Vaccine-Related Attitudes and Decision-Making among Uninsured, Latin American Immigrant Mothers of Adolescent Daughters: A Qualitative Study

"Engaging women from this population in discussing their attitudes and beliefs regarding vaccinations is critical to identifying modifiable targets for interventions to increase adolescent vaccine uptake."

Structural-level factors (e.g., lack of health insurance, poverty, and immigration status) act as barriers to vaccination among Hispanic populations. This study explored vaccine-related knowledge, attitudes, and decision-making for tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, meningococcal conjugate vaccine (MenACWY), and human papillomavirus (HPV) vaccine among uninsured Latin American immigrant mothers of adolescent daughters in the United States (US).

In light of prior research demonstrating the importance of both adolescent and parental attitudes with respect to vaccine acceptability, the researchers recruited a purposive sample of 30 low-income, uninsured, predominantly Latin-American immigrant mothers of adolescent daughters aged 13-17 from 2 academic-community managed free health clinics in Virginia, US. The majority of participants self-identified as Hispanic and had less than a high-school level education. From March-September 2016, data were collected through in-person, semi-structured interviews. According to participants, most adolescents were up-to-date on routine childhood vaccinations (e.g., measles, mumps, and rubella - MMR) (24/30 = 80.0%).

Qualitative themes and illustrative quotes regarding vaccine decision-making are displayed in Table 2 in the article. (Quotes are provided in English and Spanish, where relevant.) Key themes included:

• Overall attitudes toward vaccines - There was general acceptance of vaccines and prevention/protection. However, some acknowledged vaccine hesitancy among themselves or their children. Mothers who expressed more hesitancy regarding adolescent vaccines compared to childhood vaccines expressed an increased sense of agency in their ability to determine what is best for their child.
• Knowledge and attitudes toward adolescent vaccines - There was a general lack of knowledge regarding adolescent vaccines. Sub-themes included lack of knowledge or mixed knowledge about: (i) vaccine-preventable diseases (VPDs), 2) the meningococcal, Tdap, and HPV vaccines, and 3) daughters' vaccination history. Facilitators to vaccinating against HPV, for instance, included school mandates, doctor recommendation, or participants feeling responsible for keeping their children healthy. Barriers to vaccinating included: not knowing about it, not thinking about it, or not asking about it; not believing it is necessary; not having health insurance; or concerns about safety and side effects.
• Vaccine decision-making - The clear consensus was that mothers are the primary decision-maker, and mothers have control over whether or not their adolescents get vaccinated. When participants were asked about sources of information and whose opinion they trust regarding whether or not their daughters should get vaccines, the prominent key influence was a doctor; other key influences mentioned were school requirements, spouse/family influences, the internet, and media.

Reflecting on the findings, the researchers stress that, "While uninsured Latin American immigrant mothers might have supportive attitudes toward vaccinations in general, they cannot ensure that their adolescent children are vaccinated if they do not know what vaccines are recommended for their adolescent children, why these recommended vaccines are important, what vaccines their daughters have already received, or where to go to get recommended vaccines." Thus, they recommend efforts to engage uninsured, Latin American mothers in dialogue and education regarding their daughters' vaccination history to ensure they are able to make informed decisions.

Also, considering the finding that a provider's vaccination recommendation is highly influential among this population, the researchers recommend education and training for physicians regarding the importance of endorsing all adolescent immunisations for their patients. Furthermore, they say, "interventions are needed to train physicians regarding how to effectively communicate the importance of vaccinating in a culturally competent manner to mothers who may be from disadvantaged backgrounds."

In conclusion: "Interventions to increase vaccine-related knowledge and access among uninsured, Latin American immigrant mothers of adolescents are crucial to increasing vaccine uptake among this priority population."