key: cord-0272533-s27s4umt authors: Piper, B. J.; Sanchez, B. V.; Madera, J. D.; Sulzinski, M. A. title: Profiles of US Hispanics Unvaccinated for COVID-19 date: 2021-09-23 journal: nan DOI: 10.1101/2021.09.17.21263464 sha: 1f4548b0c3bccb16f296f796e5a8a879d4b771b0 doc_id: 272533 cord_uid: s27s4umt Background: The COVID-19 pandemic has disproportionately impacted Hispanics in the US with increased rates of SARS-Cov2 infections, hospitalizations, and deaths. The objective of this report was to characterize the demographics and beliefs of unvaccinated Hispanics to help address their concerns that lead to vaccine hesitancy. Methods: Of 1,011 potential participants from a national online panel, 22.3% (N = 225, 51.6% female, age = 40.5) met inclusion criteria of Hispanic adults and not receiving at least one dose of the COVID-19 vaccine. The 30-item survey included items about demographics, political affiliations, sources of news (e.g., Fox vs. CNN), reasons for being unvaccinated, and ratings (0 = strongly disagree, 100 = strongly agree) of 10 controversial statements regarding COVID-19. Results: Over three-fifths (62.6%) identified side effects and safety concerns while almost one-third (30.5%) a lack of efficacy as their top reasons for being unvaccinated. Agreement to statement: The developers of the COVID-19 vaccine rushed the development and cut-corners, was rated highest (63.22) which was significantly (p < .001) higher than the other nine statements (e.g., The COVID-19 vaccine does not work). Many vaccine attitudes differed significantly by political party affiliation and some by gender and news source. Republicans (59.9 + 4.2) scored higher than Democrats (38.5 + 4.2, p < .001) to the statement: If I have already had COVID-19, I do not need the vaccine. Conclusions: This study identified heterogeneity in COVID-19 vaccine attitudes among Hispanics. Further research is needed to determine if the subgroups identified are differentially receptive to interventions to facilitate reconsideration of prior vaccination decisions. Although the coronavirus disease 2019 (COVID- 19) pandemic has affected everyone, the disease burden in the US has disproportionately impacted minorities. A systematic review determined that Hispanic populations had a 1.3 to 7.7 times greater risk for a positive SARS-COV2 (Severe Acute Respiratory Syndrome Coronavirus 2) RNA-PCR relative to non-Hispanic White populations. 1 Moreover, Hispanic or Latino individuals were 2.7 to 4.4-fold more likely to be hospitalized due COVID-19 and 2.8 fold more likely to die from the disease, relative to non-Hispanic Whites. [1] [2] [3] Further, more years of life were lost due to COVID-19 before age 65 among the Hispanic and non-Hispanic Black populations than Whites, despite the smaller size of these groups. 3 However, vaccination rates of Hispanics lagged relative to Whites in 34 of the 40 states reporting ethnicity. For example, one-third (33%) of Hispanics versus two-thirds of Whites (64%) had received a COVID-19 vaccine dose in Arizona. 4 Vaccination decisions are complex and impacted by a variety of cultural, demographic, sociopolitical, religious, and economic factors. [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] A scoping review of ninety-two studies from highincome countries determined that risk for vaccine hesitancy was highest for those of non-White ethnicity, younger-age, females, lower-education, lack of recent history of receiving the influenza vaccination, decreased perceived risk of contracting COVID-19, and not having chronic medical conditions. 10 Similarly, an online study with a national sample (N=1,878) conducted in 2020 determined that Hispanics, those with children at home, rural residents, and people identifying politically as Republicans were less likely to be vaccinated. 11 Phone-interviews of Medicare patients completed in the fall of 2020 revealed that those whose primary information source was social media had lower perceptions of COVIDdisease severity and lower likelihood of getting a vaccinated. 12 Four out of five (79.9%) Hispanic/Latino women who were pregnant were unvaccinated for COVID- 19. 13 As the 62.1 million Hispanics constitute the largest minority in the US, 14 the objectives of this investigation were to extend upon past research 9, 11 to further characterize Hispanics who were unvaccinated for COVID-19 upto August 1, 2021. August 1, 2021. The survey was hosted on this survey firm's panel which has 2.5 million daily respondents who are compensated ($0.25 -$0.50/survey). Inclusion criteria were identification as Hispanic, adult (age > 18), and a negative response to "Have you received at least one dose of the COVID-19 vaccine, from any maker?". There were six items about demographics (age, gender, ethnicity, income, education, political affiliation). There were ten statements and misconceptions, e.g. "The COVID-19 vaccine will make me infertile", selected based on research [15] [16] [17] with GraphPad Prism, version 6.07 with variability depicted as the SEM. When the "prefer not to disclose" option was selected, these participants were removed from the denominator for percentage calculations for that question. Associations between the ten COVID-19 statement ratings were determined with Pearson correlations. Cronbach's alpha was used for internal consistency and principle component analysis for the ten statements. A p < .05 was considered statistically significant although analyses that met more conservative cutoffs (e.g., p < .0005) were noted. