Multi-Stakeholder Perspectives on COVID-19 Vaccine Acceptance: A Qualitative Study from African, Caribbean, and Black Communities in Ottawa, Ontario, Canada

Abstract

Through engagement with multi-stakeholders—including African, Caribbean, and Black (ACB) community members and leaders, as well as service providers in Ottawa, Ontario, Canada—this study explores in-depth narratives and first-hand accounts of their lived experiences in the context of COVID-19 vaccine promotion. A thematic analysis of the focus group discussions, conducted in NVivo, revealed that vaccine acceptance among ACB communities is shaped by factors such as racial discrimination, COVID-19 knowledge, misconceptions, communication strategies and barriers, preference for alternative medicines, and community resilience. These findings highlight several implications for policymakers and provide directions for future research.

1. Introduction

Compared with other racial and ethnic groups, African, Caribbean, and Black (ACB) populations had lower rates of COVID-19 vaccination adoption [1]. To raise the effectiveness of COVID-19 vaccinations in lowering the probability of severe symptoms, hospitalization, and mortality, governmental attention may be needed to rectify this discrepancy [2]. To protect communities that could be more susceptible to serious illness or have weakened immune systems, vaccines are essential in building community immunity. In this situation, ACB communities may encounter difficulties in preventing the virus from spreading further as well as in safeguarding their own health.

The obstacles to vaccination adoption in these communities have been the subject of several studies. For instance, doubt of COVID-19 vaccinations may be exacerbated by past and present mistrust resulting from experiences of systematic racism and discrimination stemming from healthcare institutions [3]. Concerns over the safety, effectiveness, and possible adverse effects of vaccines may also exist within ACB groups [4]. Decision-making and comprehension may also be hampered by a lack of availability of reliable and culturally relevant information on COVID-19 vaccinations [3]. Furthermore, low income and unemployment—two socioeconomic disadvantages that disproportionately impact ACB communities—can impede vaccination adoption because they conflict with other priorities, such as providing for daily necessities like food and shelter [5].

Although these studies are useful, very little attention has been paid to ACB communities’ barriers to COVID-19 vaccine acceptance from the perspective of multi-stakeholders, including ACB members and leaders, as well as service providers such as healthcare providers, social workers, and community workers in a joint focus group discussion. This void in the literature may be concerning because it overlooks the insights and experiences of those who interact closely with ACB communities. Specifically, service providers often play a critical role in understanding and addressing the barriers to vaccine acceptance [6].

Through engagement with service providers serving ACB communities in Ottawa, Ontario, Canada, and ACB community members and leaders, this study aims to describe in-depth narratives and first-hand accounts of their lived experiences in the context of COVID-19 vaccine promotion. Their perspectives can shed light on the unique challenges faced by ACB communities and inform targeted strategies for increasing vaccine acceptance. It is important to bridge this void in the literature while actively involving service providers, which may be useful for gaining a comprehensive understanding of the barriers and developing tailored interventions that can address the specific needs of ACB communities in promoting COVID-19 vaccine acceptance.

2. Materials and Methods

In this study, we conducted an explanatory qualitative analysis that involved focus group discussions (FGDs), community leaders, and health and social service providers who cater to ACB communities and members of the Black community. All the participants were informed that their involvement in focus group discussions was voluntary, and we recruited them through the Peer Equity Navigation (PEN) program. The PEN program is a peer-led educational initiative designed to engage ACB community members and enhance their awareness of and access to COVID-19 vaccines [7]. To prepare the PENs for their roles, they underwent 12 weeks of in-class and lab training, followed by a 6-week practicum training within various service organizations, including the Ottawa Public Health (OPH), Somerset West Community Health Centre, AIDS Committee of Ottawa, and South-East Ottawa Community Health Centre. The staff working at these clinics served as preceptors to provide the PENs hands-on coaching and clinical teaching as they operationalized the knowledge and skill learned from the critical health and racial literacy program for PENs. The PENs then disseminated information to ACB community members, aiming to encourage them to utilize vaccination services. It is noteworthy that, while the OPH has its own community champions program to promote vaccine uptake, the PENs act as an extension of that program, extending its reach beyond the scope of Francophone ACB communities. We conducted a total of six ACB community focus group discussions, spread over a three-day period, with 45 participants (initial goal of 60 stakeholders).

