Race/ethnicity,online information and COVID-19 vaccination: Study of minority immigrants’ internet use for health-related information

Abstract

The COVID-19 pandemic aggravated existing challenges for racial/ethnic minority immigrants in the U.S. in obtaining health information and seeking health care. Based on in-depth interviews with 49 racial/ethnic minority immigrants in the U.S. Midwest, this study examines how they navigated online health information related to general health issues and in particular COVID-19, how they encounter online misinformation related to COVID-19 vaccination and their willingness to get vaccinated. Results show that participants use online health information from both the U.S. and their home country to stay informed about the pandemic, but often encounter misinformation and hate speech online. Further, participants are hesitant to correct misinformation due to contentious online environment. Additionally, findings revealed that younger participants tended to be less willing to get vaccinated due to low perceived benefits. The study suggests scholarly and practical implications for those who work in the area of health communication, digital media messaging and minority communication.

Keywords

COVID-19 vaccine hesitancy minority immigrants online health misinformation race/ethnicity

Introduction

With the COVID-19 pandemic around the world in 2020–2021, a large proportion of the U.S. population reported online information-seeking as their primary choice to obtain health information (Pickles et al., 2021; Singh et al., 2020). While various health-related materials online enabled individuals to identify relevant information and motivated some to make important decisions such as getting vaccinated against COVID-19, there is also an increasing level of concern related to misinformation and anti-vaccination messages (Armitage, 2021; Desmond and Offit, 2020; Katz et al., 2017; Malhotra, 2020). Misinformation related to COVID-19 is particularly concerning for racial/ethnic minority groups who have historically been specifically targeted for coordinated misinformation campaigns (NPR, 2020). Health disparities that have long existed for these minority groups are added concerns, as they tend to receive lower quality of care than their white counterparts for various reasons including socioeconomic inequality and lack of trust in the healthcare system (Egede, 2006; Mitchell et al., 2019; Richardson et al., 2012; Rooks et al., 2012).

Racial/ethnic minority immigrants faced particularly precarious situations during the COVID-19 pandemic in terms of finance, employment and health (Donà, 2021; LaRochelle-Côté & Uppal, 2020). In addition to the aforementioned challenges, immigrants had to deal with language and cultural barriers and limited experience with the U.S. medical system, which can increase their vulnerability during the pandemic (Behbahani et al., 2020; Katz et al., 2017; Seo et al., 2016; Wilson and Stimpson, 2020). This is an important issue to consider, as the U.S. has more immigrants than any other country in the world and the number of racial/ethnic minority immigrants has increased over the years (International Organization for Migration, 2020). While racial and ethnic diversity in the U.S. has improved, income and health inequality has worsened both at individual and systemic levels (Katz et al., 2017).

Given the precarious situations many racial/ethnic minority immigrants faced during the pandemic and lack of research in this area, this study examines how race/ethnicity and migration experiences influence the immigrants’ use of digital media in seeking information related to COVID-19, how this group is exposed to and evaluates online health information related to COVID-19 vaccination and what factors influence race/ethnic minority immigrants’ willingness to get vaccinated against COVID-19. Studies on race/ethnicity on health information seeking and Health Belief Model provide theoretical guidance to this study, and empirical data come from in-depth interviews with racial/ethnic minority immigrants living in two neighboring states in the U.S. Midwest.

This study fills an important gap in the literature and has scholarly and practical implications for health communication involving racial/ethnic minority immigrants. To the best of our knowledge, no published research has so far examined online health information seeking and COVID-19 vaccine hesitancy among racial/ethnic minority immigrants in the U.S. Through in-depth interviews with 49 racial/ethnic minority immigrants in the U.S. Midwest, this research enhances our understandings of minority immigrants’ use of digital media in seeking information related to COVID-19, their exposure to and evaluation of COVID-related health information online and factors that affect their willingness to be vaccinated against COVID-19. The findings should be useful for those who study or practice social media-facilitated health communication among marginalized populations. Research in this area may also contribute to developing evidence-based health community messages and policies which in turn can help reduce existing health disparities, and improve long-term health outcomes for racial/ethnic minority immigrants.

