key: cord-0960263-j1s62fhx
authors: Redmond, Michelle L.; Mayes, Paigton; Morris, Kyla; Ramaswamy, Megha; Ault, Kevin A.; Smith, Sharla A.
title: Learning from maternal voices on COVID‐19 vaccine uptake: Perspectives from pregnant women living in the Midwest on the COVID‐19 pandemic and vaccine
date: 2022-04-13
journal: J Community Psychol
DOI: 10.1002/jcop.22851
sha: 88b3915893832d2368d76f16cf327b66425c5c4c
doc_id: 960263
cord_uid: j1s62fhx

The aim of this study was to understand COVID‐19 vaccine perceptions and decision‐making among a racially/ethnically diverse population of pregnant and lactating women in the Midwest. Pregnant female participants (N = 27) at least 18 years. or older living in the Midwest were recruited to participate in a maternal voices survey. A mix‐methods approach was used to capture the perceptions of maternal voices concerning the COVID‐19 vaccine. Participants completed an online survey on COVID‐19 disease burden, vaccine knowledge, and readiness for uptake. A total of 27 participants completed the Birth Equity Network Maternal Voices survey. Most participants were African American (64%). Sixty‐three percent intend to get the vaccine. Only 25% felt at‐risk for contracting COVID‐19, and 74% plan to consult their provider about getting the COVID‐19 vaccine. At least 66% had some concerns about the safety of the vaccine. Participants indicated a willingness to receive the COVID‐19 vaccine, especially if recommended by their provider. We found little racial/ethnic differences in perceptions of COVID‐19 and low vaccine hesitancy.

The COVID-19 pandemic has greatly impacted the health and well-being of communities nationally and globally.

Pregnant women and their infants are no exception. From January 2020 to June 2021 over 98,000 pregnant women in the United States tested positive for COVID-19, resulting in over 16,000 hospitalizations and at least 109 deaths (Centers for Disease Control and Prevention [CDC] , 2021a). With mitigation efforts in place, vaccines have shown promising results in helping to lessen the impact of severe COVID-19 infection and or death (Thompson et al., 2021) . COVID-19 vaccines are particularly important for high-risk populations such as pregnant women, but perhaps even more so for groups of pregnant women with already high maternal and infant mortality rates.

Racial and ethnic minority populations are disproportionately affected by COVID-19 through severe disease, mortality, and death (Abedi et al., 2020; Webb Hooper et al., 2020) . Racial and ethnic minority pregnant women are also disproportionately affected by COVID-19 (CDC, 2021b; Onwuzurike et al., 2020) . Onwuzurike et al. (2020) found significant disparities in a small northeast United States population of pregnant women. The most severe cases of COVID-19 were among Non-Hispanic Black patients (34%) and Hispanic patients (30%). They also found of those with the most severe disease, 67% had at least one other chronic disease condition (i.e., lung disease, hypertension, diabetes, obesity), which likely increased COVID-19 complications. Grechukhina et al. (2020) observed over 1500 pregnant women and found women of Hispanic ethnicity to have the most severe COVID-19 disease. While most focus is on the health-related risk of COVID-19 and pregnancy, there are also social, financial, and mental health concerns. For a Hispanic pregnant population in the Northeast United States, housing insecurity was an added concern during COVID-19 (Onwuzurike et al., 2020) . African American women not only suffer disproportionately from health disparities related to COVID-19, but mental health-related issues as well. Gur et al. (2020) found pregnant African American women have higher rates of anxiety related to the current COVID-19 pandemic compared to other groups of pregnant women. African American women were also more likely to suffer from COVID-19 related job loss and stress (Gur et al., 2020) . Perzow et al. (2021) found pregnant women across all races/ethnicities doubled in depressive symptoms, from 15.5% reported depressive symptoms-pre-pandemic, to 35% reported depressive symptoms during the COVID-19 pandemic. Mental health and emotional well-being have likely added to anxiety that can exacerbate pre and postnatal health problems (Perzow et al., 2021) .