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; Table 1 shows a ranking for the top three reasons for not receiving the COVID-19 vaccine. Over three-fifths endorsed concern about side effects and safety. Three out of ten indicated that they do not believe it will protect them from COVID-19. Over one-quarter did not believe it was necessary because they had a prior COVID-19 diagnosis or suspected one. One out of eleven reported a medical exemption. Religious beliefs were endorsed by one-ninth. Logistical issues like cost, transportation to the vaccination site, obtaining time off work, or difficulty signing up for a vaccination were each selected by less than 8%. Among the eighteen participants that elected to provide an "other" reason, these were varied and included "allergy" or "autoimmune disease" (three responses), "believe it's . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; a placebo", "don't like needles", "pregnant", "I have a healthy body", "I just don't want to", or "haven't had a reason to". The response to "How likely would you be to take the COVID vaccine if it were a pill?" with options ranging from 0 to 100% were generally low (Mean = 32.01%, SD = 34.41%, Median = 16.50%) but higher for Democrats (44.36%, SD = 34.08) than Republicans ( Ten controversial COVID statements were ranked on a 0 (strongly disagree) to 100 (strongly agree) scale. Figure 1 shows that the belief that "The developers of the COVID-19 vaccine rushed the development and cut-corners" was rated highest (63.22) which was significantly (p < .001) higher than the other nine-statements. The only other statement to score greater . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; than 50 (i.e. neutral) was "The COVID-19 vaccine does not work" (51.04) which was rated significantly (p < .05) higher than statements in the fourth to tenth rank. The third highest ranking (48.13) was for "If I've already had COVID-19, I don't need the vaccine" which had a significantly (p < .05) elevated score relative to statements ranked fifth and below. Table 2 shows generally moderate (r = 0.3 to 0.6) correlations among these statements with the partial exception of "I only need the vaccine if I want to travel out of the country." The internal consistency of these ten items was 0.874 which showed only a modest improvement (0.883) with the travel item removed. An exploratory principal component analysis was completed. The first two components accounted for 47.85% and 12.20%, respectively, of the variance. The first component constituted all items except for "travel" which had a high negative loading on the second component (Supplemental Table 1 ). A total score for agreement to these ten controversial COVID statements was created which was 29.4% higher for Republicans than Democrats and also elevated relative to Independents. Table 3 shows that Republicans and Democrats differed significantly on twice as many items (six) as Republicans and Independents (three). There was a significant correlation between total score and likelihood of voting for Donald Trump in the next presidential election (r(207) = 0.33, p < .0005). However, the total score did not differ by gender or age (not shown). Only those with a graduate or professional education had a mean above 500 (i.e., on the "agree" end of the spectrum for all items, Supplemental Figure 2 ). The total score was examined based on news source. Those whose primary source of news was CNN had a lower score relative to Fox, NBC, CNN en Espanol (p < .05), and local newspaper (p < .01, . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; This novel report with a national US sample of unvaccinated Hispanics is generally congruent with and extends upon prior COVID-19 vaccine hesitancy research conducted earlier in the pandemic and with less targeted samples. 8, 9, 11, 12, 16, 17 Two complementary approaches were used to identify the rationale for not being vaccinated eight months after the first vaccine had received an emergency use authorization. First, when participants were asked to select their top three-reasons, concern about side-effects and safety concerns regarding the vaccine contents were identified by over three-fifths of participants. Side-effects were the primary concern even before a COVID vaccine was available. 