Literature review

Health information online and health behavior among minority immigrants

Mass media and communication technologies help foster immigrants’ use of health-related resources not only for long-distance communication with friends and family members but also to seek health information (Gonzalez and Katz, 2016; Richardson et al., 2012). However, previous research indicates that immigrants tend to receive lower quality of health care than nonimmigrants due to trust issues in the healthcare system and lack of understanding (Egede, 2006; Mitchell et al., 2019; Richardson et al., 2012; Rooks et al., 2012). Further, race and ethnic disparities in healthcare systems play a critical role in seeking health-related information. For example, in their research examining effects of race, ethnicity and socioeconomic status on health information-seeking, confidence and obtaining health information, Richardson et al. (2012) found that participants of lower education were less likely to seek health information and had lower confidence in their ability to search for health information. Particularly, Blacks, Hispanics and other minority groups were less trusting of doctors, other healthcare professionals and sources on the internet as compared to non-Hispanic whites and those of higher education levels.

Previous studies suggest the internet is an important source of health information among immigrants but specific uses of the internet depend a lot on their ethnic and racial backgrounds (KHademian et al., 2020; Wang and Yu, 2015). For example, found that those from South Korea, specifically international students from the country, used the internet as the primary source for health information and preferred Korean resources online due to language barriers and difficulties understanding medical information written in English. They also seek online health information to address family member’s health problems and evaluate sources for credibility and misinformation. Wang and Yu (2015) found that Chinese immigrants living in the U.S. engage in online health information seeking using a wide range of approaches. Specifically, when they identify closely with a new culture, they use the language spoken in that culture (i.e. English) and online health information within the new culture more frequently. However, the authors also identified resistance to adapting to the new health culture with participants of the study continuing to use health sources hosted in their original culture due to comfort and familiarity. Additionally, another study conducted by Zhang et al. (2021) found that immigrants use the internet for health information and that they are more likely to trust family and friends as reliable information sources as compared with U.S. respondents.

While studies show that immigrants and racial/ethnic minorities use the internet for health-related information, more research is needed to better understand how their digital experiences interact with cultures and norms of both their country of origin and country of residence to affect their health information-seeking or trust of specific online resources such as government websites, news sites, social media and general internet search. Another issue to consider is a frequent lower level of access to and use of digital communication technologies among these minority groups. This can affect their seeking and obtaining health information online. In particular, analyzing these issues in the context of COVID-19 is important given the sample’s multicultural backgrounds.

Online health misinformation

While vaccines are among the greatest public health achievements in modern history (Alidu, 2021; Puri et al., 2020; Ugwuoke et al., 2021), the past few decades experienced an increase in vaccine hesitancy leading to major public health problems and outbreaks of communicable diseases such as measles or other viruses in parts of the U.S. (Zipprich et al., 2015). Recently, COVID-19 saw an amplification of concerns about vaccine safety issues driven by anti-vaccine misinformation activities on social media (Hornsey et al., 2020; Roozenbeek et al., 2020).

Misinformation is not a new phenomenon as anti-vaccine movements have existed at least since the 18^th century (Williamson, 1984) right through the development of COVID-19 vaccines (Ale, 2020; Ashton, 2021; Gever, 2020). Despite scientific evidence supporting the efficacy and safety of vaccines (Callender, 2016) and recently COVID-19 vaccines (Center for Disease Control and Prevention, 2020), sharing misinformation about COVID-19 (Pennycook et al., 2020 Pickles et al., 2021) remain a challenge. For example, a recent study conducted by Allington et al. (2020) found an association between belief that the COVID-19 virus was created in a laboratory and reduced protective behavior such as non-adherence to social distancing guidelines and meeting with friends and family outside the home. Another study showed that conspiracy beliefs about chloroquine and predisposition to conspiracy theories negatively predict intention to get vaccinated against COVID-19 in the future (Bertin et al., 2020). Furthermore, literature indicates misinformation on Twitter circulating that the pandemic was a hoax and no worse than the flu led to people having misperceptions about the virus and was associated with non-compliance behavior with preventive measures (Bridgman et al., 2020). Pennycook et al. (2020) suggest that in order to improve users’ health information seeking and sharing of content online, social media companies must intervene and ask users to rate the accuracy of random information. Boodoosingh et al. (2020) added that for individuals to accept the COVID-19 vaccine, awareness and public education will play a significant role. Further, including anti-vaxxers in the discussion will be critical to enhance vaccine acceptance.

