Perceptions and Motivating Factors Regarding COVID-19 Vaccination in Latinx Older Adults in Chicago: A Local, Qualitative Perspective

Introduction

The impact of the COVID-19 pandemic in the United States (US) has been drastic and far-reaching, especially for older adults and those with underlying health conditions, who are at greater risk for infection as well as adverse outcomes if infected.^1–3 Moreover, the pandemic has disproportionately affected historically marginalized racial and ethnic groups, including Black, Hispanic/Latinx (hereafter referred to as Latinx), Asian, and Native American/Indigenous populations.⁴ Due to longstanding structural and societal inequities that have affected economic opportunity, access to healthcare, and overall health status, many such communities have been placed at greater risk of harm from the very onset of the outbreak.^5,6 Further, individuals who are at the intersection of these two disproportionately affected communities, being of older age and members of historically marginalized communities, may be at a multiplicative risk for adverse consequences.⁷

Widespread access and timely uptake of preventative vaccines is vital to halting the spread of the COVID-19 virus and minimizing the consequences of new variants.^8,9 Vaccine hesitancy, defined as either the refusal of or the delay in the acceptance of vaccination despite availability,¹⁰ threatens not only to attenuate progress made in the fight against COVID-19, but also to exacerbate health disparities. Recent cross-sectional surveys have demonstrated the relatively lower rates of COVID-19 vaccine acceptance in historically marginalized racial and ethnic communities compared to predominantly White communities in the US.^11,12 Importantly, vaccination rates may be influenced by mistrust of the medical system, due to a long history of unethical research practices on historically marginalized racial and ethnic groups, as well as generations of exposure to and anticipation of discrimination.¹³ In addition, logistical challenges, including transportation barriers or an inability to take time off work, can further augment disparities in vaccine uptake.^14,15 Moreover, language is among the most important factors influencing whether health information is understood and whether individuals, particularly Latinx adults, can access care. Language-concordant care is consistently associated with improved health outcomes; yet amid the COVID-19 pandemic, decreased access to in-person health services and medical interpreters has exacerbated existing challenges.¹⁶ Recent surveys suggest that Latinx individuals are approximately 1.5 times more likely than non-Latinx Whites to report vaccine hesitancy.^11,12,17 This is of particular concern given that – due to myriad social determinants of health – Latinx individuals are 1.5 times more likely to be infected, 2.2 times more likely to be hospitalized, and 1.8 times more likely to die from COVID-19 compared to non-Latinx White individuals.⁴

To our knowledge, no published studies have specifically focused on vaccine acceptance and promotion among Latinx older adults, who represent an important group that has been disproportionately affected by the pandemic. Of note, by 2060, nearly 1 in 4 individuals in the US is projected to be 65 years of age or older, and Latinx individuals – already the largest ethnic group in the US – are projected to make up 29% of the population, further underscoring the significance of this group.¹⁸ As stated in a recent Lancet Commission publication, sustained, tailored efforts to reach and engage all US communities about COVID-19 vaccination is crucial to disrupt disparities in morbidity and mortality.¹⁹ Prior research has demonstrated that public health messaging campaigns can have differential efficacy by race/ethnicity and age group,^20,21 and health messages are likely to be more effective when conceptualizing historically marginalized communities as heterogeneous and considering multiple dimensions of social identity at once.^19,22–24 Therefore, it is important to engage with local community members in order to guide messaging that is culturally attuned to the unique intersection of their unique, interacting, multiple identities – being of older age and of Latin American decent. Understanding stakeholders’ experiences via in-depth interviews can inform ongoing efforts to promote vaccine uptake by identifying current gaps and integrating real-life, personalized perspectives into the development of materials. Thus, we conducted a qualitative study designed to inform linguistically- and culturally-tailored quality improvement and health communication efforts to enhance COVID-19 vaccine uptake at federally qualified health centers in Chicago. Conclusions and recommendations may be of interest to public health experts responding to the ongoing pandemic and other public health crises, with regards to this important subset of the US population.

