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. Author manuscript; available in PMC: 2026 Jun 1.
Published in final edited form as: J Community Health. 2024 Dec 19;50(3):442–453. doi: 10.1007/s10900-024-01428-4

The roles of acculturation and pre-migration experiences in influencing the confidence of Vietnamese parents in vaccine use among adolescents

Nhat-Ha T Pham 1, Milkie Vu 2,3
PMCID: PMC12445103  NIHMSID: NIHMS2111061  PMID: 39702660

Abstract

Vaccine confidence is a critical antecedent of vaccine uptake. Little research has examined vaccine confidence among Asian communities, particularly the associations with acculturation and pre-migration experiences. We explored this issue among U.S. Vietnamese parents. Our study uses an explanatory sequential mixed-methods design to investigate the influence of American acculturation, Vietnamese acculturation, and pre-migration experiences on U.S. Vietnamese parents’ vaccine confidence for their adolescents. A cross-sectional web-based survey (n=408) was followed by semi-structured interviews (n=32). Quantitative analysis showed that many participants reported high or complete trust in scientists involved in vaccine development (61%), federal agencies responsible for vaccine safety monitoring and licensure (53%), the CDC (62%), and the FDA (58%). High or complete trust in scientists was associated with a higher Vietnamese acculturation score (aRR=1.20 [1.03–1.40]), while trust in federal government agencies was associated with English medical proficiency (aRR=1.42 [1.15–1.76]). Qualitative findings provided deeper insights, with many parents expressing trust in vaccine efficacy, safety, and the rigorous development and approval process. Pre-migration experiences in Vietnam had mixed influences on vaccine confidence. Some participants cited positive experiences with the national immunization program, while others were influenced by negative vaccine-related injury stories. Newer immigrants reported limited familiarity with U.S. health authorities. Language preferences (Vietnamese versus English) for vaccine information varied. Our study highlights the complex interplay of acculturation, cultural identity, language, and historical experiences in shaping vaccine confidence among U.S. Vietnamese parents and emphasizes the need to take these factors into account with tailored public health strategies.

Keywords: vaccine confidence, immigrants, acculturation, pre-migration, U.S. Vietnamese

Introduction

Vaccine hesitancy (i.e., delay in acceptance or refusal of vaccines despite availability of vaccination services) is listed as one of the top ten global health threats by the World Health Organization (MacDonald, 2015; World Health Organization, 2019). Vaccine hesitancy undermines immunization campaigns and can lead to insufficient herd immunity and disease outbreaks (Nuwarda et al., 2022). Vaccine confidence (i.e., the belief that vaccines work, are safe, and are part of a trustworthy medical system) is crucial to combat vaccine hesitancy (Centers for Disease Control and Prevention, 2022). These issues are particularly relevant given the context of the COVID-19 pandemic, which has significantly amplified vaccine hesitancy and eroded vaccine confidence in the United States (U.S.) (Larson et al., 2022; Leonardelli et al., 2023; UNICEF, 2023). However, it should be noted that the decline in vaccine confidence has been noted in the U.S. and globally even before the pandemic (Dubé et al., 2014; Larson et al., 2014).

Social Contexts of Vaccine Confidence

To explore vaccine confidence, a few studies have focused on individual-level determinants, including personal beliefs, risk perceptions, and trust in healthcare providers (Gerend & Shepherd, 2012; Ling et al., 2019; Schmid et al., 2017). However, it is increasingly recognized that a broader multilevel perspective is needed to fully understand the complex social and structural contexts shaping vaccination decisions (Larson et al., 2011; Peretti-Watel et al., 2019; Vardavas et al., 2023). Several researchers have posited that vaccine confidence comprises not only individuals’ belief in the efficacy and safety of vaccines but also their confidence in the healthcare system responsible for vaccine administration and their trust in the various societal entities involved in vaccine development, approval, and regulation (Larson et al., 2018). In the U.S., several key entities are involved in the development, approval, and regulation of vaccines. Scientists and pharmaceutical companies conduct research and develop new vaccines. (Centers for Disease Control and Prevention, 2023b) The Food and Drug Administration (FDA) is responsible for reviewing and approving vaccines based on their safety and efficacy data from clinical trials (COVID Vaccine Project, 2020). The Centers for Disease Control and Prevention (CDC) provides recommendations on vaccine schedules and uses; it also oversees vaccine safety monitoring systems (Centers for Disease Control and Prevention, 2024).