With various features facilitating peer-to-peer communication, social media is rife with health misinformation and often amplifies misleading messages (Singh et al., 2020; Vosoughi et al., 2018). Various studies have reported presence of misinformation on social media during epidemics such as Ebola (Fung et al., 2016; Sell et al., 2020) and Zika (Bora et al., 2018; Wood, 2018). For example, studies focusing on Zika demonstrated that misinformation was three times more likely to be shared than was verified information (Sharma et al., 2017; Sommariva et al., 2018). Similar studies on the outbreak of Ebola identified roles of Twitter and Sina Weibo (Chinese microblog, equivalent to Twitter) in spreading rumors (Fung et al., 2016) and speculations on treatments (Pathak et al., 2015). These studies also found several misleading videos online regarding Ebola virus disease.

Misinformation regarding vaccines has been persistent (Panatto et al., 2018) as shown by the continued misconceptions about MMR vaccine and autism on social media (Aquino et al., 2017) and misinformation spread on HPV vaccine (Singh et al., 2020). More recently, the COVID-19 pandemic highlighted increased concerns about health misinformation online (Allington et al., 2020). Studies show that misleading information has been documented across almost all social media platforms including Facebook, Twitter, YouTube, Pinterest and Instagram (Vraga and Bode, 2020). This is particularly concerning as, according to Pew Research Center, 59% of Twitter, 54% of Facebook and 42% of Reddit users are exposed to and get their news directly from these sites (Pew Research Center, 2020).

Research shows that Facebook is the most popular site for sharing misinformation with approximately 2.85 billion users (Hopp et al., 2020; Statista, 2021). Hopp et al.’s (2020) study investigated why people focused on sharing misleading information on social media. Their analysis of countermedia content dissemination on Facebook and Twitter demonstrated that 1152 pieces of fake news content were shared via Facebook, with one user sharing such content as much as 171 times. In turn, 128 pieces of countermedia were shared on Twitter. Moreover, individuals that reported as being extremely politically conservative shared 26% of the misinformation on Facebook, accounting for 32% misleading information on the Twitter sample. Vosoughi et al.’s study (Vosoughi et al., 2018) tracked 126,000 unverified rumors which were spread by more than three million individuals on Twitter. Their findings showed that unverified rumors were diffused farther, faster and more broadly than verified information.

With the increase of health misinformation online (Romer and Jamieson, 2020), it is important for more studies to examine why and how people create and share misleading information online and what makes certain populations vulnerable to such information. It is particularly important to examine these issues in the context of racial/ethnic minority immigrants who often are targets of misinformation campaigns including during the COVID-19 pandemic (NPR, 2020).

Health belief model

The Health Belief Model (HBM) provides a helpful guidance in understanding how people evaluate health-related information and adopt related behaviors. Indeed, HBM is one of the most widely used theoretical approaches to understanding health-related behaviors over the last few decades (Champion and Skinner, 2008; Green et al., 2020; Strecher and Rosenstock, 1997). This study extends our understanding on immigrants’ use of the internet for healthcare sources and how race and ethnicity influence health information consumption and health behavior using HBM.

Health belief model postulates that people take actions based on their evaluation of the likely outcome of engaging in a new form of changing existing behavior. Specifically, the model suggests that an individual’s willingness to change their health behavior is influenced by perceived susceptibility, perceived severity, perceived barriers, perceived benefits and self-efficacy (Glanz et al., 2008; Guidry et al., 2020). Perceived susceptibility refers to an individual’s subjective perception concerning the level of risk of contracting a particular disease. Specifically, individuals are less likely to change health behavior when they perceive lower levels of susceptibility to the disease. Perceived severity is related to an individual’s belief about how serious the health threat is. Those believing the threat is less serious are less likely to adopt measures needed to protect them from the disease such as getting vaccinated. Perceived barriers and benefits are related to one’s sense of what/how much obstacles they expect to face and what/how much gains they anticipate from health measures. Self-efficacy in this context is related to how confident an individual is in their ability to successfully take a health-related measure to prevent a negative health consequence.

Health belief model has been used in different health contexts (Okpara et al., 2021). For example, applying HBM to human papillomavirus (HPV) vaccination, Di Giuseppe et al. (2008) found that susceptibility to HPV, severity of HPV and benefits of the vaccine predicted young women’s intentions to get HPV vaccination. HBM has also been used to examine beliefs and attitudes toward influenza pandemic and swine flu vaccine (Santos et al., 2017; Teitler-Regev et al., 2011) and to identify factors predicting individuals’ vaccine acceptance (Gorman et al., 2012; Mo and Lau, 2015; Shahrabani and Benzion, 2012; Wong et al., 2021). Guidry et al.’s (2020) study suggests that individuals are more likely to get vaccinated when they have higher levels of perceived susceptibility, perceived severity, perceived benefits and self-efficacy and lower levels of perceived barriers.

