COVID-19 Vaccine Acceptance Among Latino/a Immigrants: The Role of Collective Responsibility and Confidence

Abstract

Research on COVID-19 vaccine hesitancy has been sparse among Latino/a immigrants, a population at high risk for infection. This exploratory study examines rates of vaccine acceptance and its association with psychological antecedents of vaccination among Latino/a immigrants. A cross-sectional telephone survey on perceptions of COVID-19 was administered between October 2020 to February 2021 in South Florida to 200 adult Latino/a immigrants. Descriptive statistics, bivariate analysis, and logistic regression were employed to determine the influence of independent variables on vaccine acceptance. Most participants indicated a willingness to get vaccinated. Participants with higher confidence (aOR = 10.2, 95% CI: 4.8–21.8) and collective responsibility scores were (aOR = 3.1, 95%CI:1.3–6.9) more likely to report vaccine acceptance than those with lower scores. No other psychological antecedents or demographic variables were significantly associated with vaccine acceptance. Study results provide insights into motivating factors for vaccination that can inform culturally tailored education campaigns to increase vaccine acceptability in this population.

Introduction

The novel coronavirus (COVID-19) outbreak struck China in late 2019 and grew exponentially in severity and range worldwide. In response to COVID-19 and to mitigate its propagation, municipalities throughout the United States (US) restricted permissible activities and limited social interactions. Businesses were forced to close or reduce capacity, and schools and universities across the country transitioned to completely online learning. These mitigation strategies impacted various populations differently and ranged from the ability to comply based on occupation, living situation, and literacy to disparate financial outcomes.

COVID-19 in the US has disproportionately impacted racial/ethnic minority populations. Black, Latino/a, and Native American people have borne a greater burden of disease and financial hardships compared to Whites [1-4]. In fact, Latino/a persons have experienced twice as many infections, three times the rates of hospitalization, and more than twice as many deaths from COVID-19 compared to White non-Latino/as [5-7]. These increased rates of infections, hospitalizations, and deaths are attributable to longstanding social and environmental disparities [4]. This sometimes may include employment risks as front-line or essential workers and social distancing challenges, typically in congregate settings (e.g., homeless shelters, prisons, public transportation) where minorities are over-represented [8]. Additionally, disparities can also be amplified by pre-existing vaccine hesitancy, reduced health access, previous history with biomedical and healthcare mistrust, affordability, lower awareness, and education [9, 10]. In addition, the initial response efforts fell short of reaching minorities related to testing and the dispersing of information. A recent study by Jones et al., reveals that Latino/a and non-Latino/a Black populations fared considerably worse on COVID-19 knowledge scales than Whites [4]. In another study conducted in North Carolina, Latino/a participants were reported as having lower socioeconomic status and education than Whites and non-Hispanic Blacks, and that only 36.5% of the Latino/a sample trusted health care providers for information on COVID-19 compared to 71% and 67% for Whites and Blacks respectively [1].

As the pandemic now shifts to a biomedical approach via vaccines, it is imperative to understand how amenable minority populations are to vaccination. This is a challenge as research among Latino/a immigrants is sparse. In part, this is due to language barriers, mistrust of research/medical professions, lack of knowledge, and concerns of being experimented on [11-13]. This is a significant public health problem because many Latino/a immigrants are at higher risk of being exposed to COVID-19 due to housing and employment circumstances, and may lack resources (e.g., health insurance) to treat health complications associated with the virus [4, 5]. Therefore, the purpose of this exploratory research is to examine the rate of vaccine acceptance and its association with individual demographic characteristics, complacency, convenience, confidence, risk calculation, and collective responsibility among Latino/a immigrants.

Vaccine Hesitancy

As efforts to reach herd immunity against COVID-19 within the US grow, understanding the barriers and facilitators to vaccine uptake becomes more pertinent. Prior research has identified some characteristics associated with vaccine hesitancy, which is defined as a delay or refusal to accept a vaccine [14]. Race, age, income, education, gender, trust in government, fear of becoming infected, belief in the effectiveness of vaccines, and concern about COVID-19 are factors that research suggests would influence COVID-19 vaccine hesitancy [9, 14-18]. Other research studies indicate the likelihood of refusal of vaccines due to safety and efficacy concerns is higher for Blacks, women, and conservatives [19]. Reluctance to receive a vaccine varied across subpopulations with the women surveyed reporting hesitancy based on safety concerns and effectiveness, and Black Americans stating a lack of financial resources or health insurance [19]. Nevertheless, there is limited existing research on vaccine hesitancy within the Latino/a community.

