Health Care Discrimination and Immigration Fears: Unpacking COVID-19 Vaccine Hesitancy in Latino Adults

Abstract

Objectives. To examine the relationship between health care discrimination and COVID-19 vaccine hesitancy attributed to fears of immigration status complications among unvaccinated Latino adults and to determine whether the association differs among immigrants and US-born individuals.

Methods. After universal adult eligibility for the COVID-19 vaccine, a nationally representative sample of 12 887 adults was surveyed using online and mobile random digit dialing from May 7 to June 7, 2021. The analytic sample (n = 881) comprised unvaccinated Latino adults. We examined the association between individual and cumulative health care discrimination measures and COVID-19 vaccine hesitancy assignable to immigration-related fears.

Results. Using a cumulative measure of health care discrimination, each additional experience corresponded to a 28% higher odds of reporting vaccine hesitancy Because of immigration-related fears. Findings were consistent across US-born and immigrant Latino adults. Four of the 5 discriminatory experiences were positively associated with vaccine hesitancy, including the absence of optimal treatment options, denial or delayed access to necessary health care, physician communication barriers, and lack of specialist referrals.

Conclusions. Findings confirm a positive association between health care discrimination and COVID-19 vaccine hesitancy attributable to immigration-related fears among Latino adults, regardless of immigration status. (Am J Public Health. 2024;114(S6):S505–S509. https://doi.org/10.2105/AJPH.2024.307668)

Vaccine hesitancy, the reluctance to accept a vaccine despite its availability, impedes equitable COVID-19 vaccination coverage.^1,2 Previous studies have explored racial and ethnic disparities in vaccine hesitancy, mainly focusing on factors like efficacy and side effects.^3,4 However, limited attention has been given to the unique challenges faced by Latino adults. Latino individuals experienced the COVID-19 pandemic against the backdrop of the Trump administration’s attempt to track citizenship in the US Census and the anti-immigrant public charge expansion policy.

The public charge expansion, initiated in February 2020, a month after COVID-19 became a national emergency, broadened criteria disqualifying immigrants using social programs from obtaining legal residency.⁵ In a hostile environment, Latinos, irrespective of immigration status, may have felt hesitant to seek health care, fearing it could impact their or their family’s future legal status.^6,7 Although the Biden administration overturned the public charge rule in March 2021, confusion about disqualification criteria remained a possible deterrent to immigrants from accessing health care, including COVID-19 vaccines. Qualitative studies revealed that fears of being labeled a public charge influenced vaccine intentions among Latino communities.⁸ Yet, the role of institutional factors, such as discrimination in health care settings, in vaccine hesitancy because of fears of immigration-related consequences has been largely overlooked.⁹ Discrimination in health care has historically led to patient mistrust and avoidance of health services, and trust is a critical determinant of vaccine intentions.¹⁰

We examined the relationship between prior discriminatory health care experiences and COVID-19 vaccine hesitancy assignable to concerns about immigration status. This study contributes to shifting the focus from individual-level health behaviors to the sociopolitical context influencing Latino individuals’ COVID-19 vaccine decisions.

METHODS

This study used data from the African American Research Collaborative COVID-19 Vaccination Poll. Using prestratified randomized quota sampling, we aimed for nationally representative subsamples across racial and ethnic groups. The survey, available in multiple languages, gathered responses from 12 887 adults between May 7 and June 7, 2021. The overall response rate was 61%, with a completion rate of 95.4%. A multimode recruitment approach ensured broad coverage through random digit dialing (31% of the sample) and online samples through a comprehensive mix of text-to-web, email-invitation, and online panels (69% of the sample). Poststratified weights were applied for each racial group using a raking algorithm to balance the sample to the 2019 Census American Community Survey (ACS) estimates for gender, age, education, nativity, and geography.¹¹ The analytic sample (n = 881) comprised unvaccinated US-born and immigrant Latino adults.