The focus group discussions were transcribed and uploaded into NVivo 12 for analysis. Our approach to data analysis involved a mixed inductive–deductive method, in which an FGD guide provided some structure to the discussions, while still allowing the interviewees the flexibility to elaborate on their responses. Through open coding, we systematically labelled each transcript phrase with relevant themes, which were then further grouped into broader themes, as presented in the Results Section. In addition, to provide a comprehensive understanding of the discussions, we highlighted various subthemes that added richness to the interviewees’ narratives. To ensure the rigor of this study, we utilized a sizable sample of 45 participants, which allowed us to reach data saturation, meaning that no new ideas or themes were emerging from the transcripts. This process helped ensure that we captured a comprehensive range of perspectives and experiences related to the research topic. Furthermore, we took extensive measures to maximize this study’s rigor by conducting member checking, audit trails, and peer debriefing of close partnerships and collaborations with community organizations, as described earlier. These collaborations allowed us to gain valuable insights and context, enhancing the relevance and applicability of our findings. Regular meetings were held to ensure the consistency and accuracy of this study’s findings throughout the research process [8].

3. Results

3.1. Sample Characteristics

Table 1. Demographic characteristics of focus group discussion participants.

Age	Number of Participants
25–34	5
35–44	15
45–54	10
55–64	10
65+	5
Gender
Male	10
Female	35
Race/ethnicity
African	31
Caribbean	7
Black	7
Education
Less than high school	1
High school/some college	18
Bachelor’s degree	11
Postgraduate degree	11
Other	4
Profession
Community worker	18
Social worker	15
Nurse	2
Medical doctor	2
Counsellor	2
Other	8
Work sector
Community health centre	11
Long-term care	13
Medical clinic	3
Other	18
Total	45

shows the demographics of the focus group discussion participants (n = 45). The largest age group was 35–44 (33%) followed by 55–64 (22%) and 45–54 (19%). The participants were predominantly female (81%) and African (70%). In terms of education, 40% of the participants had a high school diploma or some college education, while 50% had a bachelor’s degree or higher. The participants were primarily community workers (40%) and social workers (30%), while a small proportion of participants worked as nurses (4%), medical doctors (4%), or counsellors (4%). The areas of the participants’ work sectors included community health centre (25%), long-term care (30%), and medical clinic (5%). In addition, this study involved organizing and facilitating three FGDs—one in French and two in English—involving ACB community members and leaders, as well as service providers. In collaboration with CADHO, the FGDs were conducted virtually via Zoom. The participants were recruited using a simple random sampling technique, with each FGD comprising approximately 8–10 participants.

3.2. Theme: Social Service Workers’ Views of COVID-19 Vaccine Acceptance in ACB Communities

From a total of six focus group discussions, we identified five themes regarding social service workers’ views of COVID-19 vaccine acceptance among ACB communities: (1) the impacts of racism on vaccine acceptance; (2) COVID-19 knowledge; (3) COVID-19 misconception; (4) communication strategies and barriers; and (5) alternative remedies, agency, and community resilience.

3.2.1. The Impacts of Racism on Vaccine Acceptance

The participants shed light on the role racism plays in influencing the acceptance of COVID-19 vaccines among ACB communities at multiple levels, namely at the interpersonal, community, and institutional levels. For example, some community members illustrated the power dynamic between providers and patients at the interpersonal level. One participant noted the following:

Because of racism, it’s hard to interact well with health care professionals. So, when you know that the doctor might be, or that the nurse is a little bit racist about you, I’m definitely not going to go and ask for the services. Then, even the health professionals, sometimes, they are not very friendly. Honestly, they’re not very friendly and especially, for example, a person who, is it, can we talk about racism if there’s a language barrier?