In the U.S. in recent years, research has noted a degradation of trust in these entities due to several factors, including the COVID-19 pandemic, misinformation campaigns, and a perceived lack of transparency (Jennings et al., 2023; Latkin et al., 2021; Lee et al., 2022; Savoia et al., 2022). Furthermore, trust in these entities and vaccine confidence are intricately linked to historical interactions with healthcare systems, which, particularly for marginalized groups and people of color, likely include instances of medical exploitation and systemic discrimination (Morgan et al., 2022; Tsui et al., 2023). For example, research shows that lower trust in healthcare systems and higher vaccine hesitancy among Black/African American individuals are tightly linked to a long history of racism and unethical medical experiments (e.g., Tuskegee Syphilis Study) as well as discriminatory healthcare practices (Gamble, 1997; Scharff et al., 2010). Similarly, a legacy of colonialism and forced assimilation through healthcare policies may have lowered confidence in government-sponsored vaccination programs among Native American communities, while unsatisfactory treatment and discrimination in healthcare settings are correlated with lower levels of trust in medical authorities and vaccines among Latinx and Asian communities (Escobedo et al., 2023; Guadagnolo et al., 2009; Ngo-Metzger et al., 2004).

The Influences of Acculturation and Pre-Migration Experiences on Vaccine Confidence

Existing literature on vaccine confidence among racially and ethnically minoritized populations in the U.S. has mostly focused on Black/African American and/or Latinx populations (Marcelin et al., 2021; Newman et al., 2023; Quinn et al., 2019). Little research has studied vaccine confidence among Asian Americans, and even fewer studies have investigated this topic among specific Asian origin groups. One such understudied group is U.S. Vietnamese, defined as those living in the U.S. and self-identifying as Vietnamese. In the U.S., the Vietnamese population (~2.3 million) is the 4th largest Asian origin group (U.S. Census Bureau, 2022). Approximately 56% were born outside of the U.S., 72% speak a language other than English, and 41% speak English less than “very well.” Compared to non-Hispanic White and several Asian populations in the U.S., Vietnamese have lower English proficiency, income, and educational attainment while also being more likely to be uninsured and in poverty (U.S. Census Bureau, 2022). These disparities indicate potential obstacles to accessing healthcare services and underscore the importance of studying health beliefs and behaviors within this particular origin group (as opposed to Asian Americans as an aggregate).

Among U.S. Vietnamese and Asian immigrant populations, acculturation and pre-migration experiences may shape health attitudes, beliefs, and behaviors. A multidimensional construct, acculturation often refers to the process by which individuals and groups experience changes and adjustments (e.g., in language, cultural practices, and identities) as they encounter new cultures and contexts (Berry, 1997; Sam & Berry, 2010; Ward et al., 1996). While a growing body of literature has demonstrated associations of acculturation with various health behaviors and outcomes among the U.S. Vietnamese population, it should be noted that these associations are complex and not unidirectional. In several studies, higher American acculturation has been linked to better access to healthcare services and higher knowledge of preventive health among U.S. Vietnamese (Hwang et al., 2008; Kim & Gorman, 2022). However, a few studies also found that in this population, higher American acculturation is linked to increased substance use and risky health behaviors (Kaplan et al., 2003; Yi & Daniel, 2001). Few studies have looked at how Vietnamese acculturation (in addition to American acculturation) influences health behaviors and outcomes. Moreover, the role of acculturation and vaccine confidence has not been studied among U.S. Vietnamese. A study with Mexican American mothers of young children found that higher American acculturation was associated with inadequate immunization (Prislin et al., 1998). Higher American acculturation is linked to less favorable views on immunization, reduced parental obligation to vaccinate their children, and increased obstacles to accessing vaccinations (Prislin et al., 1998).

Pre-migration experiences can also impact immigrants’ perceptions of the healthcare systems of the host country and their post-immigration health-seeking behaviors (Leduc & Proulx, 2004; Portes et al., 1992). Compared to acculturation, this topic has received less attention. Pre-migration factors such as interruptions to vaccination programs in emergencies and humanitarian settings can lead to lower vaccination coverage (WHO-UNHCR-UNICEF, 2015). A study with Afghan refugees in Australia showed that due to the infrastructure of childhood immunization provision in Afghanistan (i.e., where vaccination is provided through community health workers who visit the children in their homes), parents may be unlikely to bring their children to health facilities for primary vaccination, even when they have migrated (Cheng et al., 2015).

To our knowledge, no study has investigated the influence of acculturation and pre-migration experiences on vaccine confidence among U.S. Vietnamese or Asian immigrants. To fill this gap in the literature, we conducted a mixed-methods study investigating U.S. Vietnamese parents’ vaccine confidence for their adolescents. Following Larson et al.’s model of vaccine confidence, we posited that vaccination occurs in the context of trust held in the various actors involved in making, approving, and administering the vaccine (Larson et al., 2011). We explored the influences of acculturation and pre-migration experiences within this context.

