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. 2023 Feb 3;45(2):172–194. doi: 10.1177/10755470221151184

Communication and Perspectives About COVID-19 and Vaccinations Among Native Americans

Rachel Ellenwood 1, Amanda D Boyd 1,2,✉, Zoe Higheagle Strong 1
PMCID: PMC9899666  PMID: 38603454

Abstract

The COVID-19 pandemic disproportionately affected Native American people and communities across the United States. Despite unequal losses during the pandemic, Native Americans have high vaccination rates. We provide insight into perspectives of COVID-19 and vaccinations through in-depth interviews with Native Americans. Through this research, we provide a holistic view of how Native Americans perceive vaccines by pairing Indigenous perspectives of risk and the Health Belief Model. We discuss the importance of tribal sovereignty in developing health communication strategies, and the need for messaging that is trusted and culturally appropriate.

Keywords: Indigenous, Health Belief Model, disease, vaccine, COVID-19, elder, culture

COVID-19 has disproportionately affected Native American populations in the United States. Native Americans have infection rates more than three times higher than non-Hispanic Whites and are more than four times more likely to be hospitalized as a result of COVID-19 (Indian Health Service, 2022). Racial inequities and historical trauma continue to contribute to disparities that impact morbidity and mortality rates associated with COVID-19 (O’Keefe & Walls, 2021). COVID-19 vaccines remain the primary means to eradicate the pandemic (Le et al., 2020); however, many people remain hesitant (Troiano & Nardi, 2021). Researchers, public health officials, and policymakers have stressed the need to develop effective COVID-19 vaccine-acceptance messaging to increase vaccination rates (Malik et al., 2020).

To develop effective health risk messages, communicators must first understand the factors that influence perceptions of a hazard (e.g., a health hazard such as COVID-19) (Fischhoff, 2013). It is especially important to understand the factors influencing Native American perceptions of COVID-19 because there may be distinct factors unique to this population (Boyd & Buchwald, 2022; Finucane et al., 2000). For example, studies find that Native Americans often combine culturally grounded perspectives of health with conventional biomedicine to form a holistic view of well-being (Lang, 1989). It is particularly important to study perspectives and communication about COVID-19 vaccinations because Native Americans have high vaccination rates. The Centers for Disease Control and Prevention (CDC, 2022) reports that Native Americans are 24% more likely than Whites to be fully vaccinated, 31% more likely than Latinos, 64% more likely than African Americans, and 11% more likely than Asian Americans. There may be much to learn from this case, yet to date there are few studies that examine communication about COVID-19 vaccines with Native Americans.

In this study, we examined risk perceptions of Native American people from the Nez Perce reservation. Specifically, we examined social, historical, and cultural factors that influence their beliefs about COVID-19 vaccines. Guided by the Health Belief Model, we also sought to understand how health communication may have contributed to high vaccination rates. In this article, we present context for the study including health disparities among Native American people, factors that may influence perceptions, and communication about COVID-19 vaccinations and provide background on our theoretical approach which is guided by the Health Belief Model and Indigenous perspectives of risk. Conclusions and discussion focus on how this study advances the science about perspectives of COVID-19 vaccinations, and how the Health Belief Model can be advanced by incorporating cultural considerations of risk.

Background

Native Americans, Health Disparities, and Disproportionate Rates of COVID-19

Approximately 0.9% of the U.S. population, or 2.9 million people, identify as American Indian or Alaska Native (U.S. Census Bureau, 2020). The Native American population is one of the highest growing groups in the United States and is expected to increase to 5 million by 2065 (U.S. Census Bureau, 2020). There are 574 federally recognized tribes (National Congress of American Indians, 2021). These tribes are classified as sovereign—meaning a tribe has a right to govern their own people and are considered separate from the state. With sovereign status, tribes are responsible for their own governments, health care, and education systems (National Congress of American Indians, 2021).

Healthy People 2020 defines health disparities as, “a particular type of health difference that is closely linked with economic, social, or environmental disadvantage.” In particular, health disparities adversely affect populations who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group (Office of Disease Prevention and Health Promotion, 2020). In comparison with other racial and ethnic groups, Native Americans have a lower life expectancy and are disproportionately affected by many chronic diseases (Arias et al., 2014; Cobb et al., 2014). According to the Indian Health Service, the age-adjusted death rate for Native American adults exceeds that of the general U.S. population by almost 40%, with death due to diabetes, accidents, and chronic liver disease and cirrhosis occurring at least three times the national rate, and deaths due to tuberculosis, pneumonia and influenza, suicide, and homicide also exceeding those of the general population (Sarche & Spicer, 2008).

It is well established that some people have a higher risk for severe illness from COVID-19. The risk of severe illness increases for people 50 and older, and people 85 and older are most likely to get very sick if they contract COVID-19 (CDC, 2022). This fact is important to note as elders are greatly respected in Native American communities. In addition, those with underlying medical conditions (including cardiovascular disease and diabetes) are at higher risk of developing severe COVID-19 than those without these conditions (CDC, 2022). It is important to consider that Native American populations often have disproportionate rates of underlying medical conditions than non-Hispanic Whites (Indian Health Service, 2019). A challenge Native Americans continue to face is poor access to adequate health care (Jones, 2006). Multigenerational households are consistently considered a strength and source of resilience for Native American people (Belone et al., 2020). However, during the pandemic, living in a multigenerational household was associated with an increased risk of COVID-19 death (Ghosh et al., 2021). In addition, numerous inequalities in infrastructure, public health funding, access to medical care, housing, and clean water that has contributed to the health disparities that place Native American communities at higher risk for infection, mortality, and severe illness from COVID-19 (Arrazola et al., 2020). All of these factors contributed to disproportionate rates of morbidity and severe COVID-19 illness among Native American people. The risk of COVID-19 infection for American Indian and Alaska Native people was 1.6 times higher than for White people, and the risk of death from COVID-19 was twice as high (CDC, 2022).