Vaccine Acceptance

Recent studies among minorities and the general population have uncovered potential predictors of vaccine acceptance, which is defined as whether or not people accept, question, or refuse vaccination [20, 21]. Age, income, employment status, concern about COVID-19, and belief in vaccine efficacy were associated with vaccine acceptance. Generally, people who were more concerned about COVID-19 were less likely to refuse the vaccine [22, 23], and positive views of vaccination efficacy were negatively associated with vaccine refusal intention [19]. Older people and those with higher incomes were more likely to report that they would take a vaccine [15]. One study in the U.S found that those who were employed were more likely to accept a COVID-19 vaccine than those unemployed [18].

The language used to describe factors influencing COVID-19 vaccine hesitancy and acceptance varies widely, including the collapsing of hesitancy and acceptance and a myriad of terminology to assess both attitudes and motivators. For clarity, this study will utilize the concepts of the Five c’s approach to understand and describe COVID-19 vaccine acceptance among Latino/a immigrants living in South Florida [21, 24, 25]. The Five C (5 C) antecedents of vaccination were developed to better understand the psychological reasons behind vaccine acceptance. Developed by Cornelia Betsch, the 5 C approach encompasses existing widely used measures of confidence, complacency, and convenience and recent evidence that information gathering, calculation, and a willingness to protect others, collective responsibility, also help explain vaccine behaviors [25]. The 5 C’s include complacency, convenience, confidence, risk calculation, and collective responsibility. Complacency is defined as a low risk of perception resulting in a diminished urgency for vaccination. Convenience is described as the accessibility of the vaccine to a given individual or community. Confidence relates to the perceived trust in the safety and efficacy of the vaccine. Risk calculation involves a weighing of risks between infection and vaccine. Collective responsibility refers to the willingness to consider others’ needs above one’s own with regard to vaccine protection [21]. The purpose of this research is to examine the rate of vaccine acceptance and its association with individual demographic characteristics and the influential factors of the 5 C’s.

Methods

Design & Sample

Participants for the present study are from the Recent Latino Immigrants Study (RLIS), a longitudinal study that examined pre- to post-immigration alcohol use trajectories among recent Latino/a immigrants across 12 years (2007–2019). Participants from the original RLIS who immigrated to the US approximately 12 years ago, were randomly selected to complete a cross-sectional survey on perceptions towards COVID-19 from October 2020 to February 2021. Surveys were conducted via telephone by trained bilingual interviewers.

Measures

Surveys took about 30 min to complete and included questions related to mitigation strategy adherence, COVID-19 related stress, vaccine acceptance, and demographic and neighborhood information.

Vaccine Acceptance

Vaccine acceptance was evaluated using one question that queried participants if a vaccine were to become available would they receive it. Potential answers were yes, no, and don’t know/not sure. Responses that indicated yes or no were used in the analysis and coded yes = 1 and no = 0.

Mitigation

Mitigation was assessed using fifteen questions adapted from the COVID-19 International Survey related to individual mitigation precautions taken by respondents. Answers were scored 1 if checked and 0 if unchecked and a composite score from 1 to 15 was created.

Concern

Concern for COVID-19 was assessed using a 3-point Likert question that asked how concerned the participant was about the COVID-19 pandemic. The responses ranged from not at all (0) to very concerned (3) [2].

5 C Psychological Antecedents of Vaccination

The Five C’s Scale is a 15-item scale developed and validated for predicting vaccine acceptance [24]. The 15-item scale utilizes true/false questions to assess agreement or disagreement with three statements for complacency, convenience, confidence, risk calculation, and collective responsibility. Statements marked true were assigned the value 1 and those marked false 0. A composite score of 0–3 was generated for each of the five C’s.

Demographic

Age, gender (Male/Female), country of origin (Cuban/other), education level (College or Higher/≤ high school), and marital (Married or in a relationship/ single or separated) and employment status (employed/unemployed) were the demographic characteristics included as covariates.

Data Analysis

Statistical analysis included descriptive statistics and bivariate analysis to examine frequency and percentages for dependent and independent variables and logistic regression to determine the influence of independent variables on vaccine acceptance. We first generated descriptive statistics for the study sample, including frequencies and percentages for the categorical variables, and sample means and standard deviations for the continuous variables. We employed a Chi-square test between each categorical variable and the COVID-19 vaccine acceptance, while we used the two-sample t-test to each continuous variable by the COVID-19 vaccine acceptance. Then we applied multiple logistic regression for predicting COVID-19 vaccine acceptance with predictors of the five C’s, concern, and mitigation index, while controlling for demographics. SAS^®, v9.4 was used for all statistical analyses and 0.05 was used as the level of statistical significance.