Design and Methods

Study design and participants:

The data came from an explanatory sequential mixed-methods study that examined multilevel factors influencing HPV vaccine decision-making among U.S. Vietnamese parents. Details about eligibility criteria, study recruitment, and data collection have been previously published (Vu et al., 2021). Briefly, participants were U.S. Vietnamese parents with at least one child aged 9–18 living in the same household. Initially, a total of 408 parents participated in the cross-sectional, web-based survey (response rate of 72%). Then, a subset (n=32) of the 408 survey respondents participated in qualitative semi-structured interviews (response rate of 84%). Electronic consent was obtained before the surveys and interviews. The Institutional Review Board at Emory University approved this study (IRB00111688).

Survey measures

Sociodemographic covariates included the child’s country of birth as well as parental sex and parental education. To measure vaccine confidence, we used four questions from the Emory Vaccine Confidence Index, a scale that has been previously developed to measure parental vaccine confidence (Frew et al., 2019). Questions inquired about trust in: scientists involved in developing and testing vaccines; federal government agencies responsible for monitoring vaccine safety; Centers for Disease Control and Prevention (CDC) (i.e., the agency making recommendations about who should get licensed vaccines); and Food & Drug Administration (FDA) (i.e., the agency that licenses vaccines). Acculturation was operationalized using several questions. The Asian American Multidimensional Acculturation Scale was used to assess Vietnamese acculturation and American acculturation (Gim Chung et al., 2004). We also assessed participants’ percentage of life in the U.S., ability to understand medical information in Vietnamese, and ability to understand medical information in English.

Interview questions

Interview questions expanded upon survey items and explored how acculturation and pre-migration experiences influenced vaccine confidence. Examples of questions included: “How has your experience in Vietnam and/or your migration experience to the U.S. influenced your views on adolescent vaccines? What sources of information and advice about adolescent vaccines do you trust? What kind of language(s) are these sources in?” We also probed for understanding and utilization of information from U.S. and Vietnamese federal health agencies.

Data analysis

All statistical analyses were conducted in Stata 16.0. Descriptive statistics were used to summarize sample characteristics. Bivariate and multivariable modified Poisson regressions with robust error variance were conducted to explore correlates between sociodemographic factors and acculturation variables and each of the four outcomes. A total of 32 interviews were conducted, with 24 conducted in Vietnamese and eight in English. All interviews were recorded and transcribed verbatim. The 24 Vietnamese transcripts were subsequently translated into English by two professional translators, and the translations were validated by bilingual research team members. All interview data were analyzed using MAXQDA 2020. We used a hybrid approach of qualitative thematic analysis, which incorporated both 1) a deductive a priori template of codes and themes from the survey items and 2) a data-driven inductive approach (Fereday & Muir-Cochrane, 2006). Additional information about the qualitative data analysis process, including steps taken to reach saturation and establish validity and trustworthiness of findings, has been previously published (Vu et al., 2022).

Results

Sample Characteristics

Table 1 provides an overview of the sample characteristics. Among the 408 U.S. Vietnamese survey participants, 98% were born outside of the U.S. (not shown in Tables). The majority of participants were female (83%) and had attained a college education (85%). The 32 participants who participated in in-depth, semi-structured qualitative interviews were all female and all born outside of the U.S. They were highly educated (94% with a college education).

Table 1.

Sociodemographic and acculturation characteristics among survey and interview participants

Survey participants Interview participants (subset of the survey participants)
N = 408 N = 32
N (%) or M (SD) N (%) or M (SD)
Age 43.50 (5.77) 45.06 (2.23)
Sex (a)
 Male 69 (17.0%) 0 (0.0%)
 Female 336 (83.0%) 32 (100.0%)
Education
 Less than a Bachelor’s degree 61 (15.0%) 2 (6.3%)
 Bachelor’s degree 157 (38.5%) 11 (34.4%)
 Master’s degree or more 190 (46.6%) 19 (59.4%)
Percentage of lifetime in the U.S. 33.72 (25.38) 29.54 (26.47)
Understand medical information in English
 Not at all to somewhat easy 255 (62.5%) 20 (62.5%)
 Very to extremely easy 153 (37.5%) 12 (37.5%)
Understand medical information in Vietnamese
 Not at all to somewhat easy 113 (27.7%) 11 (34.4%)
 Very to extremely easy 295 (72.3%) 21 (65.6%)
Vietnamese acculturation (range 0–5) (b) 4.15 (0.60) 4.05 (0.56)
American acculturation (range 0–5) (b) 2.88 (0.82) 3.11 (0.71)
Child’s country of birth
 In the U.S. 198 (48.5%) 19 (59.4%)
 Outside of the U.S. 210 (51.5%) 13 (40.6%)
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(a)

Three participants either indicated their sex was “Other” or chose “Prefer not to answer.”

(b)

Those who indicated that their heritage culture was not Vietnamese (n = 1 for survey participants, n = 0 for interview participants) were coded as having missing data.