Risk Perceptions and Communication Processes

Risk perceptions can be defined as the subjective judgments people make about the characteristics and severity of a risk (Slovic, 1987). People understand and perceive risks differently, and there are numerous factors that influence people’s perceptions of a risk (Slovic, 1987). This can include trust in the communicator, past experiences with the hazard, who the hazard impacts, among many other factors (Sandman, 1987). Examining risk perceptions provides a foundation to develop and improve health communication strategies (Fischhoff, 2013) and can inform effective health messaging strategies for Native Americans (Boyd & Furgal, 2019).

It is important to understand risk perceptions of COVID-19 vaccinations to better understand vaccine hesitancy (Ding et al., 2020). There is a critical need for information on knowledge, attitudes, and beliefs among Native Americans regarding vaccines (Urban Indian Health Institute, 2021), particularly because they are disproportionately impacted by COVID-19. This information will provide the critical information needed to develop informed, culturally appropriate health communication strategies.

Recent unpublished studies have examined Native American perceptions of COVID-19. For example, community groups and researchers recently hosted listening sessions as part of the COVID-19 Vaccine Confidence Project (Regan-Udall Foundation, 2021). The intent of this project was to help understand public perceptions about COVID-19 vaccines, identify what information key audiences want, and ultimately create messages to provide the information. An additional study was completed by the Urban Indian Health Institute to understand knowledge, attitudes, and beliefs about COVID-19 vaccines (Urban Indian Health Institute, 2021). These two studies found that many Native Americans are concerned about disparities in the health care system and there is some distrust in Western medicine and research (Regan-Udall Foundation, 2021). This distrust stems from a legacy of genocide, medical experimentation, as well as wrongdoings by medical personnel and organizations (Pacheco et al., 2013). Many participants also considered the historic spread of infectious disease in their perceptions of COVID-19. For example, in the 1700s, smallpox was transmitted to Native Americans through infected blankets or clothing (Patterson & Runge, 2002). It is therefore important to understand the historical contexts that may factor into how Native Americans perceive COVID-19 and vaccinations.

The COVID-19 Vaccine Confidence Project and Urban Indian Health Institute studies both showed that information source about COVID-19 vaccinations is critical. The COVID-19 Vaccine Confidence Project study found that examples of trusted messengers for information about COVID-19 included tribal leaders and elders (Regan-Udall Foundation, 2021). Studies among the general United States population have shown that people are more likely to get the vaccine if their doctor or another health professional recommends it (Reiter et al., 2020). According to the Urban Indian Health Institute (2021) survey, the most trusted source of information about COVID-19 vaccines among Native Americans was health care professionals. However, it is also important to note some Native Americans may not fully trust non-Indigenous health care providers (Walters et al., 2020).

Responsibility to community, elders, ancestors, and children is important among Native Americans. These priorities may influence perceptions of vaccines. For example, the Urban Indian Health Institute found that the primary reason why participants indicated a willingness to get vaccinated was not only “to prevent unnecessary death and illness of loved ones, but also to preserve Native cultures, traditions, languages and sacred knowledge” (Urban Indian Health Institute, 2021, p. 38). About three-quarters of participants believed getting vaccinated was their responsibility to their community. In regard to sense of community, vaccination was also seen as a way to return to in-person community more quickly, which is also an important aspect of Native American culture and life (Urban Indian Health Institute, 2021).

The Health Belief Model and Indigenous Perspectives of Risk

The Health Belief Model is a theoretical model that has been used to inform health promotion and communication campaigns (Strecher & Rosenstock, 1997). It was originally developed by social scientists to better understand why people did not adopt disease prevention behaviors (Rosenstock, 1974). The Health Belief Model contends that an individual’s actions related to a health behavior depend on the person’s perceptions of the benefits and barriers related to that behavior (Rosenstock, 1974). There are six primary constructs of the Health Belief Model, including (Strecher & Rosenstock, 1997):

  1. Perceived susceptibility: Perceptions of the risk of getting an illness or disease.

  2. Perceived severity: Perceptions of the seriousness of contracting the illness or disease.

  3. Perceived benefits: An individual’s perception of the benefits of taking action to reduce the hazard (i.e., an individual will consider the benefits associated with the action).

  4. Perceived risks/barriers: Perceptions of the obstacles to performing a recommended health action (i.e., an individual will consider the negatives associated with the action).

  5. Cues to action: The internal or external stimuli that trigger the decision-making process and action.

  6. Self-efficacy: A person’s confidence in their ability to successfully perform a behavior.

There are few studies conducted using the Health Belief Model that are congruent with Indigenous or Native American cultural perspectives. We aim to undertake a study that is both informed by the Health Belief Model and Indigenous perspectives or risk to examine how people perceive COVID-19 and ultimately decide to (or not to) get vaccinated. This contributes to not only application but seeks to better understand how perceptions of culture and community inform the theory. Indigenous perspectives include knowledge that is not necessarily from books, rather it is a knowledge that has been passed down through generations and verbal storytelling. Brayboy (2005) recommends that Indigenous perspectives are much needed in research to provide context and meaning to approaches and findings. It is important to include the combination of perspectives (in this case Health Belief Model and Indigenous perspectives) to better understand how Indigenous people view, perceive, obtain, and use the knowledge provided to them. The combination of approaches provides an understanding of the factors that inform an individual’s attitudes and beliefs toward COVID-19 vaccines. This is particularly important because Indigenous populations highly value relationships with kin and cultural traditions. The importance of kin, community, and culture are especially relevant to communication strategies and health policy decisions (Boyd & Furgal, 2019). Figure 1 presents our conceptualization of the Health Belief Model incorporating specific perspectives that are critical to Indigenous perspectives of hazards. These include social, cultural, and historical factors (Boyd & Furgal, 2019; Waterworth et al., 2015).

Figure 1.

Figure 1.

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Framework study guided by Health Belief Model and Indigenous perspectives of risk. RQs refers to research questions and are discussed in the following section.

