Social Factors, Health Care Inequities and Vaccination: Volume 40

Since the development of the COVID-19 vaccinations, questions surrounding race have been prominent in the literature on vaccine uptake. Early in the vaccine rollout, public health officials were concerned with the relatively lower rates of uptake among certain racial/ethnic minority groups. We suggest that this may also be patterned by racial/ethnic residential segregation, which previous work has demonstrated to be an important factor for both health and access to health care.

In this study, we examine county-level vaccination rates, racial/ethnic composition, and residential segregation across the U.S. We compile data from several sources, including the American Community Survey (ACS) and Centers for Disease Control (CDC) measured at the county level.

We find that just looking at the associations between racial/ethnic composition and vaccination rates, both percent Black and percent White are significant and negative, meaning that higher percentages of these groups in a county are associated with lower vaccination rates, whereas the opposite is the case for percent Latino. When we factor in segregation, as measured by the index of dissimilarity, the patterns change somewhat. Dissimilarity itself was not significant in the models across all groups, but when interacted with race/ethnic composition, it moderates the association. For both percent Black and percent White, the interaction with the Black-White dissimilarity index is significant and negative, meaning that it deepens the negative association between composition and the vaccination rate.

The analysis is only limited to county-level measures of racial/ethnic composition and vaccination rates, so we are unable to see at the individual-level who is getting vaccinated.

We find that segregation moderates the association between racial/ethnic composition and vaccination rates, suggesting that local race relations in a county helps contextualize the compositional effects of race/ethnicity.

Across the United States (US), COVID-19 vaccination coverage was lower in rural counties compared to urban counties, exacerbating rural health inequities. While rural communities fall short of the public health goal to vaccinate all who are eligible, most rural residents have chosen to vaccinate for COVID-19. The aim of this study was to better understand rural New Mexicans' attitudes and beliefs about COVID-19 vaccines.

We conducted and analyzed 51 in-depth, semi-structured interviews with adults living in rural New Mexican counties, covering a range of topics related to the pandemic, including vaccines. These interviews were conducted in the Summer of 2021 after the vaccines were widely available to all adults over the age of 18 and youth between the ages of 12–17, but not yet available for children under 12 years.

Two major perspectives were identified: (1) the idea that COVID-19 vaccinations are a tool that individuals can use to achieve freedom and protection and (2) the view which regarded vaccines as an infringement of personal rights and one's autonomy of health. For people who viewed the vaccine as a tool for freedom, several themes emerged, including (1) a preference for vaccine manufacturers, specifically a preference for Pfizer, and (2) frustrations related to vaccine access, specifically, older adults expressed frustrations with the difficulty of scheduling vaccination appointments. However, most participants felt as though they had enough vaccination resources. For people who viewed vaccines (and vaccine mandates) as limiting their freedom, additional themes emerged: (1) overarching distrust of government and the perception that vaccines were an extension of government and (2) distrust in the vaccines themselves, including a perceived lack of research on the vaccines and a perception that the vaccine was developed in too short of a period. Some of the people who hold these beliefs are also vaccinated. We draw from social psychology theories to better understand how people who hold a rural identity come to establish different beliefs and practices compared to larger metropolitan regions. While political identity is a contributor, of our participants, the group who were most likely to report not being vaccinated were the “independent” or “unaffiliated voters.” Our findings can help craft culturally responsive vaccine initiatives for rural communities.

This study compared different types of full-time caregiver (e.g., children, older adults, COVID-19 patients) and subgroups (e.g., disability, race/ethnicity, sexual orientation) in the United States during the COVID-19 pandemic for potentially meaningful distinctions.

Data from the 9,854 full-time caregivers identified in Phase 3.2 (July 21–October 11, 2021) of the US Census Household Pulse Survey (HPS) were analyzed in this study using multinomial logistic regression to examine relationships between caregiver types, marginalized subgroups, generation, and vaccination status.

The prevalence of caregiving was low, but the type of full-time caregiving performed varied by demographic group (i.e., disability, race/ethnicity, sexual orientation, gender, generation, and vaccination status). The relative risk of being a COVID-19 caregiver remained significant for being a member of each of the marginalized groups examined after all adjustments.

To date, the HPS has not been analyzed to predict the type of full-time informal caregiving performed during the COVID-19 pandemic or their characteristics. Research limitations of this analysis include the cross-sectional, experimental dataset employed, as well as some variable measurement issues.

Prior informal caregiver research has often focused on the experiences of those caring for older adults or children with special healthcare needs. It may be instructive to learn whether and how informal caregivers excluded from paid employment during infectious disease outbreaks vary in meaningful ways from those engaged in other full-time caregiving. Because COVID-19 magnified equity concerns, examining demographic differences may also facilitate customization of pathways to post-caregiving workforce integration.

