Applying a Social Determinants of Health Framework to Understand COVID-19 Vaccine Decision-Making during Pregnancy and Postpartum: A Convergent Mixed Methods Study
Main Article Content
Abstract
Background: The COVID-19 pandemic disrupted healthcare access and trust, influencing vaccine decision-making among pregnant and postpartum individuals. While vaccine hesitancy research has focused primarily on individual-level attitudes, this study applies the Healthy People 2030 Social Determinants of Health framework to explore the broader system-level factors that shaped COVID-19 vaccine decision-making among pregnant and postpartum women.
Methods: Between March and November 2022, pregnant (≥24 weeks) and postpartum (≤12 weeks) individuals (n=38 for survey; n=28 for interviews) were recruited in the southeastern region of the United States. A convergent mixed method approach was used to analyze both the quantitative and qualitative data through five Social Determinants of Health domains: economic stability, education access and quality, healthcare access and quality, neighborhood and built environment, and social and community context. Data integration occurred during interpretation using the Social Determinants of Health framework.
Results: We found that economic pressures, with many reporting employment-related vaccine mandates as a significant factor influencing their decision to vaccinate, educational disparities, healthcare interactions, neighborhood conditions, and social contexts all influenced vaccine-related behaviors during the pandemic. Qualitative data revealed that pregnant and postpartum women relied on trusted entities, such as their trusted healthcare providers, as one of the sources for vaccine information.
Conclusion: COVID-19 vaccine decisions-making during pregnancy were influenced by a complex interplay system-level factors. Interventions should integrate SDOH-informed screening in perinatal care, expand community-based communication strategies, and prioritize public health responses tailored to maternal health, especially during time of health crises.
Article Details
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References
2. Razzaghi H. COVID-19 vaccination coverage among pregnant women during pregnancy—eight integrated health care organizations, United States, December 14, 2020–May 8, 2021. MMWR Morbidity and mortality weekly report. 2021;70.
3. Adhikari EH, Moreno W, Zofkie AC, et al. Pregnancy outcomes among women with and without severe acute respiratory syndrome coronavirus 2 infection. JAMA network open. 2020; 3(11):e2029256.
4. Adhikari EH, Spong CY. COVID-19 vaccination in pregnant and lactating women. Jama. 2021;325 (11):1039-1040.
5. Emeruwa UN, Gyamfi-Bannerman C, Miller RS. Health care disparities in the COVID-19 pandemic in the United States: a focus on obstetrics. Clinical obstetrics and gynecology. 2022;65(1):123-133.
6. Shephard HM. Inequities in COVID-19 Vaccination Coverage Among Pregnant Persons, by Disaggregated Race and Ethnicity—Massachusetts, May 2021–October 2022. MMWR Morbidity and Mortality Weekly Report. 2023;72.
7. Avorgbedor F, Gondwe KW, Aljarrah A, Bankole AO. COVID-19 vaccine decision-making among black pregnant and postpartum women. Journal of Racial and Ethnic Health Disparities. 2024;11 (4):2073-2082.
8. Bhattacharya O, Siddiquea BN, Shetty A, Afroz A, Billah B. COVID-19 vaccine hesitancy among pregnant women: a systematic review and meta-analysis. BMJ open. 2022;12(8):e061477.
9. Creswell JW, Klassen AC, Plano Clark VL, Smith KC. Best practices for mixed methods research in the health sciences. Bethesda (Maryland): National Institutes of Health. 2011;2013:541-545.
10. Office of Disease Prevention and Health Promotion. Social determinants of health. Healthy People 2030, U.S. Department of Health and Human Services. Retrieved June 18, 2025, from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health
11. Ruyak SL, Kivlighan KT. Perinatal behavioral health, the COVID-19 pandemic, and a social Determinants of Health framework. Journal of Obstetric, Gynecologic & Neonatal Nursing. 2021; 50(5):525-538.