Some providers suggested that racism can impact the care ACB people receive from various healthcare providers at the community level. Another participant stated the following:

But if they take sensitivity training, it can help. It can help so that the other one doesn’t feel. Yes, because often people are not aware that the actions, the things they say, it is considered or perceived as racist. So, if the person can have training, they can think differently or speak differently.

One ACB community leader reflected on the impact of historical trauma and the ongoing systemic effects that racism has in our society. Specifically, it was indicated as follows:

On this theme as well, like what I tell on the vaccines, like looking at the history of Black racism and just the healthcare, most Black people were used as sacrificial lambs in the past, took vaccines. So, it’s very, very hard right now to convince a Black person to get a vaccine because they don’t know, they don’t trust them to say they are getting the same vaccine. Even for me, like when I went to get the vaccine and I find the vaccine is already in a needle, I’m not seeing where it is coming from, honestly, I’ve questioned that 1000 times. I am seeing a needle that is saying it’s Pfizer, the medicine is already in the needle, it’s in the syringe. I didn’t see the bottle. How am I sure that that’s the same vaccine that’s being given to my next White neighbour to me? So, when you look at those things, they are the things that make people to distrust even the healthcare system itself. If in the past, I know my ancestors have been used as sacrificial lambs to developing a vaccine, why can I not think even this time they are able to do the same. It’s the same people, nothing has changed.

3.2.2. COVID-19 Knowledge

In the focus group discussions, the participants discussed several subthemes related to their knowledge of the COVID-19 pandemic. The first subtheme was vaccine protection. Many participants expressed their understanding of the importance of vaccination in preventing COVID-19 and its potential complications. For example, this community member expressed knowledge gaps about vaccine protection as one of the important conditions:

Yeah, for me, what I can say, when I look, I’m from Africa, when I look back in Africa, people they didn’t get, a lot of people they were not vaccinated. And people were not dying like the way we are dying here. So, we are getting vaccinated but people, what is the contrast. Like people there, they are not vaccinated, they are not dying like the way people are dying here. Because apparently, it’s not the same virus. It’s not the same virus. Here people are dying, people were dying like fleas but in Africa, we were expecting people to die more than here because of hygienic conditions and so on in the healthcare system. But it was proven that we did get to … more to what we were waiting for, for Africa. That’s mean that we have, is it, we’re still concerned by the virus itself. Is it the same which we are, which is infected Africa that we have, we are, we have here?

Another participant also discussed knowledge gaps about the cause of COVID-19 stemming from the environment and the accuracy of the clinical trials to create the vaccine:

I don’t know if it’s the heat, but my question kind of bounces off of the observations that you made as soon as we started, particularly with respect to the North American population. If the North American population has had a great catastrophe in relation to that, and we know very well that it’s, well, we think it’s related to the environment, do you think that the African environment is better than the American environment for black people.

This participant further indicated the importance of the right information as a determinant to getting vaccinated:

I was concerned about the side effects, that was my main issue—not side effects, but long-term effects. And until I spoke to a friend who works in labs and a scientist and kind of explained how the vaccine worked, then I was able to have a better sense and when Health Canada started to publish more information on the vaccine, how they evaluate it and things like that. I was reluctant to take the vaccine because I was not sure of like the type of vaccine and there wasn’t that much information out there. But once information started to trickle down and then I felt more comfortable.

3.2.3. COVID-19 Misconceptions

COVID-19 misconceptions emerged as a critical theme during the focus group discussions, reflecting the prevalence of misconception and misunderstandings surrounding the pandemic. The first subtheme, news media, centred on the role of media in disseminating information about the pandemic. The participants expressed concerns about the reliability and accuracy of information presented in various media outlets. The following is an example of a participant presenting some challenges of the misconception in the news media:

In the beginning it was very difficult because the news was giving so many information, some which were not accurate, and which were very confusing. And that made it, really, really, really, it was so difficult to know what’s next.

