Perceptions of COVID-19 vaccination and factors influencing COVID-19 vaccine acceptance among indigenous peoples in Quebec, Canada: Insights from a facebook posts and comments analysis

ABSTRACT

Vaccination rates in Canada tend to be lower among Indigenous peoples than the rest of the population. The COVID-19 pandemic provided an unprecedented opportunity to better understand Indigenous perceptions about vaccination. The aim of this study was to explore perceptions of COVID-19 vaccine and other factors influencing COVID-19 vaccine acceptance as evidenced by public posts and comments on Facebook by Indigenous peoples in Quebec, Canada. We collected data on 95 Facebook pages or groups used by Indigenous peoples in Quebec between November 1, 2020, to June 15, 2021. To identify posts relating to COVID-19 vaccination, a keyword search (“vaccination,” “vaccine,” “shot,” “does,” “Moderna,” “Pfizer”) was carried out in English and French in the search bar of each Facebook page/group. Results show that First Nations peoples and Inuit in Quebec had important concerns about the usefulness, safety and effectiveness of COVID-19 vaccine. They also expressed fear of being used as test subjects for the rest of the population. Motivations mentioned by First Nations peoples and Inuit to get vaccinated against COVID-19 included to travel again and return to normal life with their loved ones, and the desire to protect the most vulnerable in their communities, especially Elders. Results show that Indigenous health care professionals were considered as reliable and trustful source of information regarding COVID-19, and that seeing role models being vaccinated build confidence and foster acceptance of the vaccine. Culturally adapted messages and vaccination campaigns by and for Indigenous peoples appear to be key to building trust toward COVID-19 vaccination.

Introduction

The COVID-19 pandemic and its impacts on individuals and societies initiated an unprecedented effort to support the rapid development and deployment of vaccines. In December 2020, approximately 9 months after the state of emergency was declared in Canada, the first COVID-19 vaccine was authorized in the country. In a context of limited doses and unpredictable supply, the National Advisory Committee on Immunization (NACI) recommended the prioritization of key populations for early COVID-19 immunization.¹ Indigenous adults living in communities (i.e., First Nations reserves, Inuit northern villages and Metis settlements) were prioritized at the first stage. In the province of Quebec, where this study was conducted, the government followed the recommendations of NACI as well as those of its own advisory committee, the Quebec Immunization Committee, and gave priority to Indigenous peoples living in communities for COVID-19 vaccination. As indicated in a governmental directive issued in February 2021, the main rationale behind the decision of the Quebec Government included the “level of isolation” of most First Nations reserves and Inuit northern villages, and the lack of health services and frailty of local health systems associated with it, and the risk that it poses in case of severe COVID-19. These recommendations were also based on perceived “vulnerability” of Indigenous peoples living in communities in the context of the COVID-19 pandemic, vulnerability attributed to an increased risk of COVID-19 complications among Indigenous peoples living in communities due to a high prevalence of preexisting health conditions and behaviors (obesity, smoking, diabetes, etc.), a high risk of COVID-19 transmission in multi-generational and overcrowded housing, and socioeconomic and psychosocial issues including substance misuse, suicide, and violence that could be aggravated by the pandemic.²

Vaccination rates in Canada tend to be lower among Indigenous peoples than the rest of the Canadian population.^3–5 This trend has also been observed among First Peoples in other countries.^6,7 While structural and organizational barriers play a role in vaccine uptake (e.g., geographical location, cost, transportation, clinic location and opening hours, appointment logistics, etc.),^8–11 the acceptance or refusal of vaccination among Indigenous peoples is more frequently attributed to vaccine hesitancy. Vaccine hesitancy may be defined as the reluctance to receive recommended vaccination because of concerns and doubts about vaccines.^12–15 Different factors influence vaccine hesitancy and they vary across time and place, and with different vaccines. Confidence and complacency are two critical factors involved. As MacDonald wrote, confidence refers to “trust in (i) the effectiveness and safety of vaccines; (ii) the system that delivers them, including the reliability and competence of the health services and health professionals; and (iii) the motivations of policy-makers who decide on the needed vaccines.” (2015: 4162). Complacency refers to the fact of perceiving the risk of vaccine-preventable diseases as low and of considering vaccination as not necessary.^15,16

