was 39 (SD = 14.1), with a range from 18 to 83 years. The sample was predominately female (85.5%) and Spanish-speaking (75.6%). Close to half (48.5%) of participants were married and the majority (67.3%) had less than high school education. Approximately 43% of participants were agricultural workers themselves and 58.2% of participants endorsed having an immediate family member, living in the same household, who was an agricultural worker. Of all participants in a household with an agricultural worker, 50.7% were migrant, relocating for seasonal work.
COVID-19 Experiences
Participants were asked several questions to measure the impact of COVID-19, including if they or someone they knew had tested positive for the virus. Approximately 16% of participants had tested positive for COVID-19, 22% had an immediate family member who tested positive, 15% had an extended family member test positive, and 21% had a friend with the virus. Approximately 17% of participants endorsed having a coworker who tested positive. Participants were also asked to report whether the pandemic affected their employment resulting in a loss of income (i.e., make less money or work less hours) and/or their mental health (i.e., felt more stress, sad or worried). Approximately 89% of subjects endorsed experiencing loss of income and 47% reported that their mental health was affected.
Vaccination Status
Participants were asked to report their current COVID-19 vaccination status. In total, 80 (46%) respondents reported having received a COVID-19 vaccine. The 93 who reported they had not received a COVID-19 vaccine were asked about their future vaccination intent. Of the unvaccinated, approximately 38% (n = 35) indicated that they did intend on getting a vaccine; 28% (n = 26) endorsed that they did not plan on becoming vaccinated; about 34% (n = 32) reported that they were undecided.
Vaccine Hesitancy Factors
Participants, regardless of their current vaccination status or future intent, were asked to respond to five Yes/No items indicating whether or not several individual and group factors were of concern or worry related to COVID-19 vaccines. Table 1 displays the number and percent of subjects that endorsed Yes, being concerned, across the five items administered. Approximately 58% of subjects endorsed concern about the side effects of vaccines and 34% endorsed concern that the side effects of the vaccine were likely to be worse than the virus itself. Approximately 38% of subjects indicated concern that COVID-19 vaccines themselves could cause COVID-19 infection. Close to 23% of subjects indicated that they would rather build immunity by exposure to the virus over receiving a vaccine.
Individual and Group Factors: Vaccination Concerns and Reasons for Vaccine Hesitancy.
Those subjects who endorsed that they either did not intend to get a COVID-19 vaccine or were undecided were asked to select from a list of seven statements which one most closely resembled their reason (for not getting the vaccine or why they were uncertain about getting it) (Table 1). From the list of reasons provided, approximately 41% of subjects who responded indicated that they did not believe the vaccine was safe. Only about 2% did not believe the vaccine was effective. Approximately 33% of subjects indicated they had other reasons not listed and were given an opportunity to explain. Their responses were grouped into common themes by hesitancy factor (i.e., individual factors, vaccine/vaccination-specific factors, and contextual factors) (see Supplemental Table 1). Most individual factors were associated with vaccination fears like perceived risk of death, infection, or other health complications. There were also some concerns related to vaccine effectiveness. Vaccine/vaccination-specific factors were mostly related to fears over the development of a new vaccination—like concern that there may not be enough research on the vaccine and that its development was too fast and thus potentially unsafe. Finally, several contextual factors were also identified. These included hesitancy related to religious beliefs and political concerns—like mistrust in the government’s intentions with mass vaccination efforts.
Vaccine Hesitancy by Vaccination Status
To understand how vaccination hesitancy factors differed by vaccination status, all subjects, regardless of their vaccination status, were asked several items related to their beliefs and concerns about the vaccine (i.e., individual factors) along with questions related to preference for receiving the vaccine (i.e., vaccine/vaccination-specific factors). Subjects were also asked questions to measure several contextual factors—mainly focused around the use of public health and social measures for COVID-19. These items were selected given that the public health measures used, such as mask wearing and social distancing, were often controversial policies at the center of the media environment (i.e., contextual factor) during the pandemic. Table 2 lists each of the items asked along with subject responses by vaccination status. Chi-square tests (or Fisher’s exact test) were utilized to test for any associations between the listed factors (individual factors, vaccine/vaccination-specific factors, and contextual factors) and vaccination status. Most of the individual hesitancy factors tested were associated with vaccination status including beliefs that vaccinations would help control the pandemic, a preference for building immunity by exposure to an infected individual over receiving the vaccine and three items from the list of concerns about vaccine side effects. Two of the vaccine/vaccination-specific factors were also associated with vaccination status—a preference for receiving the COVID-19 at the same time as other scheduled vaccinations and worried that the rushed pace of testing the new vaccine failed to detect potential dangers. None of the contextual factors tested were associated with vaccination status—concern that the rushed pace of testing for the new vaccine failed to detect potential side effects.
Vaccine Hesitancy Factors by Vaccination Status.
p value: from Fisher’s exact test.
