Exploring COVID-19 Vaccine Concerns,Uptake,and Hesitancy Among Pregnant Central American Immigrant Women in the United States During the Pandemic

Abstract

Objective:

The COVID-19 vaccine is vital for protecting pregnant women and their babies, yet many foreign-born women face unique challenges in vaccine uptake. This study explores COVID-19-related fears and vaccine acceptance among from the Northern Triangle countries—El Salvador, Guatemala, and Honduras in the United States (U.S.).

Methods:

This cross-sectional study aimed to identify factors influencing COVID-19 vaccination among foreign-born pregnant women from Central America, specifically El Salvador, Guatemala, and Honduras, living in the U.S.

Results:

The study included 93 women (mean gestation: 23.3 weeks), most of whom had lived in the U.S. for at least 10 years and had low acculturation. Over two-thirds (66.7%) were fully vaccinated. Key factors driving vaccine acceptance included healthcare access, community health initiatives, and trusted provider recommendations. Cultural values emphasizing family protection and a heightened sense of vulnerability to COVID-19 also contributed to higher vaccination rates. However, 33.3% expressed hesitancy, particularly due to distrust in government, fear of needles, and concerns about the vaccine’s rapid development, with Guatemalan participants showing the highest hesitancy.

Conclusions:

The findings underscore the critical role of healthcare providers in vaccination decisions. Tailored communication strategies that address cultural and emotional factors are essential for improving vaccine uptake, particularly within immigrant communities.

Keywords

COVID-19 vaccination vaccine hesitancy pregnant women immigrant healthcare providers

Introduction

The COVID-19 pandemic led to the rapid development of vaccines such as Moderna (mRNA-1237) and Pfizer (BNT162b2), which sparked debates on vaccine uptake.^1,2 These discussions were influenced by factors like prior experiences, misinformation, beliefs about side effects, political ideology, and perceptions of COVID-19 as a low-risk disease.^1,2

Pregnant women, a vulnerable group who were excluded from clinical trials, expressed heightened concerns about the safety of the vaccine during pregnancy.² Pregnancy-related physiological changes, such as shifts in cardiovascular and respiratory systems, increase susceptibility to infections like COVID-19.^3,4 Pregnant women contracting COVID-19 are at significantly higher risk of severe illness, including mortality, ICU admissions, and preterm birth.^2,4 While COVID-19 vaccines have proven effective in the general population, healthcare providers (HCPs) were initially hesitant to recommend vaccination for pregnant patients due to limited data.^5,6 Leading organizations in the United States (U.S.), such as the Centers for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG), now recommend vaccination when the benefits outweigh the risks.^7,8 Despite these recommendations, pregnant women have shown lower vaccination rates, with fewer than 45% expressing intent to vaccinate due to concerns about fetal safety and vaccine side effects.^8
-10

The challenges of vaccine uptake are further compounded for immigrants, who often face significant health disparities, including limited access to healthcare, language barriers, and cultural differences. The Central American population in the U.S., particularly from El Salvador, Guatemala, and Honduras, is one of the largest and fastest-growing immigrant groups.¹¹ Many of these individuals experience lower socioeconomic status, limited health insurance, and higher rates of untreated chronic conditions, all of which hinder healthcare access and vaccine uptake. For pregnant women from Central America in the U.S., additional barriers such as misinformation and distrust in healthcare further contribute to vaccine hesitancy, placing them at greater risk for adverse health outcomes from COVID-19.¹²

Although data on Central Americans in the U.S. is limited, studies on the broader Hispanic population highlight similar disparities in vaccine uptake. For example, a study of racial/ethnic disparities across 27 U.S. cities found that Hispanics had COVID-19 incidence rates 2.2 to 6.7 times higher than non-Hispanic Whites.¹³ Similarly, vaccination coverage among Hispanics was lower than that of non-Hispanic Whites.¹⁴ Among pregnant women, only 11.9% of Hispanic women received at least one COVID-19 vaccine dose during pregnancy, compared to 24.7% of non-Hispanic Asian women and 19.7% of non-Hispanic White women.¹⁵

Given the elevated risks and lower vaccination rates among Hispanic pregnant women in the U.S., along with the lack of specific data on pregnant Central American immigrants, this study aims to explore COVID-19-related fears and vaccine uptake among pregnant women from the Northern Triangle countries of El Salvador, Guatemala, and Honduras residing in the U.S.

Materials and Methods

Study Design

Data from the present study were collected as part of an exploratory cross-sectional study designed to assess beliefs, experiences, and sources of information regarding gestational weight gain (GWG), diet, exercise, and oral health during pregnancy among pregnant Central American immigrant women from the Northern Triangle countries–El Salvador, Guatemala and Honduras.¹⁶ Initially, the study focused solely on health behaviors and information sources during pregnancy. However, following the onset of the COVID-19 pandemic in March 2020, the research team decided to include questions related to the pandemic and COVID-19 vaccination.

