Supporting Equitable Immunisation Across Culturally and Linguistically Diverse Communities in Australia: Perspectives from Community Members and Healthcare Workers

Abstract

Background: Immunisation coverage among culturally and linguistically diverse (CALD) communities in Australia is heterogeneous, with barriers shaped by language, trust, health-system navigation, affordability, and access to vaccination services. This study explored how adults from diverse CALD backgrounds and professionals working with CALD communities understand vaccine decision-making, with particular attention to adult vaccination, and identified opportunities to support vaccination through routine and community-based health-care interactions. Methods: We conducted 24 semi-structured interviews with CALD community members, healthcare professionals, and multicultural service workers living or working in New South Wales, Western Australia, and the Northern Territory. We analysed the data using reflexive thematic analysis. Results: Participants generally expressed strong support for childhood vaccination, whereas views about adult vaccination were more conditional and varied. Key themes included strengthening vaccine literacy; recognising heterogeneity within CALD communities; using social media to support accurate, timely health communication; building trust between health-care providers and community members; engaging cultural and religious leaders while maintaining clinically led vaccine communication; and expanding community-based opportunities to support participation in immunisation programs. Participants identified childhood vaccination appointments, primary care consultations, community organisations, migrant resource centres, English-language classes, and broader health programs as potential opportunities to discuss and offer adult vaccines. Conclusions: Supporting equitable immunisation among CALD communities requires approaches that address both vaccine decision-making and practical access to services. Future research should co-design and evaluate strategies that integrate adult vaccination discussions and delivery into trusted health and community settings, while addressing language, trust, eligibility, cost, vaccination records, and health-system navigation.

1. Introduction

Population-level immunisation averages can obscure pockets of under-immunisation, including among those from Culturally and Linguistically Diverse (CALD) backgrounds [1,2,3,4]. However, the evidence remains heterogeneous, with vaccine coverage varying by age, maternal country of birth, migration pathway, time since arrival, socioeconomic position, and jurisdiction [3,5,6]. CALD communities are defined broadly as people and communities who have diverse cultural, ethnic, linguistic, or religious backgrounds other than the mainstream English-speaking population (within the Australian context), particularly where those backgrounds may influence service access, communication needs, or health and social outcomes [7]. For people arriving through migration or humanitarian pathways, interconnected community, informational, and health-system factors may influence access to vaccination in Australia. These include awareness of vaccine requirements and eligibility, the quality and availability of vaccine records, trust in systems and providers, access to understandable information in English or other preferred languages, ability to navigate Medicare/primary care booking systems and other health system access factors [5]. Australian studies involving migrant and refugee populations have identified these factors as barriers to completing vaccination, particularly when people are unfamiliar with the Australian immunisation schedule or health system [6,8,9,10]. Many of these barriers are not unique to immunisation and have been identified as affecting broader access to health services and health promotion programs among CALD communities [11].

Strategies to support vaccine uptake in Australia among people from CALD backgrounds stress the need for culturally tailored approaches, including multilingual education campaigns, information in languages, and interpreters to ensure clear communication [11,12]. However, while these approaches should be the baseline for any public health strategy, they may not be enough to increase uptake and reduce inequity across the lifespan. To support vaccine decision-making and reduce inequity in vaccine coverage for CALD communities, our strategies must be shaped by the wider range of drivers identified. A culturally responsive approach requires attention not only to the content and language of health information but also to factors that support trust, service accessibility, affordability, timing, and opportunities for dialogue. Therefore, this study explored how adults from diverse CALD backgrounds and healthcare providers understand vaccination decision-making, including perceived barriers and facilitators to adult vaccination. It also examined where and how vaccination information and services could be incorporated into routine and community-based health-care interactions.

2. Materials and Methods

This qualitative study used semi-structured, in-depth online and phone interviews with individuals who self-identified as members of CALD communities, as well as healthcare professionals and multicultural service workers who work directly with CALD community members. The UNSW Sydney Human Research Ethics Committee granted ethics approval for this research (HC220795). This work was supported by an investigator-driven grant from Moderna, Inc.