Studies about COVID-19 vaccination among Indigenous peoples have shown various factors affecting vaccination acceptance and intentions.^7,17–19 A study conducted in the first months of 2021 by²⁰ revealed that motivations to be vaccinated mentioned by Aboriginal peoples and Torres Strait Islanders living in Western Sydney, Australia, included to protect themselves from infection and severe illness, to travel again and return to “normal life,” and to protect others from their community, especially Elders. Reasons why participants were hesitant about being vaccinated included fear of vaccine side effects, and distrust in Australian governments and medical institutions. Trust in those providing the vaccine and the availability of Aboriginal-centered health services played a key role in the decision-making of participants to get vaccinated against COVID-19.

In a study conducted between December 2020 and January 2021²¹ showed that Native Americans living in Los Angeles County expressed concern that COVID-19 vaccine development and approval were “rushed through” and that the vaccine process was potentially influenced by politicians. Participants in this study also worried about being experimentation subjects and shared their concern over vaccine trials, including those approved by tribal leaders, as ways to “try it out first on Natives and see how it worked.” (2022: 3) Participants in this study mentioned that transparent and contextually tailored messaging of scientific information was critical to fight historical distrust of biomedical research among Native Americans and to foster acceptance of COVID-19 vaccine. They also emphasized the need for public health entities to partner with community-based organizations with existing trust and reach among urban Native American communities in order to encourage uptake of the COVID-19 vaccine.

In a study carried out between December 2020 and February 2021 with African American, Native American and Hispanic participants,²² showed that Native Americans from the Great Plains and the Northern Great Plains expressed a need for more information about COVID-19 vaccine, especially data about vaccine effectiveness and safety specific to people who are Native Americans. They also reported a lack of trust in governments and the pharmaceutical industry, and expressed the belief that researchers and pharmaceutical companies experiment on people like them. Native American participants in this study mentioned concern over possible long-term side effects of the COVID-19 vaccine and tied their preoccupation to the inter-generational well-being of their tribe, explaining that the loss of an Elder or effects on fertility “would add to the loss of people, culture, and language.” (2023: 425) Conversation about COVID-19 vaccine in their community led by people they know and trust, instead of doctors and public health experts, was what Native American wanted. Information from Elders was said to be particularly influential.

Similarly²³ in a study conducted between February and August 2021 with African American, Native American and Hispanic participants from the state of Arizona, revealed that Native Americans attributed COVID-19 vaccine hesitancy in their nations to mistrust due to past histories of epidemics introduced by Europeans (measles and smallpox) that resulted in the loss of entire tribal nations, and to the fear of being used as medical test subjects. They showed that motivations mentioned by Native American participants to be vaccinated included the desire to return “back to normal,” to protect their immediate family members and to protect the Elders. Brief personal testimonials from leaders, Elders and other community members who received the COVID-19 vaccine was perceived by Native Americans from Arizona to be the best way to increase trust in science, vaccine confidence and to promote uptake of the COVID-19 vaccine.

Taken together, these disparate findings point to a broad range of factors that affect the experience and understandings that Indigenous peoples have with respect to vaccination. Research that considers vaccine acceptance within the specific historical and cultural contexts of Indigenous peoples is needed to support the equitable distribution of health resources and improve health outcomes of medical interventions. The aim of this article is to explore the perceptions of COVID-19 vaccination and factors influencing COVID-19 vaccine acceptance among Indigenous people in Quebec, Canada, as evidenced by public posts and comments on Facebook. First, Facebook posts and comments are examined to gain insights into Indigenous peoples’ COVID-19 information needs, their perceptions regarding COVID-19 risks, and their perceptions regarding COVID-19 vaccine benefits and safety. Second, motivations for getting vaccinated are analyzed. Third, Facebook posts and comments are looked for indications and evidence related to the value of culturally adapted messages and vaccination campaigns by and for Indigenous peoples.