With the increased use of social media for health information, HBM has been used in studying user-generated content and social media platforms around vaccines and disease outbreaks (Ahadzadeh et al., 2015; Guidry et al., 2020). As the current study examines health information online and COVID-19 vaccine hesitancy, HBM serves as an effective framework for analyzing individuals’ perceptions regarding COVID-19 vaccines as well as perceived benefits and barriers to get vaccinated. In particular, our study contributes to filling gaps in the literature in the areas of health communication and minority communication, as few studies have applied HBM to examining the acceptance of COVID-19 vaccine among immigrants, in particular racial/ethnic minority immigrants.

Research questions

RQ 1: How do race/ethnicity and migration experiences influence immigrants’ use of digital media in seeking information related to COVID-19 in the United States?

RQ 2: How do minority immigrants in the United States get exposed to and correct misinformation related to COVID-19?

RQ 3: What factors influence COVID-19 vaccine hesitancy among minority immigrants in the United States?

Methods

To answer the research questions, we conducted in-depth interviews with racial/ethnic minority immigrants ages 18–64 who migrated to the U.S. since 2014 and were living in two neighboring states in the U.S. Midwest as of Spring 2021. Interview research was used for this study, as it provides a rich narrative account from each individual’s point of view (Lamont and Swidler, 2014; Rufas and Hine, 2018). In-depth interviews allow researchers to gain deeper understandings of the challenges individuals face, in this case minority immigrants, and how those challenges are perceived by the individuals and affect their thoughts and feelings (Weiss, 1995). The research processes described below followed protocols reviewed and approved by the Institutional Review Board (IRB) of the authors’ university.

All interviews were conducted between mid-February and mid-March in 2021 when each city had the vaccination rate of less than 10% and limited vaccination eligibility to those younger than 65 (Center for Disease Control and Prevention, 2021). Participants in the study were recruited through nonprofit organizations that support immigrants as well as research team members’ personal contacts. Using a semi-structured interview method, each interview session covered a set of prepared questions on the participant’s social media use, health information-seeking online, experiences with misinformation on COVID-19 and perspectives on COVID-19 vaccination. The interviewer asked follow-up questions for clarification and additional information as deemed appropriate (DeJonckheere & Vaughn, 2019). Each interview was conducted and transcribed by research team members approved by the IRB. The final number of interviews was determined by theoretical saturation of data with the research team conducting interviews until no new information occurs in the data (Saunders et al., 2018).

We used Dedoose 8.0.35, a qualitative data analysis platform, to analyze our interview transcripts. Specifically, we developed codes using the constant comparison technique based on grounded theory and organized the coding of themes related to social media use, health information online and misinformation and perceptions related to COVID-19 vaccination (Charmaz, 2014; Glaser and Strauss, 1967; Rubin and Rubin, 2011; Strauss and Corbin, 1994). Our final set of codes is comprised of pre-existing codes derived from research topics and emergent codes through the open-coding or in vivo process. Once a stable categorization of codes was formed, interview transcripts were coded in a second round of focused coding. For a full account of themes and sub-themes, see Table 1.

Table 1.

Overview of themes.

Theme	Sub-theme	Comment count
Social media use	U.S. social media	21
	Country of origin social media	35
	Negative effects	29
Health information online	COVID-19 information sources	96
Health information online	General information source on social media	232
Misinformation	Encountering COVID-19 misinformation	65
	Correcting misinformation online	49
	Online misinformation in general	2
Perceptions related to COVID-19 vaccinations	COVID-19 infection experience	65
	Perceived susceptibility/benefits	34
	Following health guidelines	53
	Vaccination willingness confidence	97

Results

A total of 49 racial/ethnic minority immigrants living in two neighboring states in the U.S. Midwest participated in the interview research. A summary of key demographic characteristics of the interviewees is shown Table 2. In terms of age, 19 (38.8%) were ages 18–29, 16 (32.7%) were ages 30–39, 8 (16.3%) ages 40–49, 5 (10.2%) ages 50–59 and 1 (2.0%) ages 60–64. Twenty-one participants (42.9%) identified themselves as Asian, 10 (20.4%) African, 10 Middle Eastern (20.4%), and 8 (16.3%) Latino. About a half of the participants (n = 25) identified themselves as female and the other half male (n = 24). In terms of the highest level of education completed, 12 said high school (24.5%), 13 bachelor’s degree (26.5%), 23 master’s degree (46.9%) and one PhD (2.0%).