Participants included community members born overseas who spoke a language other than English at home or people who self-identified as having a cultural or ethnic heritage from the Arab World, Eastern Europe, or Asia. These diverse groups were chosen based on health department feedback that some members of these communities were at risk of being under-immunised. Key healthcare stakeholders include individuals actively involved in delivering health services through multicultural health and other support services, such as migrant resource centres, refugee health services, settlement services, community-based organisations, and primary care settings. The study identified key service and advocacy organisations providing health and community-based services for migrant communities and asked them to share the study opportunity within their networks.

These networks shared key study information, and potential participants were encouraged to contact the research team for more information or to express interest. To ensure diverse perspectives, participants lived in different Australian states and territories, including New South Wales (NSW), Western Australia (WA), and the Northern Territory (NT).

The researchers developed and reviewed an interview guide to identify critical areas of interest for the study. The questions covered personal vaccine history; general attitudes towards vaccines; sources of immunisation information; factors influencing adult vaccination and booster uptake; challenges to accessing vaccines; suggestions for improving immunisation communication; and strategies for increasing vaccination rates among CALD communities, among others. Questions were asked in an open-ended manner to allow room for expansion, and interviews lasted approximately 30–45 min. Data were collected between May and October 2024. Interviews were conducted in English, and one participant with limited English proficiency invited their daughter to help translate. Interviews were conducted by EW, a public health researcher with relevant qualitative research experience.

The team used purposeful sampling to capture and describe a range of experiences across different cultural groups. Data collection continued until the research team judged that the dataset contained sufficient depth and variation to address the research questions across the participant groups and jurisdictions. The team assessed sufficiency iteratively by reviewing emerging codes, participant characteristics, and the recurrence and explanatory richness of themes. This approach differs from the concept of data saturation, which implies that additional data collection is unlikely to lead to additional valuable insights [13].

Data were analysed using reflexive thematic analysis by EW and HS, following the six-phase approach described by Braun and Clarke [14]. The analysis involved familiarisation with the transcripts, generating initial codes, developing and reviewing candidate themes, defining and naming themes, and producing the analytic account. Coding was iterative and primarily inductive, while remaining informed by the research questions concerning vaccine decision-making, access, communication, trust, and opportunities to support immunisation. The researchers used NVivo 12 (QSR International) to organise the transcripts, codes, analytic memos, and themes. The researchers met regularly to discuss their interpretations, examine similarities and differences across participant accounts, and reflexively consider how their disciplinary backgrounds, experiences, and assumptions shaped the analysis, particularly given neither researcher identifies as CALD. These discussions supported theme refinement and development rather than seeking a single objectively correct coding structure or calculating inter-coder agreement.

3. Results

We conducted 24 interviews with CALD community members (CM; n = 10), multicultural service workers who also identified as CALD community members (MO; n = 8), and healthcare professionals (HP; n = 6)in NSW (n = 13), NT (n = 2), and WA (n = 9), of which 20 were female and 4 were male. CALD participants represented 13 countries of origin: China, Egypt, Georgia, India, Malaysia, Macedonia, Nepal, Portugal, Sri Lanka, Syria, Tibet, Ukraine, and Vietnam. Healthcare professionals who did not identify as CALD but worked closely with CALD community members on immunisations represented Australia, the United Kingdom, and South Africa. Key themes included: strengthening vaccine literacy; acknowledging the diversity and complexity within CALD communities; leveraging social media for accurate health messaging; building and maintaining trust between healthcare providers and community members; engaging cultural and religious leaders while ensuring health advice remains led by professionals; and expanding community-based approaches to increase participation in immunisation programs.

