Ethnic Minorities’ Perceptions of COVID-19 Vaccines and Challenges in the Pandemic: A Qualitative Study to Inform COVID-19 Prevention Interventions

Abstract

To inform health communication campaigns for COVID-19 prevention and vaccine promotion among racial and ethnic minorities facing disparities, we conducted formative research by interviewing Hispanic/Latino American (Latino), Black/African American (AA), and American Indian/Alaska Native (AI/AN) participants to explore their challenges during the pandemic, the barriers and facilitators to receiving COVID-19 vaccines, acceptability of using chatbots to deliver COVID-19 and vaccine information, and preferred features and suggestions for culturally tailored prevention messages. Positive perceptions of the COVID-19 vaccine were mainly derived from beliefs that the vaccine can protect oneself and families from getting infected and help stop the pandemic. Negative perceptions of the COVID-19 vaccine were driven by concerns about vaccine safety due to the rapid development process and side effects. Latino participants would like to know more information about the vaccine and evidence of its effectiveness. AA participants identified seeing others, especially government officials, get the vaccine first as a facilitator and low trust in the government and healthcare system as barriers to getting the COVID-19 vaccine. AI/AN participants emphasized the importance of equitable access to the vaccine. Participants preferred messages with the following features: informative and evidence-based messages about COVID-19 and vaccination, encouraging and motivational messages that focused on the hope to end the pandemic and return to normal, prosocial messages, and clear instructions for COVID-19 prevention strategies. Participants also suggested that messages should include different cultural practices, be translated into their native languages, and emphasize care for family members.

Coronavirus Disease 2019 (COVID-19) disproportionately impacts ethnic minorities in the United States. American Indians/Alaska Natives (AI/AN), Black/African Americans (AA), and Hispanic/Latino Americans (Latinos) are more likely than non-Hispanic White/European Americans (White) to report adverse mental health experiences during the pandemic (Czeisler et al., 2020), get infected, be hospitalized, and die from COVID-19 (CDC, 2021). Social determinants of health, including occupational and housing conditions, lower socioeconomic status, greater prevalence of underlying medical conditions, and limited access to healthcare increase exposure risk for SARS-CoV-2 as well as severe COVID-19 disease among ethnic minority populations, contributing to COVID-19 related disparities (Romano et al., 2021). Structural racism and discrimination also widen ethnic inequities in health (Njoku, 2021). Ethnic minorities face barriers to receiving culturally tailored medical treatment, have poorer healthcare experience, and may receive biased health communication. Understanding the challenges faced by ethnic minorities during the pandemic can inform the design of culturally tailored health communication interventions for COVID-19 prevention that help mitigate COVID-19 related health disparities.

COVID-19 Vaccine Hesitancy

The advent of COVID-19 vaccines increases prevention opportunities and will contribute greatly to terminating the pandemic. Currently in the U.S., three COVID vaccines are authorized and available for everyone ages five years or older. An issue of concern is vaccine hesitancy, which refers to the uncertainty or unwillingness to get the recommended vaccine, leading to delay or refusal of vaccination even if vaccine services are available (MacDonald, 2015). Vaccine acceptance is much lower among AA (40%) than Whites (68%) (Kreps et al., 2020); and vaccine hesitancy is higher among AA (34%) and Latinos (29%) than Whites (22%) in the U.S. (Khubchandani et al., 2021; Nguyen et al., 2021) and worldwide (Razai et al., 2021). Understanding ethnic minority’s perceptions of the vaccine and reasons for hesitancy is essential for strengthening public health messaging on COVID-19 prevention and reducing ethnic health disparities.

A few factors have been identified to be associated with COVID-19 vaccine hesitancy based on survey findings, including being younger, not being Asian, living in rural areas, living in a community with higher support for Trump in the 2020 presidential election, and perceiving lower risk of the COVID-19 disease (King et al., 2021; Malik et al., 2020). Confidence in vaccine safety and effectiveness, calculation about the risks and benefits of the vaccine, and collective responsibility to protect other people significantly predicted acceptance of COVID-19 vaccine (Barello et al., 2021; Betsch et al., 2018). While these representative surveys are valuable in helping identify epidemiological patterns and factors related to vaccine acceptance and hesitancy, qualitative studies (e.g., interviews) are needed to provide in-depth understandings and nuanced analysis of the reasons and cultural influence behind hesitancy.

Health Communication on Vaccine Promotion and the Potential of Mobile Technologies

Effective communication is key to the success of vaccination programs (Rimal & Lapinski, 2009). Common communication strategies for vaccine promotion include providing balanced information (both risks and benefits), enabling two-way communication, presenting facts, statistics, and quotations from trusted sources, and tailoring messages to specific groups (Dubé et al., 2020; Olson et al., 2020). Understanding the target audience’s needs and preference is critical throughout the process of designing, implementing, and disseminating a health communication intervention. Interventions promoting the uptake of COVID-19 vaccine among ethnic minorities rely heavily on formative research to understand their cultural norms and values and to ensure that messages are accessible, appropriate, acceptable, engaging, and can resonate with the intended audience (Najib Balbale et al., 2014).