Table 2.

Demographics of interviewees.

Variable	Value	Count	Percent (%)
Age	18–29	19	38.8
	30–39	16	32.7
	40–49	8	16.3
	50–59	5	10.2
	60–64	1	2.0
	Total	49	100
Race	Black or African-American	10	20.4
	Asian or Asian-American	21	42.9
	Hispanic or Latina/o	8	16.3
	Middle Eastern	10	20.4
	Total	49	100
Gender	Female	25	51
	Male	24	49
	Total	49	100
Education	High school completed	12	24.5
	Bachelor’s degree	13	6.5
	Master’s degree	23	46.9
	PhD	1	2.0
	Total	49	100

RQ1: Intersection of race/ethnicity and migration experiences on health information consumption

Straddling between U.S. and country-of-origin media

Our data suggest that participants use a mixture of U.S. and country-of-origin news sites and social media to stay informed of health news updates and other information during the pandemic. The overwhelming majority of participants reported accessing digital news sites of U.S. media (e.g. CNN) and outlets local to their country of origin (e.g. News24 in South Africa) on a regular basis. Other U.S. news sources that were frequently mentioned include MSNBC, Fox News and The New York Times. For example, a 53-year-old woman from Mexico said, ‘I read news stories by Mexican and U.S. news outlets and stories shared via social media by my friends and family in the two countries’. In addition, several participants indicated that they follow Facebook groups specific to the pandemic that are run by news outlets in their country of origin.

Our participants’ social media use also suggested that they regularly searched social media sites popular in the U.S. or their country of origin to stay informed about events and updates from family and friends. Instagram was most frequently mentioned social media platform, with more than a half of the participants citing it as their most preferred social media site. Facebook, YouTube, Twitter and TikTok were also mentioned frequently by the participants. A 26-year-old woman from Iran said, ‘I usually use Instagram because it has lots of pictures so it’s just easier to see what’s going on. And then I use TikTok because I find it really entertaining, especially I watch a lot of educational videos or cooking hacks or life hacks. Then I use WhatsApp and Telegram for a video call with my family [in Iran] or to chat with them’. Other participants from the Middle East also mentioned Telegram as an important social media site to stay in touch with their family and friends in their country of origin. Frequent use of social media sites popular in their country of origin was apparent from interviewees as well. For example, participants from China mentioned WeChat or Xiaohongshu and those from South Korea mentioned KakaoTalk. These social media sites allowed them to receive relevant support from social connections in their country of origin. For example, a 26-year-old woman from Bangladesh said, ‘I talk with my friends and family living in the country [Bangladesh]. I also use Facebook so that I can see what they post. I follow many different pages of Facebook including news portals and other pages on travelling, political issues and social issues. I also watch news about Bangladesh on YouTube’.

Added stress stemming from hateful comments toward immigrants and their health information-seeking experiences

While social media allowed interviewees to get much-needed social support during the pandemic, content on popular social media sites at times was sources of stress and even fear for some participants. In describing social media use during the pandemic, a dozen interviewees mentioned added stress from hateful comments toward immigrants on social media. A 39-year-old man from Columbia said, ‘Looking at hateful messages about immigrants on social media in addition to stories of people dying of COVID is exhausting’. Specifically, several interviewees who migrated from China, South Korea and India stated that they encountered racial slurs during the pandemic and avoided going online due to stress stemming from such experiences. This is in line with Asians facing xenophobia related to COVID-19 on social media since early 2020, following early media reports of a laboratory in China being the origin of the virus and then U.S. President Trump calling it ‘Chinese Virus’ (Abidin and Zeng, 2020; Gostanian et al., 2020; Reja, 2021). A 56-year-old woman from South Korea described her experience of encountering hateful comments toward Asians on Facebook. ‘I saw hateful comments toward Asian immigrants, some posts more specific to people from China, on Facebook calling them “spreaders of coronavirus” while using F-words. These experiences got me really stressed and nervous, so I didn’t want to visit even social media sites for a while’, the interviewee said. For some, such experience was not confined to an online environment. A 41-year-old woman who migrated from India to the U.S. in recent years said a white man yelled at her saying ‘Go back to your country and stop spreading the virus’, as she was shopping at a grocery store in summer 2020.