The second subtheme related to vaccine protection and involved misconceptions and doubts about the safety and efficacy of COVID-19 vaccines. The participants discussed concerns about the perceived effectiveness and risks of vaccines, which led to hesitancy among some individuals to get vaccinated. Another participant shared the following:

Like when I hear from people, many people feel like okay, they got the vaccine, but they are dying. What the vaccine is, it’s just there to protect you. It doesn’t mean if you take it you won’t die. You could die. They’ve been giving vaccines for like centuries. It’s just there for prevention, but it doesn’t mean you are going to die. But many people in their head, they feel that if they take this vaccine they can’t die.

The third subtheme centred on the number of vaccine shots required for protection. The participants expressed confusion about the dosing schedules for different COVID-19 vaccines. Some participants were unsure how many shots they needed for full protection, while others questioned the need for booster shots. For example, one participant mentioned the following:

Well, I heard if you take the fourth shot after October then you will have to take no more shots after that because the one that’s coming out after October, it’s one of the strongest shots that you will be getting.

3.2.4. Communication Strategies and Barriers

Communication was another significant theme with several subthemes such as barriers and strategies. Some of the barriers that existed were contradicting messages from the medical community and language barriers between provider and patient:

The medical community too, they are not unanimous. They contradict each other. Europe, the U.S., Canada, the thing, they say, “You shouldn’t … the three Pfizer vaccines,” whatever, and they even disagree.

There’s a big language barrier too. Yeah, a lot of people don’t speak French or English and so they have a hard time accessing all the services, especially when you go to the hospital and the doctor, he’s just an English speaker and you’re a French speaker. What do you do? You have to call someone else.

Various communication strategies were shared among service providers that are outlined in these quotes. The participants shared some communication strategies that could help increase vaccine uptake among ACB populations: ACB population-centred communication approaches, utilizing ACB leaders in the community, and reaching out to local African and Caribbean radio stations in the Ottawa region. The participants shared the following opinions:

They should support the initiative that is really targeting this population. Healthcare, whatever the system is, this Ottawa Hospital should be able to support any Black clinics or programs that would target that population of Blacks.

Black people we are different. We don’t like to be rushed, and we don’t like somebody to come and just interfere like that. So, you have to kind of be friendly and introduce yourself and tell them we are here to talk about the COVID, we are here to talk about the vaccine. And tell them on… don’t laugh them when you talk.

But we have Caribbean radio station in the country, in Ottawa, go to a Caribbean radio station, get the word out there. We have the multicultural station right on the market. They would love to accommodate people with multicultural things, to go and talk about all of these things. So, somebody have to go, and you know, talk to those people and come on the air and spread the word. You know because lots of people from all walks of life listen to that Caribbean station. They have on Saturdays one in the morning, one in the evening, one at night. So, you can go there and reach the community who listen to that Caribbean station.

3.2.5. Alternative Remedies, Agency, and Community Resilience

During the focus group discussions, service providers expressed diverse beliefs about Western medicine and its effectiveness in providing protection against COVID-19. These beliefs were shaped by cultural, social, and historical contexts, and they influenced individuals’ attitudes towards seeking medical treatment, following preventive measures, and embracing vaccination. The participants represented some of the unique challenges that are related to this theme:

This is an African reality and I believe that we have knowledge that Westerners, unfortunately, do not have, but as they are the ones who have the infused science, they always tend to simply ignore it. Then, I believe that medicine, research would have a lot to gain by getting closer to our traditions.

They should support the initiative that is really targeting this population. Healthcare, whatever the system is, this Ottawa Hospital should be able to support any Black clinics or programs that would target that population of Blacks.

How about you bring a neutral person, a neutral Black person who has taken the vaccine and this as testing to… oh, okay, I’ve taken the vaccine, this is how it is going. And then you tag along now both celebrities and the doctors. So that way there will be a variety range of group of people to look to.