The universal use of mobile phones and the ubiquity of text messaging across gender, age, class, and language make short message services (SMSs) ideal for delivering COVID-19 prevention messages. Automated text-message programs can send prevention information to users’ mobile phones at a fixed frequency. In addition, artificially intelligent “chatbots”, i.e., a software application using algorithmic scripts and natural language processing to automate a task, offers an innovative approach to delivering support that directly addresses an individual’s questions online or via text messages. Advantages offered through text messaging and chatbots include being automated, scalable, cost-effective, interactive, and can constantly update the content as we gain new information about COVID-19 and its vaccine. While ethnic minorities may be open to various mobile platforms, we need to attend to messaging expectations and identify their preferred communication channels (Mercadante & Law, 2021).

Study Context and Theoretical Framework

This formative research intends to inform the development of a public health intervention aiming at promoting prevention measures and improving the uptake rate of COVID-19 vaccine among U.S. ethnic minorities. We wanted to investigate a priori the use of automated text messaging and/or chatbots to communicate COVID-19 prevention information in response to requests from multiple partner health care delivery systems who indicated a high-risk for staff burnout after being inundated with repetitive questions about the COVID vaccine that pulled them away from primary care priorities. A chatbot can efficiently answer user-initiated questions and address people’s diverse concerns about COVID-19 and its vaccine by simulating human conversations, which may be beyond the capability of many traditional communication channels.

Guided by the PEN-3 cultural model, we developed the interview guide to explore culture impacts on vaccination decisions and behaviors among minority populations. The PEN-3 cultural model has been widely applied in guiding the development and assessment of culturally tailored health interventions (Iwelunmor et al., 2014; Olufowote & Aranda, 2017; Orrego Dunleavy et al., 2018). Airhihenbuwa (1989) proposes three domains to consider when planning, implementing, and evaluating a public health intervention with each domain consisting of three components—cultural identity (i.e., person, extended family, and neighborhood), relationship and expectations (i.e., perception, enabler, nurturer), and cultural empowerment (i.e., positive, existential, negative). “Cultural identity” determines where to intervene and the level of the intervention, whereas “relationship and expectations” and “cultural empowerment” are used for needs assessment and to identify critical issues to be addressed in an intervention, which are more relevant to the goal of the current formative study.

We also want to pilot test the initial version of health communication messages and optimize the messages to be culturally tailored to ethnic minorities. Message development was guided by the Integrative Model of Behavior Change (Fishbein & Yzer, 2003), targeting key antecedents to behavioral change, including outcome expectations, perceived social norms, and perceived capability in performing prevention behaviors and getting vaccinated. Messages covered topics from prevention measures (e.g., hand washing, wearing a mask, social distancing), myths and facts, mental health support, knowledge about vaccines, risks, benefits, and norms of getting the vaccines, to COVID-19 vaccine safety issues.

Method

We conducted semi-structured in-depth interviews to understand the challenges for ethnic minorities in the pandemic, their perceptions of COVID-19 vaccines, intervention acceptability, and message preferences. Interviews were composed of four major sections to address the following research questions: 1. What are the challenges and concerns faced by ethnic minorities in the pandemic? 2. Is the text message-based or chatbot-based intervention an acceptable modality to communicate COVID-19 prevention information to ethnic minorities? 3. What are the barriers and facilitators to getting the COVID-19 vaccine? 4. What do ethnic minority participants like or dislike about the initial version of the COVID-19 prevention messages, and what are the suggestions for optimizing the messages to be more culturally relevant?

Recruitment

Participant recruitment occurred between October 29^th and November 24^th of 2020. Eligible participants were (1) between 18–89 years old; (2) self-identified as Latino American or Hispanic, African American or Black, American Indian or Alaska Native; (3) speak either English or Spanish; and (4) currently live in the Denver Metropolitan Area.

Participants were recruited through two ways—being referred by a community engagement coordinator or responding to an online advertisement posted on the craigslist, a cost-effective Internet recruitment tool (Antoun et al., 2016). The community engagement coordinator emailed study information to eligible individuals in her network. Those interested in the interview emailed back with their contact information. Participants who saw our online ad and wanted to participate in the study would complete a brief Qualtrics survey to sign up for the study and provide contact information. We called or emailed potential participants to confirm their eligibility, complete informed consent and schedule interviews. We contacted 25 participants and completed interviews via Zoom (Zoom Video Communications Inc., 2016) with 18 participants (see Figure 1). Recruitment materials and the study protocol were reviewed and approved by the Colorado Multiple Institutional Review Board (protocol # 20–2014).

Figure 1. Flowchart of Recruitment Process.