Eligibility, Recruitment, and Data Collection

Women were eligible if they: (a) self-identified as Salvadoran, Guatemalan, or Honduran; (b) were pregnant with a single birth; (c) were at least 14 weeks gestation; (d) were 18 or older; (e) lived in Massachusetts communities with significant Central American populations; (f) spoke Spanish or English; and (g) provided informed consent.

Participants were recruited using methods that had been successfully employed in previous community-based studies involving immigrant Central American populations in Massachusetts, such as flyers at local businesses and churches, announcements, and network sampling.^17,18 Research staff, including Central American immigrants, utilized community networks and social media, particularly Facebook, for recruitment. Participants were primarily recruited from towns in the Greater Boston area with large Central American populations, such as Revere, East Boston, Chelsea, and Somerville. Interested individuals were screened in-person or by phone. After confirming eligibility, bilingual interviewers explained the informed consent form, and participants completed a brief survey consisting of 72 items.¹⁶

Survey Measures

The survey, adapted from previous research, included questions on health practices (eg, gestational weight gain, diet, physical activity, oral health), sociodemographic, acculturation, and two scales addressing COVID-19 fear and vaccination hesitancy.^16,19
-22 The focus was on participants’ fears about COVID-19, vaccine uptake and hesitancy, and information sources.

COVID-19 Fear Scale for the Perinatal Period

We used nine items from the “Fear of COVID-19” scale, focusing on personal safety, pregnancy impacts, and transmission to the baby.¹⁹ The scale, validated in Spanish, uses a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree).^20,21

Vaccination Concerns and Reasons for Hesitancy

Eighteen questions adapted from the CDC survey addressed concerns about the vaccine, including side effects, distrust in government and pharmaceutical companies, and rapid development.²² Participants selected the main reason for vaccine hesitancy from multiple options.

Sociodemographic, Acculturation, and Healthcare Access

The survey collected data on age, marital status, country of birth, U.S. residency, language, education, household income, pre-pregnancy weight status, and healthcare access (eg, regular provider, insurance, WIC). These questions were adapted from previous studies with Central American immigrants.^17,18 Acculturation was assessed using the Short Acculturation Scale for Hispanics (SASH), a validated 12-item scale with high reliability (Cronbach’s α: .72–.92).^23,24 Scores were dichotomized at 2.99 to classify participants as high or low acculturation.²³

The survey was pilot tested with three pregnant women, taking an average of 15 minutes to complete. Participants received a $25 gift card.

Ethical Considerations

The study adhered to the ethical principles outlined in the Helsinki Declaration and received ethical approval from the Institutional Review Board at the University of Massachusetts Boston (IRB: #2915 2021102). Participants were informed about the study both verbally and in writing, and their participation was voluntary, with the option of withdrawing at any time without consequence.

Data Analysis

Descriptive statistics were calculated for all variables, with means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Responses to the “Fear of COVID-19” scale were dichotomized into two groups: “strongly agree/agree” versus “neutral/disagree/strongly disagree,” with frequencies reported for the “strongly agree/agree” category due to the small sample size. Chi-square (χ²) and Fisher’s exact tests were used, as appropriate, to assess differences in fear of COVID-19, vaccine uptake, and vaccine hesitancy by country of origin (El Salvador, Guatemala, and Honduras). All analyses were performed using SAS 9.4.²⁵

Results

As shown in Table 1, the study included 93 foreign-born pregnant women from El Salvador, Guatemala, or Honduras, with a mean gestation of 23.3 weeks (SD = 6.6). The majority (59.1%; n = 55) had lived in the U.S. for at least 10 years. Most participants were from Guatemala (46.2 %, n = 43), married or cohabiting with a partner (91.4%; n = 85), had at least a high school degree (83.9%; n = 78), and reported a household income of less than US $40,000 per year (91.2%; n = 62), which is below the federal poverty line.²⁶ Most participants had a SASH score of less than 2.99 (76.3%; n = 71), indicating low levels of acculturation.

Table 1.

Demographic, Socioeconomic, and Health-related Characteristics of the Study Sample (N = 93).

