key: cord-0956452-b61krlz5 authors: Geana, Mugur V.; Anderson, Sherri; Ramaswamy, Megha title: COVID‐19 vaccine hesitancy among women leaving jails: A qualitative study date: 2021-05-11 journal: Public Health Nurs DOI: 10.1111/phn.12922 sha: b8658a22459af9969bfa16039bd8033634e8de7b doc_id: 956452 cord_uid: b61krlz5 In many correctional facilities across the United States, COVID‐19 vaccine refusal rates are as high as 50%. Most women leaving jails have low SES, health literacy, and mistrust of governmental institutions, thus exacerbating existing health disparities and making women leaving jail vulnerable. Data from 25 interviews with recently released women suggest that interventions to promote vaccines to this population will have to address health education and mitigate mistrust, misinformation, and conspiracy theories. Of all the developed nations, the United States has one of the largest numbers of women in correctional or detention facilities. A study by ACLU shows that women's incarceration has grown at twice the pace of men's incarceration in the last decades and that most women are held in jails, not prisons (Kajstura, 2019) . These women often come from marginalized communities, have complex trauma, mental health, and drug problems. They are less likely to have stable employment, health insurance, or a medical home once they leave jail, often compounded by low education, low health literacy, and low self-efficacy in navigating the medical system, even under "normal" conditions. Some of them are chronic drug users or sex workers. The COVID-19 pandemic has added to and complicated the problems these women face when leaving jail. They risk exposure while detained, and most of these women return to communities that the coronavirus epidemic has ravaged. Correctional and detention facilities in the United States have had the second-highest incidence of COVID-19 outbreaks among U.S. institutions, involving inmates and their staff (Williams et al., 2020) . Women incarcerated before March 2020 are being released in a novel reality, one with an abundance of restrictions and limitations in employment opportunities and social life. It is a changed life in which information about the pandemic abounds, but it is not easy to understand or disputable. The ideologically and socially polarized American society has become the perfect ground for disseminating half-truths and conspiracy theories (Dib et al., 2021) . Women leaving jails are exposed to a barrage of misinformation, fabrications, and "fake news." From posts shared on social media to "documentaries" with a "scientific" undertone -Plandemic, 2020 -American media abounds of COVID-19 information that is false and geared toward creating mistrust in authorities and discontent (Flaskerud, 2021) . The COVID-19 pandemic shaped the perfect backdrop for what is labeled as a resurgence of concentrated attacks to polarize U.S. audiences further. Persons with low health literacy or suspicion of the government are the perfect targets for such messages. How women in the criminal justice system uptake recommended preventive measures, from social distancing to vaccines, are impacted by mistrust in the health care system and on scientific approaches that try to mitigate the novel coronavirus infection. These behaviors will exacerbate existent health disparities and make women leaving jail even more vulnerable. Although acceptance of the COVID-19 vaccine is relatively high, between 30% to 40% of Americans have stated that they will not be getting the vaccine, which poses a severe challenge to achieving herd immunity and eliminating the pandemic (SteelFisher et al., 2021) . In many correctional facilities across the United States, both staff and inmates refuse vaccines, with refusal rates as higher as 50%, by citing safety concerns, religious beliefs, or conspiracy theories for not voluntarily accepting the vaccine (Manganis, 2021) . Public health interventions with women leaving jail focused on disease preventive behavior have been proven effective in eliciting attitude and behavioral change (Ramaswamy et al., 2017) . However, they need to be tailored to the particularities of how this audience perceives a particular topic. To that purpose, this study explores the underlying reasons that drive vaccine hesitancy among women leaving jail. None of the women had received the vaccine against COVID-19 (at the time of the interviews, the states where these women reside only vaccinate adults 65+ years old and essential workers). Although all participants stated that they abided by mitigation recommendations (social distancing, washing their hands, avoiding crowds, using face masks) in their quest to protect themselves and to protect others, most women stated they were tired of the pandemic and social distancing and that wearing masks is one of the major nuisances of the mitigation protocols: "I felt like I had to wear the mask thing. Okay, I feel claustrophobic, I feel so claustrophobic, and I have to wear it to work, and the reason why that is kind of annoying because you cannot breathe, and nobody can hear you when you're talking. They say repeat yourself 100 times, you know." (Dolores, 52 years old, unemployed, would not vaccinate). 