Research Questions

To examine the factors that influence Native American attitudes toward the COVID-19 vaccine through the lens of Health Belief Model and informed by Indigenous perspectives of risk, our research questions include:

  • Research Questions 1: What is the perceived susceptibility of contracting COVID-19 among Native Americans?

  • Research Questions 2: What is the perceived severity of COVID-19 among Native Americans?

  • Research Questions 3: What are the perceived risks and benefits of receiving a COVID-19 vaccine related to personal, cultural, social, and historical factors?

  • Research Questions 4: (RQ4a) What are the internal and external cues to action to COVID-19 vaccination? (RQ4b) How did communications/messages about COVID-19 influence vaccination behavior?

  • Research Questions 5: What is the perceived self-efficacy associated with successfully receiving a COVID-19 vaccine?

Method

Site of Study

This study was conducted with the Nimiipuu people on the Nez Perce Indian Reservation located in north-central Idaho in the United States. There are approximately 3,500 enrolled citizens of the Nez Perce Tribe and 1,800 enrolled Nimiipuu members residing on the reservation (Nez Perce Tribe, 2020). There are six small towns on the reservation. The Nez Perce Reservation is headquartered in Lapwai and spans approximately 770,000 acres of Idaho (Nez Perce Tribe, 2020).

The Indian Health Service provided health care to the Nez Perce Tribe until 1997 when the Tribe ultimately took over health care under the Indian Health Care Improvement Act (Northwest Portland Area Indian Health Board, 2015). The Tribe now operates in a Self-Governance Compact which allows the Tribe autonomy and the ability to reallocate funds to suit the needs of the population. Nimiipuu Health has two locations: the Lapwai Clinic and an ambulatory clinic in Kamiah.

There are three vaccines available at Nimiipuu Health, including Moderna, Pfizer, and Johnson & Johnson. As of July 2021, there were a total of 3,622 doses of the COVID-19 vaccine administered by Nimiipuu Health. This includes 3,300 doses of Moderna, 200 doses of Johnson & Johnson, and 162 doses of Pfizer (Nimiipuu Coronavirus Response, 2021).

Data Collection and Interview Protocols

Qualitative interviews have successfully been employed with studies using the Health Belief Model (see, for example, Herrmann et al., 2018; Li et al., 2016; Mehta et al., 2013) and are congruent with Indigenous methodologies (Kovach, 2015). We conducted 30 in-person interviews, following COVID-19 precautions. In-person interviews were conducted because they were considered culturally appropriate in this context, and many Native American cultures prefer face-to-face meetings rather than interviews by telephone or internet applications (Letiecq & Bailey, 2004). The primary interviewer for this study was an enrolled member of the Nimiipuu Nation and lived on the Nez Perce reservation. She received training in qualitative research, particularly in interviews with Native American people. Three practice interviews were completed preceding this study. Debriefings were held between the researchers after each of the first five interviews to ensure no additional questions were needed and that the interview protocol was clear. Any issues or questions arising about the interview process were discussed among and addressed by the three authors.

All research participants voluntarily adhered to the CDC regulations for safe work practices (CDC, 2021). Special effort was made to ensure that participants were comfortable with the study by explaining what the study was about, how data would be used, and how results would be returned.

Interviews were conducted using a semi-structured questionnaire that included questions about experience with COVID-19, as well as awareness and perceptions of COVID-19 vaccine messaging. We also included questions guided by the Health Belief Model and Indigenous perspectives of risk (see Table 1). Tribal affiliation and time living on the Nez Perce reservation were also asked. Finally, we asked demographic questions including participant’s age and gender (see Table 2). Participants were provided with a $25 gift certificate to honor their time.

Table 1.

Interview Questions.

Category Questions
General Introduction Questions
1 How long have you lived on the Nez Perce Indian Reservation?
2 Please tell me about your community or living on the Nez Perce Reservation.
COVID-19 Introduction Questions
3 Please tell me about your experiences with COVID-19.
4 Tell me about how it has affected your life (if it has affected you).
Health Belief Model and Indigenous Perspectives of Risk Questions
5 How susceptible do you think you are to contracting COVID-19? (RQ1) What about those in your community? What about American Indians in general?
6 How severe or dangerous do you think it is to get COVID-19? (RQ2) For yourself, for those in your community and for American Indians in general?
7 My next questions focus on your thoughts about COVID-19 vaccines or getting vaccinated (RQ3). What do you see are the benefits to getting a COVID-19 vaccination? What do you see as the risks to getting a COVID-19 vaccination?
8 If you have received a COVID-19 vaccine, what made you ultimately get it (RQ4a)?
What factors influenced your decision to get or not get the vaccine?
9 How do you get information on COVID-19 generally, and COVID-19 vaccinations specifically (RQ4b)? Have you seen any messages or advertisements on COVID-19 vaccines to American Indians? Can you please tell me about them, or what you can remember of them?
10 Can you tell me about the process of getting a COVID-19 vaccine? Is it fairly easy or hard (RQ5)?
General Closing Questions
11 Is there anything else you would like to share about COVID-19 or COVID-19 vaccinations?
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Note. RQ = research question.

Table 2.

Summary of Participant Demographics.

Age Female Male
18–30 3 1
31–40 6 1
41–50 5 2
51–60 1 0
61–70 5 1
71+ 4 1
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Tribal and Institutional Review Board Approval

All research studies conducted on the Nez Perce reservation require a special research permit and must be reviewed by the Nez Perce Tribal Executive Committee (commonly referred to as NPTEC). The Nez Perce Tribal Executive Committee approved our research permit application in October 2020. The study was also approved by the Washington State University Institutional Research Board.

Sample and Recruitment

Snowball sampling was used to recruit participants into the study. Snowball sampling is a nonprobability sampling method in which existing participants suggest other potential participants (Goodman, 1961). This is an ideal sampling method for a small rural reservation, as word of mouth has been shown to be an effective form of recruitment (Goodman, 2011). In addition, we advertised the study and recruited participants through local social media platforms. We also were available to provide information about the study and recruited participants at the Spring General Council located in Kamiah, Idaho. All enrolled Nez Perce citizens over the age of 18 can attend General Council. We attended the meeting, answered any questions about the research, and had a sign-up sheet for the participants who were interested in participating in the study. Interviews were held until the saturation point was reached. In qualitative research, a saturation point occurs when no new ideas are generated in the data and additional interviews will not lead to new emergent themes (Saunders et al., 2018).