Procedure

Three research assistants (RA) experienced with qualitative research methods conducted the interviews based on an interview guide and took notes during the interviews. Each interview lasted between 45–75 minutes and was audio recorded, and later transcribed. We removed identifiable information from the audio recordings and labeled them by study IDs to maintain anonymity. At the end of the interview, participants’ demographic information (e.g., gender, age, ethnicity), whether they have any chronic conditions, or been diagnosed with COVID-19 were asked. Each participant was compensated with a $30 e-gift card after completing the interview. The main interview questions are summarized in Table 1.

Table 1.

Semi-Structured Interview Guide

Section 1	Challenges and concerns
	1. How COVID-19 has impacted your daily life? 2. What has been changed regarding your routine behaviors since the outbreak of COVID-19? 3. What are your major concerns during this pandemic period? 4. Can you share with us the specific challenges you are facing with the coronavirus pandemic?
Section 2	Intervention acceptability
	1. Do you use text messages and online chatting in healthcare? If yes, how do you use it? If not, would you like to use this technology? Why or why not? 2. What other technologies or communication platforms would you use to receive health-related information and guidelines for COVID-19 prevention? 3. Would you like to receive text messages regarding COVID-19? Could you give some examples of instances where this would be helpful? And not helpful? What concerns you may have with this text message service? 4. Short message service (SMS)-based chatbot or a text bot is a service that automatically responds to users’ questions and communicate with the user via text messages. Would you like to use chatbots to look for information about COVID-19? Why or why not?
Section 3	Barriers and facilitators to getting the COVID-19 vaccine guided by the PEN-3 cultural model
Domains	Positive	Existential	Negative
Perceptions	1. Why would you like to get the COVID-19 vaccine? 2. What are the benefits of getting the COVID-19 vaccine?	1. What do you know about vaccination in general? 2.What are in your mind when deciding whether or not to get the COVID-19 vaccine?	1. Why would you not like to get the COVID-19 vaccine? 2. What are your concerns about the COVID-19 vaccine?
Enablers	1. What are the things that would motivate you to get the COVID-19 vaccine? 2. What resources are useful for you to facilitate you to get the COVID-19 vaccine?	1. What (historical) factors would influence your decision to get or not get the COVID-19 vaccine? Could you share with us your stories?	1. What are the things that would prevent or discourage you from getting the COVID-19 vaccine? 2. What resources are lack of that prevent you from getting the COVID-19 vaccine?
Nurturers	1. Who in your social network would encourage you to get the COVID-19 vaccine?	1. What are the considerations about your significant others or community members when deciding whether or not to get the COVID-19 vaccine?	1. Who in your social network would discourage you from getting the COVID-19 vaccine?
Section 4	Message evaluation
	Participants were presented with a random set of the initial version of prevention messages. Participants read and rated each message and answered the following questions:
	1. What did you like most about these messages? 2. What did you like least about the messages? 3. How appropriate is the language for you and your family? 4. How would you revise the message to be more relevant to your culture and reflect your cultural values? 5. Is there anything you wish was included in the messages? 6. Do you have any additional comments?

Analysis Plan

We transcribed interviews verbatim using the online transcription service TranscribeMe and took an inductive approach to thematically analyze the transcripts (Braun & Clarke, 2006). Transcripts were manually coded by two RAs. In the initial round of open coding, coders inductively identified words and constructs relevant to research questions and labelled them with words as similar to the original data as possible. This was followed by theoretical sampling, in which coders explored new participants and incidents that mentioned relevant information and concepts based on the initial codes. During the selective (or axial) coding phase, coders organized fragmented codes into more abstract concepts through constant comparative analysis and identified themes that emerged from interview data for each ethnic group. Finally, themes related to COVID-19 vaccine acceptance or hesitancy were organized based on the PEN-3 cultural framework. Five transcripts were double coded and reviewed by the first author to ensure the codes, quotations, and interpretations truly represent the meaning of the interviewees, enhancing the validity and reliability of the coding process. Discrepancies were discussed until consensus was achieved.

Results

Eighteen participants (five Latinos, eight AAs, and five AI/ANs) completed the online interview. Half of them were female. Participants’ age ranged from 21 to 54 (M = 35.1; SD = 9.7). No participants had been diagnosed with COVID-19 before the interview. One interview was conducted in Spanish and all other interviews were conducted in English. In the following section, findings to each research question are organized by first reporting the general patterns and then identifying the unique themes for each ethnic group.

Challenges and Concerns in the Pandemic

Social Life Concerns

Most participants were concerned about the impacts of COVID-19 on their social life. Such concern mainly stemmed from not seeing their family and friends and lack of general human interactions due to the social distancing measure, quarantine regulations, and difficulties in transportation. People’s outing habits have changed as people were not going out often. One Latino participant said their regular family gatherings were no longer possible. Many participants had not been able to visit their family members in person since the outbreak of the COVID-19 and find it challenging to only do get-together virtually.

Participant quotes illustrating each theme and the frequency of each theme and sub-theme were summarized in Table 2.

Table 2.