The disparities of COVID-19 vaccination rates between the rural and urban areas have become apparent during this pandemic. There is a need to understand the root causes of vaccine hesitancy demonstrated by the rural population to increase coverage and to contain the disease spread throughout the United States. This study aimed to explore other factors influencing vaccine hesitancy among rural dwellers besides the geography-related barriers such as poor health care access and individuals having no or suboptimal insurance coverage.

By reviewing existing data and literature about vaccination, health literacy, and behaviors, and prevailing ideologies, we discuss the potential causes of vaccine hesitancy in rural areas that could create barriers for successful public health efforts related to vaccine coverage and provide suggestions to ameliorate the situation.

Geography-related barriers, health literacy, and preconceived notions are key determinants of adopting healthy behaviors and complying with public health authorities' recommendations among rural individuals during a public-health crisis. We argue that ideology, which is much deeper than preconception or misconception on vaccination, should be incorporated as a key factor to redefine the term “vulnerable populations” in public health research.

The limitation of our study is that we have not found an effective way to encourage the populations who hold conservative religious and political ideologies to join the efforts for public health. Even though geography-related barriers may strongly impact the rural dwellers in achieving optimal health, the various forms of ideologies they have toward certain health behaviors cannot be discounted to understand and address vaccine-related disparities in rural areas. There is a need to redefine the term “vulnerable population” particularly as it relates to rural areas in the United States. During large-scale public health disasters, scholars and public health authorities should consider the ideologies of individuals, in addition to other factors such as race/ethnicity, area of residence (rural vs. urban), and socioeconomic factors influencing the existing vulnerabilities and health disparities.

This study examines chronic illness, disability and social inequality within an exposure-vulnerabilities theoretical framework.

Using the National Survey of Drug Use and Health (NSDUH), a preeminent source of national behavioral health estimates of chronic medical illness, stress and disability, for selected sample years 2005–2014, we construct and analyze two foundational hypotheses underlying the exposure-vulnerabilities model: (1) greater exposure to stressors (i.e., chronic medical illness) among racial/ethnic minority populations yields higher levels of serious psychological distress, which in turn increases the likelihood of medical disability; (2) greater vulnerability among minority populations to stressors such as chronic medical illness exacerbates the impact of these conditions on mental health as well as the impact of mental health on medical disability.

Results of our analyses provided mixed support for the vulnerability (moderator) hypothesis, but not for the exposure (mediation) hypothesis. In the exposure models, while Blacks were more likely than Whites to have a long-term disability, the pathway to disability through chronic illness and serious psychological distress did not emerge. Rather, Whites were more likely than Blacks and Latinx to have a chronic illness and to have experienced severe psychological distress (both of which themselves were related to disability). In the vulnerability models, both Blacks and Latinx with chronic medical illness were more likely than Whites to experience serious psychological distress, although Whites with serious psychological distress were more likely than these groups to have a long-term disability.

Several possibilities for understanding the failure to uncover an exposure dynamic in the model turn on the potential intersectional effects of age and gender, as well as several other covariates that seem to confound the linkages in the model (e.g., issues of stigma, social support, education).

This study (1) extends the racial/ethnic disparities in exposure-vulnerability framework by including factors measuring chronic medical illness and disability which: (2) explicitly test exposure and vulnerability hypotheses in minority populations; (3) develop and test the causal linkages in the hypothesized processes, based on innovations in general structural equation models, and lastly; (4) use national population estimates of these conditions which are rarely, if ever, investigated in this kind of causal framework.

To understand how parents make the decision to implant their deaf young children with cochlear implants, focusing specifically on the concepts of normality, medicalization, and stigma.

I conducted 33 semi-structured interviews with the hearing parents or parent of children with cochlear implants. In all but two families I interviewed the primary caretaker which in all cases was a mother. In the remaining two interviews, I interviewed both parents together. Because of the relative scarcity of families with children with cochlear implants, and the difficulty in connecting with these families, I used a convenience sample, and I did not stratify it in any way. The only requirement for parents to be interviewed is that they had at least one deaf child who had been implanted with at least one cochlear implant. Although this is a small sample, the findings are transferable to other families with the same sociodemographic characteristics as those in my study.

Parents in the study focused on three key concepts: normality, risk analysis, and being a good parent. Dispositional factors such as the need to be “normal” and the desire for material success for one's children appeared to moderate the cost-benefit calculus.