Variables	Total	Salvadoran	Guatemalan	Honduran	P-value
Variables	N = 93 (%)	n = 29 (%)	n = 43 (%)	n = 21 (%)	P-value
Number weeks gestation, mean, (SD)	23.3 (6.6)	23.7 (8.2)	23.0 (5.4)	23.5 (6.5)	.90
Age, mean (SD)	31.2 (5.4)	32.8 (3.5)	29.4 (5.6)	32.8 (6.1)	.01**
≤25 years	12 (12.9)	2 (6.9)	7 (16.3)	3 (14.3)	.21
<25 to <35 years	56 (60.2)	17 (58.6)	29 (67.4)	10 (47.6)
≥35 years	25 (26.9)	10 (34.5)	7 (16.3)	8 (38.1)
Foreign-born
Yes	93 (100.0)	29 (100.0)	43 (100.0)	21 (100.0)
Years, mean (SD) n)	10.7 (6.1)	12.2 (6.3)	10.5 (5.6)	9.1 (6.4)	.19
<10 years	38 (40.9)	9 (31.0)	17 (39.5)	12 (57.1)	.17
≥10 years	55 (59.1)	20 (69.0)	26 (60.5)	9 (42.9)	.17
SASH score
<2.99	71 (76.3)	25 (86.2)	30 (69.8)	16 (76.2)	.32
≥2.99	22 (23.7)	4 (13.8)	13 (30.2)	5 (23.8)	.32
Marital status
Married/living together	85 (91.4)	26 (89.7)	39 (90.7)	20 (95.2)	.28
Separated/divorced	3 (3.2)	0 (0.0)	3 (7.0)	0 (0.0)
Single	5 (5.4)	3 (10.3)	1 (2.3)	1 (4.8)
Household income
<US$40 000/year	62 (91.2)	21 (87.5)	28 (96.6)	13 (86.7)	.35
≥US$40 000/year	6 (8.8)	3 (12.5)	1 (3.5)	2 (13.3)	.35
Educational attainment
<High school diploma	15 (16.1)	4 (13.8)	8 (18.6)	3 (14.3)	.93
≥High school graduate	78 (83.9)	25 (86.2)	35 (81.4)	18 (85.7)	.93
Health insurance
Government-sponsored	73 (78.5)	26 (89.7)	32 (74.4)	15 (71.4)	.19
Private	20 (21.5)	3 (10.3)	11 (25.6)	6 (28.6)	.19
Enrolled in the WIC program
Yes	39 (41.9)	9 (31.0)	19 (44.2)	11 (52.4)	.29
No	54 (58.1)	20 (69.0)	24 (55.8)	10 (47.6)	.29
First pregnancy
Yes	68 (73.1)	21 (72.4)	30 (69.8)	17 (81.0)	.66
No	25 (26.9)	8 (27.6)	13 (30.2)	4 (19.0)	.66
Pre-pregnancy self-reported weight status
Underweight	9 (9.7)	1 (3.5)	6 (14.0)	2 (9.5)	.03*
Healthy/normal weight	61 (65.6)	25 (86.2)	22 (51.2)	14 (66.7)
Overweight	22 (23.7)	3 (10.3)	15 (34.9)	4 (19.1)
Obese	1 (1.08)	0 (0.0)	0 (0.0)	1 (4.8)
Uptake of COVID-19 vaccine ^a
Yes	62 (66.7)	20 (69.0)	28 (65.1)	14 (66.7)	.94
No	31 (33.3)	9 (31.0)	15 (34.9)	7 (33.3)	.94

Abbreviations: SASH, Short Acculturation Scale for Hispanics; SD, standard deviation.

P < .05. **P < .01.

Self-report of being fully vaccinated at the time of the study.

All participants reported having health insurance, with the majority stating it was government-sponsored insurance (78.5%; n = 73), and 21.5% (n = 20) had private health insurance. Over half of the women (58.1%; n = 54) were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Over three-quarters of participants reported that this was their first pregnancy (73.1%; n = 68).

Finally, of the 93 participants, more than two-thirds (66.7%; n = 62) self-reported being fully vaccinated for COVID-19, with 69.0% (n = 20) of Salvadoran, 65.1% (n = 28) of Guatemalan, and 66.7% (n = 14) of Honduran pregnant women reporting full vaccination. The differences in vaccine uptake between the groups were not significant (P = .94).

Fear of COVID-19

Most women expressed concerns about being vaccinated against COVID-19, with their primary worries focused on the potential impact on their babies rather than themselves (Table 2). Over half of the women surveyed were afraid that their baby might become infected with COVID-19 (57%, n = 53) or that something negative could happen during pregnancy, childbirth, or the postpartum period because of COVID-19 (51.6%, n = 48). Nearly 42% (41.9%, n = 39) reported being very afraid of COVID-19. Other fears included feeling uncomfortable at the thought of COVID-19 (31.2%, n = 29) and being afraid of losing their own life due to the virus (40.9%, n = 38). There were no statistically significant differences in any of these concerns by country of origin, except for the level of fear regarding COVID-19 (P = .04).

Table 2.

Fear of COVID-19 (N = 93).

Fear of COVID-19	Total	Salvadoran	Guatemalan	Honduran	P-value
Fear of COVID-19	N = 93 (%)	n = 29 (%)	n = 43 (%)	n = 21 (%)	P-value
1. I am very afraid of the COVID-19.	39 (41.9)	8 (27.6)	24 (55.8)	7 (33.3)	.04*
2. It makes me uncomfortable just thinking about COVID-19.	29 (31.2)	3 (10.3)	20 (46.5)	6 (28.6)	.004**
3. My hands get wet when I think about COVID-19.	20 (21.5)	5 (17.2)	13 (30.2)	2 (9.5)	.16
4. I am afraid of losing my life because of COVID-19.	38 (40.9)	8 (27.6)	22 (51.2)	8 (38.1)	.13
5. When watching news and stories about COVID-19 in the media, I get nervous or anxious.	26 (28.0)	7 (24.1)	15 (34.9)	4 (19.1)	.40
6. I can’t sleep because I’m worried about catching COVID-19.	14 (15.1)	1 (3.5)	9 (20.9)	4 (19.1)	.09
7. My heart races when I think I might catch COVID-19.	22 (23.7)	5 (17.2)	12 (27.9)	5 (23.8)	.58
8. I am afraid that something will happen in my pregnancy, childbirth or postpartum due to COVID-19.	48 (51.6)	12 (41.4)	24 (55.8)	12 (57.1)	.41
9. I am afraid that my baby will be infected with the COVID-19.	53 (57.0)	15 (51.7)	26 (60.5)	12 (57.1)	.76