Other immigrants noted that uncertainties surrounding visa situations and precarious health care situations amplify their health information-seeking concerns especially amid the growing hate toward immigrants. For example, a 26-year-old woman from Bangladesh said, ‘I don’t have any health insurance here. If I get sick or if I have a problem, I try to solve it with Google. Also, I try to find home remedy that is easy for me here. Because I don’t have any insurance and it is very expensive for me to get medical care here. So I look at Google or talk to my parents and friends [in Bangladesh] who I trust...’ A 22-year-old Pakistani man said he was worried about his immigration status as ‘the laws are changing all the time’ and ‘was really depressed too at the same time being away from family and parents’. He also added, ‘I always check what’s going on because I might not be able to go home due to travel restrictions… I checked CNN, New York Times and everywhere to see the current developments in the U.S. related to COVID’. In addition, many participants expressed exhaustion and stress stemming from social isolation from the pandemic and uncertainties surrounding the situation. A 51-year-old woman from Brazil said she is ‘exhausted about the whole situation’ in particular given the high infection rates both in Brazil, where her mother and brother live, as well as in the U.S. Some participants said they were ‘very worried’ about going out and meeting people but at the same time miss social interactions.

RQ2: Exposure to and correcting misinformation related to COVID-19

The interviews suggest that participants were exposed to misinformation regarding COVID-19 both in the U.S. and their country of origin. Examples of misinformation ranged from a claim that COVID-19 is just like another flu to 5G spreading the virus and vaccination making women infertile. In addition, our analysis results suggest that the immigrants carefully tread the issue of correcting misinformation on social media as they feel they need to align with cultural norms and values of both countries.

Encountering misinformation from both U.S. and home country

Most participants said they have encountered misinformation related to the COVID-19 pandemic on social media sites. In particular, Facebook and WhatsApp were frequently mentioned as the platforms through which they were exposed to pandemic-related misinformation. Moreover, they reported encountering misinformation salient not only in the U.S. but also in their country of origin. A 25-year-old woman said some people living in Mexico who are connected with her via social media ‘dramatically blow the information out of proportion’. She added, ‘The [COVID-19] situation is different in Mexico so they were starting to say on social media that health workers are killing people and COVID didn’t exist. I don’t believe that’.

About two-thirds of the interviewees said they were exposed to misinformation about COVID-19 quite frequently. ‘Oh, yes. Many times, especially on Facebook’, a 26-year-old woman who recently moved from Bangladesh said when asked whether she has encountered misinformation related to COVID-19 on social media. ‘There are many pages on Facebook that show different things that made people panicked. I had to verify what they say is accurate or not. I stopped following those Facebook pages on COVID-19 because I got panicked about things that they lied about’, she added. A 30-year-old man from Iran also said he saw ‘a lot of misinformation’ about the pandemic on social media particularly on Telegram, a platform popular among people in Iran. A 35-year-old woman from Botswana said she saw most misinformation on Twitter, which is her ‘go-to source’ for news and updates. ‘When COVID first came out, people were like, “It’s just like a seasonal flu. You will just be sick for 2 days and you will be fine.” Also, people are saying there is 99.9% survival rates, but a lot of people have already died’. Noting that she has seen a lot of misinformation about the virus both in news media sites and social media, a 35-year-old woman from Vietnam said, ‘There’s a lot of fake news in Vietnam about COVID. Some people say, for example, if you boil 12 eggs and eat all of them together, you’re going to kill COVID. Or I saw this other article saying if you drink aspirin, that can kill COVID’. A 27-year-old man from China noted older adults seem more vulnerable to misinformation on social media. He said, ‘Older people always get fooled I think. At the early stage of the pandemic, I heard from one of my uncles saying that he was applying sesame oil to his nose to protect him from COVID-19. I was like...come on!’

Some noted politics involved in misinformation surrounding COVID-19. Several participants mentioned former U.S. President Donald Trump and other politicians spreading inaccurate or misleading information about the virus and vaccination. For example, a 32-year-old woman from South Korea said, ‘Early on, of course, even the U.S. president spread misinformation about COVID which was circulated on social media. These days, I sometimes see information that discourages people from getting vaccinated, saying it is not effective or it will alter human DNA or it will cause infertility’. In contrast, a few participants described these as ‘different viewpoints’ or ‘reflecting their own opinions’ rather than misinformation. A 29-year-old man from China said, ‘There might be some misinformation…there might be different viewpoints and they have their different perceptions of the situation’. A 49-year-old man from Senegal said, ‘I am not sure whether it’s misinformation. But like U.S. media, sometimes the perspective and angles are quite extreme’.

