Vaccines | Free Full-Text | COVID-19 Vaccinations, Trust, and Vaccination Decisions within the Refugee Community of Calgary, Canada
[ad_1]
1. Introduction
2. Methods
2.1. Study Design
This research was led by the University of Calgary, Departments of Family Medicine and Community Health Sciences. The research team included members of the University of Calgary, a research-intensive university in Canada, members of Habitus Consulting Collective, a research and evaluation consultancy with extensive experience working with newcomers, and three partners embedded in Calgary area vaccine infrastructure for refugees. The purpose of the broad research team was to bring together diverse research skill sets and facilitate access to refugees and stakeholders embedded within COVID-19 vaccination systems. These partners included the Calgary Catholic Immigration Society (CCIS), The Alberta International Medical International Graduates Association (AIMGA), and the MOSAIC Refugee Health Clinic. CCIS is a large immigrant service providing agency based in Calgary that was contracted to work directly with refugees and support them with resettlement during 2021–2022. AIMGA is an association that focuses on the integration of internationally trained physicians in Canada. Through their efforts to re-engage internationally trained physicians into Canadian healthcare systems they became heavily involved in COVID-19 vaccination efforts in 2021–2022 due to high demand for their members, as refugees responded well to members’ medical knowledge, cultural knowledge, and diverse language skills. They operated in diverse capacities in vaccination efforts in 2021–2022. The Mosaic Refugee Health Clinic is a Calgary clinic that provides refugees with primary care for a period of up to two years following entry into Canada, with rich networks and knowledge of current practices.
2.2. Sampling and Recruitment
The research team conducted a series of qualitative semi-structured interviews, structured interviews, and a group interview with refugees and key informants connected to various local COVID-19 vaccination efforts for newcomers and refugees in Calgary, Alberta. Data collection was made possible through a research partnership with CCIS—the Resettlement Assistance Provider (RAP) for Southern Alberta (meaning the contract holder for settling all Government Assisted Refugees), AIMGA and the Mosaic Refugee Health Clinic. This project was approved for ethics by the University of Calgary Conjoint Health Research Ethics Board (CHREB REB21-0859).
A total of 61 participants were included in data collection. The majority of participants were healthcare system patients. They included government-sponsored refugees from Afghanistan who landed in Calgary in 2022 and were processed through local immigration systems and received COVID-19 vaccinations at processing hotels. Others were Private Sponsors of Refugees who helped refugees access COVID-19 vaccines, and longer-term refugees who had accessed vaccinations prior to the arrival of Afghan refugees.
The project included a series of brief, structured interviews with newly arrived Government Assisted Refugees (GARs) from Afghanistan (N = 39) at processing hotels and a series of longer, semi-structured interviews with Privately Sponsored Refugees (PSRs) (N = 6) and Private Sponsors of Refugees (N = 3). Additional semi-structured interviews (N = 11) and a semi-structured group interview (N = 2) were also completed with key informants, including community organization staff, vaccine access advocates, doctors, public health nurses and internationally trained medical graduates.
Primary data were collected from March 2022 to May 2023 with participants recruited through purposive sampling, convenience sampling, and snowball sampling. Afghan GARs were recruited by convenience sampling facilitated by CCIS and AIMGA immediately following their vaccination on-site at a temporary housing facility. Prior to vaccination, participants were offered a virtual information session in Dari and Pashto, introduced to the study purpose, given an opportunity to ask questions, and self-selected for participation. PSRs and Sponsors were recruited through purposive sampling by CCIS staff. These clients were given information about the study and self-selected for participation. Non-Afghan GARs were solicited but declined to participate. Key informants were identified by project partners who supported making connections as needed, as well as through snowball sampling. Consent for GAR interviews was verbal to build rapport through a paperless and less formal experience, and written for all other interviews. Consent forms, scripts, and interview guides for refugees were translated into first languages through certified translators and data collectors. All interview participant groups were provided a cash honorarium for their participation to reflect the participant’s expertise and time commitment; the exception was GAR participants, who had brief interviews.