Materials and methods

Background

The province of Quebec, Canada, is home to 10 First Nations peoples and the Inuit. According to the 2021 Canadian census, 205,010 Indigenous people lived in Quebec, which corresponded to 4.4% of the province’s population.²⁴ Approximately half of the Indigenous population live on the 41 First Nations reserves and 14 Inuit northern villages, commonly known in everyday language and non-legal terms as Indigenous “communities.” The rest live outside of their ancestral territories, mostly in urban centers.²⁵

Indigenous nations and communities in Quebec are highly diverse in terms of geographical, cultural, social, economic, and historical characteristics. Despite their distinctiveness, First Nations and Inuit communities in Quebec share several social, economic, and historical realities that stem from colonial processes which were experienced in different forms and times by each of them. The Canadian colonial regime and policies, including the residential school system, forced relocations, the undermining of traditional family, political and social structures, and other means designed to assimilate Indigenous peoples into Euro-Canadian society, are predicated on profoundly racist ideologies that foster marginalization of Indigenous peoples^26,27 and underpin the inequalities that Indigenous peoples experience today.^28,29 Disparities in the everyday determinants of Indigenous health, including poverty, overcrowded housing, food insecurity, difficulty to access services, lead to poor health and increased risk of COVID-19 contraction.^26,27,30

Additionally, political relations between the state and the 11 Indigenous nations and peoples in Quebec have, over time, resulted in different health administrative systems in force in different communities. Most significant is the clear distinction between “treaty” and “non-treaty” nations where the former have a direct relationship with the province and regional control over health and social services that are enshrined in land claims agreements. The latter have a closer association with the federal government through Indigenous Services Canada. The different sizes and geographic diversity of the 55 communities in Quebec also result in a patchwork of services and capacities within and between the different nations.

The above context helps to situate the COVID-19 vaccination campaigns in the 55 First Nations and Inuit communities in Quebec. These were managed by local communities with assistance from Indigenous regional health authorities and provincial public health departments, while vaccine doses and vaccination guidelines were provided by the federal and provincial governments. Data from this study as well as data from as yet unpublished qualitative interviews conducted by two members of the research team with staff of health centers in Indigenous communities show that many distinct, creative and culturally grounded efforts were made to facilitate access to vaccination for their members, with transport services organized in several communities and mobile clinics in some, and to encourage vaccination with initiatives such as vaccine contests and lotteries. Finally, COVID-19 vaccination of Indigenous peoples living outside of communities or in urban centers was the responsibility of provincial health institutions as for the rest of Quebec population. Roughly half of all Indigenous peoples now live outside of their home communities. The COVID-19 vaccination experiences of urban Indigenous peoples are beyond the scope of this research.

Methods

Given the rapidly changing context and the impossibility of in-person data collection during the pandemic, our research team relied on a rapid situational awareness approach to collect qualitative data on Indigenous perceptions of COVID-19 vaccination from Facebook public posts and comments by.^31,32 Rapid situational awareness is a technique that allows for public health response refinement through monitoring social discourse and action, in this case through the presence of Indigenous communities and peoples on Facebook.³³ Online data collection allows researchers to access information in a near real-time manner, from a highly diverse population. As Chunara and colleagues wrote: “The Internet has become one of these sources, used ubiquitously by a variety of groups including clinicians, public health practitioners, and laypeople, to seek health information. In addition, the Internet serves as an accessible reservoir for the public regarding official announcements disseminated by government agencies and informal news from press reports, blogs, chat rooms, web searches, and media reports.”³⁴: 39) Using this iterative and emergent design methodology enabled the research team to scope a wide range of governmental, institutional, Indigenous communities and individual discourses related to COVID-19 vaccination.³⁵ Studies have proven that social media are used by minority and marginalized populations to discuss health-related information more than conventional public health channels.³⁶ Success in tracking community response to rapidly evolving health issues with social media has also been demonstrated.^34,36–41 Even though social media are a relatively recent phenomenon in many Indigenous communities, it is now widely used to reach people and has proven to be an active and relevant means of communication during the pandemic.^42–46

Data for this study were collected on public Facebook pages from November 1, 2020, to June 15, 2021. Data gathering began while the vaccination campaigns were in preparation in Indigenous communities in Quebec and continued during the administration of the first and sometimes the second dose of the COVID-19 vaccine. June 15, 2021, was chosen as the date to end data collection since it was the date that the Government of Quebec had selected to reach the target of 75% of adults who had received at least one dose of a COVID-19 vaccine.⁴⁷