Data Analysis

Interviews were transcribed verbatim. This study employs both inductive and deductive narrative analysis processes. The research questions formed the initial discrete categories (e.g., themes on social and historical factors). An inductive approach was used to determine additional themes. An inductive approach was also used because there has been little previous research examining Native American perspectives of COVID-19. The inductive approach involved systematically evaluating the data throughout the analysis process for any previously unidentified themes, verifying themes with other researchers, revising the codebook, and coding based on those emergent categories (Gibbs, 2014). The coding was primarily completed by the first author of this article. Two of the researchers coded the first five transcripts together and discussed how to classify and code participant responses. After the initial coding of the first five transcripts, the two researchers would meet regularly to discuss any inconsistencies in coding or need for additional themes.

Results

Native Americans rely on Indigenous perspectives to contextualize risk. Symbaluk (2019) describes Indigenous perspectives as tribal knowledge that is pragmatic and ceremonial, physical and metaphysical. This study intertwines both the Health Belief Model and Indigenous perspectives to gain a better understanding risk perceptions of COVID-19 and vaccinations. In the results section, we first provide a summary of participant demographics, then discuss the six constructs as guided by the Health Belief Model: perceived susceptibility, perceived severity, perceived risks and benefits, cues to action, and self-efficacy.

Participant Information and Demographics

During May and June 2021, 30 Nimiipuu people from the Nez Perce Reservation were interviewed. The average years of residency on the reservation was 41 years. There were 24 female participants (M = 50 years old) and 6 male participants (M = 47 years old).

Perceived Susceptibility

In this study, we examined three categories of susceptibility. They include personal susceptibility, community susceptibility, and Native American susceptibility in general.

Personal Susceptibility

Participants stated that demographics and health status affected personal susceptibility to COVID-19. Specifically, participants indicated age affected their susceptibility to the disease. Five elder participants in particular stated they were more susceptible to the disease because of their age. Six people specifically stated that they were more susceptible because of their underlying health conditions. Stated conditions that made them more susceptible included diabetes, asthma, heart disease, lupus, arthritis, and other unknown or unexplained medical issues. A female elder participant stated, “I cried when I found out I got COVID, because I didn’t want to get my husband sick . . . he has diabetes and was supposed to have surgery.” The need to protect loved ones, especially those with underlying health conditions, was found to be a primary reason for getting vaccinations or taking other increased health precautions.

Eleven participants stated that they were not as susceptible to contracting COVID-19 because they followed health precautions and guidance (e.g., social distancing, wearing masks indoors). Five of the 11 participants specifically praised the stay-at-home orders and stated that it is the main reason they did not contract COVID-19. Specifically, a couple of participants suggested that an organic diet along with vitamin supplements was form of defense against contracting COVID-19.

Community Susceptibility

In regard to the community in general, many respondents felt that the community was highly susceptible to contracting COVID-19, especially prior to the availability of vaccines. Overall, 12 participants stated that the community was very susceptible because it was a small tight-knit Nation. A particularly important component for the perceived susceptibility of the community was the number of multigenerational households on the reservation. Multigenerational households are common for most Native American communities (Lopez et al., 2021). Among participants in this study, it was suggested that it was an important factor in how the virus spread quickly among the community—particularly because many didn’t know they had COVID-19 until it had already spread to family members. This could in particular affect elders, as there are many who live with grandparents or elderly people in the community. For instance, a participant spoke about how one child had it, was asymptomatic, brought it home to the numerous other children, parents, and grandparents they lived with.

Native American Susceptibility in General

Many participants believed that Native Americans in general were more susceptible to COVID-19. In particular, many suggested that the health disparities common to Native Americans made them more susceptible to COVID-19. A 44-year-old female participant stated, “It affects people in different ways, but I think that we’re one of the populations that is very susceptible.” Some suggested that Native Americans are different than non-Indigenous people providing examples such as diabetes and other underlying health conditions common to Native Americans. A 29-year-old female participant stated, “I think Native Americans are more susceptible because our immune systems are different in certain ways compared to other ethnicities, our bodies can’t process of a lot of things that non-natives can.”

Additional participants suggested that the higher susceptibility rate among Native Americans is due to general housing shortages. With many Native American communities, many need to live in multigenerational households. Some of the housing units do not have adequate access to running water and electricity. A 28-year-old female participant stated, “I think minority groups in general are more susceptible because we are more community orientated, we live in closer tight-knit communities, and have multigenerational households.”

While the majority stated that Native American communities and people were more at risk. There was one participant who stated that Native Americans were not at higher risk. The 44-year-old male stated, “We are as susceptible as anyone else in this country regardless of race or ethnicity.”

Perceived Severity

The majority of participants perceived the severity of COVID-19 as high. As discussed previously, many considered themselves and their community as highly susceptible due to underlying health conditions, along with living conditions. Some participants in particular mentioned other tribes, such as the Navajo people, because of the high number of positive cases and death rates. An elder female participant stated, “COVID has done a lot of damage here on our reservation.” All but one participant indicated that COVID-19 is severe and dangerous for the Nimiipuu community but also for all Native Americans across the country.

Many participants stated that COVID-19 also negatively affected the health and health care of the general Native American population. Once COVID-19 cases increased on the reservation, access to general health care became more challenging. Nimiipuu Health canceled or rescheduled all non-emergent appointments, leaving residents with minimal care for minor health issues. One participant who works in the health care facility stated that patients did not want to go to the facility because they were scared, they would contract the virus, whether their health care needs were emergent or not. One female participant indicated that many Nimiipuu “suffered through health issues, because they felt if they contracted the disease, it would be highly likely that would not survive.”

