Approximately 25% of children in the United States are in an immigrant family, meaning they have at least 1 parent born outside of the United States.1 Parental country of birth (PCB) can influence health behaviors, including vaccine uptake. In this issue of Pediatrics, Tasslimi et al evaluated vaccine coverage of approximately 900 000 children over a 13-year period, from 2006 to 2019,2 linking 2 sources of data, the Washington State Immunization Information System and birth records. This study’s novel methodological approach allowed evaluation of PCB and vaccine uptake.
Parental country of birth is an indicator of migration, unlike race, ethnicity, or preferred language. Previously living in another country can have an influence on vaccine decisions based on differences in health care systems, cultural attitudes about health, previous health messaging, the epidemiology of the targeted disease, access to health care services, and trust in the US health care system.
Tasslimi et al found that the proportion of children up-to-date for key vaccines differed by the specific PCB with some PCBs having higher coverage and others having lower coverage.2 They conclude that PCB may guide vaccine medical decision making. Theories on potential reasons for lower coverage by some PCB are discussed, but the authors note the paucity of research examining factors contributing to high vaccine coverage by PCB. Why are parents born in the Philippines, India, or Mexico more likely to have children up to date for vaccines than US-born parents. Conversely, why do parents from Ukraine, Russia, or Moldova have children with lower rates of up-to-date vaccines than US-born parents? Perhaps the context and history of vaccination and trust in public health systems varies across PCBs. Perhaps, information in languages other than English, and from both PCB and United States (community- or web-based) sources, may influence access to or choices about vaccination once in the United States.
To understand differences in pediatric vaccine coverage, health systems and community organizations need to consider cultural safety.3 Cultural safety is a concept that recognizes the social, historical, political, and economic circumstances that create power differences and inequities in health. Cultural safety, by definition, asks individual members within an organization, and organizations at large, to be attentive to issues of communication, power sharing, and decision making, working toward understanding and addressing misunderstandings, and recognizing and respecting fundamental cultural beliefs. In approaching vaccine education and acceptance, a family-based cultural safety framework4 can help identify core concepts to ensure responsive consideration of PCB perspectives (Table 1).
A Family-Based Cross-Cultural Framework to Promote Cultural Safety
| Concept . | Example . |
|---|---|
| 1. Communication | During the COVID-19 pandemic, the Vermont Language Justice Project created videos of state health and vaccine information updates. These were in languages other than English and released within 24 h, ensuring timely, accurate, and inclusive messaging.7 |
| 2. Mistrust and prejudice | Past exposure to some sociopolitical regimes has been associated with a negative trust in vaccines, perhaps in part due to skepticism in national and local institutions.8 ,9 The Washington Department of Health describes 3 promising practices to address this mistrust: (1) hiring people from the community; (2) helping the community establish a health board; and (3) engaging with key community partners.10 |
| 3. Family and community | Pop-up COVID-19 vaccine clinics in Seattle, Washington; Erie, Pennsylvania; and Maine were driven by immigrant community leadership to be in places where people live, work, and shop.11 |
| 4. Spirituality, traditions, and customs | People from many different faith groups may describe religious-based vaccine hesitancy or declination. Immunize.org shares a paper called “What the world’s religions teach, applied to vaccines and immune globulins” to provide a factual and contextual basis for understanding faith perspectives on vaccines.12 |
| 5. Gender and sexuality | Globally, gender equality strategies have been implemented to address gender related barriers to immunization.13 For example, sociocultural and religious norms can restrict some mothers from seeking health care for themselves or their children unless they have access to a female health provider.6 Due to the important role mothers play in health decision making, the Refugee Women’s Network in Clarkston, Georgia, and IDEO.org developed a health meet-up for mothers to facilitate conversations about vaccines.14 |
| Concept . | Example . |
|---|---|
| 1. Communication | During the COVID-19 pandemic, the Vermont Language Justice Project created videos of state health and vaccine information updates. These were in languages other than English and released within 24 h, ensuring timely, accurate, and inclusive messaging.7 |
| 2. Mistrust and prejudice | Past exposure to some sociopolitical regimes has been associated with a negative trust in vaccines, perhaps in part due to skepticism in national and local institutions.8 ,9 The Washington Department of Health describes 3 promising practices to address this mistrust: (1) hiring people from the community; (2) helping the community establish a health board; and (3) engaging with key community partners.10 |
| 3. Family and community | Pop-up COVID-19 vaccine clinics in Seattle, Washington; Erie, Pennsylvania; and Maine were driven by immigrant community leadership to be in places where people live, work, and shop.11 |
| 4. Spirituality, traditions, and customs | People from many different faith groups may describe religious-based vaccine hesitancy or declination. Immunize.org shares a paper called “What the world’s religions teach, applied to vaccines and immune globulins” to provide a factual and contextual basis for understanding faith perspectives on vaccines.12 |
| 5. Gender and sexuality | Globally, gender equality strategies have been implemented to address gender related barriers to immunization.13 For example, sociocultural and religious norms can restrict some mothers from seeking health care for themselves or their children unless they have access to a female health provider.6 Due to the important role mothers play in health decision making, the Refugee Women’s Network in Clarkston, Georgia, and IDEO.org developed a health meet-up for mothers to facilitate conversations about vaccines.14 |
Key cross-cultural issues in the cultural safety framework include communication, trust, family structure, engagement of community including faith/spiritual leaders, and sexual/gender differences (Table 1). Clear and prompt communication in the family’s language of care is important to all of the other parts of the framework. Historical, cultural, and contextual factors contributing to mistrust and/or prejudice must be considered in approaches to conversations, public health messaging, and program development. In many communities, health is a collective community asset and community members and other relatives may contribute to decision making in addition to parents. If trust has been forged and earned with immigrant communities, and members of the vaccine messaging organization are from the community, then vaccine information has a greater likelihood of being accepted as true. For example, engagement of community leaders and holding community forums harmonizes messaging. Partnering with faith-based leaders can allow better understanding of spiritual perspectives on vaccination as well as support community acceptance of vaccines.5 Navigation of gender-related barriers to vaccinations may require gender-responsive interventions like the use of gender-concordant staff and informational forums.6 The framework highlights the need for health systems to have ongoing relationships with immigrant communities outside of emergency settings. Many organizations across the US model core concepts of the cultural safety framework in vaccine access, promotion, education, and delivery. See examples in Table 1.
Parental country of birth highlights differences in vaccination rates for children in immigrant families and provides opportunities to examine factors that influence vaccine access and confidence. A family-centered cultural safety framework is a responsive approach for multisector systems to understand childhood vaccine rates, as they partner with, learn from, and are led by community members who have experienced migration.
Drs Dawson-Hahn and Green drafted the commentary and critically reviewed and revised for important intellectual content; and both authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2023-064626.
FUNDING: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.
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