Materials and Methods

The current study employed in-depth, semi-structured interviews, guided by the socio-ecological model (SEM).²⁵ The SEM posits that individuals’ behaviors are determined by multiple, interacting levels of influence within a complex set of ecological environments, including individual, interpersonal, organizational, community, and public policy;²⁵ this framework was thus used to inform interview question development and thematic analysis in order to identify multiple levels of influence for individual stakeholders.²⁶ Recruitment and data collection occurred between May and July 2021 in Chicago, Illinois. Participants were eligible if they (a) were 50 years of age or older, (b) self-identified as Latinx/Hispanic, (c) were fluent in Spanish and/or English, and (d) had access to video conferencing technology and/or a phone. Participants were recruited via purposive sampling methods, with potential participants identified through social media posts, flyers and contacting participants from prior studies conducted by the research team.^27,28

Data Collection

The study was conducted according to the Declaration of Helsinki and was approved by the Northwestern Institutional Review Board (IRB). For this study, we sought to recruit 15 participants, with 8 English- and 7 Spanish-speaking adults. Prior literature suggests that this number would be sufficient to reach saturation.^29,30 Of 20 participants who were recruited and pre-screened, 15 met the eligibility criteria. In concordance with the literature, our own data analysis revealed that this number was sufficient to reach saturation.^29–31 During the pre-screening call, eligible participants provided verbal consent to participate in the interviews. Interviews were conducted by two authors (SWL, AZ) trained in qualitative research who followed semi-structured interview guides. Participants were asked a series of open-ended questions about their attitudes, beliefs, and acceptance of the COVID-19 vaccines (see Supplementary Material 1). All interviews were conducted virtually via Zoom videoconference platform’s audio-only function in order to: (a) protect participants’ privacy for the recording, and (b) allow participation of individuals without access to video technology. Interviews were administered in either Spanish or English, depending on each participant’s preference.

Interviews were supplemented with brief demographic questionnaires, which were interviewer-administered and recorded using Research Electronic Data Capture (REDCap).³² In addition to basic demographics, the survey also included assessment of participants’ health literacy and acculturation levels. A single item screener was used to assess health literacy: “How confident are you in filling out medical forms by yourself?” Responses are measured on a scale of 1 (Extremely) to 5 (Not at all), with scores of 3 or greater indicating inadequate health literacy.^33,34 The Short Acculturation Scale for Hispanics (SASH) was used to assess language use, media use, and social relations; acculturation scores represent an average of 12 responses, measured on a scale of 1 to 5, with 1 being least acculturated to US culture and 5 being most acculturated.^35,36

In total, the research activities lasted approximately 45 minutes. Interviews were audio-recorded and transcribed. Each participant received a $50 gift card for their time and effort.

Data Analysis

Data analysis was guided by the Framework Method,³⁷ with transcripts analyzed both deductively and inductively. Once a majority of interviews were completed, two authors (SWL, AP) began reading the transcripts for familiarity and content, and writing memos. A set of a priori codes, developed from the interview guide, was piloted with a subset of transcripts. These transcripts were double coded using NVivo software (release 1.4.1, QRS International), and differences in coding were reconciled for each transcript until full agreement was achieved. Memos were used to identify emergent themes and finalize the codebook. Once the codebook was finalized, two authors (SWL, AP) ensured each transcript was fully coded with a second round of coding. These authors met regularly to review coding and achieve coding consensus.³⁸ Detailed matrices were then created in Microsoft Excel, with rows representing individual participants and columns representing single codes. Content relevant to each code was summarized between and within participants.³⁹ The Consolidated Criteria for Reporting Qualitative Research (COREQ) was followed for reporting findings⁴⁰ (see Supplementary Material 2).

