Engaging Asian American Communities During the COVID-19 Era Tainted With Anti-Asian Hate and Distrust

COVID-19 has created disproportionate burdens for Asian Americans,^1–4 the fastest-growing racial group by immigration in the United States.⁵ “Asian American” refers to a diverse population of over 40 cultural groups with distinct languages.⁶ California has the highest number of COVID-19 cases,⁷ and is also home to the country’s largest number of Asian Americans, constituting 16% of the state’s population.⁵ Structural barriers, including low health care access and undertesting, have contributed to excess COVID-related mortality and burdens among Asian Americans.^8,9 Asian Americans may face additional sociocultural challenges to fully engage in appropriate COVID-19 protective measures, including limited English proficiency, mistrust of governmental or health authorities, fear and social stigma related to COVID-19, and exposure to the misinformation infodemic.^9–13

The COVID-19 era of mistrust and information overload creates significant challenges to empowering community members to access credible, timely, and linguistically appropriate information. With support from the National Institutes of Health–funded Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiative,¹⁴ Project INFORMED (INdividual and Family Oriented Responsive Messaging Education; ClinicalTrials.gov Identifier: NCT04893265) was designed to help Chinese, Hmong, and Vietnamese Americans make well-informed decisions about safety measures, testing, and vaccination for COVID-19. Herein, we describe lessons learned from engaging Chinese, Hmong, and Vietnamese Americans during the pandemic through the implementation of INFORMED. We also provide examples of recommended strategies derived from these observations and lessons learned, which may prove valuable for engaging underserved communities in facilitating health education during the COVID-19 pandemic and beyond.

INFORMED DECISION-MAKING ON TESTING AND VACCINATION

INFORMED, an ongoing community-engaged research project, has been implemented to work with Chinese, Hmong, and Vietnamese communities in urban northern and rural central California since October 2021. INFORMED aims to provide up-to-date culturally and linguistically appropriate information about COVID-19 that is responsive to the rapidly evolving pandemic in convenient locations (e.g., homes) via video conferencing and text messaging. INFORMED project partners include

• 1.Three community agencies in San Francisco, Fresno, and Santa Clara counties with extensive histories of providing culturally and linguistically appropriate social services and health education for Chinese, Hmong, and Vietnamese communities;
• 2.Ten academic researchers with expertise in psychology, public health, health communication, clinical medicine, laboratory medicine, medical anthropology, biostatistics, and community-based participatory research;
• 3.Nine lay health workers (LHWs; two Chinese, four Hmong, and three Vietnamese), with cultural and linguistic backgrounds like those of the participants, who serve as trusted health messengers; and
• 4.Eight advisors with expertise in mass and social media, patient health education, social services, and Asian American health care as Community Advisory Board members.

Initial insights are largely drawn from observed engagement of the first 177 INFORMED COVID-19 trial participants (83 Chinese, 14 Hmong, and 80 Vietnamese) in an intervention consisting of health education sessions with LHWs, a project Web site, and text messaging. This is coupled with insights from initial analysis of in-depth interviews conducted with 17 key informants (KIs; six Chinese, six Hmong, and five Vietnamese).

ENGAGING ASIAN AMERICANS IN THE COVID-19 ERA

We synthesized initial lessons learned during study implementation (October 2021 to March 2022) and recommend three strategic foci—culture, capacity, and convenience (“the three Cs”)—that played interrelated roles in engaging Chinese, Hmong, and Vietnamese community members from recruitment to participation in INFORMED (Figure A, available as a supplement to the online version of this article at http://www.ajph.org).

The First Strategic Focus of Engagement: Culture

First, we recommend embracing cultural facilitators when engaging with communities. Culture draws attention to cultural values and practices, specifically in utilizing trusted health messengers or culturally appropriate communication channels in delivering credible information. The rapidly evolving pandemic, ubiquity of misinformation, and confusion from information overload or scarcity have underscored the profound need to receive COVID-19 information from trusted sources. Navigation needs were especially pronounced among older community members. For example, an elderly monolingual Hmong KI relied on the few Hmong social media platforms to update him on COVID-19 information, including the proper use of masks and hand sanitizers. Similarly, Vietnamese KIs shared the importance of accessing COVID-19 testing and vaccination in familiar locations, such as local pharmacies served by Vietnamese-speaking staff. Several older Chinese KIs mentioned obtaining COVID-19 information through WeChat (popular especially among Chinese participants).¹⁵

Trusted health messengers

LHWs are trusted health messengers who share cultural and language backgrounds similar to those of the communities of focus.¹⁶ LHW outreach interventions have effectively promoted health, including cancer screening and smoking cessation among Chinese, Hmong, and Vietnamese Americans.^16–19 When conducting educational sessions, LHWs built trust among their participants by presenting information from credible and recognized sources (e.g., University of California researchers and local community agencies). LHWs also shared personal anecdotes and experiences with COVID-19 testing and vaccination to engage trial participants.