P-values are for χ² test (or Fisher’s Exact Test) assessing differences by country of origin.

P < .05. **P < .01.

COVID-19 Vaccine Uptake and Sources of Information

As shown in Table 3, over two-thirds of the participants (66.7%, n = 62) reported receiving the COVID-19 vaccine. When asked about their sources of information on the COVID-19 vaccine, the most common source reported was their healthcare providers (doctors or nurses); more than half of the participants (52.7%, n = 49) reported healthcare providers (doctors or nurses) as their primary source of information about the COVID-19 vaccine. The results of the analysis determined that there were significant differences in information sources by country of origin, with more Hondurans (66.7%, n = 14) and Salvadorans (65.5%, n = 19) relying on healthcare providers (doctors or nurses) for information compared to Guatemalans (37.2%, n = 16; P = .02). Other sources of information included social media (17.2%; n = 16), with WhatsApp and Facebook being the primary platforms cited, public health campaigns (11.8%; n = 11), and family members (10.8%; n = 10).

Table 3.

Uptake of COVID-19 Vaccine and Sources of Information About the COVID-19 Vaccine (N = 93).

Variables	Total sample	Salvadoran	Guatemalan	Honduran	P-value
Variables	N = 93 (%)	n = 29 (%)	n = 43 (%)	n = 21 (%)	P-value
Uptake of COVID-19 vaccine^a	62 (66.7)	20 (69.0)	28 (65.1)	14 (66.7)	.94
Sources of information about the COVID-19 vaccine ^b
Doctor or nurse	49 (52.7)	19 (65.5)	16 (37.2)	14 (66.7)	.02*
Other healthcare professional	1 (1.1)	1 (3.5)	0 (0.0)	0 (0.0)	.54
Family member	10 (10.8)	3 (10.3)	5 (11.6)	2 (9.5)	1.00
Friend	9 (9.7)	3 (10.3)	3 (7.0)	3 (14.3)	.54
Newspaper/magazine	4 (4.3)	1 (3.5)	2 (4.7)	1 (4.8)	1.00
TV advertisement (commercial ad)/TV news	3 (3.2)	0 (0.0)	2 (4.7)	1 (4.8)	.60
Public health campaign	11 (11.8)	4 (13.8)	6 (14.0)	1 (4.8)	.60
Radio	1 (1.1)	0 (0.0)	1 (2.3)	0 (0.0)	1.00
Social media (eg, WhatsApp, Facebook)	16 (17.2)	5 (17.2)	9 (20.9)	2 (9.5)	.56

P-values are for χ² test (or Fisher’s Exact Test) assessing differences by country of origin.

P < .05.

Self-report of being fully vaccinated at the time of the study.

Multiple response options allowed.

COVID-19 Vaccination Hesitancy

Table 4 outlines the primary reasons for hesitancy or refusal to get the COVID-19 vaccine among unvaccinated participants (33.3%; n = 31). The most cited reason was a lack of trust in the government (32.3%, n = 10). Other notable concerns included a dislike of needles (19.4%, n = 6) and the intention to wait and see if the vaccine is proven to be safe (16.1%, n = 5). Additionally, a few some women expressed concerns about vaccine safety and side effects (9.7%, n = 3) or believed that having had COVID-19 provided immunity, making vaccination unnecessary (9.7%, n = 3). One woman (3.2%) mentioned preferring to rely on masks and other precautions instead of getting vaccinated, while another (3.2%) cited religious reasons for their objection and hesitancy to get vaccinated.

Table 4.

Reasons for Not Getting Vaccinated Against COVID-19 Vaccine Among Unvaccinated Pregnant Women (n = 31).