Results

Demographic

The sample included 200 adult Latino/a immigrants living in South Florida (52.9% female: Mage = 38.9, SD = 4.9). Descriptive statistics of the overall data and stratified by vaccine acceptance are illustrated in Table 1.

Table 1.

Descriptive statistics of the COVID-19 data overall and stratified by the COVID-19 vaccine acceptance

Variable	Overall		COVID-19 Vaccine Acceptance				pa
	N	%	Yes		No
			N	%	N	%
	191	100	129	67.5	62	32.5
Gender							0.4930
Male	90	47.1	63	48.8	27	43.6
Female	101	52.9	66	51.2	35	56.5
Country of origin							0.2232
Cuba	48	25.1	29	22.5	19	30.7
Other countries	143	74.9	100	77.5	43	69.4
Education							0.4321
Less than high school or high school	91	47.6	64	49.6	27	43.6
College or higher	100	52.4	65	50.4	35	56.5
Marital status			127				0.4213
Married/In a relationship	133	70.4	87	68.5	46	74.2
Single or separated	56	29.6	40	31.5	16	25.8
Financial status							0.0664
Not enough money	45	22.7	23	18.1	19	30.7
Just enough money	131	66.2	93	73.2	35	56.5
More money than you need	22	11.1	11	8.7	8	12.9
Employment status							0.7999
Employed	159	83.3	108	83.7	51	82.3
Unemployed	32	16.8	21	16.3	11	17.7
How concerned are you about the covid-19 pandemic?							0.8660
Not at all	25	13.1	16	12.4	9	14.5
Somewhat concerned	75	39.3	50	38.8	25	40.3
Very concerned	91	47.6	63	48.8	28	45.2
Variable	Mean (Standard Deviation)	Range	Mean (Standard Deviation)	Range	Mean (Standard Deviation)	Range	p	Cronbach’s Alpha
Age in years	38.9 (4.9)	29–46	39.4 (4.7)	30–46	38 (5.2)	29–46	0.075	--
Mitigation index scoreb	9.0 (4.4)	1–15	9.2 (4.5)	1–15	8.6 (4.1)	1–15	0.386	0.90
Confidencec	1.9 (1.2)	0–3	2.4 (0.8)	0–3	0.8 (0.9)	0–3	< 0.001	0.73
Complacencyd	1.3 (1.2)	0–3	1.4 (1.2)	0–3	1.1 (1.0)	0–3	0.110	0.67
Conveniencee	2.3 (1.0)	0–3	2.2 (1.1)	0–3	2.3 (0.9)	0–3	0.718	0.71
Risk calculationf	2.5 (0.9)	0–3	2.5 (0.8)	0–3	2.5 (0.9)	0–3	0.936	0.66
Collective responsibilityg	1.5 (0.7)	0–2	1.7 (0.6)	0–2	1.1 (0.8)	0–2	< 0.001	0.61

^ap values were from Chi-Square tests between vaccine acceptance and each categorical variable, and two sample t-tests of continuous variables by vaccine acceptance.

^bThe potential range of mitigation index score is from 0 to 15, with a higher score indicating a higher level of COVID-19 mitigation adherence.

^cThe potential range of the confidence score is from 0 to 3, with a higher score indicating a higher level of confidence in the safety and effectiveness of the COVID-19 vaccine.

^dThe potential range of the complacency score is from 0 to 3, with a higher score indicating a higher level of vaccine complacency.

^eThe potential range of the convenience score is from 0 to 3, with a higher score indicating a greater level of reported convenience of receiving the COVID-19 vaccine.

^fThe potential range of the risk calculation score is from 0 to 3, with a higher score indicating a more careful evaluation of risk/benefits of the COVID-19 vaccine.

^gThe potential range of the collective responsibility score is from 0 to 2, with a higher score indicating a higher level of perceived collective responsibility about the COVID-19 vaccine.

Prevalence of Vaccine Acceptance

The majority of the sample (67.5%) indicated a willingness to get vaccinated. The most frequent reason given for getting vaccinated was “to protect my family”. The most frequent reasoning for not (or being unsure about) getting vaccinated was “I have heard negative information about the vaccine”. Table 2 illustrates the prevalence of vaccine acceptance and the top three reasons given for acceptance or hesitancy.

Table 2.