Pregnant women with pneumonia have a higher risk of delivering a low-birth-weight baby or preterm infant (Chen et al., 2012) . Common risk factors for poor birth outcomes are often linked to low birth weight and preterm birth (Manuck, 2017) . The health complications from COVID-19 during pregnancy and effect on mother's health are particularly concerning for certain racial and ethnic minority groups, such as African American women and Hispanic women where significant disparities already persist in maternal morbidity and mortality, infant mortality rates, and birth outcomes (Howell et al., 2018; Liese et al., 2019; Office of Minority Health [OMH], 2017) . Given the severe health risk from COVID-19 particularly for racial and ethnic minority pregnant women, the COVID-19 vaccine is needed (OMH, 2017) .

Recently, the ACOG provided guidance for pregnant and lactating individuals to receive the vaccine (ACOG, 2020). As of June 21, 2021, over 126,000 pregnant women (including those in the periconception periodwithin 30 days of last menstrual period) reported their vaccination status to the v-safe COVID-19 registry through a phone app to the Centers for Disease Control and Prevention (CDC, 2021b). The COVID-19 vaccine is now widely available in the United States but not always acceptable (as of this writing 37% of the United States population remains unvaccinated (Sparks et al., 2021) , understanding vaccine decision making and uptake is vital for at-risk populations (Kilich et al., 2020) . The current vaccine literature finds recommendations are the best way to increase uptake of vaccines during pregnancy (Ahluwalia et al., 2010; Arnold et al., 2019; Moniz et al., 2013) . Therefore, it is important from a community perspective to determine how likely racial/ethnic minority pregnant women are willing to receive the vaccine and what hesitancy may exist to prevent further disparities for this population.

The Kansas Birth Equity Network (KBEN) was formed over the past two years based on work with community stakeholders who are interested in improving maternal and child health outcomes that persist for racial/ethnic minority populations. These stakeholders include patients (i.e., mothers, fathers, and caregivers), community members, professionals in maternal and child health organizations, faith-based organizations, the education, and community sector. We engaged this community of stakeholders to recruit participants for the KBEN Maternal Voices Survey. Few studies are currently looking specially at racial/ethnic differences in perceptions of COVID-19 vaccine perceptions and beliefs among a pregnant population. Our study helps fill a gap in the literature from a community-engagement perspective about this important topic. This study was approved by the author's University Human Subjects Committee.

Our population included 27 female participants at least 18 years or older living in the Midwestern United States. To be eligible for this study, participants had to be at least 18 years of age, expecting or postpartum.

Participants were recruited for a virtual study to capture maternal voices on prenatal care access, perception of COVID-19 disease burden and vaccine. Survey responses were captured before the COVID-19 vaccines were available to the public. Participants were initially recruited from two virtual community-based webinars series on Maternal health and birth outcomes sponsored by the Kansas Birth Equity Network (website: https://www.kumc. edu/school-of-medicine/population-health/kansas-birth-equity-network.html). Participants were invited to complete the KBEN Maternal Voices Survey through a link provided through REDCap. We also used a snowball sampling technique by asking webinar participants and those enrolled in the study to share the study sign-up link to other potentially eligible study participants.

Data were collected between June 2020 and August 2020 via REDCap. Once signing-up for the initial study via a REDCap link, completing the eligibility process, and the online consent process, participants received access to the survey. Participants completed a demographic survey, quantitative survey, and qualitative questions outlined below. Participants also received a $10 gift card for their time. 

Study participants completed a 47-item online survey, which included general demographic questions on race, income, place of residence, Facebook information, and email. Other parts of the survey included a mix of quantitative and qualitative questions. Quantitative questions focused on prenatal care, birth, infant health, knowledge of COVID-19 vaccines during pregnancy, and strategies for learning about the COVID-19 vaccine.