Primary reasons^a	n = 31 (%)
1. I am concerned about the side effects and safety of the COVID-19 vaccine.	3 (9.7)
2. I am concerned that the COVID-19 vaccine is being developed too fast.	0 (0.0)
3. I plan to wait and see if it is safe and may get it later.	5 (16.1)
4. I don’t trust the government.	10 (32.3)
5. I have a medical reason that makes me ineligible to get vaccinated (eg, I have had a severe allergy to vaccines in the past).	0 (0.0)
6. I plan to use masks and other precautions instead.	1 (3.2)
7. I’m generally opposed to vaccinations.	2 (6.5)
8. I am not a member of any group that is at high risk for COVID-19.	0 (0.0)
9. I don’t think that a vaccine is necessary because COVID-19 is not a serious threat.	0 (0.0)
10. The vaccine could give me COVID-19.	0 (0.0)
11. I don’t believe the vaccines are effective at preventing the spread of COVID-19.	0 (0.0)
12. I don’t like needles.	6 (19.4)
13. I already had COVID-19 and should be immune.	3 (9.7)
14. My doctor has not recommended a COVID-19 vaccine to me.	0 (0.0)
15. A friend or family member had a bad reaction the vaccine.	0 (0.0)
16. I am concerned about the costs associated with the vaccine (such as office visit costs or vaccine administration fees).	0 (0.0)
17. I didn’t know I needed a vaccine against COVID-19.	0 (0.0)
18. I don’t know where to go to get vaccinated.	0 (0.0)
19. Other. Please specify = religion was the only other reason mentioned	1 (3.2)

Single response option.

Discussion

This study explored COVID-19 fears, vaccination uptake, and hesitancy among pregnant Central American women from El Salvador, Guatemala, and Honduras in the U.S. Over two-thirds of participants (66.7%) reported being fully vaccinated, reflecting higher uptake compared to other multi-ethnic studies, where vaccination rates were lower (11.9%),¹⁵ and 26.7%.²⁷ Future research could explore these differences.

Several factors contributed to the higher vaccination rate. All participants had health insurance and a regular healthcare provider, with community-based health initiatives, tailored messaging, and strong provider recommendations boosting vaccine acceptance.²⁸ Many participants viewed themselves and their families as vulnerable to COVID-19, and cultural values prioritizing family protection may have further increased vaccine uptake.²⁹

Fear of COVID-19 was a major concern, especially regarding pregnancy and infant health. Over half (57%) feared transmitting the virus to their babies or pregnancy complications, reflecting a desire to protect their children, consistent with prior research showing that pregnant women prioritize baby health over personal concerns.³⁰ Many also feared dying from COVID-19, underscoring the need for tailored mental health support for pregnant women. Public health messaging should emphasize vaccination’s benefits for both mother and child and address these fears directly.^31,32

Despite high vaccination rates, one-third of participants expressed hesitancy, particularly among Guatemalan women, who had the lowest uptake. Reasons for hesitancy included distrust in government and fear of needles, consistent with literature on vaccine hesitancy in marginalized communities.^33,34 Some also questioned the need for vaccination, believing natural immunity from prior infection was sufficient.^35,36 These findings highlight the need for tailored communication strategies to address individual concerns and misinformation in Latino communities.^28,34,36,37

Healthcare providers, especially doctors and nurses, were the primary sources of vaccine information, reinforcing their role in shaping health decisions.^28,38,39 Targeted public health initiatives engaging HCPs are essential to address vaccine concerns and improve uptake, particularly among immigrant populations.

Healthcare providers, especially doctors and nurses, were the primary sources of vaccine information, reinforcing their role in shaping health decisions.³⁹ Targeted public health initiatives engaging HCPs are essential to address vaccine concerns and improve uptake, particularly among immigrant populations.^36
-40 To effectively reach these communities, campaigns should leverage culturally relevant messaging through accessible mediums such as radio, television, social media, and visual materials. Previous successful initiatives, like “Juntos Sí Podemos”³⁹ and “De Ti Depende”⁴⁰ have demonstrated the power of simple, family-centered messages and visual storytelling, highlighting the importance of tailoring campaigns to language and cultural preferences to enhance health communication and outcomes.^{28
-30,41
-45}

Ethnic differences in reliance on healthcare providers were noted, with Guatemalan women showing less trust in doctors and nurses than Salvadorans and Hondurans, suggesting that cultural factors may influence vaccine perceptions.^44,46 These findings highlight the need for future research to explore how these ethnic differences in trust affect vaccine hesitancy and acceptance in these communities. Although no significant differences in acculturation were found, Guatemalans reported greater acculturation than Salvadorans and Hondurans, which may have contributed to vaccine hesitancy.^{1,31,34,36,41,45,47}

Limitations

The study’s cross-sectional design limits the ability to establish causal relationships between vaccine uptake and information sources, as it provides only a snapshot of vaccine perceptions.⁴⁸ Self-reported data may introduce bias, with potential under- or over-reporting of vaccination status and fears due to social desirability.⁴⁹ Additionally, the small sample size poses constraints for data analysis, limiting the generalizability of the findings and the ability to draw broad conclusions.⁵⁰ While the sample may not fully represent the diverse experiences of pregnant Central American immigrant women in the U.S., this study is one of the first to focus specifically on Latina women from the Northern Triangle countries—El Salvador, Guatemala, and Honduras—providing valuable insights and laying the groundwork for future, larger studies to further explore these issues.