Results

Sample Characteristics

The sample consisted of 15 Latinx adults between 50 and 79 years of age (m = 56.6 years). Ten were female. Eight participants were US-born, five were born in Mexico, and one each was born in El Salvador, Ecuador, and Canada. Of those who were foreign-born, time living in the US ranged between 8 and 51 years (m = 26.1 years), and nine participants reported low acculturation levels. Six participants were considered to have inadequate health literacy. On the SASH, four participants reported reading and speaking both English and Spanish equally, six reported using more Spanish, four reported using more English, and one reported solely using English. Nearly half (n=7) of the sample reported having government-sponsored health insurance (ie, Medicare, Medicaid), while four each reported being on private insurance or uninsured. Approximately half of the participants (n=8) were fully vaccinated at the time of their interviews, while four had received one of two doses, and three were unvaccinated. (Table 1)

Table 1 Participant Demographics

Themes and Subthemes

Four key factors influencing vaccination decision-making were identified: 1. Protecting oneself and loved ones, 2. Trust in authorities, 3. Access and availability, and 4. Employment and semblance of normalcy. Themes and sub-themes are discussed below, along with representative quotes. (Table 2)

Table 2 Key Themes

Theme 1: Protecting Oneself and Loved Ones

Sub-Theme 1A: Protecting Oneself and Loved Ones Against COVID-19

Nearly all participants (n=14) vocalized an understanding that the vaccine provides protection against COVID-19 infection, with some specifying the utility of vaccines in preventing serious illness, hospitalization, or death. Some participants highlighted the importance of being vaccinated in the context of preexisting health conditions. Over a quarter of the participants mentioned getting vaccinated as a way of assisting God’s will in allowing them to live as long as possible. These participants saw the vaccine as something that could help prevent death from COVID-19. As such, they saw themselves as working together with God.

Many participants noted that family members played an influential role in their vaccination decisions. For instance, two participants mentioned their desire to protect at-risk family members. Others discussed how witnessing loved ones suffer or die of COVID-19 influenced their decisions. Still others expressed how family members’ decisions to get vaccinated helped assuage their own hesitancy towards the vaccine.

Various participants also spoke about the vaccines on a larger, community-wide level, suggesting the importance of “stopping the spread” of COVID-19.

In addition to protecting yourself, you also protect other people. Sometimes you are asymptomatic, you may have had COVID and you don’t know because you don’t have symptoms, and if you are living with other people, you may infect them. So, out of respect for others as well. (Spanish-speaking, vaccinated male).

In this way, these participants saw the decision to vaccinate as a moral obligation or sign of respect towards others. The potential for the vaccine to protect from severe COVID-19 infections was a key reason that many participants decided to get vaccinated.

Sub-Theme 1B: Protecting Oneself and Loved Ones from Perceived Dangers of the COVID-19 Vaccine

Despite the fact that most participants equated the vaccine with protection against COVID-19, the majority of participants (n=9) also expressed concern over potential long-term side effects from the vaccines. They expressed concern regarding the perceived newness of the vaccine and/or the vaccine technology, as well as the speed with which each of the vaccines was studied. For example,

One of the concerns is that this is a new vaccine, a new technology that is being implemented for this type of vaccine. I’m worried that there will be a side effect over the years, not immediately. (Spanish-speaking, vaccinated male).

Additionally, a couple of participants mentioned their fear of needles or general dislike of shots as a factor contributing to their hesitancy. Some participants mentioned concerns about the possible effects of “unnatural” medical interventions on their bodies:

And they are saying that the vaccines only last six months and you have to get another one. So, that’s too much in your body. That scares me a lot. You’re putting so many things inside, and we don’t know what they are yet. (Spanish-speaking, unvaccinated male).

Participants shared different ideas of how the “chemicals” of the COVID-19 vaccine might affect them, including altering their genetic code or even, as one participant mentioned, summoning the “will of the devil”. The possible risks associated with the vaccines played a critical role in decision-making for sample participants. While this was a main deterrent for those who remained unvaccinated, even those who opted for vaccination endorsed weighing potential vaccine risks as key decision-making considerations.

