Modes of COVID-19 Information and Vaccine Hesitancy Among a Nationally Representative Sample of Asian Americans: The Moderating Role of Exposure to Cyberbullying

HIGHLIGHTS

• •COVID-19 information from websites, social media, and broadcast protected against vaccine hesitancy.
• •Cyberbullying was associated with greater vaccine hesitancy only in unadjusted models.
• •Cyberbullying moderated the protective effects of broadcast information only.
• •Health communication should account for the detrimental effects of cyberbullying.

Abstract

Introduction

COVID-19 vaccination is an important public health intervention to curb the pandemic's magnitude and spread, and racial discrimination is a key predictor of COVID-19 preventive behavior, vaccine hesitancy, and uptake. This study evaluated the association of vaccine hesitancy with various modes of information on COVID-19 (i.e., online, social media) and the moderating role of cyberbullying among Asian Americans.

Methods

The authors used population-weighted data from the nationwide Asian American and Native Hawaiian/Pacific Islander COVID-19 Needs Assessment Survey, which was conducted from January 2021 to April, 2021 (unweighted N=3,127). The association between various modes of COVID-19 information and vaccine hesitancy, moderated by exposure to cyberbullying, were examined.

Results

In general, 16% of Asian Americans reported vaccine hesitancy; 26% reported experiencing cyberbullying. Asian Americans reported receiving most COVID-19 information from online sources (75%) and social media (52%). In unadjusted models, receiving information via online (OR=0.46; 95% CI=0.33, 0.62; p<0.001), social media (OR=0.80; 95% CI=0.52, 0.93; p<0.05), and broadcast (OR=0.60; 95% CI=0.44, 0.81; p<0.001) were significantly associated with a lower vaccine hesitancy. However, reporting any cyberbullying was associated with increased vaccine hesitancy (OR=1.39; 95% CI=1.02, 1.90; p<0.05). The protective effects for COVID-19 information modes remained when accounting for health and sociodemographic factors, whereas the effect of cyberbullying was no longer statistically significant. Cyberbullying moderated the protective effect of broadcast information only, so those who received information via broadcast and reported experiencing cyberbullying had similar odds of vaccine hesitancy compared with those who did not receive information via broadcast.

Conclusions

Online, social media, and broadcast remain important sources of information about COVID-19 for Asian Americans; however, experiencing cyberbullying can reduce the effectiveness of these sources in the uptake of the vaccine. COVID-19 information promotion strategies for Asian Americans must account for the role of cyberbullying in social media campaigns.

INTRODUCTION

Vaccination for the coronavirus disease 2019 (COVID-19) is an important public health intervention to curb the pandemic's magnitude and spread. Beyond the direct health benefits of vaccination at individual and population levels, vaccination can address the social, economic, and health inequities of racialized and minoritized populations disproportionately affected by the pandemic.¹ Although the National Academy of Sciences, Engineering, and Medicine's Framework for Equitable Allocation of a COVID-19 Vaccine identified COVID-19 information promotion to reduce vaccine hesitancy as a key recommendation to ensure health equity for racialized and minoritized populations in the U.S., Asian Americans were notably not included in the framework during its initial publication.² This omission is problematic, given the rampant missing race/ethnicity information in COVID-19 case and vaccination data (25.6% missing race/ethnicity for those with at least one dose administered),³ race misclassification, and aggregation of Asian Americans.^4,5

Lack of reliable, accurate, and disaggregated vaccination data for Asian Americans makes it challenging to assess the specific needs of this group^5,6 and has implications for the total population.^1,7 This includes the codification of racialized biases that perpetuate the public perception that Asian Americans do not experience health disparities and ignore these communities in federal public health campaigns.⁸ Furthermore, social determinants of health that are intricately tied to COVID-19 health disparities may be exacerbated because of a lack of surveillance for certain groups.⁷ Incomplete data may lead to services that may be culturally irrelevant to certain Asian ethnic groups, leading to delays in care and worsening health for other COVID-19–related health conditions, like cardiovascular disease.^5,7 These challenges can be understood through a syndemic model.⁹ COVID-19 has magnified multiple, interrelated challenges—anti-Asian discrimination,^10,11 health and mental health threats,^12,13 and economic insecurity—that have immediate and long-term consequences on Asian American health and well-being.