3.1. Enhancing Vaccine Literacy by Leveraging Support for Childhood Immunisations

Participants self-reported adherence to their country’s mandated childhood immunisation schedules and ensured their children were fully vaccinated per World Health Organisation (WHO) or Australian guidelines, either in their home countries or after migrating to Australia. As one participant stated, “I came from a country that we believe 100% plus in vaccines. When I was a child,…we had compulsory vaccinations” [Community Member (CM) Interviewee (INT) 08]. Another echoed this sentiment, sharing: “I did receive all the required vaccinations at every milestone recommended… My mum was a strong believer that it should be done, and she… encouraged me to pass it on to my own kids as well” [Multicultural Organisation (MO) INT 11]. While some key informants voiced frustration with integrating their vaccination history into the Australian system, they generally viewed childhood immunisation positively. Viewpoints diverged on adult immunisation. While some participants wholeheartedly endorsed childhood vaccinations, they resisted adult vaccines in favour of promoting ‘natural immunity’.

Supporting community members’ vaccine literacy was seen as a vital step to improve adult vaccination rates and strengthen public health. Two significant insights emerge from this consensus. First, childhood immunisation offers a valuable opportunity to engage parents in broader vaccine discussions, including those around adult vaccines. Parents already participating in the healthcare system could benefit from dedicated time during child vaccination appointments for discussions, questions, and tailored education about their own immunisation behaviours, turning these interactions into a public health opportunity. Second, more effort is needed to actively involve and educate young people about the importance of their vaccination history, its collective benefits for herd immunity, and their role in protecting vulnerable populations as they transition into adulthood. Addressing gaps in public health education targeting youth could lay a strong foundation for informed vaccine decision-making in the future.

3.2. Recognising Heterogeneity Within CALD Communities

Participants emphasised that CALD community members are not a homogenous group, and that there is a wide range of views on health more generally, and vaccines more specifically. “There is a diversity of opinions that exists. And we, as researchers, proponents of policy, and community members, need to actually address that issue rather than saying it’s right or wrong, black or white” [CM INT 03]. It was clear that participants’ cultural background could have a profound effect on their relationship to immunisations, with some, as noted above, fully trusting of vaccine mandates, while others’ distrust in their governments (for example, those from countries with authoritarian regimes or a history of conflict) extended to vaccine mandates. Many individuals also struggled to reconcile personal health beliefs with the collective benefits of vaccination, grappling with how to contribute to the common good and protect themselves while questioning what is safe and what is not. Economic and educational disparities further reinforce heterogeneity among CALD communities and can significantly affect access to healthcare. Individuals with higher incomes often have better access to medical services, while those with limited financial means may face obstacles related to transport, out-of-pocket costs for GP visits or vaccines, and the absence of paid leave to attend appointments. These barriers can compound over time, contributing to broader health inequities across communities. These perspectives underline the importance of adopting nuanced, inclusive approaches to vaccine communication, tailored to address the varied and complex viewpoints within CALD communities.

3.3. Harnessing Social Media

CALD community members and healthcare providers agreed on the growing importance of leveraging social media to disseminate critical public health messaging and combat vaccine disinformation. Mainstream media may not reach some population groups, especially CALD communities. Participants highlighted several social media platforms they actively use for health advice or passively receive information from. “I went to Google and try to read about [the vaccine] and maybe some things that were shared on social media, either from the government or from other people” [MO INT 04]. Participants clearly said CALD communities often rely on alternative digital sources for timely, culturally relevant health information.

While key informants underscored the importance of engaging with social media, they also noted significant risks, as misinformation can spread rapidly within and across platforms, as many witnessed during the COVID-19 pandemic. “There’s always something floating around on social media and with CALD clients, … they all go on Facebook, YouTube and see one another add an article about how [the COVID] vaccination is bad…and then another five follow, so you just end up down a rabbit hole of [mis-]information” [MO INT 13]. Another key concern is the delay in translating public health advice into community languages, which allows misinformation to dominate during critical periods. “If the government made an announcement today about a new [health] policy, that information will only be available after 2–3 weeks in our community language, and by that time, there is already and a lot of misinformation” [MO INT 09]. One participant noted that if government policy roll-out was shared in more languages, it could “close the gap between people becoming very suspicious” [MO INT 13]. In a vacuum of quality health information in languages CALD community members understand, misinformation can fill the void, exactly when clarity and trust are most needed to ensure widespread uptake.