Theme 2: Confidence in Authorities, Including Government, Medical Providers, and Public Health Experts

Sub-Theme 2A: Trust in COVID-19 Information from Health Professionals and the Government

Nearly two thirds of participants (n=9) mentioned trusting their doctors or healthcare providers with personal health decisions, including those regarding the vaccine. Some connected this to their providers’ training, while others felt their providers have their best interests at heart. Many participants also mentioned that they trust information coming from public health organizations, such as the Center for Disease Control (CDC), the World Health Organization (WHO), or the National Institute on Health (NIH). Similarly, participants frequently mentioned trusting public health experts, particularly those who identify as virologists or other specialists, such as Dr. Anthony Fauci. Some participants described competing views about the quality of information coming from federal versus local officials:

I trusted the (state) government a lot because they offered statistics and they told us how people were moving. They showed us how the numbers went up and how they dropped. And if that came from people from other states, I can’t know if that information is trustworthy or where those came from. (Spanish-speaking, vaccinated female).

Therefore, for some participants, information provided by local officials was considered more relevant and meaningful to them compared to information provided by the federal government.

Sub-Theme 2B: Distrust in Authority

Some participants mentioned distrust of authority, including the government, politicians, healthcare providers, and pharmaceutical companies. A third of participants (n=5) mentioned they had heard of conspiracy theories, including that the government will be able to scan vaccinated people, that the government may be trying to kill people, and that the government could be manipulating the vaccine to contain a microchip to control the population. Four participants stated that the government needs to be more transparent, and five felt that politicians are not trustworthy. Some explained that the rapid and constant change in information provided about the vaccine contributed to their own sense of hesitancy:

I kind of take what the government says, like, with a grain of salt, one day to the next. Things are always changing. One thing’s being said and something else has been said the next day. Things are safe. Things are not safe. Um, I can’t believe everything that the government says because there’s just been too much un-transparency. (English-speaking, unvaccinated female).

Participants also expressed skepticism over entities who may be benefitting financially from the pandemic and/or the vaccines, such as pharmaceutical companies. These beliefs and attitudes reflected a general skepticism and mistrust of the reasons for which officials are promoting the vaccine.

Theme 3: Access and Availability

Sub-Theme 3A: Gratitude to Live in a Country Where Vaccines are Available

A third of participants (n=5) expressed gratitude for having access to the vaccine. A few noted that the pandemic seems more controlled in the United States than in Latin America, where some loved ones have not had the privilege of receiving vaccines. One participant specifically felt she had an obligation to receive the vaccine because, unlike her friends in various Latin American countries, she was fortunate enough to have the opportunity:

(My friends) believe that I should get it because I’m able to get it. It’s available. And that I live in a country that is providing it for free and stuff like that so I should take advantage of it (English-speaking, partially-vaccinated female).

Sub-Theme 3B: Barriers to Access

About a quarter of participants (n=4) mentioned that individuals who are undocumented may feel particularly hesitant to receive the vaccine, either due to a fear of deportation, distrust of the government, or uncertainty about the documentation required to get vaccinated. Some also mentioned uncertainty regarding eligibility when people do not have health insurance or regarding the cost of the vaccine:

Well, those who had Medicaid were eligible to receive it but those of us who don’t have it were unable to obtain it because we didn’t have Medicaid or because we were not residents in this country. (Spanish-speaking, vaccinated female).

This participant, in particular, delayed vaccination until she was assured she did not have to pay for the vaccine. Relatedly, a third of participants expressed concern about a language barrier, highlighting the need for vaccine information to be provided in Spanish or other languages prevalent in given communities. Some participants also suggested that the public vaccination of Latinx celebrities or Spanish-speaking experts might help boost vaccination rates. Approximately half of participants also mentioned the need to inform members of their communities about where to get vaccinated, how to book an appointment, or how to get there. One participant suggested the radio could be an effective mode of communication for community members, while others suggested that setting up vaccination sites in grocery store parking lots or other conveniently located places may help to increase vaccine uptake in their communities.