Summary of Themes and Subthemes about Ethnic Minorities’ Challenges during the Pandemic

Themes	Subthemes	Example Quotes	n (%)
Social life concerns	Cannot see family members	“With your friends, you can do a Zoom or you can talk to them by phone, but with my family, my close family, my daughter, my son-in-law and my babies, it’s horrible for me when I cannot go and touch them. For me the worst part of everything is the social life.” (participant #3, Latino)	7 (38.8%)
	Outing habits have changed	“I was forced to stay indoors more and like before I used to stay out. COVID has reduced my travelling a lot.” (participant #19, AI/AN)	5 (27.7%)
	Lack of human interactions in general	I don’t get as much exercise, sunlight, or human interaction as I’d like to. I’ve become anxious and a little down from lack of social interaction. (participant #13, AA)	5 (27.7%)
Financial concerns	Financial difficulties in general	“The financial aspect has been quite stressful, just to make sure that everything is taken care of. It’s more challenging. It created a lot of stress within my husband and I. Of course, we can’t splurge on things the way we used to. And so it’s hard for him to get adjusted to that.” (participant #25, Latino) “I was trying to balance my financial position. Due to COVID-19, my financial resources reduced.” (participant #10, AA)	7 (38.8%)
	Unemployment	I was working at a job downtown that relied specifically on tourism at an art gallery, and then we were shut down instantly. So I lost my job. That was challenging paying my bills. Getting on unemployment was extremely difficult. I had to reach out to one of our local legislators for assistance, which obviously was not easy. I know a lot of people don’t have access to do that. (participant #13, AA)	4 (22.2%)
	Salary cut	Salary was cut down. The cash was not coming in. We had to use the savings we had before. I couldn’t get enough cash to take care of my family. (participant #11, AA)	3 (16.7%)
Work-related stress (Salient among AA participants)	Changed to the remote working style and decreased efficiency	“Because of COVID now I’m not able to perform my job duties because I have to interact with people. And because of COVID I have to rely on other measures like Zoom meetings, phone banks, texting, but they are never effective as an in-person interaction with people.” (participant #5, AA).	8 (44.4%)
	Stressful and risky daily tasks	“My current job is in response to the COVID pandemic. So my work has increased dramatically.” (participants #4, AA)	3 (16.7%)
Neighborhood (Salient among AA participants)	Difficulties in grocery shopping and exercising	“We do not have lot of money. We don’t have, [money] again, for groceries. We have to get fast food pretty often. And then lack of exercising equipment inside our house, obviously, we don’t have access to that. We’re kind of limited in the exercise we can do from inside or near our homes.” (participant #13, AA)	4 (22.2%)
Mental health concerns (Salient among Latino participants)	Worried about loved ones	“I think the challenge is really having fear, experiencing uncertainty, and not having a reliable plan in place to protect loved ones, community members [and] our nation at large.” (participant #1, Latino) “My oldest son has been dealing with a little bit of depression as well as myself because he’s isolated… He’s already shy as it is, and the fact that he was really open to being in a group setting with others his age was—it made us happy because it was, ‘Okay. You’re opening up.’ But then it just kind of went back to him being in his room and isolated instead of being out there.” (participant #25, Latino)	7 (38.8%)
	People passing away	“I actually lost somebody close to me due to the virus.” (participant #11, AA)	3 (16.7%)

Note. The column n represents the number of participants mentioned the theme in the interview.

Financial Concerns

Another major concern was about financial difficulties. Some participants lost their job because of the pandemic, whereas others experienced salary cuts or dramatic changes in their work nature and hours. Some work (e.g., after-school programs, tourism) was cancelled entirely or reduced, thus people had to switch to part-time or have reduced working hours and received less income. Participants said they were worried about their financial situations since they did not have enough savings and the budget was tighter than usual. They struggled to balance the financial position and need to change their expenditure habits to be more conservative and avoid purchasing non-essentials things.

Work-Related Stress

Work-related stress was commonly mentioned as a critical challenge among AA participants. They were concerned about reduced work efficiency and being hard to adjust to the remote working style. They perceived that telecommunication with colleagues and clients was not as effective as in-person communication, leading to extra hours of work and higher burden of adapting to changes in job dynamics. Additionally, some AA participants mentioned their job duties required in-person interaction with people, increasing their exposure risks to COVID-19.

Neighborhood

African American participants mentioned difficulties with grocery shopping and lack of exercise due to their living environment. Some AA participants explained that they lived in neighborhoods that are far away from grocery stores to get fresh and nutritious foods, and from green open space to exercise. The limited access to healthy foods and exercise facilities made participants feel physically challenging to stay healthy.

Mental Health Concerns

Mental health concerns were more pervasive among Latino participants than other ethnic groups. Their main challenge was negative emotions, including fear of death, fear of losing loved ones, and uncertainty—without knowing what would happen next. Latina mothers were particularly worried about their family members, such as children, grandkids, and brother contracting COVID-19 or experiencing mental issues. They and their family experienced isolation, depression, and stress because of the lost opportunities to be in group settings in the pandemic.