Data collection was conducted exclusively on Facebook groups and pages publicly accessible; no private groups or pages were consulted. As such, no formal ethical approval was requested.⁴⁸ The research team relied on a list of 95 Facebook Indigenous-related pages and groups that had been prepared and validated – including by Indigenous research partners – as part of an earlier research project on Indigenous communities asset mobilization during the pandemic.⁴⁹ The 95 sources included Facebook pages/groups of nation and band councils (32), nation and community health and social services institutions (18), school boards (4), youth groups or councils (5), community organizations and initiatives (7), regional and community media (14), Indigenous and governmental political organizations (3), community COVID-19 dedicated pages (9) and pages/groups for First Nations and Inuit living in urban centers (3). To identify relevant posts, a keyword search (“vaccination,” “vaccine,” “shot,” “dose,” “Moderna” and “Pfizer”) was carried out in English and French in the search bar of each Facebook page/group. Data were collected on a regular basis (at least once a week) and an additional scan was realized at the end of data collection to capture posts or comments that could have been missed or added in the meantime. All posts, with or without comments, were included in our dataset.

Posts related to COVID-19 vaccination were organized in a database according to the following criteria: source, community, nation, date of publication, date of entry, publication initiator, associated posts and photos/videos, number of “likes” and shares, as well as comments and comment threads. Posts that had been reposted by other Indigenous groups or individuals were also identified as such. The information was compiled in an Excel document, and all the posts and their comments were also saved in PDF format for further reference.

Data were analyzed using a deductive approach. Post and comments were first coded and organized using the increasing vaccination model developed by Brewer and colleagues and endorsed by the World Health Organization.⁵⁰ This model establishes four categories of factors associated with vaccine decision-making: “what people think and feel,” “social processes,” “motivation” and “practical issues.” Based on the findings of a similar research undertaken by Dubé and her colleagues⁵¹ regarding COVID-19 vaccine hesitancy in Nunavik, the research team added an additional category, ‘’colonialism“, to code Indigenous-specific data that were not adequately captured by the model of Brewer and colleagues.⁵⁰ This category encompassed, for example, posts and comments that touched on medical experimentations, impacts of colonialist practices, and experiences of discrimination and stigma in the health care system. The aim of the research team was to understand COVID-19 vaccination as viewed by Indigenous peoples in Quebec, gather relevant information, analyze it, and make recommendations to improve vaccination acceptance in this population. As such, this study reveals trends but does not seek to quantity them.

Results

A total of 1,154 posts were collected over the data collection period of eight months. These posts and their comments originated from the 11 Indigenous nations of the province, with a majority (77%) from communities and individuals from four nations: the Cree, the Mohawk, the Innu and the Inuit. Posts and comments analyzed in this study revealed three overarching themes with implications for COVID-19 vaccination acceptance among First Nations peoples and Inuit in Quebec.

Information needs, perceived COVID-19 risks and perceived COVID-19 vaccine benefits and safety

Facebook posts and comments collected as part of this study revealed that First Nations peoples and Inuit in Quebec had concerns about the safety of COVID-19 vaccines and about its potential side effects. The rapid development of the vaccine was frequently mentioned to explain these concerns. The mRNA technology used in the Pfizer BioNTech and Moderna vaccines was also evoked and some clearly feared that these vaccines would alter their genes. For these reasons, several people mentioned that they preferred to rely on their natural immunity to protect them against COVID-19.

Apparently, this vaccine is going to alter our genetics, and that frightens me. (Inuk)

Vaccines take years and even decades to properly develop. This vaccine took less than a year. I trust my immune system a whole lot more than private corporations or the government on this matter. Just over 99% survival rate after getting infected [with COVID-19]. You can have my dose. (Inuk)

First Nations peoples and Inuit also highlighted a lack of information available on COVID-19-vaccine, particularly on its ingredients, its risks and benefits, and its effectiveness. In this context, many mentioned that they did not trust the new vaccine, and that they preferred to wait to be vaccinated until more information about its long-term effects would be known. Others said they preferred to wait until the epidemiological situation in their region was more problematic.