3.4. Maintaining Trust with Community Members Around Immunisation

When discussing with community members and healthcare providers alike on how to engage those who are hesitant about vaccines, one nurse stressed the importance of building trust with a healthcare provider, sharing evidence-based guidance documents from health departments, and having discussions about vaccines ‘a little bit often.’ “The best thing that works is a little bit often. I find that the more you see people, the more you can have just a little bit more of a chat, every time they pop in, I think that helps. You develop a rapport, you therefore develop that trust in the relationship, so that they are more open to receiving that [vaccination] information” [Health Provider (HP) INT 22]. Other key informants agreed and emphasised the importance of building trust between health practitioners and their CALD patients as a critical component in ensuring evidence-based immunisation information can be shared at routine check-ups.

Participants suggested that dialogue about distinguishing between typical and rare vaccine side effects is essential for building trust and improving vaccine uptake. Some participants suggested there needed to be more robust community understanding about the possible typical and rarer side effects of vaccines, so people were better informed of the normal range of responses to vaccines. “There hasn’t been necessarily clear communication about the possible side effects of getting vaccinated and what your body is doing once the vaccine is injected and how… your body reacts in order to build up the defences” [MO INT 04]. Visual aids such as pictograms or step-by-step infographics, similar to a business process map, were proposed as effective tools to illustrate this process, as suggested by another participant: “I’m just visualizing a map… arrows pointing to each other could be like, OK, so you get the vaccine, next what happens, and so forth” [MO INT 13]. Failure to provide transparent information about side effects may discourage further immunisation. For example, when asked whether participants intend to get an annual influenza vaccine, some referenced their last influenza vaccination: ‘I got sick with the flu’ [CM INT 12], so they do not intend to get that vaccine again. Additionally, one key informant suggested deploying ‘vaccine ambassadors’ during mass vaccination campaigns. These ambassadors could answer questions, address concerns, and calm anxieties, particularly for those mandated to receive vaccines for work [15,16,17]. Though resource-intensive, such an initiative could be invaluable, particularly if ambassadors included representatives from CALD communities. This approach could simultaneously combat misinformation, build confidence, and lay the groundwork for more positive vaccine experiences.

3.5. Engaging Cultural and Religious Leaders While Ensuring Health Advice Remains Led by Professionals

Participants offered valuable insights into balancing engagement with cultural and religious leaders in health messaging while ensuring health professionals remain the authoritative voice. “[The local health district] engaged a few religious leaders from particular communities, and we wrote the speech, and they were saying the messages in their own language. But personally, I think the message must come from health [professionals] because the priests…don’t specialise in health, even though they are trusted by the community in church settings” [MO INT 01]. They underscored the critical role that trusted community figures can play in bridging communication gaps and encouraging vaccine uptake, particularly within CALD communities. However, it also highlights potential risks of relying too heavily on untrained non-health professionals for health-related information, including misinformation, confusion, or inconsistent support for vaccination initiatives. Therefore, health departments and CALD leaders need to think more strategically about how they can collaborate effectively for future immunisation campaigns. By developing programs that enable health professionals to engage with community groups, explain vaccine benefits, and address questions and concerns, they can bridge trust and knowledge gaps.

While many participants prioritised health communication through GPs, noting the typically trusting doctor-patient relationship, diverse engagement methods could increase vaccine uptake among CALD communities. “I think community support is important. The GP is one-on-one, and people have different relationships with their GP, whether they trust them or not. So I think maybe in a group setting, you’re there with your friends, your community members, people that you know you’re in a comfortable environment as well…OK, let’s see what this is about” [MO INT 13]. Beyond the traditional GP-patient relationship, the report suggested group discussions in community centres or other accessible settings to create comfortable environments for collective education and build confidence in vaccine programs. While implementing programs like group sessions or ‘community talks’ with accredited health professionals and CALD representatives may be resource-intensive, these programs could establish vital trust networks for long-term public health efforts.