Perceptions of COVID-19 Vaccine, Facilitators, and Barriers

Participants had mixed opinions about COVID-19 vaccines. Most participants (n=13, 72.2%) said they would get the vaccine if approved. However, among these participants, eight people said they would like to see how the vaccine works on other people first and wait for more reviews. Four participants clearly stated they would not take the vaccine. We organized the themes based on the PEN-3 cultural framework and included participant quotes in Table 3.

Table 3.

Themes about COVID-19 Vaccine Hesitancy and Acceptance Organized by the PEN-3 Cultural Model

PEN-3 Domains	Example Quotes	n (%)
Positive Perceptions
The vaccine can protect the self and family from getting COVID-19	“Well, I would do it because I wouldn’t really want to get seriously sick, end up in the hospital, possibly die, or if I did survive, having to deal with the hospital costs, the impact financially. That would be stressful in itself. I would just not want to be a burden to my family in that sense.” (participant #25, Latino)	12 (66.6%)
The vaccine can stop the pandemic	“I am motivated because all I want is the best for my country and everything will go back to just like we want it.” (participant #22, AI/AN)	2 (11.1%)
Negative Perceptions
Concerns about side effects	The side effects of the vaccine would greatly matter to me. It’s a concern to me if it has side effects and that would greatly discourage me from getting the vaccine. (participant #16, AA)	7 (38.9%)
Vaccine safety is questionable given the fast development process	“It’s kind of nerve-wracking because I feel like they really are pushing this fast, trying to fast track it and I’m worried about maybe they haven’t seen or identified all the effects long term or short term yet.” (participant #17, AI/AN)	7 (38.9%)
Lack of knowledge about the vaccine (LA specific)	“We need to see more results of the vaccine. Right now, there is uncertainty. So I will not take the vaccine if the vaccine just pop up in the market.” (participant #2, Latino)	8 (44.5%)
Concerns about financial gains for manufactures	“I want to be sure that it’s just not a convoluted process of developing the vaccine and giving it to people so that some people gain a lot of money out of this pandemic.” (participant #1, Latino)	1 (5.6%)
Positive Enabler
Employer and travel requirements	I would get vaccinated if I need to travel to some place and there is a requirement to have that.” (participant # 2, Latino)	2 (11.1%)
Seeing officials and others get the vaccine first (AA specific)	“I would want to see a lot of the people and health officials and scientists who are pushing for the vaccine to take it themselves. That would give me a lot of confidence.” (participant # 13, AA)	2 (11.1%)
To ensure equitable access to vaccine (AI/AN specific)	“I guess access to it would be something. I would be very concerned about this if back home my family or I couldn’t get this vaccine. … It would have to be equitable. Everybody would need to have access.” (participant #17, AI/AN)	1 (5.6%)
Negative Enabler
Misinformation or inconsistent messages about the vaccine	“I think the barriers would be like, the rumors. A lot of people think the vaccine actually is the virus.” (participant #8, AA)	3 (16.7%)
Distrust of the government and healthcare system (AA specific)	“Historically, medicine has been systemically racist and oppressive to the black community. There have been times where medicine has been used to abuse the black community.” (participant #4, AA)	7 (38.9%)
Negative Nurturer
Family members’ discouragement (AI/AN specific)	“My family, majorly my wife, might be insisting for me not to get the vaccine. She is a major thing that can discourage me” (participant #24, AI/AN).	2 (11.1%)

Note. The column n represents the number of participants mentioned the theme in the interview.

Perceptions of the COVID-19 Vaccine

Participants hold both positive and negative perceptions about the COVID-19 vaccine. The most common positive belief was that the vaccine would keep them and their family members healthy and protect them from getting infected with COVID-19 and avoiding all the physical, mental, and financial detrimental consequences. Additionally, people believed that the vaccine could help reduce the spread of the virus and eventually stop the pandemic.

The top negative perception was concerns about the side effects of the COVID-19 vaccine. Participants expressed not wanting to get the COVID-19 vaccine because they believed that potential side effects and their seriousness have not been full revealed or well understood. Participants were also concerned about vaccine safety and its long-term impacts, given that the COVID-19 vaccines were developed and tested in a rapid manner. Participants were uncertain about the fast-tracking development process of the vaccine and were worried that the current evidence collected in such a short time may not be strong enough to prove vaccine safety.

Latino participants, in particular, felt there was a lack of knowledge of COVID-19 vaccine. They would like to wait until they learned more about the vaccines (e.g., ingredients) and the results of clinical trials regarding effectiveness, side effects, and adverse cases. One Latino participant also questioned the purpose of the vaccine—it was unclear whether the vaccine was developed for manufactures’ financial gains or for public interest.

Enablers of Getting the COVID-19 Vaccine

Several structural factors emerged as facilitators to getting the COVID-19 vaccine. Participants mentioned that they would get the vaccine if their employer mandated it or if it were part of the traveling requirements, such as requiring a vaccine certificate for work, travel, or participating in social activities.