Vaccine hesitancy is one key health inequity concern for racialized and minoritized populations, including Asian Americans, related to rampant misinformation, discrimination in health care, and medical mistrust. Culturally and linguistically appropriate COVID-19 information promotion to reduce vaccine hesitancy that is inclusive of Asian Americans is urgently needed to address these varied and complex experiences and perceptions.^13,14 Nationally, Asian Americans are significantly more likely to report COVID-19 vaccine hesitancy than Whites,¹⁵ and 76% of Asian Americans reported having >1 concern about vaccination.¹⁶ Vaccine hesitancy also significantly varies by Asian American ethnicity¹³; approximately 12% of Korean adults were unwilling to receive the COVID-19 vaccine compared with 6% of Chinese adults. However, state-level surveys reveal a different picture. Asian Americans in California, for example, reported lower vaccine hesitancy than Latinx and non-Hispanic White individuals.¹⁷

Racial discrimination is a key predictor of COVID-19 preventive behavior, vaccine hesitancy, and uptake.^13,16,18, 19, 20, 21, 22, 23, 24, 25, 26 Thus, it is critical to examine the role of anti-Asian discrimination in vaccine hesitancy in the context of the COVID-19 pandemic. With the racialization of COVID-19 as the “China virus,” anti-Asian racism and xenophobia have increased.¹⁰ Several nationally representative surveys have documented that about 20% of Asian Americans have experienced a hate incident as of late 2021.^27,28 With social distancing orders, there was an overall increase in cyberbullying during the pandemic,¹⁸ and a substantial portion of discrimination against Asian Americans occurred online. Nearly 9% of the 10,905 first-hand reports of anti-Asian discrimination reported to Stop AAPI Hate between 2020 and 2021 were online harassment.²⁷ Discrimination can also impact individuals indirectly, like seeing or hearing racist rhetoric on social media.¹² Exposure to cyberbullying, or repeated harassment through digital platforms (e.g., online forums, social media),²⁹ is one way that anti-Asian racism can dilute health promotion efforts to curb the COVID-19 pandemic. Reports and experiences with cyberbullying grew during the COVID-19 pandemic.³⁰ Cyberbullying can have detrimental psychological effects on victims³¹ and lead to increased disengagement from online activities.32, 33, 34, 35 For Asian American victims, cyberbullying harassment that is violent in nature may influence fears of leaving their home to receive COVID-19 preventive services, such as COVID-19 vaccination or testing. Given the ubiquity of obtaining information online, repeated exposures to cyberbullying can potentially prevent individuals from receiving crucial updates on COVID-19 and dilute the effectiveness of preventive COVID-19 information.

Thus, anti-Asian racism online can potentially complicate the design of COVID-19 information promotion to reduce vaccine hesitancy among Asian Americans.²⁰ Furthermore, the Asian community may also be exposed to potential COVID-19 misinformation.³⁶ This study contributes to the existing literature by examining the both the independent and joint associations of different modes of receiving COVID-19 information and exposure to cyberbullying on COVID-19 vaccine hesitancy. Our specific hypotheses are:

• 1.Hypothesis 1: Seeking COVID-19 information through various modes (e.g., online websites, social media, print, broadcast) will be associated with lower vaccine hesitancy.
• 2.Hypothesis 2: Reporting cyberbullying will be associated with greater vaccine hesitancy.
• 3.Hypothesis 3: Cyberbullying will attenuate the effectiveness of various modes of COVID-19 information, such that those who experience cyberbullying will have similar levels of vaccine hesitancy compared with those who do not experience cyberbullying and do not seek COVID-19 information.

METHODS

Study Sample

Data came from the Asian American and Native Hawaiian/Pacific Islander (NH/PI) COVID-19 Needs Assessment Study, a nationwide survey conducted between January 18 and April 9, 2021, that examined Asian American and NH/PI experiences during the COVID-19 pandemic. The project was conducted by the Asian American Psychological Association and was part of a larger project on the impacts of COVID-19 on minoritized communities sponsored by the National Urban League.³⁷ More details are provided elsewhere.³⁸ Briefly, surveys were provided in English, 9 Asian languages, and 4 NH/PI languages. Recruitment used a 2-pronged design through an online Qualtrics panel (32%)³⁹ and convenience sampling (68%) through geographically targeted recruitment and outreach by partnering Asian American and NH/PI national and community organizations. Eligibility criteria included self-identified Asian American and NH/PI adults, aged ≥18 years, who were either U.S. residents or considered the U.S. as their place of permanent residence.³⁷ The survey was available in 9 Asian languages: Bangla, Chinese (traditional and simplified), Hindi, Khmer, Korean, Tagalog, Urdu, and Vietnamese. This study was approved by the Association of Asian Pacific Community Health Organizations IRB.

Given the role of the pandemic in increasing anti-Asian sentiments, the authors restricted the study to the 3,736 participants who self-identified as Asian American, including multiracial Asians. The authors excluded participants who had missing data and NH/PI individuals given our focus on Asian people. The final analytic sample was 3,159 individuals (90.1% complete data). The authors conducted a complete case analysis, given the high completeness of the sample.

Measures

To assess vaccine hesitancy, the following question was asked: How likely are you to get vaccinated for COVID-19 once a vaccination is available to the public? Five responses were possible: Very Unlikely, Somewhat Unlikely, Somewhat Likely, Very Likely, and Unsure. The responses were dichotomized into vaccine hesitant (i.e., Unsure, Somewhat Unlikely, and Very Unlikely) versus vaccine confident (i.e., Somewhat likely and Very likely).