3.6. Leveraging Opportunities to Engage with CALD Community Members

Some participants expressed a general sense of vaccine fatigue, largely due to the COVID-19 vaccine and booster campaign. Aligned with this was the sentiment that more recent vaccine-specific information sessions were not broadly welcomed. Participants expressed greater support for including vaccine information alongside other targeted health information sessions. For example, in line with the above group sessions, migrant resource centre staff highlighted special health sessions they organise with the local health district for their elderly CALD members. These sessions could include a component on vaccines but should not be the core focus. Key informants emphasised the need to think outside the box about how to share vaccine information with CALD community members. For example, one participant shared that a local health district set up a booth at an annual migrant resources fair to provide vaccine information and offer on-the-spot vaccinations. “We were going to the Multicultural Expo…and that’s where we were promoting vaccination” [HP INT 18]. Another participant shared a positive experience of providing vaccine information as part of a broader health campaign targeting English as a second language classes in TAFE settings. “We actually took the education to the students, and we ran multiple [vaccine] education sessions and then outreach clinics on site at TAFE” [HP INT 21]. CALD community members were open to these information-sharing opportunities and got vaccinated during these sessions, suggesting that exploring vaccination delivery outside primary care settings is warranted.

4. Discussion

In our study, we identified a distinction between strong support for childhood vaccination and conditional acceptance of adult vaccination amongst participants from CALD backgrounds. Participants did not describe vaccine decision-making as determined by culture or language alone. While some individuals strongly support vaccination due to its alignment with public health goals, others may hesitate due to past experiences in their home countries, fear of adverse effects, belief in their natural immunity, susceptibility to misinformation campaigns, and/or mistrust in government and healthcare systems, among many other influences [18]. These findings align with previous Australian research, including studies documenting low trust in government and inconsistent messages and advice from healthcare providers [19,20,21,22]. Migration experiences, including whether individuals are recent arrivals, refugees, or second-generation migrants, can shape their perspectives and needs. For people arriving through humanitarian or migration pathways, vaccination challenges may extend beyond hesitancy. Incomplete records, unfamiliarity with the Australian schedule, language barriers, cost, transport, and uncertainty about where to obtain catch-up vaccinations may all contribute to delayed or missed vaccination [23]. Some identified barriers, including limited provider recommendation, cost, competing priorities, uncertainty about eligibility, and the low visibility of adult vaccination, likely affect adults more broadly and should not be interpreted as unique to CALD communities. However, migration-related experiences, limited familiarity with the Australian health system, incomplete vaccination records, language barriers, reliance on translated or community-based information, and trust shaped by previous experiences may intensify or modify these barriers for some CALD community members.

While participants supported the need for immunisations, they described the childhood program differently from immunisation directed at adults. Several explanations may account for this, including that the study cohort included few older adult participants (or those eligible for free vaccines via the National Immunisation Program due to age), so they may be unaware of the rationale for and availability of vaccines for older adults. However, it may also reflect that some participants immigrated from countries without a history of adult-focused immunisation (aside from COVID-19) and may not have been exposed to related information or recommendations. International evidence indicates that adult influenza vaccination policies vary across countries and income groups. Morales et al. examined seasonal influenza vaccination policies in all 194 WHO Member States and found that 105 countries had a policy targeting older adults. However, these policies were concentrated in higher-income settings: only 32% of low- and lower-middle-income countries and 63% of upper-middle-income countries had policies targeting older adults, compared with a substantially higher proportion of high-income countries [24]. A national recommendation does not necessarily mean vaccination is publicly funded, free at the point of delivery, or readily accessible to all eligible adults. Thus, differences in adult vaccination uptake may reflect not only individual knowledge or confidence, but also whether national programmes prioritise adult vaccination and support it through affordable, accessible delivery systems [24]. Lastly, it may reflect the continued focus on childhood immunisation within many countries. For example, research with primary-care professionals in the UK reported that adult migrants were often excluded from vaccination initiatives focused primarily on children, with incomplete records, unclear care pathways, limited provider knowledge, and a lack of dedicated time further restricting adult vaccination [25]. Amongst our participants, the suggestion to use childhood vaccination encounters to discuss adult immunisation is promising, but it should be understood as a service-design hypothesis rather than an established intervention. Its feasibility would depend on appointment length, workforce capacity, access to adult immunisation records, vaccine cost, and the availability of a clear referral or same-day vaccination pathway. Future research should co-design and pilot this approach with parents, immunisation providers, and multicultural health services, assessing not only acceptability but also whether it increases adult vaccine initiation or completion.