Me, I will wait a few months, then get vaccinated if everyone looks okay. (Inuk)

Prioritization of Indigenous peoples living in communities for early COVID-19 vaccination was a popular subject of discussions among Quebec First Nations and Inuit on Facebook. The government’s decision to give early access to COVID-19 vaccination to Indigenous peoples was very positively received by most Indigenous community leaders. Some argued that it was time for Indigenous peoples to be among the government’s top priorities, while others simply agreed with the government prioritization criteria that identified these populations as particularly vulnerable to COVID-19. For some, putting Indigenous peoples first was even perceived as an act of reconciliation. However, at an individual level, First Nations peoples and Inuit expressed mixed opinions on the question. For many people it was not clear why Indigenous communities were prioritized for early COVID-19 vaccination since few and sometimes no cases had been reported at that time. For some, it would have been only logical and fair that COVID-19 vaccines were first given to people who were living in regions where high rates of cases were reported.

We are in a COVID-free zone. Let’s donate the doses to cities, or to the hot spots of COVID-19. (Inuk)

Others, wondering why Indigenous peoples were prioritized for COVID-19 vaccination and not finding satisfactory answers, were suspicious of the intentions of the government. The most widely shared concern on Facebook was the fear that Indigenous peoples were “guinea pigs” to test the vaccines before the rest of the population. Some individuals, situating vaccination in the historical and political context of the relationships between Indigenous peoples and the governments of Quebec and Canada, also shared the view that the hidden objective behind the government’s decision to prioritize Indigenous peoples for COVID-19 vaccination was to eradicate them.

Comment [C]1: It’s suspicious! Believe it or not.

C2: We are test subjects to make sure the vaccine works.

C3: Hello, yes, you are absolutely right, we’re going to be used as guinea pigs.

Comment [C]1: It’s suspicious! Believe it or not.

C2: We are test subjects to make sure the vaccine works.

C3: Hello, yes, you are absolutely right, we’re going to be used as guinea pigs.

C4: We’re going to serve as guinea pigs, me first.

C5: Guinea pigs once, guinea pigs always.

C6: I don’t want to die right away, let them find other guinea pigs.

(Dialogue between Innu)

I won’t take any vaccine given out at our nation clinic that is controlled by a government that tried to end our existence. […] All I’m saying is investigate for yourselves instead of simply taking the government’s words for it. As Indigenous people I’d like to think that my people would be smarter, especially after how many centuries of lies and genocide committed against Indigenous peoples and others. Look before you leap! (Mohawk)

We all remember our stories from the past. It’s normal today to distrust! (Innu translated from French)

Motivations for getting vaccinated

Posts and comments analyzed in this study also revealed the reasons behind the intentions and motivations of First Nations peoples and Inuit to get vaccinated against COVID-19. Some saw vaccination as a way to go back to their normal daily lives with fewer restrictions, such as being able to meet their loved ones and resuming their personal and community activities. Being able to travel again was also a frequently mentioned motivation for receiving a COVID-19 vaccine.

For me, this is just to get out of this as fast as possible and be able to get back to our lives with family members being present. (Mohawk)

I want to get vaccinated. I miss my freedom. Eating together as families and friends, I miss traveling to Montreal, I miss not having to wear a mask every time I go shopping. It is very tiring constantly washing my hands and [those of] my kids, and worrying constantly for every little thing, even touching doorknobs, when someone comes to my place wondering if they are COVID free. I can’t wait. I’ll take a chance before I catch it. (Inuk)

Another common reason to receive a COVID-19 vaccine mentioned by Indigenous peoples online was to protect the most vulnerable in their community, especially Elders. In fact, interactions on Facebook indicate a strong concern for the elderly people, a concern consistent with the values and cultural precepts taught to children from an early age in First Nations and Inuit communities to respect, provide support and learn from their Elders.