1 Sexual health empowerment for jail-involved women's health literacy and prevention (2R01CA181047, 2019-2024), PI Ramaswamy. 2 To protect participants' privacy, all the names used in this manuscript are not their real names. All the quotes in the paper have been slightly edited for clarity, when needed, without changing the ideas shared by the participants. Not willing to vaccinate 13 52 Maybe, but not right now 2 8 Yes, but only if they must because of work requirements or family reasons 3 12 They would not refuse it if offered but would not voluntarily pursue it 1 4 Yes, but with serious concerns 1 4 Yes, they would vaccinate 5 20 Several participants even stated that not having to wear masks anymore is a solid incentive to get the vaccine: That is just crazy how they can literally take the common flu and set a whole world down." (Tracey, 41 years old, employed part time, will not vaccinate). Often, supporters of the "government control theory" argued that the number of deaths from COVID-19 was artificially inflated to scare the population into compliance, a theme that appeared several times in our interviews: Nine women said that they trust pharmaceutical companies, three said they do not know or do not care, and 13 said that they do not trust the pharmaceutical companies that have developed the vaccine. Our analysis suggests a direct correlation between trust in the phar- Although the previous quote seems to paint both the pharmaceutical and medical professions in the same light, our participants seem more trusting of the medical establishment overall. Only 24% of the interviewed women said that how the USA handled the pandemic was good. When asked about their expectations for life to return to normal, as it was before the pandemic, most held a pessimistic view, with 44% of them saying that we will never return to how things were before, 20% that it will take several years and 32% that it will take less than a year. One person did not provide an estimate. Seven out of the eight women who hoped for life to return to normal in less than a year said they would be vaccinated, and one was undecided. With one exception, all of the women who believed that life would never return to normal stated they would not get the vaccine. Forty-four percent of participants think that they know enough about the vaccine to make an informed decision about their immunization choice, and 56% think they do not know enough about the vaccine. Only three women said that they actively searched for information about the vaccine to educate themselves; most of the women in our sample were passive recipients of information from news outlets, social media, or their circle of family and friends. To provide an estimate of how much they are up to date with general information about the pandemic, we asked them to estimate the number of deaths in the United states, to date, from COVID-19, a metric that was present in the media almost daily. Only four women out of 25 were able to provide a figure close to the official number of COVID-19 deaths. Most other estimations varied significantly, often by orders of magnitude, from several thousand to millions of deaths. and living with children) (Paul et al., 2021) . The probable low health and informational literacy of these women leave them vulnerable to influence from family and friends, many sharing and promoting disinformation and conspiracy theories frequently shared by homegrown anti-vaccine organizations (Hotez et al., 2021) . There is also an evident lack of primary education about both COVID-19 and vaccines, | 5 GEANA Et Al. so women have no factual reference toward which new information can be contrasted or evaluated. There is an immediate need for interventions to address vaccine hesitancy among this vulnerable population. Previous research suggests that tailored interventions considering this audience's particularities are practical and can be successfully implemented (Geana et al., 2021) . We estimate that, due to the complexity of factors that impact these women's immunization-related behavior, interventions to promote vaccines to this population will have to be complex and decisive and include health education, as well as mitigation for mistrust, misinformation and conspiracy theories. None. The data that support the findings of this study, consisting of all coded excerpts from the interviews, are available on request from the corresponding author. The raw data are not publicly available due to privacy or ethical restrictions. Mugur V. 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The New York Times How to cite this article: Geana MV, Anderson S, Ramaswamy M. COVID-19 vaccine hesitancy among women leaving jails: A qualitative study