Conclusions

This study highlights the complex relationship between fear of COVID-19, vaccine uptake, hesitancy, and information sources among pregnant Central American immigrant women. Overcoming barriers to vaccine uptake requires culturally tailored interventions that build trust in healthcare systems and provide clear, accurate vaccine information. Public health strategies should focus on strengthening trust in healthcare providers and addressing emotional concerns about vaccination. While the pandemic is over, COVID-19 continues to impact communities, underscoring the ongoing relevance of this research. Vaccine hesitancy remains a challenge, especially with new variants. Future research should explore how the dynamics of vaccine hesitancy evolve over time, particularly through follow-up studies with participants, to assess whether concerns and hesitancy persist beyond initial intervention efforts. This could lead to a clearer identification of the long-term impact of culturally tailored interventions and the effectiveness of strategies aimed at improving trust in healthcare systems. Further, studies should continue to explore targeted approaches to enhance vaccine acceptance and address healthcare access barriers in diverse ethnic groups.

Footnotes

Acknowledgements

The authors sincerely thank the women who participated in this study for their valuable insights. We also appreciate the support from community members and organizations serving Central American immigrants in Massachusetts, which was essential to the success of this research.

ORCID iD

Ana Cristina Lindsay

Author Contributions

Conceptualization, A.C.L.; methodology, A.C.L., M.L.G., and Q.L.; software, Q.L.; formal analysis, Q.L.; investigation, N.R.-C., V.A.M., D.L., and A.C.L.; resources, A.C.L.; data curation, A.C.L., V.A.M., D.L, and N.R-C.; writing—original draft preparation, N.R.-C, M.L.G., and A.C.L.; writing—review and editing, V.A.M., D.L., N.R-C., Q.L, M.L.G., and A.C.L.; supervision, A.C.L.; project administration, V.A.M., D.L, and N.R.-C.; funding acquisition, A.C.L., D.L., V.A.M., and N. R-C. All authors have read and agreed to the published version of the manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by research trust funds from the University of Massachusetts Boston (Ana Cristina Lindsay). Nachalie Rodriguez-Cruz and Virginia A. Moreno received funding through the Beacon Student Success Fellowship, University of Massachusetts Boston. Doris Lucero was supported by a summer fellowship from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD/R25HD090723-02).

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.

Data Availability Statement

Due to privacy or ethical restrictions, the data that support the findings of this analysis are not publicly available; however, they are available upon request from the corresponding author.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of the University of Massachusetts Boston (protocol #2915, approved on May 19, 2021).

References

Majid

Ahmad

Zain

Akande

Ikhlaq

COVID-19 vaccine hesitancy and acceptance: a comprehensive scoping review of global literature. Health Promot Int. 2022;37(3):daac078. doi:10.1093/heapro/daac078

Badell

Dude

Rasmussen

Jamieson

DJ.

Covid-19 vaccination in pregnancy. BMJ. 2022;378:e069741. doi:10.1136/bmj-2021-069741

Wang

Sun

, et al. The association between pregnancy and COVID-19: a systematic review and meta-analysis. Am J Emerg Med. 2022;56:188-195. doi:10.1016/j.ajem.2022.03.060

Wei

Bilodeau-Bertrand

Liu

Auger

The impact of COVID-19 on pregnancy outcomes: a systematic review and meta-analysis. CMAJ. 2021;193(16):E540-E548. doi:10.1503/cmaj.202604

Adhikari

Spong

CY.

COVID-19 vaccination in pregnant and lactating women. JAMA. 2021;325(11):1039-1040. doi:10.1001/jama.2021.1658

Fleming-Dutra

Zauche

Roper

, et al. Safety and effectiveness of maternal COVID-19 vaccines among pregnant people and infants. Obstet Gynecol Clin North Am. 2023;50(2):279-297. doi:10.1016/j.ogc.2023.02.003

American College of Obstetricians and Gynecologists. Vaccinating pregnant and lactating patients against COVID-19. 2020. Accessed November 15, 2024. https://www.acog.org/clinical/clinical-guidance/practice-advisory/articles/2020/12/vaccinating-pregnant-and-lactating-patients-against-covid-19

Simmons

Whipps

MDM

Phipps

Satish

Swamy

GK.

Understanding COVID-19 vaccine uptake during pregnancy: ‘Hesitance’, knowledge, and evidence-based decision-making. Vaccine. 2022;40(19):2755-2760. doi:10.1016/j.vaccine.2022.03.044

Skjefte

Ngirbabul

Akeju

, et al. COVID-19 vaccine acceptance among pregnant women and mothers of young children: results of a survey in 16 countries. Eur J Epidemiol. 2021;36(2):197-211. doi:10.1007/s10654-021-00728-6

10.

Blakeway

Prasad

Kalafat

, et al. COVID-19 vaccination during pregnancy: coverage and safety. Am J Obstet Gynecol. 2022;226(2):236.e1-236.e14. doi:10.1016/j.ajog.2021.08.007

11.

Ward

Batalov

Central American immigrants in the United States. Migration Policy Institute. 2023. Accessed April 12, 2025. https://www.migrationpolicy.org/article/central-american-immigrants-united-states-2021

12.