The primary variables of interest were the modes of COVID-19 information, and these included the following: government health websites, searching for information online (e.g., Google), social media, television news/radio, newspaper/magazines, family/friends, healthcare providers, community/faith leaders, or others. The authors categorized receiving information into 4 categories based on the medium by which participants could obtain information: online (government websites and searching information online), social media, print (newspapers/magazines), and broadcast (television news/radio). The authors separated social media from online sources because of the differences in use (e.g., social media acts as a hub for both sharing and discussion, whereas online sources may not have areas for discussion). Additionally, information received from family/friends, healthcare providers, community/faith leaders, and others were excluded, as these mediums were more specific and relational or unspecified.

Any exposure to racial/ethnic cyberbullying because of COVID-19 was examined as an independent variable of interest and a moderator of each mode of COVID-19 information. Participants were asked: Due to COVID-19, how often have you been cyberbullied because of your race/ethnicity? The response choices were the following: Never, One or two times, Two or three times a month, Once a week, and Nearly every day. These variables were dichotomized as Never versus Any cyberbullying.

The authors examined 3 groups of covariates: demographic variables, socioeconomic factors, and any self-reported physical health diagnoses. Demographic covariates included age, sex (i.e., male or female), ethnicity, marital status, immigrant status (immigrant versus U.S.-born), and survey language (English versus not). Age was categorically coded as 18–24 years, 25–44 years, 45–64 years, and 65 years and older. Ethnicity included 10 categories: multiracial Asian (e.g., Any Asian ethnic group and Black), Chinese, Filipino, Asian Indian, Vietnamese, Korean, Japanese, Pakistani, other Asian (e.g., Hmong, Thai), and multiethnic Asian (e.g., Filipino and Chinese). Marital status included 3 groups: married or living with partner, single, and divorced, separated, or widowed.

Socioeconomic factors included educational attainment and yearly family income. Educational attainment was coded as 5 categories: less than high school, high school graduate or general education diploma, some college, bachelor's degree, or graduate degree or more. Yearly family income had 6 categories: <$25,000, $25,000–$34,999, $35,000–$49,999, $50,000–$74,999, $75,000-$199,999, or ≥$200,000. Having any physical health diagnosis was determined by self-report of any of the following conditions: high blood pressure, diabetes, cardiovascular disease, heart failure, lung disease, cancer, autoimmune disease, kidney disease, and low immunity.

Statistical Analysis

Using 2019 U.S. Census American Community Survey 1-year estimates, sample weights were created based on ethnicity, nativity, education, household income, and sex, using the ranking method. These weights match the 2019 Asian population estimates and account for multiracial Asian Americans.

The authors first examined the univariate and bivariate distributions of the study variables by vaccine hesitancy (Table 1). Binary logistic regression examined the odds of vaccine hesitancy in modes of COVID-19 information. To test hypotheses 1 and 2, the authors examined 3 nested models (Table 2). Model 1 examined the independent associations of modes of COVID-19 information and cyberbullying. Model 2 was built upon Model 1 by including the presence of physical health diagnoses, age, sex, ethnicity, marital status, nativity, and survey language. Model 3 was built upon Model 2 by including educational attainment and annual income.

Table 1.

Weighted Sample Characteristics for the Total Sample and by Vaccine Hesitancy, Asian American and Native Hawaiian and Pacific Islander COVID-19 Needs Assessment Survey

Variables	Total (N=3,127), % or mean (SE)	Vaccine confident (n=2,620), % or mean (SE)	Vaccine hesitant (n=507), % or mean (SE)	p-Value
Vaccine hesitant	16.4	0%	100.0%	-
Any physical health diagnosis	37.0	35.7	43.5	0.032
Modes of COVID-19 information
Online/government websites	75.0	78.0	60.0	<0.001
Social media	52.3	53.6	45.2	0.019
Print	29.1	30.4	22.0	0.011
Broadcast	62.5	64.9	50.5	<0.001
Experienced any cyberbullying related to COVID-19	26.5	25.2	33.3	0.010
Demographic variables
Age category, years				0.690
18–24	13.9	13.2	11.4
25–44	43.0	42.4	45.9
45–64	29.9	29.9	29.9
≥65	14.2	14.5	12.8
Sex				0.305
Male	48.9	49.5	45.8
Female	51.1	50.5	54.2
Ethnicity				0.547
Multiracial Asian	16.2	15.4	20.5
Chinese	18.7	19.2	16.3
Filipino	13.9	13.7	14.9
Indian	19.3	19.7	16.9
Vietnamese	8.5	8.4	8.7
Korean	6.2	6.1	7.1
Japanese	3.4	3.3	3.9
Pakistani	2.1	2.2	1.6
Other	9.5	9.8	8.2
Multiethnic Asian	2.2	2.3	1.9
Marital status				0.088
Married or living with partner	60.2	60.6	57.9
Single	31.6	31.9	30.1
Divorced, separated, or widowed	8.3	7.5	12.0
Immigrant to the U.S.	62.7	62.1	65.6	0.284
English survey	85.7	86.5	81.4	0.049
Socioeconomic factors
Educational attainment				<0.001
Less than high school	8.7	7.5	14.9
High school graduate/GED	9.6	8.9	13.0
Some college	14.3	13.5	18.7
Bachelor's degree	34.0	35.3	27.5
Graduate degree or more	33.4	34.8	26.0
Household income				<0.001
<$25,000	13.9	12.5	20.5
$25,000–$34,999	4.7	4.4	6.0
$35,000–$49,000	8.1	7.3	11.8
$50,000–$74,999	14.2	15.0	15.0
$75,000–$199,999	12.6	13.3	8.7
≥$200,000	46.7	48.4	38.0