Unique to AA participants was their emphasis on “others” receiving the vaccine. Half of AA participants mentioned that seeing others take the vaccine would encourage them to get the vaccine. This was not only about how common the vaccination behavior was in their communities, but more about whether people who made and advocated for the vaccine would do what they said to the public. They would like to see health or government officials and scientists receive the vaccine first before considering getting the shots too.

AI/AN participants mentioned equitable access to the vaccine as a facilitator to greater vaccine uptake. While most AI/AN participants were open to getting the COVID-19 vaccine, they wanted to make sure that the COVID-19 vaccine was allocated transparently and equitably.

Misinformation and inconsistent messages over the Internet discouraged participants from getting the COVID-19 vaccine. Participants felt confused and hard to distinguish myths from facts because of conflicting information regarding the effectiveness, safety, cost, and purpose of the vaccine on social media.

While most AA participants (n=6) would receive the vaccine once approved, they were reluctant to get it right way. Hesitancies mainly stemmed from distrust of the government and the overall healthcare system. Participants expressed low trust in the government’s policies on COVID-19 and were concerned that the vaccines may be politicized. Issues such as unfair medical treatment of people of color, historical trauma, and abuse from the medical field with the black community (e.g., the Tuskegee Study) also made AA participants suspicious about the true purpose of health institutions, the overall vaccination treatment, and clinical trials.

Nurturers of Getting the COVID-19 Vaccine

Two AI/AN participants mentioned that their significant others served as the important influencer for their vaccination decision. They were hesitant because their wife discouraged them from getting the vaccine.

Acceptance of Chatbots and Text-Messaging Interventions

Acceptance of Chatbots

Most participants (n=15) were willing to use chatbots to receive information about COVID-19. The most mentioned positive perception of chatbots was getting information instantly (n=4). As one participant explained, “it’s faster to get responses from a chatbot rather than from waiting for a doctor” (participant #16). Participants perceived chatbots useful when a human is not available to answer a question, “I think that chatbots would be better because a human chatting will not be available always” (participant #10). Meanwhile, participants were concerned about chatbots’ generic responses without a specific answer to their questions (n=3). Facilitators of using chatbots included providing accurate messages from trusted sources and launching the chatbot on a credible website (n=4), avoiding long responses (n=4), and ensuring a user-friendly design (n=2). Barriers of using chatbots were failing to answer users’ questions (n=3), preferring real people to a robot (n=2), and difficulties in expressing one’s thoughts and feelings via texts (n=1).

Acceptance of Automated Text Messages

Using text messages to receive information about COVID-19 was generally acceptable (n=11) but was less popular and evaluated less positively than using chatbots. The top positive perception of automated text-messaging services was easy to scale (n=3). Participants said that “most of us have cellphones in our pockets, so it’s easier to reach citizens using text messages” (participant #16); “it’s helpful to send statewide announcements so that we can decide what is the best way to act” (participant #1). Facilitators of using automated text messages included reminding and nudging people into prevention actions (n=4) and being flexible to opt-in and opt-out of the service (n=1). The top barrier was that text messages are burdensome (n=7). Participants were concerned about getting overwhelmed by text messages: “If I was overflooded with messages then I might not read it, or just not get too much inundated with the information, that might be too much information to use in a helpful way” (participant #17).

Liked/Disliked Features and Message Optimization Suggestions

Preference for Informative Messages about COVID-19 and Vaccination

A theme that emerged across all three ethnic groups was their preference for informative and factual messages. Participants liked informative messages because they wanted to learn new and up-to-date knowledge about COVID-19 and its vaccine. They also emphasized the practical value of these messages in providing clear instructions about how to prevent COVID-19. Participants liked factual messages supported by scientific evidence because these facts allow everyone to be on the same page and help establish credibility. Evidence-based messages were needed to dispel misinformation about COVID-19 vaccine. We summarized themes about message preference and the corresponding quotes in Table 4.

Table 4.

Themes about Preferred Message Features and Suggestions for Cultural Adaptation

Themes	Subthemes	Example Quotes	n (%)
Liked message features	Informative messages	“More information about the number of people who have gotten the vaccine and how many or the percentage that has benefitted from that would be helpful especially with the different cultural racial groups. How effective is it in Hispanics or African Americans etc.?” (participant #7, Latino)	16 (88.9%)
	Positive messages	“Giving people hope. It’s hopeful telling people that if get vaccinated you can go back to school healthy and happy.” (participant #21, AI/AN)	15 (83.3%)
	Prosocial messages	“Messages should show the importance of getting vaccinated for the good and for the safety of the whole community” (participant #12, AA) “The message brings in the integrity of the United States” (participant #13, AA)	13 (72.2%)
	Messages with reminders	I would like to get reminders of the rules to avoid the disease. You can even publish that on social media. (participant #8, AA)	10 (55.6%)
Disliked message features	Negative messages	“I do not like the message that puts in “the deadly” before the COVID-19 mixed in... And once you get a virus, you’re going to die. It’s kind of scary.” (participant #10, AA)	12 (66.7%)
	Complicated and long messages	“It feels like a bunch of medical jargon which I may not understand being thrown at me.” (participant #13, AA)	11 (61.1%)
Suggestions for making the messages more culturally relevant	Including cultural practices	“A native person stories can be very impactful, and we learn a lot easier. We learn better. I would probably get more out of the story than maybe somewhere else.” (participant #17, AI/AN) “For my culture, for a Peruvian, they wouldn’t understand what the ABC’s song is, they just don’t know… but there are other types of songs. I would have to accommodate them to something else from my Peruvian culture, so that they can understand what they are singing.” (participant #3, Latino) “My community is very big community-oriented…So groups will be helpful. Leaders of these groups should reach out to their members and check in with people.” (participant #05, AA)	8 (44.4%)
	Using native languages (Latino and AI/AN specific)	“I think if the message were in your own language, it probably might draw you in more. Using some of the words, maybe catchphrases, or if they were in tribal language that might make draw you in more and make you read it or adhere to it more strictly.” (participant #17, AI/AN)	4 (22.2%)
	Including family and friends	“Show your family that you care about them by wearing a mask. Most of us, we really care about our families. When vaccinated, you are really protecting your family” (participant #8, AA)	4 (22.2%)