Treading misinformation correction carefully

Interview participants reported trying to consider cultural norms in both countries in deciding to correct misinformation online. When asked whether they attempt to correct misinformation on social media sites, most participants said they try to be careful in correcting misinformation online because they are unsure of beliefs held by those connected via social media platforms or whether their connections would be willing to listen. For example, a 51-year-old woman from Brazil said, ‘These days I worry that I may end up having disputes with someone on social media if I did so. You never know what your friends on social media actually think or believe. If my close friend or family shares some information that I know for sure is wrong, I will tell them that the information is not accurate. Otherwise, I don’t try to correct misinformation on social media’. Others also expressed concerns about being attacked if they were to try to correct misinformation on social media. For example, a 25-year-old man from China said: ‘No, I would never do that. Because people are stubborn. If you try to correct them, they will...like attack you...that would be a nightmare. I wouldn’t even think of doing that’. Some others said that they do not correct misinformation on social media because they ‘don’t have that kind of personality’ and they ‘just choose to walk away and do my [their] own thing, not engage with that person’.

However, when it comes to misinformation shared by family members or close friends, many of the interviewees said they let them know that it is not accurate. In addition, some participants said they have taken proactive measures of correcting such information. A 47-year-old man from South Africa said, ‘Yes, uh, I try to you know, to communicate with especially friends or family members who are actually resistant to a COVID-19 vaccine itself, you know’. Several participants indicated that attempting to correct misinformation online depends on the platform itself on which the correction occurs. For instance, some people feel more comfortable correcting misinformation on messaging apps such as WhatsApp or KakaoTalk due to the intimacy, comfort level, and closeness to their chat partners. A 30-year-old man from Uganda said, ‘Yes, it depends. For WhatsApp, I’ll probably do so…if you are on a group and when someone posts a video [with misleading information], I will always comment and say, hey this is not true, this is propaganda, something like that’.

Several participants mentioned they do some research to determine whether the information on a social media post is accurate or not, if they are not sure about it. They mentioned using news sites including Google News or health information platforms such as WebMD as well as sites geared specifically to fight misinformation around COVID-19 such as VaxFacts.

RQ3: Factors influencing vaccine hesitancy

Participants’ responses related to questions on vaccine willingness touched on some of the key constructs of the Health Belief Model (HBM), in particular, perceived susceptibility, perceived benefits and cue to action (Glanz et al., 2008; Guidry et al., 2020). This finding is in line with previous research that shows individuals with higher perceived susceptibility and higher perceived benefits of a health measure are more likely to take the measure (Glanz et al., 2008; Guidry et al., 2020; Wong et al., 2021). Moreover, our interview data suggest that recent immigrants tapped into social connections in their country of origin as well as in the U.S. to deal with uncertainties surrounding the pandemic including vaccine availabilities. Information and suggestions from these connections as well as news and social media sites served as cues to action—the stimulus needed for their decision-making related to COVID-19.

Perceived susceptibility

While the majority of the interviewees said they planned to be vaccinated against COVID-19, about a fifth of the participants indicated that they would never get vaccinated for COVID-19 or would not get vaccinated at least ‘for now’. Those who are willing to get vaccinated against COVID-19 and those who are not differed mostly on perceived susceptibility (i.e. subjective perception about how much they are at risk of contracting COVID-19) and perceived benefits of the vaccination (i.e. what/how much gains they anticipate from the COVID-19 vaccination).

Younger and healthy interviewees tended to show lower levels of perceived susceptibility and less willingness to get vaccinated. For example, a 21-year-old man from Uganda said, ‘Ok for me personally, if it is by law that is, is compulsory then I will take it, but if it is not by law and it is personal willing, I’m not taking it because I, I don’t believe I will get this virus and it is not something that I am scared of…I don’t believe in taking any vaccine’. Similarly, a 20-year-old man from Pakistan indicated that he sees no reason to get vaccinated anytime soon. ‘No. I think at some stage…but not next 2–3 years’, he said when asked how willing he was to get a COVID-19 vaccine if it became available to him right now at no cost. A 23-year-old woman from Venezuela also said she does not think she will ‘easily’ get infected with COVID-19 and does not plan to be vaccinated ‘anytime soon’.