Theme 4: Employment & Semblance of Normalcy

Sub-Theme 4A: Vaccination to Create Work Opportunities and Return to “Normal”

Some participants spoke about how the vaccine can help people return to normal. Particularly, many participants discussed the vaccine in relationship to employment (n=6), mentioning the economic impact of the pandemic and the need to return to work. One participant suggested he would only get vaccinated if it did become mandatory for work, two mentioned family members who work in healthcare that needed to get vaccinated, and two stated that they personally received the vaccine due to their own employers’ requirements:

Yes, I thought, if I don’t receive the vaccine and I want to work in certain places –many places request that you have the vaccine. I knew that the persons I work with had already received the vaccine, so, if I didn’t get vaccinated they could ask me, “Have you received the vaccine? We have this condition and you won’t be able to come.” (Spanish-speaking, vaccinated female).

Others discussed the vaccine as a means to being able to return to church, go to weddings, travel, spend time with family members, and not have to wear masks indoors. Vaccination, for these participants, facilitated a return to events they enjoyed and missed.

Sub-Theme 4B: Concern About Missing Work and Other Present Circumstances Due to Short-Term Side Effects of Vaccines

While the fear of missing work due to side effects from the vaccine was mentioned as a potential deterrent, for the majority this did not come up organically. That said, a majority of participants (n=9) did express concern over the potential short-term side effects of the vaccines. Some mentioned concern about feeling sick after getting vaccinated.

Honestly, I, I don’t trust it … Well based on what I’ve heard, people generally can contract COVID-19 again over and over. So, I’m not so certain as to how well it works and then there are side effects. That some people tend to get. And so then, for that fact, I don’t really think that it’s that safe – for me that is … And then on the second, I guess on the second shot, everybody has not been feeling too well, so that doesn’t make me all too trusting of the vaccination either. (English-speaking, unvaccinated female).

Two participants expressed concern after hearing that some had died from the vaccine. These participants considered the possibility of short-term and immediate consequences of the vaccine interrupting their current functioning.

Discussion

The present study explored Chicago-based Latinx older adults’ perceptions, attitudes, and decision-making factors related to the COVID-19 vaccines, with the purpose of informing the development of vaccine messaging for this population. Latinx older adults represent a sector of the US that has been disproportionately impacted by the pandemic.⁷ Nevertheless, to our knowledge, this is the first study to engage stakeholders from this community in an exploration of themes related to COVID-19 vaccine acceptance and uptake, in order to inform material development. Findings revealed several factors that contribute to the vaccination decision-making process of sample participants: their desire to protect themselves and their loved ones, trust in authorities, concerns about access and employment, and desire for some semblance of normalcy. These themes suggested that, in designing vaccine messaging strategies for Latinx older adults in Chicago, general messaging strategies would benefit from key culturally-appropriate adjustments.

General Messaging

Numerous findings from the present study were similar to results found among the general population. Specifically, many participants in our study shared a “wait and see” attitude towards the vaccine – preferring to defer receiving the vaccine until more long-term consequences are clarified – or a preference for natural immunity, which has previously been associated with a lower likelihood of getting the influenza vaccine.^41–43 Similar to results of other vaccine studies,^36,44 the weighing of perceived risks and benefits of vaccination was central to decision-making among sample participants. These findings highlighted the need for increasing awareness and knowledge of the serious risks of coronavirus, the direct prevention benefits of the vaccines, and the safety of the ingredients in the vaccines. Also consistent with recent work from the United Kingdom,¹³ many respondents discussed the vaccines as a way to return to “normal” faster, including socializing with friends and family, hugging loved ones, attending weddings and religious events, and traveling and working. Consistent with Lancet Commission recommendations,¹⁹ various participants mentioned the potential of mandates from employers as an important facilitator in getting vaccinated. These findings suggested that messaging could benefit from highlighting that vaccines are a key aspect of expediting a return to a pre-COVID-19 way of life – particularly in terms of socializing and sustaining employment.