4. Discussion

The findings of this study shed light on the perspectives of multi-stakeholders—including ACB community members and leaders, as well as service providers in Ottawa, Ontario, Canada. Despite these communities being disproportionately affected by the virus, prior research revealed that they encounter specific structural barriers that hinder their willingness to accept the COVID-19 vaccine. These barriers are distinct from those faced by other populations and may require targeted interventions and tailored public health strategies to address the challenges and promote vaccine acceptance among ACB communities. Understanding and acknowledging these unique obstacles, while integrating the perspectives of service care workers, can play a crucial role in designing effective and equitable vaccination campaigns, ensuring that all communities have access to vaccines and can benefit from the protection they provide against COVID-19. In this context, it is noteworthy that we identified five themes from the focus group discussions with service care providers, namely, (1) the impacts of racism on vaccine acceptance; (2) COVID-19 knowledge; (3) COVID-19 misconception; (4) communication strategies and barriers; and (5) alternative remedies, agency, and community resilience.

As one of the themes indicated, service care providers pointed out that racism can be adversely affecting vaccine acceptance among ACB communities at multiple levels. Indeed, it has been suggested that racism can operate at various levels within our society—individually, interpersonally, and structurally. Within the context of low vaccine uptake among ACB people, previous studies have shown that structural racism eroded trust in vaccination among ACB people [9]. For instance, Eissa et al. [10] have suggested that the lack of Afrocentric healthcare could be a form of institutional/structural racism at work, since a lack of this form of healthcare impedes ACB peoples’ access to services like vaccination. In addition, racism at the interpersonal level can negatively impact the relationship among service providers and patients and reduce their health outcomes. This can be manifested in many ways, such as healthcare providers making assumptions about ACB peoples’ knowledge of vaccines or vaccination, dismissing questions or concerns people might have about the vaccine based on their distrust for the healthcare system. Supporting this argument, McClure et al. [11] have pointed out that about half of the physicians in the study reported that their jobs were less satisfying because they had to explain the importance of vaccination to vaccine hesitant patients.

Based on two other themes, the service care providers identified that some psychosocial conditions such as COVID-19 knowledge and misconception can be important to understand the low level of vaccine acceptance among ACB communities. The importance of COVID-19 knowledge may underscore the role of accurate and accessible information about the virus and vaccines. Limited access to reliable information can lead to gaps in understanding, resulting in misconceptions and hesitancy towards vaccination. This finding aligns with previous research highlighting the critical role of education and awareness campaigns in increasing vaccine uptake and dispelling the myths surrounding COVID-19 [12]. Relatedly, the theme on COVID-19 misconception may point to the impact of false beliefs and misconceptions on vaccine acceptance among ACB people. Their hesitancy may be influenced by unfounded concerns about vaccine safety, efficacy, or potential side effects, especially considering that COVID-19 misconception has been observed as highly correlated with a lack of COVID-19 knowledge [13]. In this context, addressing these misconceptions may be essential in building vaccine confidence and promoting public health.

According to another theme, it was identified by service care providers that there may be unique communication issues in the context of vaccine acceptance within ACB communities. Essentially, this theme may underscore the importance of understanding the cultural, linguistic, and contextual factors that may influence communication and information use among ACB people. Specifically, ACB communities have been documented as linguistically diverse, making it difficult for some community members to be proficient in the dominant language(s) of the region, which can serve as a barrier to their access to accurate information about vaccines and COVID-19 [14]. In this context, it may not be too surprising that this linguistic barrier may result in difficulties in understanding public health guidelines, vaccine benefits, and vaccine registration processes. In addition, communication obstacles may be related to cultural nuances and beliefs unique to the ACB communities, which may play a critical role in shaping communication effectiveness [4]. Misconceptions or misunderstandings of health information may arise due to differences in cultural norms, values, and communication styles.