Measures

The outcome was a binary measure assessing COVID-19 vaccine hesitancy assignable to fear of complicating one’s immigration status with the government. The question asked, “Have you heard the following statement about the COVID-19 vaccine? Signing up for the COVID-19 vaccine could complicate your immigration status with the government. If so, what is your reaction?” Responses included: (1) Yes, I have heard this, and it makes me less likely to get a vaccine; (2) Yes, I have heard this, but it does not impact whether I will get a vaccine; and (3) No, I have not heard this. Immigration-related COVID-19 vaccine hesitancy (response 1; weighted prevalence: 8.62%) was coded as 1. The reference category included individuals who decided not to get vaccinated and were not influenced by fears of immigration-related consequences. This category consisted of 2 groups: first, those who acknowledged hearing the statement, but it did not affect their vaccine behaviors (response 2; 24.98%), and second, those who had not heard the statement, and thus, their vaccine behaviors were not influenced by immigration-related fears (response 3; 66.39%).

The independent variable comprised 5 items assessing past discriminatory experiences in health care. Respondents were asked, “Have you or anyone in your household experienced the following due to your/their race, ethnicity, or language?” Items included:

• 1.Not offered the best treatment,
• 2.Not referred to specialists,
• 3.Denied the opportunity to speak with a physician,
• 4.Denied or delayed access to needed health care, and
• 5.Unable to access medical care in their preferred language.

Responses were 1 = Yes, 0 = No. We created a cumulative measure by summing individual experiences into a continuous variable (range = 0–5) with a Cronbach α of 0.81. In the exploratory factor analysis, 1 factor with Eigenvalue greater than 1 explained 85.3% of the measure’s variance, indicating an underlying construct. Each discriminatory experience was also used as an independent variable.

We accounted for covariates linked to vaccine hesitancy: gender, age, education, income, employment status, health insurance, usual source of care, and chronic conditions. We adjusted for political affiliation in consideration of the politicized nature of the pandemic. To assess the robustness of our findings against generalized immigration fear, we included an indicator of whether the respondent knew someone who was undocumented, encompassing family or friends.

Analysis

Descriptive statistics were performed using a t-test for continuous variables and a χ² test for categorical variables for the full, US-born, and immigrant samples. We conducted 6 weighted, fully adjusted multivariable logistic regressions to identify the relationship between (1) cumulative discriminatory experiences in the health care system and (2) each of the 5 discriminatory health care experiences and vaccine hesitancy because of fear of complicating their immigration status among unvaccinated Latino respondents. We tested an interaction term that assessed whether nativity (US-born in mainland/US territory and foreign-born) moderated the relationship between cumulative discriminatory experiences and COVID-19 vaccine hesitancy. The variance inflation factor was 1.38, indicating multicollinearity was not an issue. We conducted analyses in Stata version 17 (StataCorp LP, College Station, TX) using weights to account for survey design.

RESULTS

Approximately 41.1% of the sample reported health care discrimination based on race, ethnicity, or language, and 8.6% expressed vaccine hesitancy as a consequence of immigration concerns. Most respondents were female (54.7%), unmarried (57.1%), had at least a high school education (63.8%), knew an undocumented person (52.6%), and completed the survey in English (80.8%). Approximately 31.9% were aged 18 to 29 years, and 31.7% lacked a usual source of care (i.e., a health care facility or provider an individual usually visits for medical attention or health guidance). Immigrant Latino respondents made up 27.1% of the sample. Immigrant respondents had higher marriage rates (32.2% versus 50.3%), greater pandemic-induced unemployment (29.4% versus 20.0%) and were more likely to have an education level of a high school degree or less (70.4% versus 60.8%) than US-born counterparts (see Appendix, Table A).

Table 1 presents the results of 6 distinct weighted multivariable logistic regressions of the relationship between (1) cumulative discriminatory health care experiences and (2) each discriminatory experience and vaccine hesitancy attributable to fear of complicating their immigration status. For each additional discriminatory experience in health care, respondents had 28% higher odds of reporting COVID-19 vaccine hesitancy attributable to fear of complicating their immigration status (adjusted odds ratio [AOR] = 1.28, 95% confidence interval [CI] = 1.09, 1.49). There were no differences in vaccine hesitancy between immigrant and US-born Latino adults based on the interaction between nativity and cumulative discriminatory health care experiences (Appendix, Table B, available at https://www.ajph.org as a supplement to this article). Four discriminatory experiences were positively associated with vaccine hesitancy on account of immigration-related fears: not offered the best available treatment (AOR = 2.44; 95% CI = 1.38, 4.31), denial or delayed access to any needed health care services (AOR = 2.31; 95% CI = 1.20, 4.43), denied physician communication (AOR = 2.12; 95% CI = 1.04, 4.32), and not referred to a specialist (AOR = 1.95; 95% CI = 1.06, 3.57). The inability to access health care in a language other than the respondent’s preferred language was positively associated with vaccine hesitancy attributed to immigration concerns; however, the relationship was not statistically significant.