Note: Vaccine confident=very likely/somewhat likely to get the vaccine; vaccine hesitant=unsure or very unlikely/somewhat likely to get the vaccine.

Table 2.

Weighted Binary Logistic Regression of Vaccine Hesitancy on Modes of COVID-19 Information and Cyberbullying, Asian American and Native Hawaiian and Pacific Islander COVID-19 Needs Assessment Survey (N=3,127)

Key variables of interest	Model 1		Model 2		Model 3
	OR	95% CI	OR	95% CI	OR	95% CI
Mode of COVID-19 information
Online/government websites	0.46***	0.33, 0.62	0.42***	0.31, 0.57	0.48***	0.35, 0.65
Social media	0.70*	0.52, 0.93	0.70*	0.50, 0.97	0.66*	0.47, 0.92
Print	0.74a	0.53, 1.05	0.73a	0.52, 1.03	0.74a	0.52, 1.05
Broadcast	0.60***	0.44, 0.81	0.59***	0.43, 0.81	0.62**	0.45, 0.86
Any exposure to cyberbullying (never ref)	1.39*	1.02, 1.90	1.29	0.92, 1.80	1.29	0.92, 1.79
Any physical health diagnosis (none ref)	—	—	1.35a	0.98, 1.85	1.33a	0.97, 1.83
Age, years (18–24 ref)	—	—
25–44	—	—	1.11	0.76, 1.62	1.48a	0.96, 2.29
45–64	—	—	1.05	0.61, 1.81	1.39	0.79, 2.44
≥65 years	—	—	0.84	0.41, 1.71	0.91	0.44, 1.89
Female (male ref)	—	—	1.25	0.92, 1.69	1.20	0.89, 1.63
Ethnicity (multiracial Asian ref)	—	—
Chinese	—	—	0.67	0.41, 1.10	0.73	0.44, 1.22
Filipino	—	—	0.81	0.49, 1.34	0.92	0.55, 1.52
Indian	—	—	0.61a	0.34, 1.09	0.68	0.38, 1.22
Vietnamese	—	—	0.75	0.44, 1.28	0.74	0.43, 1.28
Korean	—	—	0.87	0.52, 1.47	0.85	0.50, 1.45
Japanese	—	—	0.70	0.26, 1.89	0.78	0.27, 2.26
Pakistani	—	—	0.46	0.18, 1.22	0.43a	0.16, 1.16
Other	—	—	0.40*	0.18, 0.90	0.29**	0.12, 0.70
Multiethnic	—	—	0.67	0.34, 1.32	0.65	0.32, 1.32
Marital status (married ref)
Single	—	—	0.99	0.69,1.42	0.87	0.60, 1.26
Divorced, separated, or widowed	—	—	1.36	0.76, 2.42	1.08	0.60, 1.95
Immigrant status (nonimmigrant ref)	—	—	1.10	0.80, 1.52	1.07	0.77, 1.47
English interview (non-English ref)	—	—	0.94	0.57, 1.54	1.32	0.78, 2.24
Education (less than high school ref)
High school graduate or higher	—	—	—	—	0.83	0.41, 1.69
Some college or associate degree	—	—	—	—	0.71	0.36, 1.37
Bachelor's degree	—	—	—	—	0.42**	0.22, 0.81
Graduate degree	—	—	—	—	0.44*	0.21, 0.93
Income (<$25,000 ref)	—	—	—	—
$25,000–$34,999	—	—	—	—	0.85	0.51, 1.41
$35,000–$49,000	—	—	—	—	0.98	0.60, 1.60
$50,000–$74,999	—	—	—	—	0.65a	0.40, 1.04
$75,000–$199,999	—	—	—	—	0.44**	0.26, 0.73
≥$200,000	—	—	—	—	0.67a	0.44, 1.03
Constant	0.53***	0.37, 0.77	0.61	0.26, 1.43	0.94	0.34, 2.60

Note: Boldface indicates statistical significance (*p<0.05, **p<0.01, ***p<0.001).