Kirchoff

Penn

Wang

, et al. COVID-19 vaccine acceptance among Latino/a immigrants: the role of collective responsibility and confidence. J Immigr Minor Health. 2023;25(6):1246-1253. doi:10.1007/s10903-023-01513-1

13.

De Ramos

Lazo

Schnake-Mahl

, et al. COVID-19 outcomes among the hispanic population of 27 large US cities, 2020-2021. Am J Public Health. 2022;112(7):1034-1044. doi:10.2105/AJPH.2022.306809

14.

Pingali

Meghani

Razzaghi

, et al. COVID-19 vaccination coverage among insured persons aged ≥16 years, by race/ethnicity and other selected characteristics—eight integrated health care organizations, United States, December 14, 2020-May 15, 2021. MMWR Morb Mortal Wkly Rep. 2021;70(28):985-990. doi:10.15585/mmwr.mm7028a1

15.

Razzaghi

Kahn

Masalovich

, et al. COVID-19 vaccination and intent among pregnant women, United States, April 2021. Public Health Rep. 2022;137(5):988-999. doi:10.1177/00333549221099244

16.

Moreno

Lucero

Rodriguez-Cruz

Greaney

Lindsay

AC.

Exploring beliefs, concerns, prenatal care advice, and sources of information about gestational weight gain among immigrant central American pregnant women in the United States. Int J Environ Res Public Health. 2024;21(12):1672. doi:10.3390/ijerph21121672

17.

Lindsay

Pineda

Valdez

Torres

Granberry

PJ.

Central American immigrant parents’ awareness, acceptability, and willingness to vaccinate their adolescent children against human papillomavirus: a pilot cross-sectional study. Int J Environ Res Public Health. 2020;17(8):2869. doi:10.3390/ijerph17082869

18.

Diaz

Pineda

Wright

Greaney

Lindsay

AC.

How do Central American Parents in the United States view the importance of and obtain information about behaviors associated with the risk of early childhood obesity?

Hisp Health Care Int. 2023;21(2):78-88. doi:10.1177/15404153221093735

19.

Ahorsu

Lin

Imani

Saffari

Griffiths

Pakpour

AH.

The fear of COVID-19 scale: development and initial validation. Int J Ment Health Addict. 2022;20(3):1537-1545. doi:10.1007/s11469-020-00270-8

20.

Soto Briseño

Gomez-Diaz

Saldaña Espinoza

Lavielle

Valdez González

Wacher

NH.

Validation of the COVID-19 Fear Scale modified for application during the perinatal period. J Psychosom Obstet Gynaecol. 2022;43(4):447-452. doi:10.1080/0167482X.2022.2050210

21.

Barrios

Ríos-González

O’Higgins

, et al. Psychometric properties of the Spanish version of the fear of COVID-19 scale in Paraguayan population. Ir J Psychol Med. 2021;38(4):266-271. doi:10.1017/ipm.2021.5

22.

Nguyen

Srivastav

Razzaghi

, et al. COVID-19 vaccination intent, perceptions, and reasons for not vaccinating among groups prioritized for early vaccination—United States, September and December 2020. MMWR Morb Mortal Wkly Rep. 2021;70(6):217-222. doi:10.15585/mmwr.mm7006e3

23.

Marin

Sabogal

Marin

Otero-Sabogal

Perez-Stable

EJ.

Development of a short acculturation scale for Hispanics. Hisp J Behav Sci. 1987;9(2):183-205. doi:10.1177/07399863870092002

24.

Ellison

Jandorf

Duhamel

Assessment of the Short Acculturation Scale for Hispanics (SASH) among low-income, immigrant Hispanics. J Cancer Educ. 2011;26(3):478-483. doi:10.1007/s13187-011-0233-z

25.

SAS Institute Inc. SAS 9.4 Software. SAS Institute Inc; 2013.

26.

U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. 2023 Poverty Guidelines Computations. U.S. Department of Health and Human Services; 2023.

27.

Shephard

Manning

Nestoridi

, et al. Inequities in COVID-19 vaccination coverage among pregnant persons, by disaggregated race and ethnicity—Massachusetts, May 2021-October 2022. MMWR Morb Mortal Wkly Rep. 2023;72(39):1052-1056. doi:10.15585/mmwr.mm7239a2

28.

Kroll

McQueen

De La Vega

, et al. Trusted sources for COVID-19 testing and vaccination: lessons for future health communication. J Commun Healthc. 2023;16(4):350-357. doi:10.1080/17538068.2023.2255408

29.

Vincenzo

Spear

Moore

, et al. Reaching late adopters: factors influencing COVID-19 vaccination of Marshallese and Hispanic adults. BMC Public Health. 2023;23(1):631. doi:10.1186/s12889-023-15468-3

30.

Seddig

Maskileyson

Davidov

Ajzen

Schmidt

Correlates of COVID-19 vaccination intentions: attitudes, institutional trust, fear, conspiracy beliefs, and vaccine skepticism. Soc Sci Med. 2022;302:114981. doi:10.1016/j.socscimed.2022.114981

31.