TABLE 1—

Associations Between Discriminatory Experiences in Health Care and COVID-19 Vaccine Hesitancy Because of Fear of Immigration Status of Unvaccinated Latinos United States, May 7–June 7, 2021

Discriminatory Experiences	AOR (95% CI)
Cumulative no. of experiences of racism in health carea	1.28 (1.09, 1.49)
Each individual experience as an independent variableb
Not been offered the best available treatment	2.44 (1.38, 4.31)
Not been referred to see specialists	1.95 (1.06, 3.57)
Been denied the opportunity to speak with a physician	2.12 (1.04, 4.32)
Been denied or delayed access to any needed health care services	2.31 (1.20, 4.43)
Not able to access medical care in preferred language	1.38 (0.68, 2.80)

Note. AOR = adjusted odds ratio; CI = confidence interval. The analytic sample size was n = 881. Covariates, based on weighted multivariable logistic regressions, include age, gender, marital status, education, political affiliation, usual source of care, health insurance, income, unemployment during COVID-19 pandemic, income, chronic conditions, preferred language, knowing an undocumented person, and nativity (US-born vs foreign-born).

Source. The African American Research Collaborative COVID-19 Vaccine Poll, May 7 to June 7, 2021

^a Continuous measure of the total number of discriminatory experiences in health care reported, ranging from 0 to 5.

^b Each experience of discrimination in health care was used as a primary exposure in 5 independent and distinct logistic regression models.

DISCUSSION

Our study investigated the influence of health care discrimination on COVID-19 vaccine hesitancy attributable to fears of immigration-related complications among US-born and immigrant Latino adults. The examination of institutional barriers within health care revealed a significant association between experiences of health care discrimination and increased likelihood of immigration-related COVID-19 vaccine hesitancy among unvaccinated Latino individuals. This association held for both US-born and immigrant Latino respondents, emphasizing the pervasive impact of discrimination, highlighting the interconnected lives of Latino adults in the United States, and revealing that anti-immigrant policies have wide-ranging implications for the Latino community’s well-being, irrespective of immigration status.¹²

Health care discrimination may impede Latino adults’ ability to navigate immigration policy changes by eroding trust in health care institutions. The erosion of trust may result in reluctance to obtain the COVID-19 vaccine, boosters, and treatment of COVID-19 and other diseases.^13,14 This is especially critical when considering the complex relationship between immigration and health policies, as seen in the public charge expansion. Our study highlights the need to understand how discriminatory health care experiences may intensify mistrust among Latinos and lead to avoidance of preventive measures, especially in the context of anti-immigrant policies.

Previous studies have examined the role of discrimination and COVID-19 vaccine uptake generally¹⁵; we advance this work by focusing on vaccine hesitancy as a consequence of a salient structural issue among the Latino community.

Limitations

Our study has limitations. First, the cross-sectional data lacks clarity on when respondents experienced health care discrimination, hindering causal relationship assessment. Additionally, despite efforts to sample a diverse population resembling the US population, respondents may differ from the target population in unmeasured ways. Furthermore, we cannot attribute vaccine hesitancy to 1 policy, like public charge, and instead must ascribe it to a broader anti-immigrant climate. Our study’s strength is the focus on institutional factors (e.g., health care discrimination) that predispose Latinos to vaccine hesitancy attributable to fears of immigration status complications.

Public Health Implications

We examined COVID-19 vaccine hesitancy tied to immigration concerns among Latino adults as a function of health care discrimination. Beyond implicit bias training, improving health care financing can enhance service availability, fostering trust in health systems by providing equitable care access for underserved groups. Public health efforts can prioritize equitable access, safe spaces, and institutional policies supporting immigrant integration and health.