2.3. Data Collection
Researchers explored the experiences of refugees and key informants with different types of interview guides for each participants group. Interviews with GARs, PSRs, and Sponsors focused on patient experiences with COVID-19 vaccinations, issues with vaccinations, concerns, and recommendations, with a semi-structured format being used for the latter two groups to ensure room for diverse avenues of conversation. The structured interview format for the former group, GARs, allowed researchers to conduct numerous interviews within specific and limited time frames and compare answers between respondents. Interviews with key informants were semi-structured and focused on descriptions of vaccination models, how they changed over time, strengths of models, barriers to vaccination, strategies to address barriers, trends with patients, and key lessons. As vaccination strategies by key informants differed over the course of the study, interviews with key informants adapted to focus on emergent findings, such as specific ways of encouraging vaccine uptake where details were sparse. The research team concluded that a point of data saturation was reached when no new patterns were identified through interviews.
The interviews were conducted in face-to-face, telephone, and video conference (Zoom) format, ranging between 5–45 min, after obtaining informed consent. Structured GAR interviews were face-to-face and ranged between 5 and 10 min. Semi-structured interviews were conducted over telephone for PSRs and Sponsors and over Zoom for key informants. These semi-structured interviews lasted from 20 to 45 min. Researchers conducted interviews with refugees in their preferred language. As this required numerous interviewers, a designated team member delivered interviewer training sessions to cover the research method, note taking, research topic, informed consent, working with refugees in a culturally sensitive manner, and transcription. All interviews were audio recorded and transcribed in English, with the exception of a few participants who preferred to not be recorded. In such cases, interviewers took in-depth notes during and following the session. The designated team member worked with first-language interviewers throughout the process of data collection to address questions and/or concerns, provide ongoing training, and ensure a consistent level of quality for translations and transcriptions.
2.4. Data Analysis
3. Results
Refugee decisions to vaccinate for COVID-19 are a complex phenomenon that include vaccine hesitancy, vaccine confidence, and vaccine uptake, along with contextual and structural factors associated with the COVID-19 global pandemic. The experiences of refugees provided a rich picture of the context and motivations that surround decisions regarding vaccination. Given that refugees often face multiple barriers to health, their stories shed light on the complexities surrounding refugee health and have crucial implications for health systems.
Refugee and sponsor accounts focused predominantly on individual, interpersonal, and community factors. Key informants involved in vaccination systems, on the other hand, provided numerous community and structural factors. The following summary outlines the various factors involved in refugee decision-making. Participant responses linked to these factors are presented at the end of this section.
3.1. Individual Factors
-
Concerns about side effects: Concerns refugees had or held about the negative side effects of the vaccine and mortality rates were discussed by several refugees (n = 6) as a factor shaping their decisions. Concerns were for themselves or for their family members, and these sentiments tended to correspond with informal knowledge networks or broader community discourse. Such concerns were generally addressed when healthcare professionals took the time to ask about and address their concerns.
-
Personal ‘disbelief’ in vaccine necessity or effectiveness and/or preference to avoid medical intervention: Another factor shared by refugees (n = 7) was a belief that the COVID-19 vaccine, or vaccines/medical intervention in general, is not effective or not a necessary form of defence against illness. This factor included the belief that their bodies are able to defend against diseases naturally and do not need additional assistance from vaccines.
-
Concerns about risks to subpopulations: Individual refugees and all key informants involved in service provision spoke about vaccine safety concerns for specific subpopulations, such as children, youth, pregnant women, and persons with allergies or underlying health conditions. Similar to concerns about vaccine side effects, participants shared that concerns about specific subpopulations were addressed when healthcare professionals took the time to ask about and address such concerns.
-
Fear of COVID-19: An important individual factor was the willingness and eagerness to be vaccinated. Refugees linked vaccine compliance to desires to mitigate physical health risks of COVID-19, including for healthy and at-risk persons. This motivation for health ultimately superseded any uncertainty about the vaccine or its safety, even in cases where refugees had remaining concerns, and key informants noted an ongoing desire to protect children with initial doses.