Perceived Risks and Benefits of COVID-19 Vaccinations

Most participants indicated that the benefits of the COVID-19 vaccination outweighed any risks. Many indicated that Native Americans, and in particular Nimiipuu, cannot afford to lose their population to a viral pandemic. For many reasons, including the continuation of culture and language, participants stated that Nimiipuu must survive the pandemic. Among those that indicated risks of vaccinations, many referenced the unknown—both in regard to the virus, and the vaccination. An elder female participant stated, “according to the news, the virus was only out for 10 months, how can they develop a vaccine so quickly? So, I was skeptical.” The benefits of vaccinations were highly tied to “cues to action”—a topic we turn to next.

Cues to Actions

Twenty-six of the study participants were vaccinated. Four participants did not receive the vaccination. Three of the four participants stated that they will not get the vaccination due to personal reasons or beliefs. One of the four wanted to get the vaccination but was unable to do so because of underlying health conditions preventing her from receiving one.

There were numerous reasons participants were vaccinated. Five participants specifically mentioned their strong belief in science as the reason they chose to get vaccinated. Several participants who had previously had COVID-19, stated they would rather get the vaccination and deal with any symptoms associated with the vaccination, than to get COVID-19 again. Additional reasons to get the vaccine was to avoid wearing a mask, less chance of getting COVID-19 or passing the disease to a loved one, and the associated mental health benefits (e.g., less anxiety, depression, and worrying about passing to others, and increased feeling of safety). Many just indicated the importance of getting back to some sort of normalcy. A cue to action specifically related to the historical loses, deaths, and trauma of past pandemics and disease. One participant stated,

How hard is COVID-19 going to hit you if you get it? Especially in our community because we are a tribe and so we don’t want to have our people killed off, our population is so small already and it’d be unfortunate for something like this to come wipe us out.

Messages and Media Sources

The majority of participants received their information on COVID-19 and COVID-19 vaccinations through the internet and social media. Most looked at the CDC website, the Nimiipuu Health website, and Nimiipuu Facebook page for information. There were specifically Nimiipuu Health Facebook live sessions that were put on by Nimiipuu Health Medical Director Dr. Kim Hartig. Dr. Hartig is Nimiipuu and grew up on the Nez Perce reservation. Importantly, the Nez Perce Tribe developed an emergency response team to help filter through the facts in real-time, meaning the information that was provided through the Nimiipuu website and Facebook page originated from the CDC and other medical health care professionals. There were also links on the Nimiipuu website and Facebook page that connected to other sources. The emergency response team met weekly to discuss case numbers for the reservation, prevention plans, and ways to help keep the community safe and healthy. This included ensuring that there was adequate food, water, and shelter, and issuing the stay-at-home order. The importance of trusted information sources, specific to the Nez Perce Reservation, was a common point of discussion in the interviews. A 28-year-old female participant stated,

I do think that Nimiipuu Health and the tribe did a great job at putting out the information. It’s on their website and they documented it from the start so you can go back and look. They have information on their website, the team at Nimiipuu Health has done a great job by putting out the Q & A sheets, facts sheets. When you want to get your vaccine, they sent out mass emails and have information available. Any question I had on the vaccine; it has been answered.

Self-Efficacy

Another construct of importance to the Health Belief Model is self-efficacy (Strecher & Rosenstock, 1997). It was clear that almost all participants found it easy to get a COVID-19 vaccination on the reservation. There were stories of Nimiipuu people who lived off the reservation, coming back to the reservation to get COVID-19 vaccinations because they were easily available.

Discussion

Results show that most Nimiipuu participants thought they, their community, and Native Americans in general were highly susceptible to COVID-19. This was in part because of factors that were specific to Native American populations. For instance, the health disparities that are common among Native American populations and living conditions where different generations may live in one household. The tight-knit community was also a factor in perceived susceptibility, as it was generally acknowledged that there were strong social and cultural ties between people that would facilitate the spread of the virus throughout the community. Nimiipuu people were indeed aware of the risk factors and what make Native Americans, and specifically their community, more vulnerable to COVID-19 spread. Similarly, participants felt that there was high severity. This related to their views of how it would affect elders. As discussed previously, elders are knowledge keepers and intergenerational transmitters of culture and tradition. They are respected and valued in Native American culture (Jervis et al., 2010), and this holds true among Nimiipuu people. The susceptibility and severity of elders to the disease was found to affect risk perceptions of the participants. Historical contexts were also an important factor in understanding severity. It was clear that participants remembered historical events in the United States that facilitated the spread of disease and the ultimate decimation to many tribes. People referenced the need for Nimiipuu survival, and concern about how COVID-19 would affect their nation and population. Many people discussed that it was easy to get vaccinated. This was one of the great strengths of sovereign nations in the United States. Many nations created their own COVID-19 distribution methods that were tailored to individual tribes or regions (Haroz et al., 2022; Hill & Artiga, 2021). Other studies using the Health Belief Model would indicate that when there are high perceptions of severity and susceptibility and high self-efficacy, there may be increased preventive behaviors (Mehta et al., 2013). In this case, these factors may have led to increases in COVID-19 vaccination rates.

There were few concerns about COVID-19 vaccines. The concerns that were provided were similar to concerns of Americans in general, including negative side-effects and the speed at which the vaccine was developed (Paul et al., 2021). Even though there is a history of skepticism and distrust of Western medicine and research (Bassett et al., 2012), numerous participants indicated that they believed in the science around the vaccine. People indicated that they trusted the science of vaccine development. The trust in scientists may have been in part due to the fact Native Americans could be vaccinated at their own health center, by community health care workers who were Native Americans, and were presented with information from the tribe. This likely engendered trust in science and vaccines.