Casubhoy

Kretz

Tan

, et al. A scoping review of global COVID-19 vaccine hesitancy among pregnant persons. NPJ Vaccines. 2024;9(1):131. doi:10.1038/s41541-024-00913-0

32.

Nomura

Tavares

Ubinha

, et al. Impact of the COVID-19 pandemic on maternal anxiety in Brazil. J Clin Med. 2021;10(4):620. doi:10.3390/jcm10040620

33.

Kajdy

Sys

Pokropek

, et al. The role of information in the COVID-19 vaccine decision-making process. J Health Commun. 2020;25(10):780-788.

34.

Betsch

Korn

Holtmann

The influence of political attitudes and government trust on vaccine hesitancy. Vaccine. 2018;36(4):557-563. doi:10.1016/j.vaccine.2017.11.040

35.

Kreps

Kriner

DL.

How do COVID-19 vaccine mandates affect attitudes toward the vaccine and participation in mandate-affected activities? Evidence from the United States. Vaccine. 2022;40(51):7460-7465. doi:10.1016/j.vaccine.2022.02.083

36.

Finney Rutten

Zhu

Leppin

, et al. Evidence-based strategies for clinical organizations to address COVID-19 vaccine hesitancy. Mayo Clin Proc. 2021;96(3):699-707. doi:10.1016/j.mayocp.2020.12.024

37.

Rawal

Tackett

Stone

Young

HN.

COVID-19 vaccination among pregnant people in the United States: a systematic review. Am J Obstet Gynecol MFM. 2022;4(4):100616. doi:10.1016/j.ajogmf.2022.100616

38.

Razai

Mansour

Ravindran

, et al. Facilitators and barriers to vaccination uptake in pregnancy: a qualitative systematic review. PLoS ONE. 2024;19(4):e0298407. doi:10.1371/journal.pone.0298407

39.

Sukumaran

We can do this: the COVID-19 public education campaign in English, Spanish. Salud America! at UT Health San Antonio. 2021. Accessed April 12, 2025. https://salud-america.org/we-can-do-this-the-covid-19-public-education-campaign-in-english-spanish/

40.

Ad Council and COVID Collaborative. “It’s up to you” COVID-19 education initiative launched in partnership with the CDC. GetVaccineAnswers.org. 2021. Accessed April 12, 2025. https://www.getvaccineanswers.org

41.

Gibson

Rand

Olson-Chen

Attitudes toward COVID-19 vaccination among pregnant persons in urban hospital-affiliated practices: exploring themes in vaccine hesitancy. Matern Child Health J. 2023;27(10):1855-1863. doi:10.1007/s10995-023-03752-y

42.

Owens

Pertuz

Sanchez

, et al. The COVID-19 pandemic in a Hispanic population: a primary care perspective. J Am Board Fam Med. 2022;35(4):686-694. doi:10.3122/jabfm.2022.04.210163

43.

Molina-Rogers

Kam

Cornejo

Mendez Murillo

Using the structural influence model to explore U.S. Latina/O/X/E undocumented immigrants’ COVID-19 information acquisition, perceptions, and prevention behaviors. Health Commun. 2024;39(13):3180-3194. doi:10.1080/10410236.2024.2309808

44.

Lopez

Altamirano

Melchor

, et al. Learning lessons from the COVID-19 pandemic-a qualitative assessment of the experiences of pregnant Latinas infected with COVID-19 and their perspectives on vaccination. J Racial Ethn Health Disparities. 2025;12:1804-1810. doi:10.1007/s40615-024-02010-3

45.

Marcell

Dokania

Navia

, et al. One vax two lives: a social media campaign and research program to address COVID-19 vaccine hesitancy in pregnancy. Am J Obstet Gynecol. 2022;227(5):685-695.e2. doi:10.1016/j.ajog.2022.06.022

46.

Cristancho

Peters

Garces

Health information preferences among Hispanic/Latino immigrants in the U.S. rural Midwest. Glob Health Promot. 2014;21(1):40-49. doi:10.1177/1757975913510727

47.

Durkee

Gazmararian

Escoffery

Fernandez

DeLaughter

Foster

PP.

Understanding vaccine hesitancy in pregnant women. JAMA Netw Open. 2021;4(7):e2115021. doi:10.1001/jamanetworkopen.2021.15021

48.

Creswell

JW.

Research Design: Qualitative, Quantitative, and Mixed Methods Approaches, 4th edn. Sage; 2014.

49.

Althubaiti

Information bias in health research: definition, pitfalls, and adjustment methods. J Multidiscip Healthc. 2016;9:211-217. doi:10.2147/JMDH.S104807

50.

Biau

Kernéis

Porcher

Statistics in brief: the importance of sample size in the planning and interpretation of medical research. Clin Orthop Relat Res. 2008;466(9):2282-2288. doi:10.1007/s11999-008-0346-9