Participants were also asked how past historical studies that involved medical misuses such as Tuskegee Syphilis Study (Corbie-Smith, 1999; Gamble, 1997) and Henrietta Lacks (Wolinetz & Collins, 2020) influenced their vaccine decision (see Table 1 ). Participants were also asked if they have ever experienced racial discrimination during a medical visit. These questions were asked to better understand how this may influence their decision on receiving a vaccine or if it impacts their perception of trust when receiving advice from the health care field. Table 2 ).

This study used a mix-methods approach utilizing quantitative and qualitative design and data analysis. Standard descriptive statistics were used to create a demographic profile and measure survey responses. For quantitative, bivariate analysis was used to examine survey responses. We used descriptive statistics and Fisher's Exact Test to examine survey responses by race. For qualitative data, we used thematic analysis to examine participants openended responses to survey questions. Two coders (Megha Ramaswamy and Paigton Mayes) conducted the coding.

The study coders (Megha Ramaswamy and Paigton Mayes), conducting the initial open coding, met to discuss initial coding findings, then conducted a second round of coding to arrive at emerging themes, following by a final round of coding and a discussion to finalize the study's emerging themes.

Before we present our findings, the authors would like to provide our positionality to help frame this study. The authorship of this study is multi-cultural and multi-generational. The following authors are of African American descent (Redmond, Smith) . The Following author is of African American and Indigenous descent (Mayes). While our other two co-authors are of Asian descent (Ramaswamy) and Non-Hispanic White descent (Ault). Authors which the data is presented. We understand the importance of the lens we use to present this data. We reflected in our coding and interpretation of the data how our personal experiences frame our lens as well as what this study means in the current state of our COVID-19 pandemic. Therefore, our effort was collaborative to ensure the work was sensitive and appropriate in the manner it was conducted.

Results from this study captured data from twenty-seven individuals who participated in the COVID-19 KBEN Maternal Voices survey. Many of the participants were African American (66.7%), followed by 29.6% identifying as Non-Hispanic White or 3% self-identifying as Hispanic. A majority were in their first trimester of pregnancy (44%).

Most of the participants had completed prenatal education classes (see Table 3 ).

Most participants indicated they had concern about the safety of the COVID-19 vaccine (67%). When looking at racial groups we found no significant differences. Participants also expressed a strong concern over the effectiveness of the COVID-19 vaccines but acknowledged having sufficient information (52%). In terms of social norms, most participants were not influenced by family, religious beliefs, or other social influences in their decision about the COVID-19 vaccine. There was also no general fear that getting the vaccine would give one COVID-19.

Overall, most participants did not believe they or their unborn child were at-risk for contracting COVID-19 (74%), and they generally had little concerns about the vaccine (100%) (see Table 4 ).

Participants were asked which strategies would most influence their decision to get vaccinated for COVID-19. The most influential strategy was a health care provider who would both recommend the vaccination and provide access to the vaccine in their clinic. While results by race and ethnicity were not significant, most Non-Hispanic

White patients endorsed this statement. African American patients were split evenly on this question. The least effective strategies for this patient population were knowing their healthcare provider was vaccinated, receiving a patient-friendly pamphlet, attending a community forum, and receiving text message reminders about the vaccine (see Table 5 ).

Participants were asked about their general knowledge of historical events and the influence this may have on their decision to get vaccinated for COVID-19. A majority were not aware of the Tuskegee Syphilis Study. Only 5 (18%) were aware of the Tuskegee experiments (Corbie-Smith, 1999; Gamble, 1997) . A similar finding was found regarding the Henrietta Lacks case from at Johns Hopkins University (Nature, 2020; Skloot, 2011; Wolinetz & Collins, 2020) . Nine of the participants (33%) were aware of the Henrietta Lacks story. Participants, regardless of race or ethnicity indicated a history of racial discrimination with the health care system was not an influential factor in their decision to get vaccinated nor did it raise concerns about the vaccination (see Table 6 ).