Communication channels

To comply with COVID-19 safety practices, we designed study participation to be entirely remote. INFORMED utilized various channels to deliver COVID-related education, including text messaging, an in-language educational Web site, and LHW interactions with trial participants via educational sessions on Zoom and follow-up telephone calls. All trial participants received weekly text messages over the course of 12 weeks in their preferred language regardless of their group assignment; these covered topics from COVID-19 impacts to testing and vaccination resources. Half of the participants were randomly assigned to participate in small group educational sessions with their LHWs using Zoom at a mutually agreed-upon time. All trial participants had used text messaging, but about half were new to Zoom. Two trial participants joined by telephone to participate in the sessions using hard copies of the presentation handouts that they picked up before the session at a local pharmacy that was convenient to them. LHWs also conducted individual telephone calls to follow up with each participant to address questions. A Vietnamese trial participant commented on the survey that Zoom meetings were highly acceptable: “Họp trên zoom rất sống động, rất thú vị và học hỏi nhiều điều mới lạ” (“Meeting on Zoom was very lively, very interesting and [I] learned many new things”). Overall, using multiple culturally appropriate communication channels to engage community members across generations was essential.

The Second Strategic Focus of Engagement: Capacity

Second, we recommend integrating intervention strategies to build capacity when engaging with communities. Capacity relies on an individual’s knowledge and skills in transforming knowledge into action, such as adhering to COVID-19 safety measures. This involves identifying the community’s evolving needs, including knowledge gaps, misinformation, and barriers to the targeted actions (e.g., getting tested or up-to-date on COVID-19 vaccination). One key objective was to craft health educational messages in the preferred language, considering cultural context to facilitate understanding and decision-making in practicing recommended COVID-19 safety measures. The following are examples of evolving community needs that guided our responsive engagement strategies.

Evolving community needs

One of the prominent evolving community needs was related to barriers to COVID-19 testing. Some Chinese LHWs reported that most of their trial participants only tested because of work regulations or symptoms. Many Chinese-speaking participants refused testing for fear of catching COVID-19 by congregating at testing sites. A Vietnamese KI shared their anxiety about having to wait several days to get tested and potentially exposing those around them to the virus. Older Hmong KIs shared that they were limited to a COVID-19 testing site with Hmong staff, which only offered testing once a week. Younger Hmong participants who were bilingual in English and Hmong, however, did not have the same challenges accessing COVID-19 testing.

Concerns about vaccination

Although most KIs were fully vaccinated, they expressed concerns about long-term side effects of the vaccines and the need for booster shots. Some Vietnamese KIs questioned the evidence supporting the fourth dose and doubted that it could prevent COVID-19 infections. KIs from all three groups expressed concerns about vaccinating children, mentioning fears that it would change DNA, lead to autism, or affect development. LHWs also noticed that their participants expressed concerns about the vaccine’s effects on growth and development among children. Thus, acknowledging community members’ concerns about booster vaccination and vaccination in children was important in guiding our engagement strategies.

Emerging and unmet mental health needs have become apparent in the context of the pandemic. Several KIs shared the mental health toll of practicing COVID-19 prevention strategies, such as limiting social interactions. A Chinese KI described being “imprisoned at home” for the past two years. Several Hmong KIs indicated the need to provide psychological support, including virtual mental health services for COVID-19 patients during their diagnosis and fears about quarantine. A Chinese KI provided unprompted descriptions in the interview that she was concerned about safety and anti-Asian racism.

Responsive strategies

Drivers for engagement and participation in the project include interest in the latest news, credible information, and information that is easy to comprehend. INFORMED educational content was guided by literature and input from the Community Advisory Board on evolving needs of respective communities. The project’s core messages were modified in response to feedback and questions from LHWs and their participants, the ongoing and changing pandemic, and insights from in-depth interviews with KIs. Each text message provided an image with brief information on a topic; a link to the project Web site providing additional relevant, current, and credible information; and links to the Centers for Disease Control and Prevention and to state and county public health departments that address specific concerns, such as booster vaccination and vaccination in children. To accommodate the literacy levels of some Hmong trial participants who could not read, the weekly text messages were offered in both visual and audio formats. In addition, we also crafted messages with high relevance to our communities.

For example, the first weekly text message—“COVID is a serious problem among Asian Americans. Find out why here: http://covid-informed.org/en/messages/1”—was used to engage trial participants in learning and sharing their views about the impacts of COVID-19 on Asian Americans. One Chinese trial participant wrote, “Covid 病毒对我们影响极大.不敢出街.又怕被别人挨打。” (“The COVID virus has a great impact on us. We dare not go out. We are afraid of being beaten up by others”). Another participant mentioned the rampant discrimination against Chinese people, commenting, “COVID-19 对中国人在美的影响很大,岐视华人” (“COVID-19 has a great impact on Chinese people in the US, discriminating against Chinese”). As of March 2022, this first message received 68 comments from trial participants, including 37 likes, two dislikes, and 29 individual written comments. These observations supported participants’ high acceptability and comfort level in utilizing the study Web site to share their concerns.

