{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T05:13:51Z","timestamp":1787030031612,"version":"build-2736575974"},"reference-count":52,"publisher":"MDPI AG","issue":"5","license":[{"start":{"date-parts":[[2025,4,24]],"date-time":"2025-04-24T00:00:00Z","timestamp":1745452800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Tennessee Department of Health","award":["NH23IP922617"],"award-info":[{"award-number":["NH23IP922617"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Vaccines"],"abstract":"<jats:p>Introduction: The COVID-19 pandemic disrupted routine childhood vaccinations schedules, posing significant challenges among underserved communities. Understanding how different sociodemographic groups in Tennessee perceive and navigate childhood vaccination barriers is critical for developing strategies to improve vaccination rates and reduce vulnerability to vaccine-preventable diseases. Methods: A cross-sectional survey was conducted to explore barriers to vaccination across diverse sociodemographic groups in Tennessee. Data were collected from caregivers\/parents of children aged 18 years and younger across all 95 counties in Tennessee at community events and through partnerships with schools and other local organizations. Parental responses were analyzed to identify barriers in access, concern, and importance domains. The distribution of barriers across different sociodemographic groups such as race, income, education level, and insurance status was identified. Descriptive statistics, non-parametric tests, and log-binomial regressions were used to address the research objectives. Results: This study found that the most prominent barriers to childhood vaccination were concerns regarding vaccine safety and side effects. Significant differences in vaccine barriers were observed across racial and ethnic groups for access barriers (p &lt; 0.001), concern barriers (p = 0.006), and importance barriers (p &lt; 0.001). Parents with lower education levels, children without health insurance, and lower-income families faced disproportionate challenges across two of the three barrier domains studied (access and perceived importance of vaccines). Additionally, concern barriers (aPR = 0.998, p &lt; 0.001) and importance barriers (aPR = 0.997, p &lt; 0.001) were strongly associated with the parent-reported prevalence of up-to-date vaccination status. Conclusions: Addressing parental vaccination barriers related to concern, access, and perceived importance is crucial, particularly for underserved populations including low-income families, uninsured parents, racial\/ethnic minorities, and those with limited education. A sustained, equity-focused approach integrating scientific communication, community engagement, and policy interventions is essential for increasing vaccine uptake and ensuring equitable vaccination access.<\/jats:p>","DOI":"10.3390\/vaccines13050452","type":"journal-article","created":{"date-parts":[[2025,4,24]],"date-time":"2025-04-24T09:26:58Z","timestamp":1745486818000},"page":"452","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Parental Barriers and Sociodemographic Disparities in Childhood Vaccination Post-COVID-19 in Tennessee"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9321-7887","authenticated-orcid":false,"given":"Sanjaya","family":"Regmi","sequence":"first","affiliation":[{"name":"College of Nursing, The University of Tennessee, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Elizabeth","family":"Sowell","sequence":"additional","affiliation":[{"name":"College of Nursing, The University of Tennessee, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chenoa D.","family":"Allen","sequence":"additional","affiliation":[{"name":"Social Work Office of Research and Public Service, The University of Tennessee, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin E.","family":"Jones","sequence":"additional","affiliation":[{"name":"College of Nursing, The University of Tennessee, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7600-453X","authenticated-orcid":false,"given":"Nan M.","family":"Gaylord","sequence":"additional","affiliation":[{"name":"College of Nursing, The University of Tennessee, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1279-8614","authenticated-orcid":false,"given":"Victoria","family":"Niederhauser","sequence":"additional","affiliation":[{"name":"College of Nursing, The University of Tennessee, Knoxville, TN 37996, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,4,24]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"276","DOI":"10.2471\/BLT.23.290129","article-title":"Global vaccine coverage and childhood survival estimates: 1990\u20132019","volume":"102","author":"Zhang","year":"2024","journal-title":"Bull. World Health Organ."