In both samples, on average, participants had lived in the U.S. for nearly a third of their lives. In addition, 37.5% of both samples were able to understand medical information in English. In both samples, participants had stronger ties to Vietnamese culture, evidenced by their higher Vietnamese acculturation scores compared to their American acculturation scores.

Quantitative Findings

In the sample, more than half of the participants indicated high or complete trust in scientists developing adolescent vaccines (61%), federal government agencies (53%), the CDC (62%), and the FDA (58%) (Table 2 and Table 3). In multivariable analyses, high or complete trust in scientists was associated with higher Vietnamese acculturation score (aRR=1.20, 95% CI 1.03 – 1.40) and a higher ability to understand medical information in English (aRR=1.21, 95% CI 1.01 – 1.46) (Table 4). High or complete trust in federal government agencies was associated with a higher ability to understand medical information in English (aRR=1.42, 95% CI 1.15 – 1.76) (Table 4). We did not find significant associations between other outcomes and acculturation-related factors (Table 4).

Table 2.

Sociodemographic and acculturation characteristics in relation to trust in scientists developing vaccines and federal government agencies

Sociodemographic and acculturation characteristics Total (n=408) High/complete trust in scientists developing vaccines (N=250) No trust to moderate trust in scientists developing vaccines (N=158) p value High/complete trust in federal government agencies (N=216) No trust to moderate trust in federal government agencies (N=192) p value
N (%) or M (SD) N (%) or M (SD) N (%) or M (SD) N (%) or M (SD) N (%) or M (SD)
Age 43.50 (5.77) 43.89 (5.67) 42.88 (5.90) 0.08 43.74 (5.52) 43.23 (6.05) 0.38
Sex (a) 0.84 0.53
 Male 69 (17.0%) 43 (17.3%) 26 (16.6%) 39 (18.1%) 30 (15.8%)
 Female 336 (83.0%) 205 (82.7%) 131 (83.4%) 176 (81.9%) 160 (84.2%)
Education 0.59 0.79
 Less than a Bachelor’s degree 61 (15.0%) 34 (13.6%) 27 (17.1%) 30 (13.9%) 31 (16.2%)
 Bachelor’s degree 157 (38.5%) 96 (38.4%) 61 (38.6%) 83 (38.4%) 74 (38.5%)
 Master’s degree or higher 190 (46.6%) 120 (48.0%) 70 (44.3%) 103 (47.7%) 87 (45.3%)
Percentage of life in the U.S. 33.72 (25.38) 32.67 (24.78) 35.38 (26.30) 0.29 29.50 (23.22) 38.47 (26.90) < 0.001
Understand Vietnamese medical information 0.46 0.05
 Not at all to somewhat easy 113 (27.7%) 66 (26.4%) 47 (29.7%) 51 (23.6%) 62 (32.3%)
 Very to extremely easy 295 (72.3%) 184 (73.6%) 111 (70.3%) 165 (76.4%) 130 (67.7%)
Understand English medical information 0.13 0.15
 Not at all to somewhat easy 255 (62.5%) 149 (59.6%) 106 (67.1%) 128 (59.3%) 127 (66.1%)
 Very to extremely easy 153 (37.5%) 101 (40.4%) 52 (32.9%) 88 (40.7%) 65 (33.9%)
 Vietnamese acculturation 4.15 (0.60) 4.21 (0.54) 4.05 (0.67) < 0.01 4.24 (0.54) 4.05 (0.65) < 0.01
 American acculturation 2.88 (0.82) 2.89 (0.81) 2.86 (0.86) 0.76 2.84 (0.76) 2.92 (0.89) 0.33
 Child’s country of birth 0.50 < 0.01
 In the U.S. 198 (48.5%) 118 (47.2%) 80 (50.6%) 90 (41.7%) 108 (56.3%)
 Outside of the U.S. 210 (51.5%) 132 (52.8%) 78 (49.4%) 126 (58.3%) 84 (43.8%)
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(a)

Three participants either indicated their sex was “Other” or chose “Prefer not to answer.”

Table 3.

Sociodemographic and acculturation characteristics in relation to trust in the Centers for Disease Control and Prevention and the Food and Drug Administration