Everyone needs to do their part, not only to get back to normal life but to protect each other. (Inuk)

Tomorrow I encourage all people who choose to get the vaccine to do so; so that you protect not only yourselves but others as well. Especially our Elders. (Cree)

I am healthy and young (well, not that old!) so COVID doesn’t scare me that much. So I didn’t do it for me. I did it for my parents, their brothers and sisters, the sick people, the immunosuppressed, the unlucky people (yes, there are unlucky young people who go through it too!). I also did it so that my children wouldn’t have to miss school anymore. So that they could start practising their sports again. In fact, I did it a little bit for myself: I really miss dinners with friends. And you? I know you’re young and healthy. Besides, you surely have other things to do today. But believe me: in 15 minutes it will be done, and you will have contributed to solve this COVID crisis. (Innu, translated from French)

The importance of culturally adapted vaccination messages and campaigns

Data from this study showed that First Nations and Inuit authorities took ownership of the COVID-19 vaccination campaigns and adopted culturally appropriate strategies to build trust and foster acceptance of the vaccine among their communities. In a Mohawk community, for example, the launching of the vaccination campaign was preceded by a ceremony during which a community member said a prayer and burned tobacco. In a Cree community, leaders posted messages on Facebook to encourage individuals to rely on Elders, traditional healers, and their traditions and values to guide them in their vaccine decision-making. In another Cree community, a hockey tournament was organized and people who attended the event were encouraged to get their vaccine shot at the same time. These interventions had a significant influence on Indigenous peoples on Facebook, as indicated by the high number of “likes” and shares of these posts.

The use of Indigenous languages to disseminate information about COVID-19 and COVID-19 vaccination was also a strategy employed by several nations and communities. Many created videos in their native language to provide information to their community members. Posters using native languages and iconography were also produced and shared online.

Post and comments by Indigenous peoples on Facebook also showed the importance of Indigenous voices to build trust and foster acceptance of COVID-19 vaccine among First Nations peoples and Inuit. Indigenous health care professionals were seen as a particularly reliable and trustful source of information on COVID-19, as evidenced by the abundantly relayed public statements of Dr. Stanley Vollant, a well-known Indigenous surgeon trained in Quebec. A Mohawk also explained how having received information from a general practitioner from his community was determinant in his intention of getting vaccinated:

I don’t trust the government. I have seen systemic racism in health care first-hand. Malpractice played a role in the death of [people I love]. I have not been vaccinated in 40 years. But I will get this vaccine. One woman from my community [name] has been working to fight the virus, and has been explaining things well enough that I trust her. Doctor [name] is her name. Read her posts on the matter. (Mohawk)

Seeing role models such as community leaders, Elders and Indigenous celebrities receiving the COVID-19 vaccine also seems to have had a crucial role in reassuring people and encouraging them to get vaccinated. Although the message from these key individuals was often the same as public health experts, posts in which role models shared their experiences and perspectives on vaccination had a greater positive impact among Indigenous Facebook users.

Post: Chef [name] was the first person to receive the COVID-19 vaccine at the [community name] health centre.

C1: It doesn’t hurt him. If you look closely at his face, it seems he’s all smiles.

C2: Wow! When will we receive information about the vaccine?

C3: We can’t wait!

C4: Well done!

C5: It looks like the vaccine is hurting him … Well done Mister [name]!

C6: Well done Chef.

(Dialogue between Innu translated from French)

Post: [Name], Manager and Registered Nurse at the [name of an Indigenous community hospital] inpatient, received a vaccination.

C1: Rock star! Nia:wen [thank you][name]!

C2: Can’t wait to go back to normal. I miss you [name] and family.

C3: Way to go [name]!

C4: You’re awesome!

C5: 👍

C6: ♥

C7: Thanks for sharing your experience!