Model 1 examines the independent associations of each mode of COVID-19 information and cyberbullying in vaccine hesitancy. Model 2 builds on Model 1 by including possible confounding factors by the presence of physical health diagnoses, age, sex, ethnicity, marital status, nativity, and survey language. Model 3 builds on Model 2 by accounting for the additional contribution of educational attainment and yearly income.

^ap<0.10.

To test Hypothesis 3, the authors examined a set of models similar to that of hypotheses 1 and 2, except that they focused on the joint association of each mode of COVID-19 information with cyberbullying (Table 3). Model 1 examined the unadjusted joint association of each mode of COVID-19 information with cyberbullying as a series of 4 interaction terms (e.g., receives information via broadcast × experienced any cyberbullying). Model 2 included physical health diagnoses and sociodemographic factors, whereas Model 3 included socioeconomic factors. Finally, to facilitate the interpretation of the interaction between each mode of COVID-19 information and cyberbullying, the authors created figures illustrating the fully adjusted predictive probability of vaccine hesitancy by the use of information mode and cyberbullying.

Table 3.

Weighted Binary Logistic Regression of Vaccine Hesitancy on the Joint Association of Modes of COVID-19 Information and Cyberbullying, Asian American and Native Hawaiian and Pacific Islander COVID-19 Needs Assessment Survey (N=3,127)

Key variables of interest	Model 1		Model 2		Model 3
	OR	95% CI	OR	95% CI	OR	95% CI
Mode of COVID-19 information
Online/government websites	0.52**	0.35, 0.77	0.45***	0.30, 0.67	0.52**	0.35, 0.79
Social media	0.65*	0.46, 0.94	0.66*	0.44, 0.99	0.63*	0.42, 0.95
Print	0.77	0.50, 1.17	0.76	0.49, 1.16	0.77	0.49, 1.20
Broadcast	0.50***	0.35, 0.72	0.48***	0.33, 0.69	0.50***	0.34, 0.72
Any experience of cyberbullying	1.23	0.62, 2.44	1.02	0.51, 2.06	1.06	0.53, 2.14
Mode of COVID-19 information × cyberbullying
Online × any cyberbullying	0.70	0.37, 1.33	0.79	0.41, 1.52	0.74	0.38, 1.44
Social media × cyberbullying	1.17	0.63, 2.18	1.16	0.61, 2.22	1.12	0.58, 2.14
Print × cyberbullying	0.84	0.41, 1.74	0.83	0.41, 1.70	0.82	0.41, 1.67
Broadcast × cyberbullying	1.77+	0.94, 3.36	1.96*	1.03, 3.73	2.03*	1.07, 3.84
Any physical health diagnosis (none ref)	—	—	1.37*	1.00, 1.89	1.36a	0.98, 1.87
Sociodemographic factors
Age, years (18–24 ref)
25–44	—	—	1.11	0.76, 1.63	1.52a	0.98, 2.35
45–64	—	—	1.07	0.62, 1.86	1.46	0.82, 2.59
≥65	—	—	0.87	0.42, 1.77	0.95	0.46, 1.99
Female (male ref)	—	—	1.27	0.94, 1.73	1.23	0.90, 1.67
Ethnicity (multiracial Asian ref)	—	—
Chinese	—	—	0.68	0.42, 1.11	0.75	0.45, 1.25
Filipino	—	—	0.82	0.50, 1.35	0.93	0.56, 1.53
Indian	—	—	0.61+	0.34, 1.08	0.69	0.38, 1.23
Vietnamese	—	—	0.77	0.45, 1.31	0.77	0.45, 1.32
Korean	—	—	0.88	0.53, 1.48	0.88	0.52, 1.49
Japanese	—	—	0.67	0.24, 1.84	0.77	0.27, 2.23
Pakistani	—	—	0.47	0.18, 1.26	0.45	0.17, 1.22
Other	—	—	0.39*	0.17, 0.87	0.29**	0.12, 0.69
Multiethnic	—	—	0.68	0.34, 1.33	0.67	0.33, 1.34
Marital status (married ref)	—	—
Single	—	—	0.99	0.69, 1.42	0.87	0.60, 1.26
Divorced, separated, or widowed	—	—	1.32	0.74, 2.34	1.04	0.58, 1.88
Immigrant status (nonimmigrant ref)	—	—	1.07	0.78, 1.47	1.03	0.75, 1.42
English interview (non-English ref)	—	—	0.95	0.57, 1.57	1.34	0.79, 2.27
Education (less than high school ref)
High school graduate or higher	—	—	—	—	0.84	0.41, 1.70
Some college or associate degree	—	—	—	—	0.70	0.36, 1.36
Bachelor's degree	—	—	—	—	0.41**	0.21, 0.78
Graduate degree	—	—	—	—	0.42*	0.20, 0.88
Income (<$25,000 ref)	—	—	—	—
$25,000–$34,999	—	—	—	—	0.87	0.53, 1.44
$35,000–$49,999	—	—	—	—	0.98	0.60, 1.60
$50,000–$74,999	—	—	—	—	0.66a	0.41, 1.06
$75,000–$99,999	—	—	—	—	0.46**	0.28, 0.76
≥$200,000	—	—	—	—	0.69a	0.45, 1.06
Constant	0.55**	0.35, 0.86	0.65	0.27, 1.57	0.95	0.33, 2.71