Sociodemographic and acculturation characteristics High/complete trust in the Centers for Disease Control and Prevention (N=254) No trust to moderate trust in the Centers for Disease Control and Prevention (N=154) p value High/complete trust in the Food and Drug Administration (N=237) No trust to moderate trust in the Food and Drug Administration (N=171) p value
N (%) or M (SD) N (%) or M (SD) N (%) or M (SD) N (%) or M (SD)
Age 44.19 (5.78) 42.36 (5.60) < 0.01 44.03 (5.72) 42.77 (5.77) 0.03
Sex (a) 0.43 0.29
 Male 46 (18.2%) 23 (15.1%) 44 (18.7%) 25 (14.7%)
 Female 207 (81.8%) 129 (84.9%) 191 (81.3%) 145 (85.3%)
Education 0.92 0.99
 Less than a Bachelor’s degree 39 (15.4%) 22 (14.3%) 36 (15.2%) 25 (14.6%)
 Bachelor’s degree 96 (37.8%) 61 (39.6%) 91 (38.4%) 66 (38.6%)
 Master’s degree or higher 119 (46.9%) 71 (46.1%) 110 (46.4%) 80 (46.8%)
Percentage of life in the U.S. 32.58 (25.01) 35.60 (25.96) 0.25 33.11 (24.62) 34.57 (26.46) 0.57
Understand Vietnamese medical information 0.94 0.60
 Not at all to somewhat easy 70 (27.6%) 43 (27.9%) 68 (28.7%) 45 (26.3%)
 Very to extremely easy 184 (72.4%) 111 (72.1%) 169 (71.3%) 126 (73.7%)
Understand English medical information 0.56 0.20
 Not at all to somewhat easy 156 (61.4%) 99 (64.3%) 142 (59.9%) 113 (66.1%)
 Very to extremely easy 98 (38.6%) 55 (35.7%) 95 (40.1%) 58 (33.9%)
Vietnamese acculturation 4.19 (0.56) 4.08 (0.66) 0.07 4.19 (0.58) 4.09 (0.62) 0.10
American acculturation 2.87 (0.81) 2.89 (0.85) 0.79 2.91 (0.78) 2.84 (0.88) 0.40
Child’s country of birth 0.20 0.84
 In the U.S. 117 (46.1%) 81 (52.6%) 114 (48.1%) 84 (49.1%)
 Outside of the U.S. 137 (53.9%) 73 (47.4%) 123 (51.9%) 87 (50.9%)
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(a)

Three participants either indicated their sex was “Other” or chose “Prefer not to answer.”

Table 4.

Associations between sociodemographic and acculturation characteristics and trust in scientists developing vaccines, federal government agencies, the Centers for Disease Control and Prevention, and the Food and Drug Administration (N=408)

Sociodemographic and acculturation characteristics Trust in scientists developing vaccines Trust in federal government agencies Trust in the Centers for Disease Control and Prevention Trust in the FDA
aRR aRR aRR aRR
Age 1.01 (1.00 – 1.03)* 1.01 (0.99 – 1.02) 1.02 (1.01 – 1.03)** 1.02 (1.00 – 1.03)*
Sex
 Male Reference Reference Reference Reference
 Female 1.02 (0.83 – 1.26) 0.92 (0.74 – 1.15) 1.00 (0.83 – 1.21) 0.96 (0.78 – 1.18)
Education
 Less than a Bachelor’s degree Reference Reference Reference Reference
 Bachelor’s degree 1.11 (0.86 – 1.44) 1.03 (0.77 – 1.39) 0.99 (0.79 – 1.24) 0.98 (0.77 – 1.26)
 Master’s degree or higher 1.10 (0.84 – 1.44) 0.96 (0.70 – 1.31) 0.99 (0.77 – 1.26) 0.93 (0.71 – 1.21)
Percentage of life in the U.S. 1.00 (0.99 – 1.00) 0.99 (0.99 – 1.00)* 1.00 (0.99 – 1.00) 1.00 (0.99 – 1.00)
Understand Vietnamese medical information
 Not at all to somewhat easy Reference Reference Reference Reference
 Very to extremely easy 0.95 (0.78 – 1.15) 0.98 (0.77 – 1.25) 0.94 (0.77 – 1.13) 0.87 (0.71 – 1.06)
Understand English medical information
 Not at all to somewhat easy Reference Reference Reference Reference
 Very to extremely easy 1.21 (1.01 – 1.46)* 1.42 (1.15 – 1.76)** 1.15 (0.95 – 1.38) 1.21 (0.99 – 1.49)
 Vietnamese acculturation 1.20 (1.03 – 1.40)* 1.20 (0.99 – 1.45) 1.11 (0.96 – 1.29) 1.13 (0.96 – 1.32)
 American acculturation 0.99 (0.88 – 1.11) 0.98 (0.86 – 1.13) 0.99 (0.89 – 1.11) 1.04 (0.91 – 1.19)
 Child’s country of birth
 In the U.S. Reference Reference Reference Reference
 Outside of the U.S. 0.99 (0.80 – 1.21) 1.10 (0.85 – 1.43) 1.09 (0.89 – 1.34) 0.96 (0.76 – 1.21)
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Note:

*

p < 0.05;

**

p < 0.01

Qualitative Findings

Trust in scientists and the process of vaccine development and approval

In general, U.S. Vietnamese participants discussed considerable or high trust in the credibility of scientists who developed vaccines and the process of vaccine development and approval. For example, a participant said, “I strongly believe in science. I believe a lot of research must have gone into the development of vaccines” (#01). Another echoed a similar sentiment: “In general, I trust in science and healthcare. Therefore, I don’t have any concerns about vaccination. I think getting vaccinated would be better than not” (#28).