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"591","DOI":"10.15585\/mmwr.mm6919e2","article-title":"Effects of the Covid-19 pandemic on routine pediatric vaccine ordering and administration\u2014United States, 2020","volume":"69","author":"Santoli","year":"2020","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"837","DOI":"10.1016\/j.vaccine.2021.12.022","article-title":"COVID-19 and routine childhood and adolescent immunizations: Evidence from Louisiana Medicaid","volume":"40","author":"Walker","year":"2022","journal-title":"Vaccine"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"740","DOI":"10.1080\/14760584.2024.2389922","article-title":"National trends in patterns of under-vaccination in early childhood: National Immunization Survey-Child, United States, 2011\u20132021","volume":"23","author":"Daley","year":"2024","journal-title":"Expert. Rev. Vaccines"},{"key":"ref_5","unstructured":"TN Department of Health (2025, April 14). Immunization Coverage Rate Dashboards. TennIIS Reported Data, Available online: https:\/\/www.tn.gov\/health\/cedep\/immunization-program\/ip\/immunization-fact-sheet\/coverage-rate-dashboard.html."},{"key":"ref_6","unstructured":"America\u2019s Health Rankings|AHR (2024, December 22). (n.d.). America\u2019s Health Rankings. Available online: https:\/\/www.americashealthrankings.org\/explore\/states\/TN."},{"key":"ref_7","unstructured":"CDC (2024, September 10). Measles Cases and Outbreaks. Measles, Available online: https:\/\/www.cdc.gov\/measles\/data-research\/index.html."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Thakur, M., Zhou, R., Mohan, M., Marathe, A., Chen, J., Hoops, S., Machi, D., Lewis, B., and Vullikanti, A. (2022). COVID\u2019s collateral damage: Likelihood of measles resurgence in the United States. BMC Infect. Dis., 22.","DOI":"10.1186\/s12879-022-07703-w"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"81","DOI":"10.5993\/AJHB.29.1.7","article-title":"Immunization Attitudes and Beliefs Among Parents: Beyond a Dichotomous Perspective","volume":"29","author":"Gust","year":"2005","journal-title":"Am. J. Health Behav."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"453","DOI":"10.1016\/0022-1031(86)90045-4","article-title":"Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control","volume":"22","author":"Ajzen","year":"1986","journal-title":"J. Exp. Social Psychol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1891\/1061-3749.18.1.26","article-title":"Measuring parental barriers to childhood immunizations: The development and validation of the searching for hardships and obstacles to shots (SHOTS) instrument","volume":"18","author":"Niederhauser","year":"2010","journal-title":"J. Nurs. Meas."},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Olusanya, O.A., Bednarczyk, R.A., Davis, R.L., and Shaban-Nejad, A. (2021). Addressing Parental Vaccine Hesitancy and Other Barriers to Childhood\/Adolescent Vaccination Uptake During the Coronavirus (COVID-19) Pandemic. Front. Immunol., 12.","DOI":"10.3389\/fimmu.2021.663074"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e12268","DOI":"10.1111\/nin.12268","article-title":"Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review","volume":"26","author":"Baah","year":"2019","journal-title":"Nurs. Inq."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1733","DOI":"10.1080\/13557858.2021.1990220","article-title":"Medical mistrust among women with intersecting marginalized identities: A scoping review","volume":"27","author":"Ho","year":"2022","journal-title":"Ethn. Health"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"101804","DOI":"10.1016\/j.pmedr.2022.101804","article-title":"Barriers to and facilitators of early childhood immunization in rural areas of the United States: A systematic review of the literature","volume":"27","author":"Albers","year":"2022","journal-title":"Prev. Med. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"102648","DOI":"10.1016\/j.jiph.2024.102648","article-title":"Parental vaccine hesitancy: Recent evidences support the need to implement targeted communication strategies","volume":"18","author":"Cagnotta","year":"2025","journal-title":"J. Infect. Public Health"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"2200","DOI":"10.1111\/cts.13077","article-title":"COVID-19 vaccine hesitancy: Race\/ethnicity, trust, and fear","volume":"14","author":"Willis","year":"2021","journal-title":"Clin. Transl. Sci."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"75","DOI":"10.1016\/S0140-6736(22)01693-2","article-title":"The legacy of the COVID-19 pandemic for childhood vaccination in the USA","volume":"401","author":"Opel","year":"2023","journal-title":"Lancet"},{"key":"ref_19","first-page":"1","article-title":"COVID-19 disinformation and political engagement among communities of color: The role of media literacy","volume":"1","author":"Austin","year":"2021","journal-title":"Harv. Kennedy Sch. Misinf. Rev."