As part of the COVID-19 Maternal Voices survey, participants were asked to complete four qualitative questions on vaccine knowledge and concerns about COVD-19. After several rounds of coding, the following themes emerged:

concern about vaccine safety, general anxiety from the pandemic, limited vaccine hesitancy, and seeking knowledge. Overall, the concerns expressed in the open-ended questions differ slightly from the quantitative survey responses (Table 7) . "I don't know if the vaccine will work. The virus is too scary." While some just simply stated they were not interested, "I don't want to get vaccinated. I think I'd be better off not getting vaccinated" (African American female, Andover, KS). In many instances, the hesitancy over the vaccine was expressed as a safety concern.

3.1.5 | General vaccine safety concerns Even though there was limited hesitancy, many mothers expressed concern about vaccine safety. Several Note: Number of respondents who indicated this statement was true for them African American (n = 18), Non-Hispanic White (n = 8), and Hispanic (n = 1). Percentage = % of respondents who indicated this statement was true for them. The denominator for columns b is total N for each column. The total N represents the total number of respondents regardless of race/ethnicity who indicated this response was true for them.

Participants were also seeking more information on the COVID-19 vaccine. Many indicating they would get the Note: Number of respondents who indicated this statement was true for them African American (n = 18), Non-Hispanic White (n = 8), and Hispanic (n = 1), total of (n = 27) participants. Percentage = % of respondents who indicated this statement was true for them. The denominator for columns b is total N for each column. The total N represents the total number of respondents regardless of race/ethnicity who indicated this response was true for them.

Many participants indicated they were living with anxiety since the pandemic started. This anxiety was also linked to a lack of knowledge about the vaccine and COVID-19 pandemic itself, as one White female participant from Northeastern KS stated, "I don't know much about it but I'm in a bad way. So, take the necessary steps to comfort yourself when necessary." There was also anxiety and concern over their general 

This study sought to explore the perceptions of the COVID-19 vaccine and health risk among a diverse group of maternal voices during the COVID-19 pandemic. We found participants had mixed reactions about COVID-19 vaccine and risk of disease. We did not find significant differences among racial/ethnic groups in our sample. Most T A B L E 7 Major themes and participant quotes

Limited vaccine hesitancy "I don't think the vaccine will work. The virus is too scary."

General safety concerns "I don't know if the vaccine is safe. I hope it can be used when it is safe" Seeking greater knowledge "I'm trying to learn more about the vaccine, and if it's safe enough, I'll get it as soon as possible."

Ongoing anxiety and worry about health and infection "I often felt anxious, not sure if I was infected."

Assurance from health care provider "If the doctor could introduce me more knowledge about vaccine safety, I would be more willing to accept it" felt they were not at-risk for contracting COVID-19. There were a few participants who did express anxiety or concern about health risk from COVID-19. Participants appeared to embrace the importance of receiving the vaccine and were seeking knowledge to learn more about their options.

We found little vaccine hesitancy within this population of participants. There was general concern about vaccine safety and effectiveness, but a consensus that the vaccine was trusted. We anticipated the African American participants in our study would report more hesitancy in receiving the vaccine. This was not present in our data. This contrasts with what was expected based on the literature regarding vaccine hesitancy among pregnant African Americans (Moniz et al., 2013) . Our findings on low vaccine hesitancy among a pregnant population is similar to a recent study published on COVID-19 vaccine and pregnancy (Levy et al., 2021) . Levy et al. (2021) surveyed over 600 pregnant women about receiving the COVID-19

vaccine and found the majority (58%) were willing to receive the vaccine once available. In our study, we found women were willing to receive the vaccine or consider getting their shot if their health care provider recommended, they do so.

While there is limited data on the COVID-19 vaccine uptake during pregnancy, our results favor other vaccine literature during pregnancy when it comes to provider recommendation (Kriss et al., 2017) . With

Tdap and influenza there is a low prevalence of vaccine uptake among pregnant women in general (Ahluwalia et al., 2010; Arnold et al., 2019; Moniz et al., 2013) . This prevalence is further exacerbated along racial lines.