One participant stated:

[All the pharmaceutical companies] have strictly followed the phases of clinical trials. After they have gone through all the phases of clinical trials, they got the FDA to approve what they have claimed about the level of protection the vaccine provides (#30).

Another participant said: “I believe in science. I know the vaccine has been tested and gone through clinical trials, so I trust the science. I believe the benefits outweigh the side effects” (#03). In addition, a participant mentioned:

Before a vaccine is tested on humans or before the results are published, there must have been a lot of research and clinical trials. Therefore, I think that when a vaccine is made available to the public, the success rate and the effectiveness must be high. If my son get vaccinated, I would feel secure, and I will not worry much (#08).

Trust in federal government health agencies

Several participants mentioned the Vietnamese word “chính thống” (official) when discussing trusted vaccine information sources. Many participants recognized the roles of the FDA and CDC in providing authoritative guidance and relied on their recommendations. One participant articulated their perspective: “I think CDC is a reliable source. I’d trust the CDC. I also trust drugs and supplements approved by the FDA” (#06). A participant explained that

The CDC or FDA are independent agencies. Those agencies have nothing to do with profit. They control the quality of the vaccine… Information from those sources is more reliable… the process from the FDA is pretty stringent (#21).

Interestingly, a few participants who were newer immigrants reported limited familiarity with the CDC. When asked about the CDC or FDA, a participant answered:

I don’t pay attention to those sources because I am Vietnamese. Only Vietnamese people who have assimilated here can be convinced by such agencies. People who have just moved here recently, like me a few years ago, do not know anything (#25).

Another participant said: “Since I came [to the U.S.], I have not learned much [about vaccines]” (#28).

Language of vaccine information source

Some participants indicated that they often searched for information in Vietnamese or understood information in Vietnamese better than in English. A participant said: “I have been in the U.S. for only 13 years, so I prefer to speak Vietnamese. Personally, I think I will understand information in Vietnamese better and more clearly” (#10). Another participant said: “In order to learn information about vaccines more easily and understand the vaccine more thoroughly, I search for information in Vietnamese. When I read the information in Vietnamese, I understand it more thoroughly than in English” (#28).

At the same time, other participants thought that there was more scientific information available in English than in Vietnamese and discussed how they were able to better assess the trustworthiness of English sources than in Vietnamese. A participant said:

Sometimes, after I read information in Vietnamese, if I want to know for sure, I will also read the information in English… With information written in Vietnamese, some people write about the vaccines based on their own point of view… But English websites mainly analyze how the vaccines work and how they affect us. I also want to know where and how the vaccines were made, so I read that information in English (#18).

Pointing to greater availability of “reliable” resources in English, a participant said:

I think it’s because I can find more resources in English. For example, if there’s a certain word that I don’t understand, I can Google it. It feels like there’s more resources in English, which can help me better understand because of the resources available (#31).

Another participant mentioned: “I hardly read the websites in Vietnamese, not because I do not want to… but because I don’t know which sources are reliable, and I cannot find them” (#19). Discussing Vietnamese translations of medical terminology, a participant said:

Sometimes, when I read the websites in Vietnamese here, I feel that the Vietnamese translations do not sound right, and I do not understand them well, so I go back to the English websites. In general, I read both in English and in Vietnamese (#21).

Pre-migration experiences in Vietnam

Participants discussed mixed influences of pre-migration experiences in Vietnam on their vaccine confidence. Several participants mentioned positive interactions with vaccination in Vietnam, which reinforced their vaccine confidence. A participant said: “I used to live in Vietnam, and I find the expanded program on immunization in Vietnam quite beneficial. Once a vaccine is recommended by the government, we usually have confidence in the vaccine” (#30). The same participant stated:

The expanded program on immunization in Vietnam has extensive coverage, so the program has been good at protecting the community. I had great confidence in the programs conducted by the government, so since I have come here, I have also brought that belief here (#30).

Another participant discussed the extensive vaccine surveillance system in Vietnam, saying “When my neighborhood’s administrative office asked my children to get vaccinated or organized vaccination sessions for the children in the neighborhood, they would provide recommendations and reminders about vaccinations through the [local] media” (#28).

Others, however, discussed how their vaccine hesitancy stemmed from stories they were exposed to in their pre-migration experiences about adverse reactions to vaccination. A participant stated: “To be honest, I don’t completely trust vaccines. In Vietnam, I heard about many vaccine-related accidents. It’s not that I don’t completely not trust vaccines, but I have doubts about their effectiveness in preventing diseases” (#06). The same participant mentioned stories of vaccine-related injuries she had learned: “There was a wave of child fatalities due to vaccination. They received some shots and then their arms became immobile.” Another participant discussed similar beliefs: “I often worried about the vaccines for young children. In Vietnam, there were cases with anaphylactic shock or serious reactions after vaccination. Therefore, people are very worried” (#13).