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"105","DOI":"10.1007\/s40272-020-00385-4","article-title":"Vaccine Hesitancy: A Growing Concern","volume":"22","author":"Kennedy","year":"2020","journal-title":"Pediatr. Drugs"},{"key":"ref_21","first-page":"175","article-title":"Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents","volume":"65","author":"Shen","year":"2019","journal-title":"Can. Fam. Physician"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2286","DOI":"10.1080\/07853890.2021.2009128","article-title":"Impact of COVID-19 pandemic on routine immunization","volume":"53","author":"Ota","year":"2024","journal-title":"Ann. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"e006860","DOI":"10.1136\/bmjgh-2021-006860","article-title":"Parent-level barriers to uptake of childhood vaccination: A global overview of systematic reviews","volume":"6","author":"Kaufman","year":"2021","journal-title":"BMJ Glob. Health"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"2246502","DOI":"10.1080\/21645515.2023.2246502","article-title":"The impact of the COVID-19 pandemic on vaccination uptake in the United States and strategies to recover and improve vaccination rates: A review","volume":"19","author":"Cunniff","year":"2023","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Kuehn, M., LaMori, J., DeMartino, J.K., Mesa-Frias, M., Doran, J., Korrapati, L., Bhojwani, R., Lefebvre, P., and Kirson, N. (2022). Assessing barriers to access and equity for COVID-19 vaccination in the US. BMC Public Health, 22.","DOI":"10.1186\/s12889-022-14636-1"},{"key":"ref_26","unstructured":"National Vaccine Advisory Committee [NVAC] (2021). Advancing Immunization Equity: Recommendations from the National Vaccine Advisory Committee."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"82","DOI":"10.1016\/j.puhe.2022.06.002","article-title":"Child and adolescent COVID-19 vaccination status and reasons for non-vaccination by parental vaccination status","volume":"209","author":"Nguyen","year":"2022","journal-title":"Public Health"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"14","DOI":"10.12784\/nzcomjnl59.2023.2.14-20","article-title":"Women\u2019s knowledge, attitudes and access to vaccines in pregnancy: A South Auckland study","volume":"59","author":"Priday","year":"2023","journal-title":"N. Z. Coll. Midwives J."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"2984","DOI":"10.1016\/j.vaccine.2015.04.069","article-title":"Vaccines4Kids: Assessing the impact of text message reminders on immunization rates in infants","volume":"33","author":"Niederhauser","year":"2015","journal-title":"Vaccine"},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Hobani, F., and Alharbi, M. (2024). A Psychometric Study of the Arabic Version of the \u201cSearching for Hardships and Obstacles to Shots (SHOT)\u201d Instrument for Use in Saudi Arabia. Vaccines, 12.","DOI":"10.3390\/vaccines12040391"},{"key":"ref_31","unstructured":"Center for Disease Control [CDC] (2025, January 21). Recommended Immunizations. Vaccines & Immunizations, Available online: https:\/\/www.cdc.gov\/vaccines\/imz-schedules\/child-easyread.html."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1016\/j.pedhc.2020.07.003","article-title":"Vaccine Hesitancy in Rural Pediatric Primary Care","volume":"35","author":"Mical","year":"2021","journal-title":"J. Pediatr. Health Care"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"e2020007609","DOI":"10.1542\/peds.2020-007609","article-title":"Parental Vaccine Hesitancy and Childhood Influenza Vaccination","volume":"146","author":"Santibanez","year":"2020","journal-title":"Pediatrics"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1016\/j.vaccine.2024.01.001","article-title":"The Social Ecology of Health Beliefs and Misinformation Framework: Examining the impact of misinformation on vaccine uptake through individual and sociological factors","volume":"42","author":"Enyinnaya","year":"2024","journal-title":"Vaccine"},{"key":"ref_35","unstructured":"CDC (2024, September 22). CDC\u2019s State of Vaccine Confidence Insights Report, Available online: https:\/\/archive.cdc.gov\/#\/details?url=https:\/\/www.cdc.gov\/vaccines\/covid-19\/downloads\/SoVC-Quarter-4-2022.pdf."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"125989","DOI":"10.1016\/j.vaccine.2024.05.037","article-title":"Changes in vaccine hesitancy among parents of children aged 6 months\u201317 Years, National Immunization Surveys, 2019\u20132022","volume":"42","author":"Vashist","year":"2024","journal-title":"Vaccine"},{"key":"ref_37","unstructured":"Radley, D.C., Baumgartner, J.C., Collins, S.R., Zephyrin, L.C., and Schneider, E.C. (2021). Achieving Racial and Ethnic Equity in U.S. Health Care. Commonw. Fund."