Note: Boldface indicates statistical significance (*p<0.05, **p<0.01, ***p<0.001).

Model 1 examines the joint associations of each mode of COVID-19 information and cyberbullying on vaccine hesitancy as interaction terms. Model 2 builds upon Model 1 by including possible confounding by the presence of physical health diagnoses, age, sex, ethnicity, marital status, nativity, and survey language. Model 3 builds upon Model 2 by accounting for the additional contributions of educational attainment and yearly income.

^ap<0.10.

As part of sensitivity analyses, the authors examined the robustness of the association among COVID-19 modes of information, cyberbullying, and vaccine hesitancy by conducting a series of stratified analyses. These analyses involved examining exposure to cyberbullying (as opposed to an interaction term) among subgroups based on age (aged <65 years), nativity, Asian ethnicity, and interview language.

RESULTS

Table 1 presents the weighted sample characteristics. Overall, 43% of Asian American participants were aged between 25 and 44 years. The majority identified as women (51.5%), were married/living with a partner (60.2%), and were immigrants to the U.S. (62.7%). Most participants had at least a bachelor's or graduate degree (67.4%) and an annual household family income >$200,000 (46.7%). About 37% of the participants had a physical health diagnosis at the time of the study.

About 16% of the participants indicated that they were unsure or unlikely to obtain the COVID-19 vaccine when it became available and 26% reported that they were cyberbullied because of the COVID-19 pandemic. Obtaining COVID-19 information from online websites was the most popular source (75.0%), followed by broadcast (62.5%), social media (52.3%), and print (29.1%).

There were statistically significant differences in vaccine hesitancy by each mode of COVID-19 information and exposure to cyberbullying (Table 1). In general, people who were vaccine confident consulted each mode of COVID-19 information at higher proportions than people who were vaccine hesitant. For example, 78% of people who were vaccine confident received COVID-19 information online or from government websites, whereas only 60% of people who were vaccine hesitant indicated that they received COVID-19 information online or from government websites (p<0.001). A greater proportion of people who were vaccine confident received COVID-19 information via social media (56.3%) than those who were vaccine hesitant (45.2%) (p=0.02). There were also significant differences in reports of any experiences of cyberbullying by vaccine hesitancy; 33.3% of Asian Americans who were vaccine hesitant reported that they experienced cyberbullying related to COVID-19 compared with only 25.2% of Asian Americans who were vaccine confident.

Table 2 presents the weighted binary logistic regression of the modes of COVID-19 information and cyberbullying on vaccine hesitancy. Model 1 shows that most COVID-19 information modes were significantly and independently associated with lower COVID-19 vaccine hesitancy. Online/government websites had the largest effect size (OR=0.46, 95% CI=0.33, 0.62, p<0.001). Consultation of print media, although only marginally significant (p=0.071), trended toward being protective. Furthermore, exposure to cyberbullying was significantly associated with increased odds of vaccine hesitancy (OR=1.39, 95% CI=1.02, 1.90, p<0.05). When considering health conditions and sociodemographic factors (Model 2), consultation of online/government websites, social media, and broadcast media remained significantly associated with lower vaccine hesitancy. However, cyberbullying was no longer statistically significant when considering physical health conditions and demographic factors (p=0.140), but it is considered a risk factor. The protective effects of online/government websites, social media, and broadcast remained statistically significant when adjusted for socioeconomic factors (Table 2; Model 3).

Table 3 examines the joint association of each mode of COVID-19 information and cyberbullying on vaccine hesitancy. In the unadjusted model (Model 1), the main effects were statistically significant for online/government websites (p<0.01), social media (p<0.05), and broadcast (p<0.001). The interaction terms were not statistically significant for each mode of COVID-19 information and cyberbullying, with one exception. The joint association of broadcast COVID-19 information with cyberbullying was marginally significant (p=0.091), indicating a possible statistical interaction. When accounting for physical health diagnoses and sociodemographic factors (Model 2), the joint association of broadcast COVID-19 information with cyberbullying becomes statistically significant (p<0.05). This significant joint association remained when accounting for socioeconomic factors (Model 3).