3.2. Interpersonal Factors
-
(Mis)information: Information was a key factor in shaping decisions which could positively or negatively influence vaccine uptake. Refugees shared examples of multiple and competing sources of information and linked these to feelings of hesitancy and confidence with the vaccine. Sources of misinformation commonly cited included social media and stories from friends and family. Despite being immersed in multiple sources of information, the large majority of refugees interviewed shared they were able to navigate misinformation and were not opposed to vaccinations. However, refugees also feared the influence of misinformation on other people who may be hesitant to vaccinate.
-
Desire to protect others: Interpersonal factors included desires to protect others through vaccination. For example, some refugees framed their decision to be vaccinated as being for the protection for others, especially family members, rather than themselves.
-
Influence of family members: Similar to (mis)information, a key factor that refugees contended with was the influence of family members. Refugees expressed different levels of hesitancy and/or vaccine confidence among family members, which shaped their thoughts and feelings around vaccinations. There were also cases where refugees explicitly stated that pressure or preference from family members, such as spouses, was a deciding factor in being vaccinated.
3.3. Community Factors
-
Information overload: While multiple and competing sources of information shaped vaccination decisions, according to participants, a key factor related to this was information overload. This factor had the potential to erode any positive gains in vaccine confidence that information from trusted and reliable sources could contribute to. For example, refugees linked the recurring changes in public health information to feelings of confusion, being overwhelmed, and uncertainty, especially with regards to information about the minutiae around risks and effectiveness of various brands of vaccines. While this wasn’t a factor in vaccine refusal per se, it added difficulty in determining personal vaccine confidence and participants highlighted desires to ‘shop around’ for specific vaccines.
-
Access to evidence-based information: Evidence-based information was highlighted by refugees and key informants as key to gaining confidence. Access to such information was facilitated by multiple sources, including social media, primary sources, family members, and information sessions at vaccine clinics. While access could be facilitated through different sources, both refugees and key informants identified that evidence-based information helped increase confidence when it was delivered in a timely and trusted manner through personnel such as nurses or doctors prior to vaccination.
-
Secondary information sources and personal networks: Another route to information was through secondary sources, such as social media, television, friends, and acquaintances. Refugees shared that these sources frequently delivered information related to the virus and the vaccine, whether they were actively seeking information (such as searching on the internet) or coming it across it more passively (such as hearsay). Family and friendship networks were also flagged as common sources of counsel and information about the vaccine.
-
Pre-migration experiences: A more subtle factor in participant accounts was how refugees’ experience in Canada and their pre-migration experiences with vaccine access shaped their outlooks. This contributed to unique perceptions and concerns, such as whether patients perceived vaccination personnel to be open to questions, whether they had a choice in being vaccinated, or comparisons to other countries. Others noted that Canada had broad allowance for variations of personal preference in choosing the vaccine.
-
Fatigue, indifference, and booster-specific hesitancy: The dose in question was a factor which influenced whether refugees pursued vaccinations or not. All participant groups shared cases where they, a family member, or a patient who conformed to or were even eager to get first and/or second doses refused subsequent boosters. Justifications for booster refusals varied, with examples of vaccine fatigue, indifference, or not wanting to go beyond the mandatory two doses. Key informants also reported that booster hesitancy trends followed the hesitancy patterns of early doses of the vaccine, with concerns around boosters’ side-effects and risks to subpopulations, with the added layer of fatigue and indifference.
3.4. Societal Factors
4. Discussion
This research focused on the experiences of refugees with COVID-19 vaccination systems within and around Calgary, Canada. The purpose was to understand vaccine hesitancy, barriers to access, decision-making factors, and refugee patient experiences during the COVID-19 vaccination roll out. This paper argues that vaccine confidence, hesitancy, uptake, and vaccination intent are not mutually exclusive. In fact, their complex relationship sheds light on how data on vaccine confidence and hesitancy need to be decoupled from data on vaccinations. Our paper shows that, for recently arrived refugees, the COVID-19 vaccination process became a testing ground for building and negotiating their relationship with a new healthcare system, and offers implications for strengthening the broader healthcare system’s capacity to serve refugee patients and implications for service providing collaborations focused on refugee patients.