The benefits of getting vaccinated were linked to cues to action. Most of the benefits related to community and culture. This is likely due to how community-oriented Native American populations generally are, and how health and well-being is tied to cultural well-being. COVID-19 vaccines were seen as ways to protect knowledge keepers, the highly respected elders. It was seen as a way to get back to cultural practices, such as powwows and stick games. A COVID-19 vaccination could protect community and the tribe against disease. Very few participants discussed individualized benefits of getting vaccinations—rather they discussed their responsibility to the community. The imperative goal was to keep the community safe. These factors are consistent with other studies that examined reasons why Native American people may get vaccinated (Urban Indian Health Institute, 2021). However, this finding is in opposition to other studies examining the effectiveness of messages to the general U.S. population. For example, a study by Borah and colleagues (2021) found that vaccination messages that have an individual loss framing were most persuasive among the general population. This could be due to the fact that people are highly concerned about individual consequences, or that culturally people in the United States tend to be more individualistic. Our contrary findings show the importance of understanding risk perceptions of sub-populations, the need for culturally appropriate communication, and tailoring messages to priority populations.

When examining preferred information sources about COVID-19 and COVID-19 vaccinations, it was clear that some looked at broader news sources such as television. However, the majority looked at tribal specific information sources, or sources that were approved by the tribe. This included information from the Nimiipuu emergency response team, and the Nimiipuu Health Facebook page. It was likely due to the fact that these were internal sources, and people knew the people behind this information. In many cases, the information sources were Native Americans, or people well-known by the community—likely making them more trustworthy.

Guided by the Health Belief Model and Indigenous perspectives of risk, insights have been gained into Native American risk perceptions of COVID-19 and what prompted people to get (or not to get) COVID-19 vaccinations. Benefits and cues to action were directly tied to protecting community, culture, and respected elders on the reservation. Results also show that Native Americans may integrate cultural knowledge, or information provided by tribal health sources, into their perceptions of a hazard, such as COVID-19. Indeed, this study shows us the importance of Indigenous perceptions in understanding health communication and risk perceptions. Without considering cultural, social, and demographic factors, we would unlikely understand the motivating factors behind the high COVID-19 vaccination rates among the Nimiipuu people on the Nez Perce reservation. Therefore, we recommend that when using the Health Belief Model to examine health communication among Native Americans, it will be important to view important factors to these populations, such as culture and community.

This study contributes to the advancement of the Health Belief Model by incorporating the cultural perspectives of Native Americans. In numerous ways, the Health Belief Model resonates with Indigenous conceptions of well-being—as a combination of many influences. However, the model does not directly account for Indigenous concepts directly. In this study, we added to the knowledge by also examining factors that may influence risk perceptions, particularly ones that have been shown to be important for Native American populations such as culture and community (see Boyd & Furgal, 2019). Our goal was to provide a more holistic view of risk perception factors to gain a more complete picture of how Native Americans perceive vaccines. We indeed found that Indigenous perspectives were imperative to understanding the cues to action and communication methods that were most effective among this population. Specifically, we found that sovereignty, and the ability to develop tailored information through Nimiipuu Health was critical in providing culturally congruent information, particularly information that addressed Native American concerns about the effects of COVID-19 on culture, community, and elders.

Limitations and Future Research

This study expands our understanding of perceptions of COVID-19 and COVID-19 vaccinations, there are some limitations. We would note limitations in our sampling, particularly regarding age, gender, and location of participants. In this study, we interviewed those who were 18 years and older. The average age was 41. Those who are 55 and older are often categorized as an elder in the Nimiipuu culture. This is different from the government category of “elder” which is more commonly related to those 65 years and older. Future research could examine potential age-related differences in the perceptions of COVID-19 risk factors and motivations to get vaccinated. Location of participants remains a limitation of this study. There are six towns within the boundaries of the Nez Perce Indian Reservation. They include Craigmont, Culdesac, Lapwai, Kamiah, and Orofino. Despite attempts to recruit throughout the reservation, 29 interviews took place in Lapwai and only one took place in Orofino. However, this is a minor limitation because the most Nimiipuu reside in or near Lapwai.

This study illuminated two avenues for future research. First, it would be beneficial to examine other tribes within the Pacific Northwest, or the United States. There are five main tribes in the region, and it could be beneficial to compare and contrast differences in how tribes perceive the pandemic and vaccinations because there may be other underlying factors that influence perceptions of COVID-19 and communication about the disease. Second, more information should be gleaned about health and risk communication among Native Americans. It was clear from the study that participants looked at information from Nimiipuu Health and the tribe for information. More research should examine why the information was trusted and was sought out. Furthermore, should future situations arise, what additional information or resources are needed to provide information to tribal members.

Conclusions

COVID-19 has been devastating to Native American populations throughout the United States. Even though there is much mistrust of Western medicine, research, and researchers—there have been high vaccination rates among Native Americans, including those on the Nez Perce reservation. This study provides insight into the risk perceptions of COVID-19 and COVID-19 vaccinations through the lens of the Health Belief Model and Indigenous perspectives of risk. The results demonstrate the importance of tribal sovereignty in developing health communication strategies, which are effective, trusted, and culturally congruent. It is our hopes that the results and insights can be used to encourage further action and continue increasing vaccination rates. This study demonstrates that health communication messages that resonate with Indigenous people are crucial to providing information and supporting preventive behaviors that increase the health and well-being of this priority population.

Author Biographies

Rachel Ellenwood, MA, is a PhD student in the Edward R. Murrow College of Communication at Washington State University. She is a member of the Nez Perce tribe. Her research focuses on health, risk, and science communication with Native Americans.

Amanda D. Boyd, PhD, is a co-director at the Institute for Research and Education to Advance Community Health (IREACH). She is also an associate professor in the Elson S. Floyd College of Medicine and the Edward R. Murrow College of Communication, both at Washington State University. She is a member of the Métis Nation from Treaty 8 territory in Canada. Her research focuses on science, health, and risk communication.

Zoe Higheagle Strong, PhD, is an associate professor in the College of Education and is the Executive Director of Tribal Relations at Washington State University. She is a member of the Nez Perce tribe. She conducts research on social, emotional, and environmental factors that shape adolescent development and educational outcomes.