The last theme was related to beliefs concerning Western medicine and its ability to offer protection against COVID-19. Importantly, these beliefs were found to be affected by cultural and historical factors, which in turn held significant implications for medical treatment, preventive measures, and vaccination among ACB people [15]. For example, some service care providers identified with cultural practices and traditional healing methods, leading them to rely more on alternative or contemporary treatments rather than on Western medicine. This is consistent with previous research, indicating that the influence of cultural norms and beliefs on health and illness perception can affect people’s willingness to consider vaccination as a preventive measure [16]. This cultural explanation is also nested within unique historical experiences of medical mistreatment, systemic discrimination, or other injustices in healthcare systems, which have influenced some ACB people to question the trustworthiness of Western medicine and vaccination efforts. These historical legacies could foster skepticism and mistrust, hindering the acceptance of medical interventions, including COVID-19 vaccines, despite their potential benefits [3].

Reflecting on these observations, we offer several important policy implications. First, as a crucial measure to address the influence of racism on COVID-19 vaccine uptake at multiple levels, it may be imperative to focus on augmenting the representation of ACB healthcare professionals. By increasing their numbers within the healthcare workforce, it may be possible to mitigate disparities and enhance culturally responsive care, thereby contributing to improved vaccine acceptance and uptake among ACB communities. In addition, policymakers should pay close attention to COVID-19 knowledge and the effectiveness of public health communication within ACB communities. For example, equipping service providers with culturally appropriate fact sheets and resources that encompass the experiences of ACB communities is essential. The integration of cultural competence frameworks into knowledge resources will facilitate more informed and respectful interactions. In this context, empowering ACB leaders to disseminate accurate information about COVID-19 vaccines across various sources can dispel prevalent myths and contribute to increased vaccination uptake. Encouraging a peer-led approach, akin to the PENs program, can foster proactivity within the community.

Despite these useful policy implications, we acknowledge that there are several noteworthy limitations. For example, this qualitative study has certain limitations that warrant consideration. A notable limitation is the potential lack of generalizability of findings due to the focused nature of qualitative research. The context-specific nature of qualitative data may limit the extent to which the conclusions can be extrapolated to broader ACB populations or other demographic groups. In addition, while qualitative analysis provides depth and richness, the absence of quantitative analysis in this study could hinder a comprehensive understanding of the quantitative impact of the proposed policy recommendations. A combination of both qualitative and quantitative approaches would provide a more comprehensive picture of the complexities involved in addressing vaccine uptake disparities. Moreover, this study centres on ACB communities, potentially limiting insights into the challenges faced by other racial and ethnic minorities. Exploring a broader range of communities would enhance the applicability of the policy recommendations to a more diverse population. Another limitation to consider is the potential selection bias inherent in qualitative research, particularly in studies relying on focus group discussions. The participants who chose to take part in this study may have had stronger opinions about vaccine hesitancy, racism, or healthcare access than those who opted not to participate. This self-selection could lead to an overrepresentation of certain perspectives while underrepresenting those who might have more neutral or opposing views. Moreover, given that this study included service care providers, their insights may reflect professional experiences and biases, which may not fully align with the lived experiences of the ACB community members themselves. Future research should incorporate diverse recruitment strategies to ensure a more representative sample and a broader spectrum of viewpoints within ACB populations. Furthermore, while we present demographic data in Table 1, our analysis does not disaggregate findings by specific subgroups such as gender, education level, or distinct ethnic backgrounds within ACB communities. Future research with larger sample sizes and mixed-method approaches could provide a more granular understanding of how vaccine hesitancy and confidence vary across different sociodemographic groups. Finally, the geographic focus of this study solely on one location in Canada, without considering variations across different provinces or urban and rural settings, may limit the transferability of the findings to ACB communities in other regions. Expanding this study to encompass a wider geographical scope could yield more nuanced insights into the challenges and solutions for vaccine uptake disparities among ACB populations. To address these limitations, it may be useful for future studies to adapt mixed-method research with a particular focus on multisite data collection from multiple ACB communities within Canada.