8 A small subset, one out of eleven, endorsed religious beliefs. There was a negative association between an external health locus of control and vaccination intentions 5 as well as misconceptions about fetal tissue being used in vaccine production 19 so this reported frequency was lower than anticipated. One out of twelve participants selected "cost" which is curious as the vaccine is freely provided, perhaps revealing an important misconception that could be targeted. Continued educational efforts on how to sign-up for the vaccination or greater use of mobile clinics or increased vaccination availability by primary care providers may be practical strategies to target these small ( < 6% each), but important, unvaccinated subgroups. The subset (9.1%) of participants reporting a medical exemption may also warrant further attention as the Centers for Disease Control currently recommends vaccination for everyone > age 12 20CDC with no absolute contraindications. Our second strategy to identify individual differences in vaccination decisions was to ask participants to rate their agreement with ten contentious COVID-19 statements. Interestingly, even among this unvaccinated sample, participants, on average, disagreed that the COVID-19 will make them infertile, will change their DNA, or that the disease is a myth. The statement that was most strongly endorsed was that "The developers of the COVID-19 vaccine rushed the development and cut corners." These quantitative findings are congruent with a large (N = 754) qualitative report from Arkansas. 16 The second highest rated statement "The COVID-19 vaccine does not work." The continued emergence of new variants makes the earlier randomized controlled trials 21,22 less helpful for efficacy information but these . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 23, 2021. ; well-powered datasets are still valuable to inform short-term safety. Some hospitals make publicly available the pronounced over-representation of the unvaccinated among those that were hospitalized 23, 24 which may also combat this misperception. It is difficult to understate the degree that political ideology has come to overlap with COVID-19 beliefs. 8, 9 Republicans more strongly endorsed three of the ten COVID statements including that COVID will change my DNA and that "The COVID-19 vaccine is just the virus and will infect you with the disease." relative to those who identified as Independents. Republicans and Democrats differed on six items and on the total score for all ten statements. While the strength of attitudes differed by political party, it is important to recognize that all three political affiliations (Republican, Democrat, and Independents) were equally represented among the unvaccinated. Similarly, as reported previously, 8, 25 whether these participants obtained their news from more liberal (e.g. CNN) or more conservative (e.g. Fox) sources differentiated COVID-19 attitudes. Importantly, there is some evidence that vaccination disparities by race/ethnicity have narrowed while disparities by political affiliation have widened. 26 Although it is unfortunate that this pressing medical and public health issue is subsumed within the US culture wars for many, these findings and others 9, 11 indicate that unique messages may continue to need to be differentially targeted to these sub-groups. Vaccination decisions are due to a variety of sociological and psychological factors including race/ethnicity, political beliefs, rural/urban residence, economic considerations, and the intersection of these characteristics. 11, 27 Hispanics unvaccinated for COVID-19 are non-homogenous and exist on a continuum that includes those that are hesitant (e.g. "wait and see") or facing logistical barriers (e.g. time off work, transportation) to those that whose views are entrenched and may require substantial education, or employment requirements, to change their behavior. There are broad tools like mandates to get vaccinated as a requirement for employment, education, or travel, and more subtle nudges employed by behavioral economists [28] [29] [30] . While recognizing that the relationship between attitudes and behaviors is complex, 31 utilization of positive, targeted 32 , and culturally responsive messaging on COVID-19 vaccines . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this this version posted September 23, 2021. ; and using vaccinated Hispanic health-care workers as vaccine ambassadors targeting the themes identified here should be evaluated in controlled research. Some caveats and future directions are noteworthy. First, this investigation relied on self-reported data from a national sample of one-thousand with two-hundred which met the unvaccinated inclusion criteria, recruited online. Future investigations should also target Hispanics whose primary language is not English. Second, we were initially surprised that religious factors did not rank more prominently as a reason for not being vaccinated. The low attendance at virtual or in-person religious events may reflect either the magnitude of COVID-19 induced disruption of these events or that the sample was atypical on this variable. Third, as is true for any point in time survey, these data reflect the interval (Summer, 2021) of data collection which was before the vaccines received full Food and Drug administration approval. Much clinical, epidemiological, and basic science COVID-19 information is rapidly changing 15,20-22 which will inform survey items on future attitudinal studies. In conclusion, the stakes are high for understanding, and overcoming, the multifaceted nuances of vaccine hesitancy among Hispanics and others. 4 We are cautiously optimistic that this report, and future quantitative and qualitative ones, can empirically inform strategies to most efficiently target a decreasing subset of the US population that is unvaccinated against COVID-19. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; Figure 1 . Rating (+SEM) of ten controversial COVID-19 disease and vaccine statements (0 = strongly disagree to 100 = strongly agree) among unvaccinated Hispanics, ranked. Neutral (50) is shown with a vertical dashed line. Statements were: The developers of the COVID-19 vaccine rushed the development and cut corners (1. rushed), The COVID-19 vaccine does not work (2. vac not work), If I've already had COVID-19, I don't need the vaccine (3. prior COVID, no vac), The COVID-19 vaccine is just the virus and will infect you with the disease (4. vaccine = virus), The COVID-19 vaccine will make me infertile (5. infertile), The vaccine isn't necessary because COVID-19 has a low mortality rate (6. low mortality), The COVID-19 vaccine will change parts of my DNA (7. change DNA), I don't need the vaccine because everyone else around me has already received it (8. everyone else), I only need the vaccine if I want to travel out of the country (9. travel only), COVID-19 is a myth (10. COVID-19 = myth). r p < .001 versus 1. rushed, w p < .05 versus 2. vaccine not work, n p < .05 versus 3. prior COVID, no vaccine. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; Table 2 . Correlations among ten COVID-19 disease and vaccine statements (0 = strongly disagree to 100 = strongly agree) among unvaccinated Hispanics. Statements were: The developers of the COVID-19 vaccine rushed the development and cut corners (1. rushed), The COVID-19 vaccine does not work (2. not work), If I've already had COVID-19, I don't need the vaccine (3. prior COVID), The COVID-19 vaccine is just the virus and will infect you with the disease (4. vac = virus), The COVID-19 vaccine will make me infertile (5. infertile), The vaccine isn't necessary because COVID-19 has a low mortality rate (6. low mortality), The COVID-19 vaccine will change parts of my DNA (7. change DNA), I don't need the vaccine because everyone else around me has already received it (8. everyone else), I only need the vaccine if I want to travel out of the country (9. travel only), COVID-19 is a myth (10. COVID = myth). All correlations were p < .001 except n nonsignificant. ____________________________________________________________________________________________________________________ is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Supplemental Figure 1 . Percent responses to "Which of the following are your top 3 primary sources of news?", ranked, among COVID-19 unvaccinated Hispanic U.S. respondents (N = 171, N = 37 "prefer not to say" not included). Conservative sources are in red and liberal sources in blue . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; Supplemental Figure 2 . Total score (+SEM) of rating for ten controversial COVID-19 disease and vaccine statements (0 = strongly disagree to 100 = strongly agree) among unvaccinated Hispanics by education (A) and income (B). A total rating of "neutral" on all items is indicated by the horizontal dashed line. The N per group is in parentheses. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) preprint The copyright holder for this this version posted September 23, 2021. ; Racial and ethnic disparities in COVID-19-related infections, hospitalizations, and deaths Age-adjusted laboratory-confirmed COVID-19 associated hospitalization rates by race/ethnicity-COVID-NET Variation in racial/ethnic disparities in COVID-19 mortality by age in the United States: A cross-sectional study Latest data on COVID-19 vaccinations by race/ethnicity. 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Fraiman, MD and Swathi Gotham, MD for discussions on survey design. Figure 3 . Total score (+SEM) of ratings of ten controversial COVID-19 disease and vaccine statements (0 = strongly disagree to 100 = strongly agree) among unvaccinated Hispanics by top three sources of news. A total rating of "neutral" on all items is indicated by the horizontal dashed line. The N per group is in parentheses. C