Cultural Tailoring

On the other hand, by engaging with the target population, our study revealed key areas where messaging should be adapted to the target population, including leveraging collective pronouns, spirituality, language, technology, trust, insurance, and immigration. Tailoring of health messages has been shown to be effective for changing behavior.⁴⁵ In our study, the concept of vaccination as a moral responsibility in “stopping the spread” of COVID-19 is consistent with previous research that demonstrated that a lower sense of collective responsibility independently predicted lack of uptake of influenza, pneumococcal, and shingles vaccines in older adults.⁴² As Latinx culture is commonly more collectivist,⁴⁶ it might be particularly useful to utilize collective pronouns such as “we” in messaging efforts, which has previously been associated with increased health intentions, including social distancing and mask wearing.⁴⁷ Personal spiritual beliefs also surfaced as a common factor in decision-making. Similar to prior research on vaccine acceptance in Latinx communities,³⁶ our findings suggested the importance of taking spiritual beliefs into account when designing and disseminating materials to promote COVID-19 vaccine uptake, for instance by seeking partnerships with religious organizations in communities targeted by vaccine promotion efforts.

Logistical barriers, such as limited language-concordant information, transportation, and technology, were mentioned by various participants. In the context of the Latinx community, the perceived language barrier is particularly relevant, as inequity in access to health services is often compounded by language and communication challenges.¹⁶ Efforts to enhance vaccination uptake among older Latinx individuals should focus on ensuring that information is conveyed in Spanish through a variety of mediums, including low-tech options. For example, language-specific advice could be disseminated in texts, emails, letters, the radio, and posters in local community sites.⁴⁸ Vaccination sites should also ensure the availability of language-concordant providers and/or interpreters, and translated, culturally-appropriate vaccine information.

Participants’ perceptions of healthcare providers and governmental officials consistently influenced decision-making. Discrimination, racialized processes, prior injustices, and unethical research have led to mistrust of the government and pharmaceutical companies among many historically marginalized racial and ethnic groups throughout history, and this has recently been shown to be associated with COVID-19 vaccine hesitancy and refusal.^13,49 Addressing this mistrust will require drastic systemic change.¹³ Our findings suggested that a first step could be embedding within informational materials the explicit acknowledgement of historical and contemporary abuses of power in the context of vaccine acceptance, and the clear articulation of roles and responsibilities of the various entities that will contribute to COVID-19 vaccination efforts.^13,19 In terms of future directions, governmental bodies and public health agencies may benefit from partnering with trusted community-based organizations and respected individuals to help spread accurate, research-based information and dispel the myths and conspiracies that have been circulated.^49,50

Poor treatment of immigrants in the US may also be negatively influencing uptake behaviors among the Latinx population, as some participants discussed the fear of deportation or the uncertainty regarding vaccine access for those without citizenship. Relatedly, doubts were raised regarding access to the vaccines for those without health insurance, highlighting deep institutional problems with the healthcare system in the US, which is largely based on employment benefits or the ability to pay, and thus inherently discriminatory.^51,52 Therefore, these findings indicated the importance of messaging that directly states that COVID-19 vaccinations are available at no cost and that citizenship and health insurance are not required for vaccination.

Limitations

The current study has several limitations. This small sample is from one geographic region and is not generalizable to older Latinx adults living in other diverse regions of the US. Latinx individuals living in the US represent diverse backgrounds and experiences, shaped by myriad social, environmental, and structural factors and must be viewed as heterogeneous. As all coding was completed on English transcripts, it is possible that the translation process obscured certain nuances present in the original Spanish recordings. Despite bilingualism and professional and personal experience with Latinx communities, neither coder identifies as Latinx. Additionally, there was researcher overlap in collection and analysis of the data, which may introduce some bias. However, this study was novel in its inclusion of both English- and Spanish-speaking Latinx older adults, as well as its utilization of qualitative methodologies, which allowed for the exploration of the complexities and nuances involved in vaccination decision-making during the ongoing pandemic.

Conclusion

Semi-structured interviews with Latinx older adults revealed several key factors involved in COVID-19 vaccine decision-making. Culturally-tailored messaging may benefit from leveraging collective pronouns and spirituality, addressing insurance and immigration doubts, and considering language concordance, low-tech options, and trusted community partners. Next steps are to develop educational materials based on these themes, followed by dissemination and evaluation of their effectiveness. Lessons learned from this local engagement with stakeholders may provide insights to support future health behavior messaging that is culturally-based and catered to unique, intersectional communities that are disproportionately impacted by various public health crises.