COVID-19 Vaccine Hesitancy and Health Literacy in US Southern States

ABSTRACT

The following are the highlights of our study * Vaccine hesitancy in Southern states is complex and extends beyond health literacy. * Vaccine hesitancy in Southern states transcends many sociodemographic differences. * Effective public health communication should be unambiguous about negative externalities of COVID-19 beyond individual threats. _____ The COVID-19 pandemic caused by SARS-CoV-2 remains a public health crisis, accounting for more than 100 million confirmed cases with more than 1,121,800 deaths in the United States as of April 26, 2023.1 Despite widespread vaccination efforts by the US government and public health leadership, the rate of vaccine uptake is still far from desirable, as researchers estimate that about 70% to 85% of the country will need to be immunized before SARS-CoV-2 can be fully contained through herd immunity.2 As of April 19, 2023, about 81% of the US population had received at least 1 dose, whereas 69.4% had completed a full primary vaccine series and only 16.7% had received an updated bivalent booster, with variations in the rate of vaccination across states and regions.3 The Southern states (Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, South Carolina, Tennessee, Texas, Virginia, and West Virginia) have relatively lower rates of full vaccination (primary series) compared with other states (mean of 61.3%, ranging from 53.2% in Alabama to 79.9% in Maryland);6 Southern states rank among the 10 states with the lowest fully vaccinated rates in the nation.3 The predominant barrier to uptake has been vaccine hesitancy,4-9 defined as the intention to delay or refuse taking vaccinations despite availability and accessibility.10,11 It may be influenced by complex contextual factors, ranging from individual and group factors to vaccine-specific characteristics.10 In particular, individual factors may be related to health literacy (HL),12 which is the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.13 HL is a phenomenon that involves individuals, families, communities, and systems, and it could be implicated in the level of COVID-19 vaccine hesitancy.5 Although HL is a major determinant of individuals' health behaviors,14 a systematic review study reported that HL's relationship with vaccination uptake prior to the COVID-19 pandemic was unclear because of variations in assessment tools, target populations, and outcome measures across available limited studies.15 Evidence suggests a relationship between HL and COVID-19 vaccine hesitancy.12,16,17 In the United States, a study among women recently released from jails found that low HL is related to COVID-19 vaccine hesitancy.16 Similarly, a study in Turkey found that low HL and a high perception of health care system distrust are associated with higher vaccine hesitancy.17 A study in China found that higher HL is associated with low likelihood of COVID-19 vaccine hesitancy, and the effect was moderated by stress.12 Overall, to the best of our knowledge, no study has examined the association between HL and COVID-19 vaccine hesitancy in populations with low vaccine uptake within the United States, including those residing in the Southern states, which served as the impetus for this study.18,19 This study aimed to estimate the level of HL among a population residing in Southern states and its association with vaccine hesitancy. Nearly 20% of the United States population had still not received a single dose of COVID-19 vaccine as of April 26, 2023, despite increases in both vaccine availability and individual eligibility over the previous 2 years.20 The observed trends in overall and region-specific COVID-19 cases and rates of vaccination in the United States demonstrate the need to examine the impact of HL on vaccine hesitancy in the Southern states, especially with the release of simplified eligibility guidelines and expanded booster recommendations.21 METHODS Participants This study included adults 18 years and older. Upon receiving institutional review board (IRB) approval from East Tennessee State University (IRB No. c0221.22e), a cross-sectional study was initiated. Race/ethnicity was collected as (1) Asian or Pacific Islander, (2) Black or African American, (3) Hispanic/Latino, (4) Native American or Alaskan Native, (5) non-Hispanic White, (6) biracial or multicultural, and (7) race/ethnicity not listed here. Because of small sample sizes for non-White racial/ethnic groups in the study population, race/ethnicity was recoded as non-Hispanic White and other.