This interview project concentrated on hearing families who had implanted their deaf children with cochlear implants; it does not include culturally Deaf parents who choose to use American Sign Language (ASL) with their Deaf children. Understanding how Deaf families understand the concepts of normality, medicalization, and stigma would shed light on how a distinctly “abnormal” group (by a statistical conception of normal) – ASL-using Deaf people-explain normality in the face of using a non-typical communication method. One can learn a lot by studying the absence of a phenomena, in this case, not implanting children with cochlear implants. It is possible that the existential threat felt by some Deaf people, specifically the demographic problem presented by cochlear implants, led Deaf educators or parents to resist being the subject of research.

Overwhelmingly the sample was female, and white. Only two participants were male, and none of the participants were non-white. The lack of diversity in the sample does not necessarily reflect a lack of diversity of children receiving cochlear implants. Medicaid, which disproportionately covers families of color, covers cochlear implants in most cases, so low SES/racial intersectionality should not have affected the lack of diversity in the sample. However, the oral schools are all private pay, with few scholarships available, so low SES/racial intersectionality in the sampling universe (all children who attend oral schools), may have played a part in the lack of racial diversity within the sample.

Parents in this study were very specific about the fact that they believed cochlear implants would lead to academic, professional, and personal success. They weaved narratives of normality, medicalization, and stigma through their stories. Normality is an important lens from which to see stories about disability and ability, as well as medical correction. As medical science continues to advance, more and more conditions will become medicalized, leading to more and more people taking advanced medical treatments to address problems that were previously considered “problems with living” that are now considered “medical problems” that can be treated with advanced science.

This chapter's contribution to the sociological cochlear implant literature is it's weaving of narratives about normality, stigma, and medicalization into parental stories about the cochlear implant decision-making process. Most literature about the cochlear implant decision-making process focus on cost-benefit analysis, and logical decision-making processes, whereas this paper focuses on decision-making factors stemming from bias, emotions, and values.

This chapter seeks to quantify the effects of geographic access to community health centers on the likelihood of an individual having a regular source of health care.

Utilizing survey and center location data, the analysis employs bivariate cross-tabulation with chi-square and multinominal logistic regression to quantify the relationship between variables.

While individuals living in close spatial proximity to community health centers were more likely to identify a community health center as a regular source of care as compared with those without proximal access, the effect of community health center access on the identification of any source of regular health care was generally insignificant or negative, except for populations with a chronic medical condition.

While these findings support current literature suggesting that spatial proximity to care is insufficient to transform at-risk populations into regular primary care users, it is important to note that it is possible that individuals prefer to access primary care services outside of their immediate neighborhoods, potentially mediating the observed effect of proximity to care on the likelihood of having a regular source of care. Also, because this analysis is based on cross-sectional survey data, it is impossible to make a causal argument about the relationship between variables. Only the observed association can be asserted and used to inform future studies.

Existing research supports a positive association between community health center utilization and measures of health for social groups traditionally facing barriers to care, but few studies isolate the effect of center availability and health, particularly when considering those living in the catchment area but are not regular users. Due to the complexity and prevalence of barriers to health care for vulnerable and at-risk populations, these findings suggest that improving geographic access to primary health care does not guarantee positive outcomes for target groups. The magnitude of social disadvantage on vulnerable and at-risk populations can have a devastating effect on health care outcomes that is not easily overcome by social programs.

The study examines health care inequities in viral load testing among hepatitis C (HCV) antibody-positive patients. The analysis predicts whether individual and census tract sociodemographic characteristics impact the likelihood of viral load testing.

This a study of 26,218 HCV antibody-positive patients in Orange County, California, from 2010 to 2020. The case data were matched with the 2017 American Community Survey to help understand the role of neighborhood socioeconomic characteristics in testing for viral load. Multivariable logistic regression was used to predict the probability of ever testing for HCV viral load.

Thirty-six percent of antibody-positive persons were never viral load tested. The results show inequalities in viral load testing by sociodemographic factors. The following groups were less likely to ever test for viral load than their counterparts: (1) individuals under 65 years old, (2) females, (3) residents of census tracts with lower levels of health insurance enrollment, (4) residents of census tracts with lower levels of government health insurance, and (5) residents of census tracts with a higher proportion of non-white residents.

This is a secondary database from public health department reports. Using census tract data raises the issue of the ecological fallacy. Detailed medical records were not available. The results of this study emphasize the social inequality in viral load testing for HCV. These groups are less likely to be treated and cured, and may spread the disease to others.

This chapter is unique as it combines routinely collected public health department data with census tract level data to examine social inequities associated with lower rates of HCV viral load testing.