The Third Strategic Focus of Engagement: Convenience

Third, we recommend incorporating methods that would be convenient for community members when engaging them. Convenience focuses on facilitating easy access to updated information and recommendations. Creating opportunities for accessing trustworthy information in a preferred language through convenient communication channels was important in engaging community members.

In-language outreach

Our Chinese LHWs, trial participants, and KIs used WeChat,¹⁵ a social media messaging app popular among the Chinese, as a source of COVID-19 and health-related information. A Chinese KI mentioned that she needed to gather information from multiple sources because she did not trust the common narrative about vaccines and wanted to understand all sides. Hmong KIs shared that they used Google, local TV, YouTube, and social media to acquire COVID-19 information. LHWs working with Hmong and Vietnamese communities shared that texting and telephone calls remained the most frequently used and preferred methods of communication. Despite the risk, community members with limited English proficiency expressed a preference for in-person meetings for learning new information. For example, COVID-19 centers located in familiar and easily accessible locations, such as pharmacies in popular Vietnamese shopping areas with Vietnamese-speaking staff, served as a convenient source of COVID-19 testing and vaccination information. A monolingual Vietnamese-speaking KI shared that it was easy for her to get tested because the staff spoke Vietnamese and the location was convenient.

Convenient channels

Establishing a trusting relationship remains an important initial step. Although most trial participants (all Chinese and Vietnamese and a majority of Hmong) had their educational sessions online via Zoom video conferencing, some monolingual Hmong participants preferred to meet in person. Following the agency’s COVID-19 safety protocol, our Hmong LHWs hosted in-person group sessions at the Fresno Center, a well-known social service agency that is in a conveniently accessible location.

Once enrolled, participants were scheduled to receive automated SMS text messages that delivered 12 weekly messages in their preferred language (English, Chinese, Hmong, or Vietnamese). Each message included a short text and an image with information about the COVID-19 topic. Clicking on links within the text message brought participants to the INFORMED Web site, where they could read more about that specific topic, find additional resources to explore, indicate like or dislike, and write comments. As of March 2022, 476 comments were made in Chinese, Vietnamese, and English by 75 unique trial participants across the 12 message boards, representing 63% of the trial participants who visited the Web site and 42% of all the enrolled participants at the time.

In addition, participants also received text message alerts about relevant COVID-19–related events or news, such as notifications of free at-home COVID-19 testing kits, community seminars, and new COVID-19 vaccination sites with language support. Alerts were also sent to participants for culturally appropriate celebrations or events, such as a greeting for Lunar New Year. A Vietnamese trial participant commented that information on the Web site was very helpful: “Các thông tin về covid 19 rất hữu ích và thú vị, do đó xin luôn cập nhật” (“The information about COVID is very useful and interesting, so please keep it up to date”). Another Chinese trial participant also shared appreciation for the educational contents of the program and the convenience of text messaging: “喜爱,提供很多内容另我知道得更多关于疫苗和疫情的资信,短信传递方便! ” (“Love it. It provides a lot of content and I know more about vaccines and the pandemic information. SMS delivery is convenient!”)

CONCLUSIONS

The research team benefited from the trust established by long-standing partnerships among community organizations, academic institutions, and community members to create culturally appropriate study activities to further understand evolving needs and develop potential solutions to facilitate information-seeking behavior. This was achieved by practicing humility when examining facilitators and barriers concerning COVID-19–related health for specific cultural groups and socioeconomic characteristics.

Based on our findings thus far, we strongly recommend considering the three Cs (culture, capacity, and convenience) in designing strategies to engage communities to stay informed and take charge of their health during a novel emergency encounter such as COVID-19. Applying the three Cs as strategic foci could be considered to promote health equity and to build the foundation for culturally and linguistically appropriate, trusted, accessible, and timely community engagement. To move beyond engagement, we recommend collaboration as early as study conceptualization. Our recommendation highlights the importance of using a responsive, multipronged approach to facilitate a colearning process for collaboration and nontransactional partnerships among researchers, community members, and community organizations.

PUBLIC HEALTH IMPLICATIONS

COVID-19 has caused significant burdens in the United States and globally. Timely and effective communication of accurate COVID-19–related information to underserved communities has become more critical than ever and has faced unprecedented challenges. This article shares insights gained from successful initial efforts to engage three Asian American communities in COVID-19 education and provides examples of core elements in engaging Asian American communities, with attention to culture; capacity to meet evolving needs, including knowledge and practical resources; and creation of convenient, accessible, and trusted channels to facilitate reach.