There are noted racial disparities that influence vaccine uptake among African American women and Asian populations (Ahluwalia et al., 2010; Arnold et al., 2019; Moniz et al., 2013) . Both groups were found to have lower vaccine uptake, mainly due to lack of provider recommendation. In our study, we found participants were more interested in the COVID-19 vaccine if they received a recommendation from their provider or assurance about the vaccine. How this will translate into actual uptake is still unclear. However, it is an important area to consider intervening upon to ensure recommendations are being made and patients are receiving them in equal measure. Further work on provider recommendation and patient initiation of this advice for COVID-19 vaccine uptake need to be completed.

Our study found no statistical difference between race and ethnicity for concerns over getting the COVID-19 vaccination. Our study population was relatively small; however, all groups were in favor of receiving the vaccine. Other literature has found racial disparities in vaccine uptake for influenza and Tdap (Kriss et al., 2017) . We were expecting similar resistance but found none. In general, the pregnancy population has poor uptake of the influenza vaccine (Arnold et al., 2013) . It will be important that this same trend does not translate into uptake of the COVID-19 vaccine.

There are limitations to our study. We have a relatively small sample size which makes the results difficult to generalize. Even so, our results provide a snapshot of this populations perception of the COVID-19 vaccine and potential interest in getting vaccinated. Future studies will be able to expand on sample size and provide more indepth exploration of vaccine concern, knowledge, and uptake. Another limitation is the self-report nature of our qualitative questions. We anticipated a larger qualitative study where we will further explore the themes garnered in this study through more in-depth follow-up semi-structured interviews. Another limitation is the variety of voices collected from difference racial/ethnic groups. We under-sampled maternal voices from the Hispanic community and would rectify this in a future study. A final limitation was the timing of the collection of voices. Our data collection took place before the availability of the Pfizer BioNTech and Moderna vaccines. Because of our data collection timeline, we are uncertain about which participants from the study followed through in getting their COVID-19 vaccine, per their health provider's recommendation or approval. REDMOND ET AL.

| 11 6 | CONCLUSION 6.1 | Implications for community psychology and public health

The impact of COVID-19 on health, mental and existing health disparities is substantial. Understanding how pregnant women perceive and react to the availability of the COVID-19 vaccine is vital. As with the flu, COVID-19

can have severe consequences on the health of a pregnant mother and her baby. Thus, this population is at particularly high risk for mortality and morbidity due to COVID-19. Because of the risk, finding solutions and removing barriers to the vaccine for pregnant women is important. Our study adds to the literature to help researchers, public health officials and providers understand racial/ethnic maternal voices decisions on seeking knowledge about the vaccine and their decisions around getting vaccinated.

For Community Psychologists and public health researchers, a focus on future studies on COVID-19 vaccine uptake in general should examine upstream factors and social determinants of health (i.e., access, availability, health literacy) that influence vaccine decision-making among this population (Prasannan et al., 2021) . Another missing component to this study is the perspective of the provider. Fully understanding how health providers make recommendations, patient risk profile, and assessment will aid in any interventions or efforts to ensure health equity on issues of vaccine decision-making.

As community psychologists, looking at this issue from a socio-ecological framework may help determine the best way to intervene to effect change. Meaning is vaccine hesitancy or decision making most impacted at the individual level, interpersonal level, organizational level, community level, or policy (Bronfenbrenner, 1977; Kolff et al., 2018) . Using this framework can help identify where the barriers and facilitators exists in vaccine uptake. This is particularly relevant when thinking about health equity and evaluating evidence-based approaches for health literacy messaging.

The women in our study were concerned about the severity of COVID-19 on their health and the health of their unborn child but were ready to receive the vaccine to protect themselves and their children. While our findings do not focus on those who received the COVID-19 vaccine, this is good news and requires further exploration on how to increase vaccine uptake.

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The peer review history for this article is available at https://publons.com/publon/10.1002/jcop.22851