Footnotes

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under award number U54MD011240 and the National Institute on Aging of the National Institutes of Health under award number K01AG066063. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

  1. Arias E., Xu J., Jim M. (2014). Period life tables for the non-Hispanic American Indian and Alaska Native population, 2007-2009. Journal of Public Health, 104(S3), S312–S319. [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Arrazola J., Masiello M. M., Joshi S., Dominguez A. E., Poel A., Wilkie C. M., Bressler J. M., McLaughlin J., Kraszewski J., Komatsu K. K., Pompa X. P., Jespersen M., Richardson G., Lehnertz N., LeMaster P., Rust B., Metobo A. K., Doman B., Casey D., . . .Landen L. (2020). COVID-19 mortality among American Indian and Alaska Native persons. Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, 69(49), 1853–1856. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Bassett D., Tsosie U., Nannauck S. (2012). “Our culture is medicine”: Perspectives of native healers on post trauma recovery among American Indian and Alaska Native patients. The Permanente Journal, 16(1), 19–27. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Belone L., Rae R., Hirchak K. A., Cohoe-Belone B., Orosco A., Shendo K., Wallerstein N. (2020). Dissemination of an American Indian culturally centered community-based participatory research family listening program: Implications for global indigenous well-being. Genealogy, 4(4), Article 99. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Borah P., Hwang J., Hsu Y.-C. (2021). COVID-19 vaccination attitudes and intention: Message framing and the moderating role of perceived vaccine benefits. Journal of Health Communication, 26(8), 523–533. [DOI] [PubMed] [Google Scholar]
  6. Boyd A. D., Buchwald D. (2022). Factors that influence risk perceptions and successful COVID-19 vaccine communication campaigns with American Indians. Science Communication, 4, 130–139. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Boyd A. D., Furgal C. M. (2019). Communicating environmental health risks with Indigenous populations: A systematic literature review of current research and recommendations for future studies. Health Communication, 34(13), 1564–1574. [DOI] [PubMed] [Google Scholar]
  8. Brayboy B. M. J. (2005). Toward a tribal critical race theory in education. The Urban Review, 37(5), 425–466. [Google Scholar]
  9. Centers for Disease Control and Prevention. (2021). Guidance for businesses and employers responding to coronavirus disease 2019. https://www.cdc.gov/coronavirus/2019-ncov/community/guidance-business-response.html
  10. Centers for Disease Control and Prevention. (2022). COVID-19 guidance. www.cdc.gov
  11. Cobb N., Espey D., King J. (2014). Health behaviors and risk factors among American Indians and Alaska Natives, 2000-2010. American Journal of Public Health, 104, S481–S489. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Ding Y., Du X., Qinmei L., Miao Z., Qingjun Z., Xiaodong T., Qing L. (2020). Risk perception of coronavirus disease (COVID-19) and its related factors among college students in China during quarantine. PLoS ONE, 15(8), Article e0237626. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Finucane M. L., Slovic P., Mertz C. K., Flynn J., Satterfield T. A. (2000). Gender, race, and perceived risk: The “white male” effect. Health, Risk & Society, 2(2), 159–172. [Google Scholar]
  14. Fischhoff B. (2013). Risk perception and communication. In Fischhoff B. (Ed.), Risk analysis and human behavior (pp. 17–46). Routledge. [Google Scholar]
  15. Ghosh A. K., Venkatraman S., Soroka O., Reshetnyak E., Rajan M., An A., Chae J. K., Gonzalez C., Prince J., DiMaggio C., Ibrahim S., Safford M. M., Hupert N. (2021). Association between overcrowded households, multigenerational households, and COVID-19: A cohort study. Public Health, 198, 273–279. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Gibbs G. R. (2014). Using software in qualitative analysis. In Flick U. (Ed.), The SAGE handbook of qualitative data analysis (pp. 277–294). SAGE. [Google Scholar]
  17. Goodman L. A. (1961). Snowball sampling. Annals of Mathematical Statistics, 32, 148–170. [Google Scholar]
  18. Goodman L. A. (2011). Comment: On respondent-driven sampling and snowball sampling in hard-to-reach populations. Sociological Methodology, 41(1), 347–353. [Google Scholar]
  19. Haroz E. E., Kemp C. G., O’Keefe V. M., Pocock K., Wilson D. R., Christensen L., Walls M., Barlow A., Hammitt L. (2022). Nurturing innovations at the roots: The success of COVID-19 vaccination in American Indian and Alaska Native communities. American Journal of Public Health, 112, 383–387. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Herrmann A., Hall A., Proietto A. (2018). Using the Health Belief Model to explore why women decide for or against the removal of their ovaries to reduce their risk of developing cancer. BMC Women’s Health, 18(1), 1–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Hill L., Artiga S. (2021). COVID-19 vaccination among American Indian and Alaska Native people. https://www.kff.org/racial-equity-and-health-policy/issue-brief/covid-19-vaccination-american-indian-alaska-native-people/
  22. Indian Health Service. (2019). Disparities and mortality disparity rates. https://www.ihs.gov/newsroom/factsheets/disparities/
  23. Indian Health Service. (2022). Coronavirus (COVID-19). https://www.ihs.gov/coronavirus/
  24. Jervis L. L., Boland M. E., Fickenscher A. (2010). American Indian family caregivers’ experiences with helping elders. Journal of Cross Cultural Gerontology, 25(4), 355–369. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Jones D. S. (2006). The persistence of American Indian health disparities. American Journal of Public Health, 96(12), 2122–2134. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kovach M. (2015). Research as resistance: Revisiting critical, Indigenous, and anti-oppressive approaches. Canadian Scholars. [Google Scholar]