Note. The column n represents the number of participants mentioned the theme in the interview.

Preference for Positive Messages

Participants also liked inspirational, motivational, and hopeful messages. Positive messages were useful to cheer people up, calm people down, and unify the community during time of crisis. Participants from different ethnic groups emphasized different aspects of positive messages. AI/AN and AA participants felt it was important to give people hope that the pandemic would end eventually, and our life could return to normal if everyone could do their part. Messages emphasizing hope would make people feel good and motivate people to follow what was suggested in the message. In comparison, Latino participants liked real, honest, and informative messages showing the benefits of taking preventative measures and getting the COVID-19 vaccine. They also preferred uplifting messages and sharing hero stories.

Preference for Prosocial Messages

Participants liked messages that mentioned care for children, elderly, and social others in general. These messages emphasized benefits to the whole community and made participants feel unity in between everyone going through COVID-19 impacts. Prosocial messages can also stimulate altruistic mindsets, which motivate people to change behaviors for protecting vulnerable and at-risk others, particularly children and older people.

Disliking Negative Messages

Participants disliked messages that conveyed negativity or triggering negative emotions, including fear-framed, pessimistic, stressful, demotivational, and sarcastic messages. They explained that these messages were judgmental and were centered around blame. These messages made people feel deterrent and upset, and they would ultimately become irrelevant messages for prevention.

Disliking Complicated and Long Messages

Participants disliked messages that included difficult language, unclear meanings, and usage of medically advanced language or jargon. AA participants were not in favor of these messages because the use of medical jargon made it difficult to understand the prevention messages and easily lose attention. Latino and AI/AN participants disliked long messages because they would not remember them and felt they only needed messages key to the point.

Suggestion for Including Different Cultural Practices

Participants suggested to optimize the messages to be more culturally relevant, linguistically appropriate, and reflect their cultural values. The most discussed strategy is to incorporate distinct cultural practices in the prevention messages. For example, AI/AN participants mentioned native people’s stories would be impactful. One Latino participant expressed that they would like some Spanish cultural songs recommended as songs to sing while washing hands for at least 20 seconds.

AA participants mentioned that including cultural practices in prevention messages would further connect people with the messages. For example, they would like messages that clarify the myth of using spices to protect against COVID-19 since it was used in their culture. Another practice in the African American culture was that faith leaders communicated prevention information to their community members.

Suggestion for Using Native Languages

Latino and AI/AN participants valued having the messages written in their first language. For example, translating the messages into Spanish or tribal language would make the messages more relevant to their culture. This is particularly beneficial for people with limited English proficiency.

Suggestion for Including Family and Friends

Messages were perceived more culturally resonant with participants when focusing on protecting family members and loved ones, particularly among AA participants. More than half of the AA participants felt that messages talking about keeping children and their family members safe and being able to get together with people they love would be beneficial and motivate them to engage prevention behaviors.

Discussion

This formative research informs the development of health communication campaigns to disseminate COVID-19 prevention messages targeting ethnic minorities. We found that ethnic minorities were mainly concerned about their social life, financial status, work-related stress, neighborhood conditions, and mental health during the pandemic. As ethnic minorities may live in overcrowded housing (Laurencin & McClinton, 2020; Rocklöv & Sjödin, 2020) and have job duties that cannot be performed at home (Kirby, 2020), they are at greater risks of COVID-19 exposure and infection. Compared to White, minority groups have higher poverty rates (KFF, 2019), lower access to green spaces (Dai, 2011) and healthy food (Brownell & Battle Horge, 2004), which make it financially, physically, and mentally more challenging for them to follow the prevention measures and stay healthy during the pandemic, intensifying COVID-19 related disparities faced by people of color. These studies, combined with our own, suggest that communicating prevention measures, together with social and financial resources, skills to adapt to the new normal, case alerts in one’s neighborhood, community-based services, and mental health support will necessitate the design of public health messages to address long-term impacts of the pandemic.