In Australia, people from CALD communities speak a wide range of languages and dialects, making communication complex. While some individuals may be fluent in English, others may rely on information provided in their native languages or rely on health information from their home country, which may not align with—or worse, contradict-advice from the Australian Government [26]. Participants noted that, more generally, while health departments provide a wide range of translated health materials, more obscure languages from smaller CALD migrant groups often fall through the cracks and require the most support. To address this issue, we may need to look beyond health departments for solutions. Our participants discussed the role community organisations and community leaders could play in creating trusted opportunities for dialogue. Staff in migrant resource centres, multicultural services, community groups and community media have trusted relationships, language capabilities and detailed knowledge of local needs. This approach is consistent with the WHO’s Immunisation Agenda 2030, which identifies community engagement and trusted dialogue as central to improving vaccine acceptance and uptake [27]. To promote support for a wider range of actors in vaccine communication in our communities, our participants stressed that these actors should not be treated as substitutes for health professionals. These non-health actors may add value by facilitating access, contextualising information, identifying concerns, and creating trusted opportunities for dialogue. Previous Australian research has also identified the importance of training community actors to build their knowledge, communication confidence and capacity to address misinformation, explain vaccine recommendations and eligibility, and connect community members with vaccination services [28,29].

A key strength of this study is the inclusion of CALD community members, health-care professionals, and multicultural service workers from three Australian jurisdictions and a range of cultural backgrounds. Participants were self-selecting and recruited primarily through health and community-service networks, which may have skewed the respondent profile and overrepresented people already engaged with services or interested in immunisation. However, the diversity of participant perspectives and service settings broadened the findings and enabled comparison between community and provider experiences. The sample remains small and cannot represent the full diversity of CALD communities, particularly those with limited English proficiency or who are less connected to health and community services. Larger studies could also compare perspectives from community members and professional stakeholders. Participants also sometimes made broad observations about particular cultural or national groups; these accounts should therefore be interpreted cautiously and considered within an equality, diversity, and inclusion framework. The researchers’ cultural, professional, and experiential backgrounds may also have influenced their interpretation of the data. Greater cultural and linguistic diversity within the research team, including researchers with lived experience of CALD communities, may have enhanced reflexivity and generated additional insights through insider perspectives. The study was conducted in NSW, WA, and the NT, where immunisation systems, service structures, and population distributions may differ from those in other Australian jurisdictions. Although this may limit transferability, our findings align with Australian and international research identifying community, provider, and system-level barriers to vaccination, supporting their relevance beyond the participating sites. Future mixed-methods research should compare CALD and non-CALD populations while accounting for factors such as age, income, health status, access to primary care, migration pathway, language proficiency, and prior vaccination experience.

5. Conclusions

Our findings suggest that improving immunisation among CALD communities will require attention to how vaccination is offered, discussed, and experienced across the life course. Participants described childhood vaccination as familiar and important, but adult vaccination as less visible, less routinely discussed, and more dependent on individual encounters with health services. Future work should therefore examine whether existing contact points, such as childhood vaccination appointments, primary care consultations, settlement services, English-language classes, and community health programs, can provide appropriate opportunities to discuss and offer adult vaccines. Any such approach should be co-designed with CALD community members and service providers, with attention to trust, language, cost, eligibility, vaccination records, and service navigation. Pilot studies are needed to determine whether these opportunities are acceptable and feasible, and whether they lead to measurable improvements in adult vaccine uptake.