12. United States Department of Agriculture, Economic Research Service. U.S. Household Food Security Survey Module: Six‑Item Short Form. May 2024. Accessed April 7, 2025. https://www.ers.usda.gov/topics/food-nutrition-assistance/food-security-in-the-us/survey-tools/.
13. Flanagan BE, Gregory EW, Hallisey EJ, Heitgerd JL, Lewis B. A social vulnerability index for disaster management. Journal of homeland security and emergency management. 2011;8(1).
14. Dr W. Racial differences in physical and mental health. J Health Psychol. 1997;2:335-351.
15. Cutrona CE, Russell DW. Social provisions scale. Journal of Abnormal Psychology. 1987.
16. Hsieh H-F, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005;15(9):1277-1288.
17. Obasanya M, Igenoza O, Gupta S, McElroy K, Brannon GE, Brown K. Racial and ethnic differences in maternal and child COVID-19 vaccination intent among pregnant and postpartum women in the USA (April–June 2020): An application of health belief model. Journal of Racial and Ethnic Health Disparities. 2023;10 (5):2540-2551.
18. Alcendor DJ, Matthews-Juarez P, Smoot D, et al. The covid-19 vaccine and pregnant minority women in the us: Implications for improving vaccine confidence and uptake. Vaccines. 2022; 10(12):2122.
19. Olorunsaiye CZ, Degge HM, Osborne A, Gordon DN. COVID-19 Vaccine Literacy Among Black Pregnant and Postpartum Women in the USA. Journal of Racial and Ethnic Health Disparities. 2025:1-14.
20. Zhao S, Hu S, Zhou X, et al. The prevalence, features, influencing factors, and solutions for COVID-19 vaccine misinformation: systematic review. JMIR public health and surveillance. 2023; 9(1):e40201.
21. Spong CY, Bianchi DW. Improving public health requires inclusion of underrepresented populations in research. Jama. 2018;319(4):337-338.
22. Carson SL, Casillas A, Castellon-Lopez Y, et al. COVID-19 vaccine decision-making factors in racial and ethnic minority communities in Los Angeles, California. JAMA network open. 2021;4(9):e21275 82-e2127582.
23. Ellingson MK, Dudley MZ, Limaye RJ, Salmon DA, O’Leary ST, Omer SB. Enhancing uptake of influenza maternal vaccine. Expert review of vaccines. 2019;18(2):191-204.
24. Myers KL. Predictors of maternal vaccination in the United States: An integrative review of the literature. Vaccine. 2016;34(34):3942-3949.
25. Wilson RJ, Paterson P, Jarrett C, Larson HJ. Understanding factors influencing vaccination acceptance during pregnancy globally: a literature review. Vaccine. 2015;33(47):6420-6429.
26. Kiefer MK, Mehl R, Rood KM, et al. Association between social vulnerability and COVID-19 vaccination hesitancy and vaccination in pregnant and postpartum individuals. Vaccine. 2022;40(44): 6344-6351.
27. Preis H, Mahaffey B, Lobel M. Factors related to COVID-19 vaccination intention and uptake among childbearing women. Health Psychology. 2023;42(8):567.
28. Basile Ibrahim B, Kennedy HP, Combellick J. Experiences of quality perinatal care during the US COVID‐19 pandemic. Journal of midwifery & women's health. 2021;66(5):579-588.
29. Scroggins JK, Yang Q, Tully KP, Reuter-Rice K, Brandon D. Examination of Social Determinants of Health Characteristics Influencing Maternal Postpartum Symptom Experiences. Journal of Racial and Ethnic Health Disparities. 2025;12(1):625-639.
30. Jean-Francois B, Bailey Lash T, Dagher RK, Green Parker MC, Han SB, Lewis Johnson T. The potential for health information technology tools to reduce racial disparities in maternal morbidity and mortality. Journal of Women's Health. 2021;30(2):274-279.