This research provides preliminary data on ethnic minorities’ acceptability of chatbots and the potential of using mobile health solutions to reduce disparities. Prevention messages should be disseminated through communication channels that are well-received by ethnic minorities. Our study found that ethnic minorities better accepted chatbot services than automated SMSs. Chatbots enable natural conversations and grant users greater autonomy to control when to receive messages and what types of messages to receive. Additionally, because COVID-19 is a rapidly evolving pandemic, chatbots are well adapted to the ever-changing nature of prevention measures, vaccine status, and policies, which could be a major challenge for static health communication campaigns. Themes identified in this study will help us determine key functions and topics of the chatbot, focusing on addressing unique challenges faced by ethnic minorities and barriers and facilitators to vaccination. Participants’ preferred message features will guide us to optimize chatbot responses. Although evidence suggests that ethnic minorities face a significant technology gap, over 95% of the U.S. adults own a mobile phone in some kind, and AA and Latino adults rely on mobile phones to acquire online health information more frequently than Whites (Pew Research Center, 2017). This trend indicates that mobile technology is a promising solution to reduce ethnic health disparities.

This study contributes to the literature on vaccine hesitancy by uncovering the underlying reasons for COVID-19 vaccine hesitancy among AA, Latino, and AI/AN participants and exploring strategies to address these concerns. Ethnic minorities hold both positive and negative perceptions of the COVID-19 vaccine. Providing credible messages supported by scientific evidence and correcting myths can reinforce people’s positive perceptions about the vaccine and reduce vaccine hesitancy. Racial and ethnic minorities had experienced discrimination and injustice in medical treatment historically, which leads to low levels of trust in government and healthcare. Because our data were collected before emergency and formal authorizations were in place, we can only infer that concerns our participants raised about mistrust in governmental systems may carry forward to the present, authorization notwithstanding (Guidry et al., 2021). Intervention messages should be sensitive to these past experiences, clarify the good motives of vaccination and clinical trials, and show efforts to ensure equitable access to the vaccine. Additionally, messages emphasizing protection for family members, vulnerable populations, and other community members will be more persuasive for ethnic minority groups with a collectivist culture that values social responsibilities and prioritizes a community’s interest (Everett et al., 2020).

In summary, to address the barriers and facilitators to getting the COVID-19 vaccines, health communication campaigns should 1) increase credibility of the information source, reduce inconsistent messages, and correct misunderstandings; 2) build trust between healthcare agencies and the communities they serve and depoliticize public health policies; 3) frame the messages positively, emphasizing the hope to end the pandemic and return to normal; 4) use prosocial frames to emphasize social responsibilities and the importance of protecting family members, vulnerable groups, and others in the community to stimulate altruistic thinking and prosocial behaviors.

Finally, our study identifies several promising strategies to enhance engagement and efficacy of public health messages to promote the uptake of COVID-19 vaccines. Participants preferred transparent information with strong scientific evidence supporting the statement and explaining the rationale behind it. People resonated more with messages that offer practical value, for example, simple reminders and direct instructions for how to implement specific strategies or actions to prevent COVID-19. This approach addresses contextual factors and emphasizes skill-building, which is key to improving self-efficacy and particularly useful to nudge behavioral changes. Messages should also be tailored to target audience’s native languages, their cultural values, and traditional practices.

Strengths and Limitations

Our study is among the first to identify the challenges, barriers and facilitators to COVID-19 vaccination, acceptability of chatbot-based interventions, and preferred message features among ethnic minorities who face substantial COVID-19 disparities, including both English and Spanish speakers. By focusing on these groups as our primary populations of interest, we address a major gap in mobile health efforts to prevent COVID-19.

The study has several limitations. The convenience sampling method and the small sample size limit the generalizability of the findings. Additionally, since we only recruited participants in the Denver Metropolitan Area, we should interpret the findings with caution, being aware of its geographical constraint. The qualitative data were collected before any vaccines had been approved for emergency use. Therefore, our findings may reflect people’s concerns and attitudes about COVID-19 vaccines at a particular stage of the pandemic. Given the dynamic nature of vaccine hesitancy, further research may explore whether people’s views change before and after vaccines were approved. Although we provided participants the option for phone interviews, all participants chose to be interviewed online through Zoom. More data are needed to explore the views, needs, and preferences of those who are lower in socioeconomic status, harder to reach, and have barriers to using the Internet.

Conclusion

Ethnic minorities face unique challenges in the COVID-19 pandemic. Vaccination barriers are concerns about side effects, vaccine safety, misinformation, and distrust in the government and healthcare system. Participants preferred messages to be informative and factual, positive and motivational, prosocial, and having practical values. Participants also suggested that messages should include different cultural practices, be translated into their native languages, and emphasize the benefits for family members. This work informs the development of effective and culturally tailored public health messages to promote the uptake of COVID-19 vaccines and prevent the disease, especially for populations facing disparities during the COVID-19 pandemic.