  27. Lang G. C. (1989). “Making sense” about diabetes: Dakota narratives of illness. Medical Anthropology, 11(3), 305–327. [DOI] [PubMed] [Google Scholar]
  28. Le T. T., Cramer J. P., Chen R., Mayhew S. (2020). Evolution of the COVID-19 vaccine development landscape. Nature Reviews Drug Discovery, 19(10), 667–668. [DOI] [PubMed] [Google Scholar]
  29. Letiecq B. L., Bailey S. J. (2004). Evaluating from the outside: Conducting cross-cultural evaluation research on an American Indian reservation. Evaluation Review, 28(4), 342–357. [DOI] [PubMed] [Google Scholar]
  30. Li X., Lei Y., Wang H., He G., Williams A. B. (2016). The Health Belief Model: A qualitative study to understand high-risk sexual behavior in Chinese men who have sex with men. Journal of the Association of Nurses in AIDS Care, 27(1), 66–76. [DOI] [PubMed] [Google Scholar]
  31. Lopez L., Hart L., Katz M. H. (2021). Racial and ethnic health disparities related to COVID-19. Journal of the American Medical Association, 325(8), 719–720. [DOI] [PubMed] [Google Scholar]
  32. Malik A., McFadden S. M., Elharake J., Omer S. B. (2020). Determinants of COVID-19 vaccine acceptance in the US. eClinicalMedicine, 26, Article 100495. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Mehta P., Sharma M., Lee R. C. (2013). Using the Health Belief Model in qualitative focus groups to identify HPV vaccine acceptability in college men. International Quarterly of Community Health Education, 33(2), 175–187. [DOI] [PubMed] [Google Scholar]
  34. National Congress of American Indians. (2021). Tribal Nations & the United States: An introduction. https://ncai.org/about-tribes
  35. Nez Perce Tribe. (2020). About the Nez Perce Tribe. https://www.nezperce.org
  36. Nimiipuu Coronavirus Response. (2021). Nimiipuu coronavirus response, Nimiipuu Health. https://nimiipuu-coronavirus-response-nptgisonline.hub.arcgis.com/
  37. Northwest Portland Area Indian Health Board. (2015). Indian leadership for Indian health, Nez Perce Tribe. https://www.npaihb.org/member-tribes/nezperce/
  38. Office of Disease Prevention and Health Promotion. (2020). HealthyPeople.gov: Disparities. https://www.healthypeople.gov/2020/about/foundation-health-measures/Disparities
  39. O’Keefe V., Walls M. L. (2021). Indigenous communities demonstrate innovation and strength despite unequal losses during COVID-19. https://www.brookings.edu/blog/how-we-rise/2021/04/02/indigenous-communities-demonstrate-innovation-and-strength-despite-unequal-losses-during-covid-19/
  40. Pacheco C. M., Daley S. M., Brown T., Filippi M., Greiner K. A., Daley C. M. (2013). Moving forward: Breaking the cycle of mistrust between American Indians and researchers. American Journal of Public Health, 103(12), 2152–2159. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Patterson K. B., Runge T. (2002). Smallpox and the Native American. American Journal of the Medical Sciences, 323(4), 216–222. [DOI] [PubMed] [Google Scholar]
  42. Paul E., Steptoe A., Fancourt D. (2021). Attitudes towards vaccines and intention to vaccinate against COVID-19: Implications for public health communications. The Lancet Regional Health-Europe, 1, Article 100012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Regan-Udall Foundation. (2021). COVID-19 vaccine confidence project executive summary. https://covid19.reaganudall.org/covid-19-vaccine-confidence-project
  44. Reiter P. L., Pennell M. L., Katz M. L. (2020). Acceptability of a COVID-19 vaccine among adults in the United States: How many people would get vaccinated? Vaccine, 38(42), 6500–6507. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Rosenstock I. M. (1974). Historical origins of the health belief model. Health Education Monographs, 2(4), 328–335. [DOI] [PubMed] [Google Scholar]
  46. Sandman P. M. (1987). Risk communication: Facing public outrage. EPA Journal, 13, 21–22. [Google Scholar]
  47. Sarche M., Spicer P. (2008). Poverty and health disparities for American Indian and Alaska Native children: Current knowledge and future prospects. Annals of the New York Academy of Sciences, 1136(1), 126–136. [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Saunders B., Sim J., Kingstone T., Baker S., Waterfield J., Bartlam B., Burroughs H., Jinks C. (2018). Saturation in qualitative research: Exploring its conceptualization and operationalization. Quality & Quantity, 52(4), 1893–1907. [DOI] [PMC free article] [PubMed] [Google Scholar]
  49. Slovic P. (1987). Perception of risk. Science, 236(4799), 280–285. [DOI] [PubMed] [Google Scholar]
  50. Strecher V. J., Rosenstock I. M. (1997). The Health Belief Model. In Abraham S., Sheeran P. (Eds.), Cambridge handbook of psychology, health, and medicine (pp. 97–117). Cambridge University Press. [Google Scholar]
  51. Symbaluk D. G. (2019). Research methods: Exploring the social world in Canadian contexts. Canadian Scholars Inc. [Google Scholar]
  52. Troiano G., Nardi A. (2021). Vaccine hesitancy in the era of COVID-19. Public Health, 194, 245–251. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Urban Indian Health Institute. (2021). Results from a national COVID-19 vaccination survey. https://www.uihi.org/projects/covid-vaccines/
  54. U.S. Census Bureau. (2020). Census.gov. https://www.census.gov/
  55. Walters K. L., Johnson-Jennings M., Stroud S., Rasmus S., Charles B., John S., Allen J., Kaholokula J. K., Look M. A., de Silva M., Lowe J., Baldwin J. A., Lawrence G., Brooks J., Noonan C. W., Belcourt A., Quintana E., Semmens E. O., Boulafentis J. (2020). Growing from our roots: Strategies for developing culturally grounded health promotion interventions in American Indian, Alaska Native, and Native Hawaiian Communities. Prevention Science, 21, 54–64. [DOI] [PMC free article] [PubMed] [Google Scholar]
  56. Waterworth P., Pescud M., Braham R., Dimmock J., Rosenberg M. (2015). Factors influencing the health behavior of Indigenous Australians: Perspectives from support people. PLoS ONE, 10(11), Article e0142323. [DOI] [PMC free article] [PubMed] [Google Scholar]

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