Launching population-wide vaccination campaigns within COVID-19 proved exceedingly challenging, as understandings of COVID-19, and recommendations and technology to fight it, were established in real time. Vaccine communication was hindered by misinformation campaigns, coupled with social isolation and an overarching climate of fear. Unclear instructions about universal masking, coupled with racist rhetoric against the Asian-American population, created an even more difficult backdrop for protective decision making. All these risks amplify the importance of comprehensive, community-centered approaches to promote vaccination, particularly among populations who have been routinely alienated from public health and social services due to racism within the health system, and linguistic, cultural, and practical barriers in accessing information and care. To uncover the complexities of vaccine adoption in this context, we explored norms and practices of COVID-19 vaccination among older Asian immigrants with Limited English Proficiency (LEP), using narratives from bilingual, bicultural care professionals working with this population.
Methods: This IRB-approved study used purposive sampling among bicultural and bilingual Asian outreach specialists in a United States city (N-10), interviewed via Zoom with an open-ended modality during Winter and Spring 2020-2021 (in native languages, where requested, transcribed and translated by a professional transcriptionist and translator. Using a constant comparative analysis method, three researchers coded data independently and jointly, creating and clarifying our theoretical framework through integrating our data with behavior change theories across multiple levels of influence, interpreted as well using Asian Critical Race Theory.
Results: Once vaccination was adopted as accessible, beneficial, and culturally congruent, uptake became ubiquitous. The particulars of culture, politics, and place emerged in our analysis of risks and promotive factors for COVID-19 vaccination. For example, our results indicated elements of the Health Belief Model (perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy) were impacted by historical exclusion and mistrust faced by Asian elders in the United States. In the individual level, our findings aligned with key elements of Social Cognitive Theory (e.g., reciprocal determinism, observational learning, and reinforcements). From Community Organization Theory, we confirmed community compacity and empowerment as central behavior change theory concepts for our sample – particularly as they reflected joint actions for collective well-being. Diffusion of Innovations’ concepts of compatibility, relative advantage, and trialability fit well with our data, especially as related to cultural norms such as collective responsibility and family advising. Clients wanted to hear from family members, trusted primary care providers, and church members.
Conclusions and Implications: Findings suggest behavior change for this population is deeply rooted in collective ethos. Findings illustrate the need for multiple sources of information and modeling around vaccines: pharmacies, doctors, caregivers, friends, and family were essential to building individual and collective norms around COVID-19 vaccination. Findings points to complex processes through with elders must work out perceptions of benefits as a larger context of health literacy education, and the effectiveness of workers promoting behavior change with a sharp eye towards cultural norms, especially collectivism, and community initiatives that support reflect these norms within larger efforts at health behavior change.