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"126144","DOI":"10.1016\/j.vaccine.2024.07.045","article-title":"Challenging the \u2019acceptable option\u2019: Public health\u2019s advocacy for continued care in the case of pediatric vaccine refusal","volume":"42","author":"Silver","year":"2024","journal-title":"Vaccine"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"2261687","DOI":"10.1080\/21645515.2023.2261687","article-title":"Motivational interview-based health mediator interventions increase intent to vaccinate among disadvantaged individuals","volume":"19","author":"Cogordan","year":"2023","journal-title":"Hum. Vaccines Immunother."},{"key":"ref_40","first-page":"CD010038","article-title":"Face-to-face interventions for informing or educating parents about early childhood vaccination","volume":"5","author":"Kaufman","year":"2018","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_41","unstructured":"Sowell, E., Niederhauser, V., Allen, C., Regmi, S., Gaylord, N., and Jones, B. (2024). Rebuilding vaccine trust in the aging by deploying community registered nurse navigators across Tennessee. APHA 2024 Annual Meeting and Expo, APHA. Available online: https:\/\/apha.confex.com\/apha\/2024\/meetingapp.cgi\/Paper\/553717."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"146","DOI":"10.1177\/1942602X221106945","article-title":"Addressing Vaccine Hesitancy Among Students and Families: Interventions for School Nurses","volume":"38","author":"Wilson","year":"2023","journal-title":"NASN Sch. Nurse"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1080\/10810730.2021.1873463","article-title":"Community-based Strategies to Engage Pastors Can Help Address Vaccine Hesitancy and Health Disparities in Black Communities","volume":"25","author":"King","year":"2020","journal-title":"J. Health Commun."},{"key":"ref_44","unstructured":"Ndugga, N., Hill, L., and Artiga, S. (2024, May 21). ACCESS TO AND USE OF CARE\u2014Key Data on Health and Health Care by Race and Ethnicity. KFF. Available online: https:\/\/www.kff.org\/key-data-on-health-and-health-care-by-race-and-ethnicity\/?entry=health-coverage-access-to-and-use-of-care-access-to-and-use-of-care."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"2236","DOI":"10.1002\/nop2.1257","article-title":"Henrietta Lacks and America\u2019s dark history of research involving African Americans","volume":"9","author":"Baptiste","year":"2022","journal-title":"Nurs. Open"},{"key":"ref_46","unstructured":"Sanchez, G., Barreto, M., Block, R., Fernandez, H., and Foxworth, R. (2024, September 22). Discrimination in the healthcare system is leading to vaccination hesitancy. Brookings. Available online: https:\/\/www.brookings.edu\/articles\/discrimination-in-the-healthcare-system-is-leading-to-vaccination-hesitancy\/."},{"key":"ref_47","unstructured":"CDC (2022, November 18). Questionaires: Breastfeeding and Infant Feeding Practices, Available online: https:\/\/www.cdc.gov\/breastfeeding\/data\/ifps\/questionnaires.htm."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"385","DOI":"10.1001\/jamapediatrics.2013.4653","article-title":"Transportation Barriers to Child Health Care Access Remain After Health Reform","volume":"168","author":"Grant","year":"2014","journal-title":"JAMA Pediatr."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"196","DOI":"10.1111\/jrh.12146","article-title":"Variation in Primary Care Service Patterns by Rural-Urban Location","volume":"32","author":"Weigel","year":"2016","journal-title":"J. Rural Health"},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"eabo6254","DOI":"10.1126\/sciadv.abo6254","article-title":"Psychological inoculation improves resilience against misinformation on social media","volume":"8","author":"Roozenbeek","year":"2022","journal-title":"Sci. Adv."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"682","DOI":"10.15585\/mmwr.mm7331a2","article-title":"Health and economic benefits of routine childhood immunizations in the era of the Vaccines for Children program\u2014United States, 1994-2023","volume":"73","author":"Zhou","year":"2024","journal-title":"MMWR Morb. Mortal. Wkly. Rep."},{"key":"ref_52","unstructured":"United States Census Bureau (2025, January 21). U.S. Census Tennessee, Available online: https:\/\/www.census.gov\/quickfacts\/fact\/table\/TN\/PST045224."}],"container-title":["Vaccines"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-393X\/13\/5\/452\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T17:20:50Z","timestamp":1760030450000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-393X\/13\/5\/452"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,24]]},"references-count":52,"journal-issue":{"issue":"5","published-online":{"date-parts":[[2025,5]]}},"alternative-id":["vaccines13050452"],"URL":"https:\/\/doi.org\/10.3390\/vaccines13050452","relation":{},"ISSN":["2076-393X"],"issn-type":[{"value":"2076-393X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,4,24]]}}}