Figure 1 presents a graphical representation of the interaction for each mode of COVID-19 information (Table 2; Model 3). Consulting online/government websites (Figure 1A) reduced the likelihood of vaccine hesitancy regardless of exposure to cyberbullying. The trend for social media was less clear (Figure 1B). The probability of being vaccine hesitant was similar among those who experienced cyberbullying, regardless of consultation on social media for COVID-19 information. Among those who did not experience cyberbullying, those who received COVID-19 information via social media had a lower probability of vaccine hesitancy than those who did not receive information via social media, although with a slight overlap of the 95% CIs. For print media (Figure 1C), the probability of vaccine hesitancy was similar within level of exposure to cyberbullying, regardless of receiving information via print media. Finally, receiving information via broadcast (Figure 1D) revealed a null association for those who experienced cyberbullying. The probability of vaccine hesitancy was similar for those who received COVID-19 information via broadcast among those who reported cyberbullying. In contrast, the protective effect of receiving COVID-19 information via broadcast media was observed among the group that did not report cyberbullying.

Figure 1.

Predicted probabilities of mode of COVID-19 information by exposure to cyberbullying. (A) Receives COVID-19 information via online websites. (B) Receives COVID-19 information via social media. (C) Receives COVID-19 information via print. (D) Receives COVID-19 information via broadcast.

Note: All models account for health, demographic, and socioeconomic factors.

There were similar results when the analysis was stratified by exposure to cyberbullying (Appendix A and Appendix Table 1, available online). Among the non-cyberbullied group, receiving COVID-19 information via online/government websites, social media, and broadcast was protective (Model 1). However, among the cyberbullied group (Model 2), only consultation of online/government websites was protective.

Results were similar when restricting the analyses to people aged <65 years, given that the survey was conducted during a period when older adults were eligible to receive the vaccine (Appendix Table 2, available online). Similar to the main results, the joint association of receiving COVID-19 information via broadcast and experiencing cyberbullying was statistically significant in the fully adjusted model (p<0.05).

The association between COVID-19 vaccine hesitancy and modes of information was different when stratifying by nativity (Appendix Table 3, available online). Although receiving COVID-19 information online was significantly associated with lower vaccine hesitancy, receiving information via social media was marginally protective for non-U.S.-born individuals only.

There were heterogeneous associations between information and vaccine hesitancy when stratifying among Asian Indian, Chinese, Filipino, Korean, and Vietnamese people (Appendix Table 4, available online). Receiving information online was protective for Chinese and Filipino, but not Asian Indian, individuals.

Finally, when examining differences by language of interview (Appendix Table 5, available online), online websites were protective for those who did the English interview. However, social media was protective for both groups.

DISCUSSION

This study contributes to the growing body of work addressing COVID-19 vaccine hesitancy. To the best of our knowledge, no studies have examined the association between COVID-19 vaccine hesitancy during the early phases of vaccine rollout and cyberbullying among Asian Americans. This is important given that Asian Americans, especially Chinese Americans, were subjected to racial targeting on social media regarding the origins of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2),¹⁰ and there are known reports of Asian American individuals who were victims of both in-person and online attacks.²⁷ Additionally, the initial roll out of the COVID-19 vaccine occurred during the later stages of the stay-at-home orders. Thus, most people were likely to stay home and have a lot of exposure to different media sources to stay informed about COVID-19. The authors suspect that any information about the prevention of and vaccine for COVID-19 provided to Asian American communities was in English, with lags in any COVID-19 materials in languages other than English. Furthermore, there are no publicly available data sets (e.g., local or state Department of Health data) on COVID-19 vaccination rates with disaggregated Asian ethnic group data. This paper provides a first glimpse into the Asian American community's perspectives on COVID-19 vaccination and how information sources influence their willingness to get vaccinated.

These results reveal the various ways through which Asian Americans receive information on COVID-19 and how, ultimately, these modes of information play into their vaccine hesitancy. In times of public health emergencies, the Internet can be a fast and effective channel to provide critical information.⁴⁰ In this study, most Asian Americans received COVID-19 information online, including on government websites, followed by broadcast and social media. There were significant independent effects of engagement in different modes of COVID-19 information and lower odds of vaccine hesitancy, even in fully adjusted models. However, considering that vaccine hesitancy is prevalent in those with lower income and education, future work should explore how these individuals make decisions about the risk and benefits of vaccine. Many complex and context-specific factors (e.g., cultural norms) may mediate or moderate the relationship between information-seeking behavior and vaccine intention. Additionally, it would be useful to further explore which modes disadvantaged populations are most likely to receive COVID-19 information when they tend to seek it.