Logistic Regression
Logistic regression was performed to identify significant predictors for Covid-19 vaccine uptake (Table 3). Given the other variables in the model were held constant, there was 95% confidence that the odds of receiving the COVID-19 vaccine for subjects who tested positive for the virus was 5.055 times that of subjects who did not test positive. Subjects with a coworker who tested positive were 3.451 times more likely to receive the vaccine than subjects without a coworker who tested positive. Individuals who reported a preference for receiving a COVID-19 vaccine at the same time as other scheduled vaccines were 5.046 times more likely to be vaccinated. Subjects who endorsed worry that the side effects of a COVID-19 vaccine were worse than the virus itself were 0.179 times less likely to be vaccinated. Subjects who endorsed receiving the flu shot annually were 2.862 times more likely to be vaccinated. The odds of being vaccinated were expected to increase 1.088 times when age increased by 1 year. The factor of an immediate family member testing positive was not significant. The factor of worrying about COVID-19 vaccine side effects was marginally significant (p value = .0564). The 95% confidence interval for the odds ratio on some factors was large (Table 3). This is likely attributed to the relatively small sample sizes within the individual cell of the 2 × 2 contingency table of the outcome and the particular independent variable (i.e., Self-tested Positive, Coworker tested Positive, and Preference for receiving COVID-19 Vaccine at same time as other scheduled vaccinations).
Predictors for Covid-19 Vaccine Uptake.
Discussion
The purpose of this study was to apply the Vaccine Hesitancy Determinants Matrix to gain a better understanding of COVID-19 vaccine hesitancy among Latino agricultural workers. The present research helps to highlight several hesitancy factors across each of the Matrix categories common among Latino agricultural workers. Under the individual and group factors category, there were mostly individual factors identified—mainly associated with fears of COVID-19 vaccines. These include fear of death or illness related to vaccination complications, concern about the short and long-term side effects of vaccines, and fear of COVID-19 vaccines themselves causing COVID-19 infections. There were several vaccine/vaccination-specific factors that were prominent—including concern about how quickly COVID-19 vaccines were developed and concern that there is insufficient research on their effectiveness and/or potential risks and side effects. Common contextual factors were related to religious beliefs and political mistrust. There are several common vaccination beliefs that appear to be associated with vaccination status including uncertainty about the efficacy of vaccine development and its effectiveness at controlling the pandemic, concern about vaccination side effects, and worry that side effects are worse than the virus itself, and preferences for building immunity by exposure. This study identifies several predictors for vaccine uptake. These include having personal experiences with the virus including a past COVID-19 infection or knowing a coworker who became infected. Other predictors are related to vaccination preferences and practices like a preference to receive a COVID-19 vaccine at the same time as other scheduled vaccinations, and receiving the flu shot annually.
These results are consistent with previous findings indicating that vaccine history and vaccine safety and efficacy perception are all key predictors of attitudes toward COVID-19 vaccination (Dorman et al., 2021; Lazarus et al., 2021; Pogue et al., 2020). Some of the vaccination fears and concerns endorsed in this study (i.e., vaccines causing infection) may be associated with misinformation, which has also been found to be an important factor underlying vaccination hesitancy among Latino agricultural communities (Gehlbach et al., 2021).
Individual hesitancy factors are particularly of interest for this community—particularly related to knowledge and understanding of COVID-19 and COVID-19 vaccines. Given the framework of vaccine hesitancy as a decision-making process that is influenced by multiple factors, the degree to which individuals have the ability to find, understand, and use information to inform their vaccination decision (i.e., health literacy) is important. One implication that can be drawn from our findings is that addressing health literacy among this population may be an effective strategy to address hesitancy and better inform decision-making. For instance, culturally relevant vaccine promotion campaigns may help dispel fear and misinformation. Others have suggested using the Latino family unit as the focus of such campaigns, particularly as COVID-19 vaccination may be valued to protect the family as a pathway for employment (Garcia et al., 2021). Interestingly, in this study one predictor of vaccination was a coworker testing positive (but not a family member testing positive). It is plausible that some may be more inclined to get vaccinated in an effort to protect their family financially (i.e., avoid loss of employment/loss of income due to COVID-19 illness). The use of intergenerational vaccine communication may also be a useful consideration as youth sharing information with their family members may be key to helping adults gain trust in vaccine effectiveness (Garcia et al., 2021).
The present study represents a first attempt to better understand COVID-19 vaccine hesitancy among Latino agricultural communities. Although the results provide several considerations for improving vaccine uptake among this community, this study has several limitations. First, the study was conducted with a small convenience sample recruited from a Primary Care setting. Future studies should include a larger sample size recruited from a variety of settings that would yield a more representative sample of the population. In addition, the time in which the data for this study was collected may also represent a limitation. Data were collected during the early stages of vaccine distribution and prior to the discovery of newer COVID-19 variants; It is possible that attitudes toward vaccination may have shifted with time.
The present study suggests that there is a need for research that explores strategies for effectively improving health literacy related to COVID-19 among Latino agricultural communities. We hope that the current research will stimulate further investigation of this important area.
Supplemental Material
sj-docx-1-heb-10.1177_10901981231167893 – Supplemental material for COVID-19 Vaccine Uptake and Hesitancy in a Latino Agricultural Community
Supplemental material, sj-docx-1-heb-10.1177_10901981231167893 for COVID-19 Vaccine Uptake and Hesitancy in a Latino Agricultural Community by Javier I. Rosado, Jessica M. Costero and Yuxia Wang in Health Education & Behavior
Footnotes
Acknowledgements
We acknowledge the Healthcare Network for their support of this study.
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.
References
Supplementary Material
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