COVID-19 vaccination related questions

If a vaccine were available for COVID-19 (coronavirus ) would you get vaccinated?	N	%
Yes	129	64.5
No	62	31
I don’t know	9	4.5
If no, follow-up Options (N = 129)
To protect my family	90	69.8
I think it will be effective	88	68.2
I think it will be safe to take it	83	64.3
If no, follow-up options (N = 62)
I don’t think it will be effective	26	41.9
I think it might make me sick	28	45.2
I have heard negative information about this vaccine	23	37.1
If I don’t know, follow-up options (N = 9)
I think it might make me sick	3	33.3
I have heard negative information about this vaccine	3	33.3
I wouldn’t know where to get vaccinated	2	22.2
I don’t trust the governments recommendation	2	22.2

Association Between Vaccine Acceptance and Individual-Level Determinants

Two sample t-tests indicated that confidence and collective responsibility scores were associated with vaccine acceptance (p < .001). Gender, country of origin, education, and marital and employment status were not significantly associated with vaccine acceptance. Pandemic stress and mitigation index scores were higher in those willing to get the vaccine than those who were not, but the differences were not statistically significant.

Participants with higher confidence scores were more likely to report vaccine acceptance (AOR = 6.3, 95% CI: 3.7–10.9) than those with lower confidence scores. Respondents who expressed higher collective responsibility scores were twice as likely to report vaccine acceptance (AOR = 2.1, 95% CI: 1.2–3.7) than those with lower scores. Table 3 shows the results of the logistical regression. Convenience, risk calculation, and complacency were not significantly associated with vaccine acceptance.

Table 3.

Results from multiple logistic regression for acceptance of the COVID-19 vaccine (n = 183).

Independent Variables	Adjusted Odds Ratio	95%		p
		Confidence Intervals
Age in years	1.152	1.015	1.307	0.0281
Gender: Female vs. Male	1.237	0.419	3.657	0.7002
Education: College or higher vs. Less than high school or high school	1.622	0.497	5.290	0.4226
Employment: Employed vs. Unemployed	0.804	0.161	4.006	0.7897
Country of origin: Cuba vs. Other countries	0.016	0.001	0.574	0.0235
Marital status: Married/In a relationship vs. Single or separated	0.535	0.136	2.108	0.3715
Financial status
Not enough money vs. Just enough money	0.623	0.134	2.889	0.5455
More money than you need vs. Just enough money	0.309	0.059	1.608	0.1628
How concerned are you about the COVID-19 pandemic?
Somewhat concerned vs. Not at all	1.236	0.199	7.689	0.8202
Very concerned vs. Not at all	2.482	0.358	17.206	0.3573
Mitigation index score	0.987	0.872	1.117	0.8358
Confidence	10.202	4.768	21.830	< 0.0001
Complacency	0.657	0.342	1.263	0.2076
Convenience	1.861	0.944	3.667	0.0727
Risk Calculation	0.872	0.413	1.841	0.7188
Collective responsibility	3.052	1.340	6.949	0.0079

Bold values represent statistical significance, where alpha = 0.05.

Discussion

The objective of this research was to assess the prevalence and motivation for vaccine acceptance and identify characteristics associated with vaccine acceptance among Latino/a immigrants in South Florida. This study indicates that the majority of Latino/a immigrants in this study endorse willingness to receive vaccines, and that willingness was significantly associated with the conceptualization of solidarity as well as confidence in the vaccine. Latino/a immigrants expressed concern for others as the main impetus for getting vaccinated and a separate measure of the construct, collective responsibility, revealed a significant association with vaccine acceptance.

The current results are in line with prior research and recommendations from the World Health Organization which suggest that confidence in the safety and efficacy of the vaccine as well as the trustworthiness of those tasked with administering it are among the most influential factors contributing to vaccine acceptance. Confidence in the vaccine is positively associated with vaccine acceptance and negatively associated with refusal and hesitancy throughout the national and international literature on COVID-19 vaccines. The existing literature cites concern about COVID-19 vaccine safety, particularly in high-income countries, referring to the rapid pace of vaccine development, as a primary reason for hesitancy [26], as well as vaccine testing; concerns about novel vaccine technologies; and rampant misinformation [26-28], all play a part in reducing individual’s confidence in the vaccine [26]. Hesitant respondents in low-middle income countries, were most worried about side effects and vaccine efficacy [26]. Our results also reflect these universal apprehensions and reveal that participants with higher confidence scores were also more likely to report vaccine acceptance.