Discussion

To our knowledge, this study is the first to highlight the considerable and complex influences of acculturation levels and pre-migration experiences on U.S. Vietnamese parents’ adolescent vaccine confidence. Over half of the survey participants reported high or complete trust in the scientific community involved in vaccine development as well as the federal government agencies responsible for vaccine development, safety monitoring, and licensure. High or complete trust in scientists was associated with a higher Vietnamese acculturation score. Moreover, high or complete trust in federal government agencies was associated with a higher ability to understand medical information in English. The findings suggest the importance of recognizing acculturation as a multifaceted concept that influences health attitudes and beliefs. Vietnamese acculturation score (measured through the Asian American Multidimensional Acculturation Scale) and the ability to understand medical information in English emerged as distinct factors influencing trust in scientists and federal health agencies.

Our qualitative findings further echoed quantitative results, indicating that parents held considerable trust in scientists who developed vaccines and in governmental health agencies. Qualitative findings also provided deeper insights, as many parents expressed trust in the efficacy and safety of vaccines, scientific research, and clinical trials. In addition, some participants discussed experiences with the Expanded Immunization Program in Vietnam as a positive factor in shaping vaccine confidence. However, interestingly, this sentiment was often juxtaposed with concerns rooted in pre-migration experiences, including exposure to negative vaccine-related injury stories.

In qualitative interviews, some newer immigrants reported limited familiarity with U.S. medical authorities, which made it more difficult to assess the trustworthiness of these institutions. While survey findings did not find associations between acculturation and trust in the CDC, in interviews we found that participants who were newer immigrants had limited familiarity with the CDC. Participants reported diverse opinions on the preferred language of sources (e.g., English or Vietnamese) and whether language influences trustworthiness. Some participants displayed a preference for information in Vietnamese. However, participants also acknowledged the abundant and potentially more reliable resources available in English.

Interpretation of these results requires an understanding of the context of vaccination policies as well as vaccine confidence in Vietnam (i.e., the country of origin). The Expanded Immunization Program in Vietnam was launched in 1981 and was elevated to one of the country’s six national priority health initiatives in 1985 (Jit et al., 2015). It aims to immunize infants against diphtheria, tetanus, whooping cough (pertussis), polio, measles, and tuberculosis. By the age of 1 year, over 90% of children receive full immunization, while 80% of pregnant women achieve Tetanus Toxoid 2 Plus (TT2+) coverage (T. D. Nguyen et al., 2015). The program may have averted as many as 5.7 million cases of disease and 26,000 deaths (Jit et al., 2015). Moreover, vaccine confidence in Vietnam is generally high (The Vaccine Confidence Project, 2023). In early 2022, Vietnam reported a COVID-19 vaccination rate of 90% (Le, 2022). This context may explain the association between Vietnamese acculturation and high or complete trust in scientists, and why a dominant theme in the interviews was parents’ trust in vaccine efficacy, safety, and the rigorous development and approval process. Positive experiences with the Expanded Immunization Program understandably can lead to higher vaccine confidence.

Unlike other studies that have primarily assessed acculturation to the host country (e.g., U.S.), our study made novel contributions by including multidimensional and validated measurements of both American and Vietnamese acculturation. Previous research shows that high American acculturation is associated with increased HPV knowledge, beliefs, and vaccine coverage (Gerend et al., 2021; Varan et al., 2017). Among U.S. Vietnamese, longer duration of U.S. residence is correlated with a higher frequency of Pap smears among women and greater Hepatitis B awareness (Hwang et al., 2008; T. T. Nguyen et al., 2006). English language proficiency is associated with higher vaccination rates for Hepatitis B among Asian Americans and HPV among Vietnamese (Hu et al., 2011; Yi et al., 2013). We extend this literature by showing how trust in scientists was associated with higher Vietnamese acculturation, while trust in federal government agencies was associated with higher ability to understand medical information in English.

Another novel contribution of our study is the impacts of vaccination experiences in the immigrants’ home country. This perspective requires a shift from focusing on solely post-migration experiences to a more comprehensive understanding of the carryover of attitudes and beliefs from one’s country of origin. A study with immigrant Somali women found diverse narratives of how pre-migration experiences influenced vaccine beliefs. Some women discussed how their positive experiences with pre-school vaccination made them more likely to view vaccination positively for their children once they migrated. Conversely, other women expressed that “in our country we didn’t have one injection… and as you can see we are healthy and everything.” (Tomlinson & Redwood, 2013). These findings align with our research where we identified how effective public health campaigns and access to healthcare in the country of origin could enhance post-migration trust and acceptance of vaccinations (Ambrosetti et al., 2021; Biddle et al., 2023). Similar to our findings, a study on Polish immigrants reveals that negative perceptions of vaccine quality and healthcare systems in the country of origin can influence post-migration attitudes (Gorman et al., 2019). Some participants in this research displayed a mistrust rooted in concerns about the efficacy and safety of healthcare provisions from their homeland, noting that Polish state-funded vaccines were “second quality” and “polluted.”