Discussion

The aim of this article was to explore the perceptions of COVID-19 vaccination and factors influencing COVID-19 vaccine acceptance among Indigenous peoples in Quebec, Canada, as evidenced by public post and comments on Facebook. Facebook posts and comments about COVID-19 vaccination show that Indigenous peoples in Quebec had important concerns about the safety of COVID-19 vaccines, concerns mainly attributed to their development timeline, the new technology they used and their unknown side effects. On this, the perceptions of COVID-19 vaccines of Indigenous peoples in Quebec were similar to those reported in the rest of the population.⁵² Dubé,^{37–39,39,53,54} Coupled with the prioritization of Indigenous peoples for early COVID-19 vaccination by the federal and provincial governments, and with the long history of medical experimentation and inequitable treatments that Indigenous peoples have suffered in Quebec and Canada,^27,55–59 those concerns grew for many First Nations peoples and Inuit into a significant fear of being used as “guinea pigs” to test the new vaccines for the rest of the population. The fear of being test subjects for the COVID-19 vaccines – a feeling also reported by other authors in other contexts and for other infections (e.g., human papillomavirus, A [H1N1])^17,60–64—points to the deep mistrust that Indigenous peoples in Quebec have over a colonial system that still appears to disempower and neglect them. The results of this study show that the suspicion that Indigenous peoples have toward the governments, health institutions and health care workers should not be underestimated when understanding vaccine hesitancy or refusal among Indigenous populations, in Quebec and Canada, but also around the world.^20–23 While the “guinea pig” discourse was widely produced in anti-vaccination circles in the non-Indigenous population, for Indigenous peoples there are known instances of actual medical experimentation and imposed procedures on women and children (and, indeed, entire communities) that make such concerns legitimate and warranted.^56,65

This study revealed that the main motivations of First Nations peoples and Inuit to be vaccinated against COVID-19 include to be able to return to their normal daily lives, to spend time with family and friends and to travel again. Facebook posts and comments show that motivations to be vaccinated against COVID-19 among Indigenous peoples in Quebec were also couched in terms of culturally values principles, such as the importance of taking care of one another – and especially the Elders. Indigenous leaders and organizations relied heavily on these shared and valued social norms to encourage community members to get vaccinated, stressing the importance, in their messaging, of protecting and caring for the most vulnerable people as a community. The veneration of Elders who, as well as being cherished members of often large families, are considered by Indigenous peoples in Quebec as the cultural cornerstones and knowledge keepers of language and practices (Yang and Warburton),⁶⁶ was a strong motivating factor and argument for vaccination. Protecting the Elders as an important motivation to be vaccinated against COVID-19 has also been reported for other Indigenous groups around the world.^20,22,23 A deep knowledge of cultural values and how they can be conveyed is an important dimension of successful health messaging.^27,61,67 Health messaging that reflects the sociological significance and structures specific to Indigenous communities is an important dimension of encouraging vaccine acceptability. This is difficult when the majority of services are offered by non-Indigenous and transitory employees as is the case in many Indigenous communities in Quebec and elsewhere.

This study showed that Indigenous nations in Quebec took ownership of the COVID-19 vaccination campaigns by adopting culturally appropriate strategies to make vaccination culturally safer for members of their communities. Indigenous languages were used to disseminate information about COVID-19 vaccination. Vaccination campaigns were often preceded by prayers or ceremonies and took place during important cultural activities. Posts and comments collected as part of this study also showed that vaccination and health messaging more generally appear to be more effective in Indigenous settings when delivered directly by Indigenous Elders, leaders and health practitioners who are considered as trustworthy and credible in their communities. Personal testimonies from known people who had received the vaccine were also influential and reassuring to people.^67–72 This study emphasizes that trust and rapport are vital considerations in regard to vaccination in Indigenous nations and communities.⁷³

This study has some limitations. The size of our sample and the small number of posts for some nations prevent us from commenting on the similarities and differences between the perceptions of COVID-19 vaccine of the different Quebec Indigenous peoples. Although Facebook provides an interesting window into the perceptions of Indigenous peoples on COVID-19 vaccine, some individuals are more likely to be active on this social media (e.g., young people, people with idiosyncratic and marginal opinions, etc.) and their perspectives may be overrepresented in the data collected online as part of this study. Moreover, the changing and volatile nature of social media, where any publication can be modified at any time, can be challenging in a research setting – some Facebook groups may have been dissolved, and some posts may have been modified or deleted by individuals or organizations since the data were first gathered. Finally, as data collection was conducted prior to COVID-19 vaccine availability in communities, our findings are specific to a particular time point and reflect general intention and attitudes that are likely to have changed. However, COVID-19 vaccine uptake was lower among Indigenous communities compared to the general Canadian population which indicates that barriers to vaccination highlighted in our findings have persisted. Nevertheless, the study of Facebook posts and comments remains a useful tool to document perceptions about health and health interventions at a specific time and place, especially during a pandemic that prevents social contacts and limits more conventional research activities.