Second, given the need for rapid communication during the COVID-19 pandemic, this study provides novel insight on the moderating role of cyberbullying in relation to COVID-19 information and vaccine hesitancy. The authors found that cyberbullying moderated the association between broadcast media and vaccine hesitancy only. One possible and complex mechanism is that cyberbullying victimization may serve as a motivator for some people to disengage from the media altogether, which may, in turn, affect vaccine information seeking and vaccine intention.^33,34 Alternatively, some Asian Americans who experienced cyberbullying may have also received misinformation regarding the safety and efficacy of the COVID-19 vaccine,³⁶ which contrasts with broadcast media. It is possible that the types of information and messages about the COVID-19 vaccine may be qualitatively different depending on social media environments and platforms (e.g., Facebook versus Instagram) among people who were cyberbullied versus those who were not. Because this study did not examine the complex interplay among COVID-19 information modes, online vaccine information seeking, and vaccine intention, future research should examine these underlying mechanisms of vaccine hesitancy among Asian Americans. For example, Asian Americans may use other social media platforms like WeChat or WhatsApp to connect with family globally, which could dilute the messages on COVID-19 vaccination seen in the U.S^35,36 or generate misinformation about alternative COVID-19 treatments or prevention.⁴¹

Given the popularity of online mediums as key sources of COVID-19 information, future health communication should maximize the use of information from online/government websites. Certainly, there are differences in sources of health information across Asian American ethnic groups by demographic factors such as English proficiency, ethnicity, nativity, and age.^42,43 Still, social media represents a popular realm for sharing quick and user-curated information. However, potential misinformation could be spread. Social media companies have created algorithms to flag potentially misleading COVID-19 information. Furthermore, the authors assume that seeking COVID-19 information via social media may be attenuated because of the fatigue of social media from cyberbullying attacks. For example, the anonymity of most users creates difficulties in regulating hate speech online. This anonymity, coupled with messages spread by prominent political figures, creates a social environment that has led to in-person violence against Asian American individuals and other marginalized communities. Therefore, collaborative efforts are needed to reduce cyberbullying risks and provide clear, nondiscriminatory communication.

Limitations

The results of this study must take into account some key limitations. First, the authors cannot establish causality given the study's cross-sectional design. Second, the sample itself may not reflect fully the entire Asian American population because of recruitment through community organizations and the administration of the survey online. Although the authors used analytical weights to make the sample representative of Asian American population to mitigate some of this sample bias, residual bias may remain. Third, there may be some social desirability bias related to the measurement of vaccine hesitancy. Participants may have been inclined to endorse greater vaccine confidence knowing that the COVID-19 vaccine was one of the primary interventions to curb the pandemic. Additionally, the authors were unable to examine the role of social support on vaccine hesitancy, despite its importance.^44,45 Despite these limitations, this multiracial and community-engaged study with a large sample of Asian Americans across the U.S. allows for an assessment of the associations between vaccine hesitancy and modes of COVID-19 information and the moderating role of cyberbullying among Asian Americans. This cross-sectional snapshot can identify unmet public health needs to reduce vaccine hesitancy among Asian Americans by implementing a culturally appropriate intervention that uses nonstigmatizing messages related to COVID-19.

CONCLUSIONS

As of August 2022, up to 67.4% of people living in the U.S. have received the minimally required 2 doses of the SARS-CoV-2 vaccine (or 1 dose of the Johnson & Johnson vaccine).⁴⁶ Even fewer people (48.4%) have received booster doses. Despite the lack of publicly available vaccination data disaggregated by race and ethnicity, this study provides a nationally representative overview of vaccine hesitancy among Asian Americans at the beginning of the COVID-19 pandemic. Although it is encouraging that 84% of Asian Americans are willing to receive the COVID-19 vaccine, there may be stark disparities based on Asian American ethnicity and social factors, such as education, income, geographic region, and English language proficiency.³⁶

This study examines the complex relationship between COVID-19 information sources and their interaction with cyberbullying. The authors found evidence of the protective effects of various modes of COVID-19 information (specifically, online resources and social media) on vaccine hesitancy. Given that most people consult sources online or on social media for their information, cyberbullying can be a major deterrent in receiving correct information. Cyberbullying can also cause users to disengage, further limiting their ability to receive information quickly. Finally, the rapid pace at which social media provides information may leave users overwhelmed with mixed messages and potential misinformation.³⁶

As the world transitions to the later stages of the COVID-19 pandemic and vaccination efforts continue, it is important that health information is reported through multiple sources and combats potential stigmatization of disease. Although providing a quick and concise message is important, it is equally important that such health messages do not become diluted by misinformation and online attacks.

CRediT authorship contribution statement

Adrian M. Bacong: Conceptualization, Formal analysis, Methodology, Software, Writing – original draft, Writing – review & editing. Aggie J. Yellow Horse: Formal analysis, Methodology, Supervision, Validation, Writing – review & editing. Eunhye Lee: Validation, Writing – original draft, Writing – review & editing. Lan N. Ðoàn: Methodology, Supervision, Writing – review & editing. Anne Saw: Funding acquisition, Supervision, Writing – review & editing.