Implications for research, public health practices, and policies

This study focuses on U.S. Vietnamese parents, a demographic group that, until now, had been left out of most research on vaccine confidence. These findings highlight the need for targeted interventions that consider the unique cultural, linguistic, and immigration-related factors influencing healthcare decision-making and recognize the diversity among Asian immigrant groups (Centers for Disease Control and Prevention, 2023a; Hopkins et al., 2023; Tuckerman et al., 2022). Understanding the role of acculturation and pre-migration experiences can inform the development of more tailored and effective public health strategies (Choy et al., 2021; Fox et al., 2017; Oppedal et al., 2020). For example, our findings indicated that some searched for information in Vietnamese (their native language) more, but many also perceived a higher availability of trusted scientific information in English. Policy and research should therefore focus on increasing language accessibility and encouraging the dissemination of multilingual vaccine-related information from trusted sources (C. Nguyen et al., 2022). Engaging community-based organizations (CBOs) in the design and implementation of vaccination campaigns may also improve their trustworthiness. CBOs have a deep understanding of the impact of acculturation and experiences before migration (Chau et al., 2023; Riza et al., 2020). Policy supporting community-based outreach may facilitate better access to credible information and vaccination services (Heinrichs et al., 2023; Shen et al., 2023).

Strengths and Limitations

Our strengths include the recruitment of diverse Vietnamese parents throughout the U.S. Surveys and interviews were offered in both Vietnamese and English, which facilitated the participation of those with limited English proficiency. We also considered different types of acculturation (Vietnamese and American), measured through different items and validated scales. Moreover, by employing a mixed-methods design, we offered a richer, more nuanced picture of vaccine confidence than that from using quantitative or qualitative methods alone. At the same time, the cross-sectional nature of our survey restricts our ability to draw causal inferences. Future research should consider longitudinal designs to examine changes in vaccine-related attitudes and behaviors over time among immigrants. Given that most participants were born outside of the U.S. and had high income and educational levels, the insights may not fully extend to those born in the U.S. or those from lower socioeconomic backgrounds.

Conclusions

Taking the perspective that vaccine confidence is deeply embedded within social frameworks, cultural dynamics, and institutional structures, we used a mixed methods design to assess how acculturation and pre-migration experiences influence U.S. Vietnamese parents’ vaccine confidence for their adolescents. We found overall high levels of trust in scientists, federal agencies responsible for vaccine safety monitoring and licensure, the CDC, and the FDA. Our findings highlight the complex interplay of acculturation, cultural identity, language, and historical experiences in shaping vaccine confidence among U.S. Vietnamese parents and emphasize the need to take these factors into account with tailored public health strategies.

Acknowledgement

We acknowledge Jane Gou’s and Justine Liu’s support in the preparation of this manuscript.

Funding

This work was supported by the American Psychological Foundation 2019 Visionary Grant and the American Association for Cancer Education 2019 Grant in Research, Education, Advocacy, and Direct Service (READS), the Grants-in-Aid program from the Society for the Psychological Study of Social Issues, the Professional Development Support Fund at Emory University, and the Healthcare Innovation Program Student-Initiated Project Grant at the Georgia Clinical & Translational Science Alliance (CTSA). The Georgia CTSA was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR002378. Our data collection received support from the Center for AIDS Research at Emory University (P30AI050409). Dr. Vu was supported by the National Cancer Institute (F31CA243220), a 2020–2021 PEO Scholar Award, and the 2020–2021 Student Fellowship in Patient Engagement from the Society of Public Health Education. Dr. Vu’s effort was also supported by the National Center for Advancing Translational Science (KL2TR001424; K12TR005104).

Footnotes

Conflicts of Interests/Competing Interests

The authors declare no conflicts of interest.

Ethics Approval

We received approval for research involving human participants from the Institutional Review Board at Emory University (IRB 00111688). All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000.

Informed Consent/Consent to Participate

Electronic/online informed consent was provided by all participants.

Availability of Data and Material

The data that support the findings of this study are available upon reasonable request from the corresponding author and with the approval of Emory University Institutional Review Board (IRB 00111688). The data are not publicly available as it contains information that could compromise the privacy of research participants.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available upon reasonable request from the corresponding author and with the approval of Emory University Institutional Review Board (IRB 00111688). The data are not publicly available as it contains information that could compromise the privacy of research participants.

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