As mentioned, many other studies indicated age, gender, education, income and employment, and marital status were significantly associated with vaccine acceptance or hesitancy. However, the current results showed no association between vaccine acceptance and these demographic characteristics. So too, prior research indicated that concern/complacency, convenience, and risk calculations would influence vaccine hesitancy and acceptance. Previous research has stated that complacency can develop amongst the population once vaccine-preventable diseases have been eradicated. The perceived need and value of vaccines are diminished because the devastating impact of these diseases is not visible [28] If individuals’ view of the risk of disease is less severe, they may be less willing to accept vaccination [26]. The current study, however, found no significant association with concern/complacency or convenience which suggests different mechanisms for decision making may be at play.

Very few studies examine the role of solidarity in association with vaccine acceptance or hesitancy. Solidarity, altruism, or collective responsibility are constructs that have been measured in COVID-19 vaccine uptake research. The variation in the language used to express and assess these constructs does present problems with interpretation across studies but does suggest similar findings, especially among marginalized groups. For example, Jones et al. examined whether participants agreed with the question “getting vaccinated is important for my health and the health of others in my community?”. Though the specific question does reference one’s self and others the research findings among HIV positive patients in Miami indicate that agreement with the statement was associated with 8 times greater odds of vaccine acceptance than those who disagreed with the statement [29]. Similarly, Teixeora da Silva et al. adapted the construct of altruism, created for HIV vaccines, in a sample of sexual and gender minority men and women, to assess the association between the construct and COVID-19 vaccine acceptance [30]. In their research Teixeora da Silva et al. assess altruistic vaccination using questions such as, “I would get a COVID-19 vaccine that would prevent me from being able to infect other people with COVID-19, even if the vaccine might not protect me against COVID-19” and “My willingness to get an COVID-19 vaccine is important for the good of all people” [30].

While the construct is slightly different than the three questions from the current study, the results showed that vaccine acceptance was positively associated with altruistic attitudes towards the vaccine [30]. In other research examining vaccine acceptance and its relation to others, Doherty et al. found that Latino/a participants were the least likely (17%) to endorse that they “want others to get vaccinated first” compared to White (23%) and Black (26%) participants [1].

It is possible that these results are indicative of a greater sense of solidarity among this population due to cultural or structural reasons. From a cultural perspective, traditional family values and makeup may have a far-reaching influence on vaccination decisions [31]. Though some prior research suggests that health fatalism in this population impedes health-seeking behaviors, other research concludes the concept is not fully understood [32, 33]. Health fatalism is a belief that one’s health is out of their control [31]. From a structural lens, the fact that the examples that associated solidarity to vaccination were among marginalized populations might suggest that the insular nature of these groups is protective in this instance.

The results from this pilot study provide actionable insights into motivating factors for vaccination among Latino/a populations that differ from non-Hispanic populations. These insights can be used to create culturally tailored education campaigns to increase vaccine acceptability. By focusing resources on increasing confidence in vaccines through education and transparent communications and targeting messaging that reinforces the sense of responsibility to others and vaccinations.

Limitations of this study include its limited sample size, and the use of non-probability sampling which limits generalizability. The age range of the current sample was smaller (approximately 15 years) and can be a contributing factor to the insignificant result related to age. The timing of the survey may have influenced results due to vaccines becoming available for the public during the study. However, most of our sample would not have been eligible for vaccine until after the survey was completed given their age range. Despite these limitations, the findings provide insights to tailor vaccine messaging and strategies to specific populations to address vaccine hesitancy.

Future research should build upon these findings through larger studies that incorporate the five C’s of vaccine hesitancy and other individual-level influences on the decision to vaccinate. Additionally, future research focused on the interpersonal and community-level influences on the decision to get vaccinated are needed to gain a greater multi-level understanding of the factors that influence vaccine acceptance among Latino/a immigrants. This research adds to the body of research examining vaccine acceptance and hesitancy by specifically exploring recent Latino/a immigrant’s perspectives, a population at high risk for COVID-19 not previously studied. Identifying avenues for educational opportunities and motivational messaging surrounding vaccine acceptance within the Latino/a community will have far-reaching impacts on health and on mitigating health disparities.

Conclusion/So What?

What is Already Known on This Topic?

Very little is known on this topic as it relates to COVID-19 and Latino/a immigrants. Though research among this population related to health promotion and disease prevention suggests that health fatalism negatively affects health-seeking behaviors.

What Does This Article Add?

First, this article provides a much-needed glimpse into the Latino/a population and their perceptions of and motivations for COVID-19 vaccination. Second, this article suggests that the Latino/a immigrant community is willing to get vaccinated against COVID-19 to protect others.

What are the Implications for Health Promotion Practice or Research?

Vaccine campaigns that utilize messages of solidarity might be effective in reaching the unvaccinated. Future research should explore further the concept of solidarity within immigrant communities as a way to increase vaccination rates in this vulnerable population.