The purpose of this study was to deepen the understanding of vaccine hesitancy, barriers to access, decision-making factors, and refugee patient experiences in the COVID-19 vaccination context. Our study found that, while processing refugees may not have had options to opt out of vaccination, as mandates shaped their capacity to travel, access amenities, or access employment, there were cases where refugees still had concerns about the vaccine itself despite receiving vaccination and information about the vaccine. Refugees also shared accounts of what was useful for their decision-making. To further complicate matters, vaccine rollouts over the 2021–2022 period included multiple doses (from first dose to boosters), multiple waves of eligibility, such as adults, seniors, and young children, and multiple access points over time. In fact, the study points to the complexities that shape decisions around COVID-19 vaccination and offers insight into how refugees and other marginalized groups come to engage and build a relationship with and through the health system.
In addition to centring patient experiences at the core of decision-making, this study has key findings. The first key finding was that vaccination uptake at any given time was context-dependent. Informants observed broad ebbs and flows in public demand and willingness to be vaccinated that corresponded with changing public policy and public discourse. A key theme from informants was that vaccine sentiments and vaccination rates were shaped by several environmental or contextual factors, and that staff activities had to monitor broader trends and change accordingly to ensure that refugees had accurate and relevant information. Importantly, the various touch points that patients drew on when making decisions were not the same for individual patients, yet these paralleled longer-term trends in perspectives towards COVID-19 vaccination. Despite this, services were able to target these touch points in culturally responsive manners through measures such as information sessions in first languages, and by routinely including personnel from similar cultural backgrounds alongside refugees.
Hesitancy is a complex phenomenon that includes a range of categories, such as the refusal to be vaccinated, those who delay vaccination, and those who accept vaccination with some reservations. Participant perspectives on vaccination ranged from refusal to confidence, with the risk of negative health consequences being a major deciding factor for both groups. For others, hesitancy was presented as trust in one’s innate ability to fight the COVID-19 virus or a lack of confidence in vaccine effectiveness, while decisions to be vaccinated could be influenced by vaccine mandates or family pressure. Information and knowledge sources had the potential to validate or challenge the perspective of both vaccine hesitant and vaccine confident folks. For many, vaccination decisions were a negotiation between personal thoughts toward medical intervention, personal observation, family and community perspectives and opinions, news media, social media, direct public health guidance, and scientific evidence. A key recommendation from both patients and key informants regarding hesitancy was to ensure that ample, comprehensive information was reaching communities on an ongoing basis, from trusted sources such as personnel who were knowledgeable of their culture.
Third, vaccine confidence and uptake were facilitated by various personal and external motivators, some of which overlapped with efforts of vaccination staff. In addition to hesitancy, there were many instances of patients eager to be vaccinated or to have family members become eligible for vaccines. Confidence was largely influenced by access to information, knowledge networks, and trust. Importantly, the intent to be vaccinated is not necessarily predictive of the decision to be vaccinated. Our study included some participants who, though vaccinated, would have preferred not to have been vaccinated or did not intend to receive further doses. This further supports the argument that hesitancy should be framed as part of an ongoing set of decision-making processes rather than a finite decision, as patients shared a number of these contradictions.
Lastly, a key learning from this study was that tailored approaches for refugees are potential opportunities to build trust and bridge clients to mainstream services in the future. Refugees are a unique group because they are some of the most vulnerable members of Canadian society. Given that they had likely experienced extreme circumstances prior to arrival in Canada, the vaccination roll-out at the early stage in their migration process to Canada became a significant site for engagement, trust building, and importantly, communicating the relationship between community and the health system. For refugees, this becomes a crucial entry point.
This study does not represent an exhaustive view of the experiences of refugees within Calgary area vaccination systems. Researchers primarily focused on recently arrived government-sponsored Afghan refugees and other Privately Sponsored Refugees due to the partnership with CCIS and AIMGA, as CCIS was the designated immigrant serving organization to host and process Afghan refugees in the area. AIMGA, a partner of CCIS, provided various cultural, medical, and language supports alongside CCIS. The partnership ultimately facilitated recruitment towards participants that were connected with those organizations and was used as a basis to reach a population that is difficult to access by drawing on previously established contacts and networks of trust. Furthermore, the study design was not structured to draw conclusions through statistical analysis. As with most qualitative research, this research presents insights on vaccination from a particular group of people in one geographic region, and may not reflect the diversity of experiences of refugee patients.
[ad_2]