Conclusion

The objective of this study was to explore perceptions of COVID-19 vaccination and factors influencing COVID-19 vaccine acceptance among Indigenous peoples in Quebec, Canada, as evidenced by public posts and comments on Facebook. Data showed that the experience of, and discourse on, colonialism, both historical and ongoing, has an important impact in shaping Indigenous perceptions of COVID-19 vaccines and COVID-19 vaccination acceptance. The level of trust accorded to health authorities, institutions and providers is especially impacted by colonialism and its repercussions. Data collected in this study demonstrated that the lack of trust played a critical role in the hesitancy or refusal of COVID-19 vaccination by Indigenous peoples. To build confidence in COVID-19 vaccines and vaccination more generally, mobilizing Indigenous organizations, community leaders, role models and Elders, and culturally adapting health messages (e.g., emphasizing cultural values, using Indigenous languages, etc.) appear to be key. As this study demonstrated, involving Indigenous nations and communities in the development, the implementation and the communication of vaccine-related interventions is imperative. Supporting the ongoing development of institutional capacity and autonomy in Indigenous nations and communities to manage all aspects of the health services they use is likewise a path to greater effectiveness of vaccination campaigns and health interventions generally.

Biographies

Fabienne Labbé holds a PhD from the École des hautes études en sciences sociales, France. She is a medical anthropologist specialized on infectious and epidemic diseases. Her initial work focused on HIV in the Pacific Islands (Fiji and New Caledonia). She has conducted research on the representations of COVID-19 and COVID-19 vaccination among different groups of the population in Quebec and Canada. She has co-edited the special issue of the anthropology journal Anthropologie et Sociétés “Epidemics and Pandemics” (2022). She is a specialized research officer on Indigenous health at the Research Centre of the University Hospital Centre in Quebec (CHUQ).

Mathilde Lapointe is a medical anthropologist concerned with Inuit perspectives on health and well-being. She holds a master’s degree in anthropology from Université Laval (Québec, Canada). Mathilde works with Inuit in Nunavik (Puvirnituq, Kuujjuaq) as well as in urban settings in southern Quebec. At the time of writing, she was a Planning, Programming and Research Officer at the research center of the University Hospital Centre in Quebec (CHUQ), as well as a teaching assistant for various Indigenous health and well-being courses at Université Laval. Mathilde is now the assistant to the Executive Director and project manager at the Qavvivik Inuit Family and Community Health Centre in Montreal.

Eve Dubé is a medical anthropologist. She has a joint appointment as a research scientist at the Research Centre of the University Hospital Centre in Quebec (CHUQ) and as a professor in the department of anthropology at Université Laval in Quebec, Canada. She holds a CIHR’s Applied Public Health Research Chair on the Anthropology of Vaccination. Her research program focuses on the sociocultural determinants of vaccination. She is the lead investigator of the Social Sciences and Humanities Network of the Canadian Immunization Research Network. She is interested in how to enhance vaccine acceptance and uptake and she is leading different projects around this issue. She sits on a number of provincial, federal and international committees as an expert on vaccine acceptance and hesitancy.

Christopher Fletcher is a medical anthropologist concerned with the relationship between culture and health generally, the intersection of Indigenous models of health and healing with mainstream biomedicine, and the reduction of health inequity. He codirected the community component of the Qanuilirpitaa 2017 regional health survey in Nunavik and is the principal investigator of the Qanuikkat Siqinirmiut? population health survey with Inuit living in southern Quebec. He is professor at the Department of social and preventative medicine at Université Laval.

Funding Statement

This work was supported by the Canadian Immunization Research Network: COVID-19 Vaccine Readiness Funding Opportunity through the Canadian Center for Vaccinology at Dalhousie University under the grant SH24 QC34, 2021.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Author contribution statement

Fabienne Labbé: Formal analysis, Investigation, Writing—original draft, review & editing.

Mathilde Lapointe: Formal analysis, Investigation, Data curation, Writing – original draft.

Eve Dubé: Conceptualization, Writing – review & editing.

Christopher Fletcher: Conceptualization, Writing – review & editing, Supervision, Funding acquisition.

Data availability

Data will be made available on request.