In contrast, a 30-year-old man from Uganda, who is immune compromised, was eager to get vaccinated. He said that the COVID-19 vaccination is important to him ‘due to my health status being a high-risk patient’ and that his health condition and consequent perceived susceptibility to the virus are ‘what influence me most’. Overall, older adults showed higher levels of perceived susceptibility and more willingness to get vaccinated. For example, a 56-year-old woman from South Korea said she signed up for multiple sites for COVID-19 vaccination and was ‘eager’ to get vaccinated.

Perceived benefits

Perceived benefits of the COVID-19 vaccination is another theme that was widely mentioned in interviewees’ discussions of their willingness or hesitancy to get a COVID-19 vaccine. Those who had lower levels of perceived benefits of the vaccination demonstrated low levels of willingness to get vaccinated. For example, when asked whether he believes a COVID-19 vaccine would protect him from getting infected, a 21-year-old man from Ghana said, ‘No, because I had a friend, I had a pastor friend who had the shot and he still had COVID’. The interviewee said he did not want to get vaccinated against the virus at least ‘for now’.

The majority of those hesitant to get vaccinated expressed doubts about COVID-19 vaccines including World Health Organization-approved ones, saying the vaccines were developed and approved ‘too quickly’. For example, a 32-year-old man from Iran said, ‘Personally no. It’s not that I feel I will not get infected, but I have that impression that vaccines or any type of drug need to be tested more’. Other participants also mentioned that the pharmaceutical industry developed the vaccines too quickly and there is insufficient information about side effects. Another participant said, ‘I’m not sure about the quality. I mean I’ve read the news that 40 people in Norway died after getting vaccinated…It might not be 40, it might be 20, I might be wrong but that’s scary’. Other participants said they ‘just don’t see the need to go rushing into getting the vaccine’ because they are taking precautions such as wearing facial masks and social distancing.

Many of those who said did not want to get vaccinated expressed concerns of genetic modification caused by COVID-19 vaccination, a false claim that was widely circulated in 2021 as Pfizer and Moderna vaccines use mRNA technology (Reuters Fact Check, 2021). Several women in their late 20s and early 30s said they were concerned about their fertility being affected by COVID-19 vaccination. Some participants opposed the idea of vaccination itself.

Those who were willing to get vaccinated said that the primary benefit of COVID-19 vaccination is to prevent them from becoming seriously ill from the virus. A 35-year-old woman from Botswana said, ‘From what I understand, even if you got the vaccination, there is a chance that I can still get infected with COVID. But what I know or what I understand is that, even if I were to get it, it wouldn’t be as debilitating as someone who hasn’t gotten the vaccine’. A 30-year-old man from Uganda echoed the sentiment: ‘You can still get COVID even if you did get a vaccine, but the key important thing is that if you got vaccinated, probably you won’t experience severe symptoms, so that’s the key issue...It’s meant just to save me from getting the severe complications’.

Cue to action

Experiences and information from their family and friends often influenced how much they trust the effectiveness of vaccines and whether they were willing to get vaccinated. For instance, a 31-year-old woman from Bangladesh said, ‘My sister [in Bangladesh] is a doctor. Most times, I talk to her. If she is not available, I go to pharmacies like CVS or Walgreens…where I can go and ask questions’. A 32-year-old South Korean housewife said she follows COVID-19 information on various online communities including MissyUSA, the largest online community for Korean women living in North America (Seo, 2021). Other participants also discussed how news and information they gathered from media sites in the U.S. and their country of origin encouraged them to take certain measures related to COVID-19.

Discussion

Based on interviews with racial/ethnic minority immigrants residing in two neighboring states in the U.S Midwest, our study offers timely and relevant scholarly and practical implications in the areas of minority communication, health communication, misinformation, vaccine hesitancy and digital media. In particular, our research suggests the importance of understanding the intersectionality of race/ethnicity and migration experiences in race/ethnic minority immigrants’ use of social media, exposure to misinformation and COVID-19 vaccine hesitancy. Such intersectional approaches are essential to producing contextual research findings and developing tailored and evidence-based online health communication messages for racial/ethnic minority immigrants and other marginalized populations.

Scholarly implications

Our study offers important scholarly contributions related to the Health Belief Model (HBM) (Champion and Skinner, 2008; Glanz et al., 2008; Green et al., 2020; Strecher and Rosenstock, 1997), a theoretical framework used in this study. The results of this study suggest that perceived susceptibility and perceived benefits are key aspects that people take into account in deciding whether to get vaccinated against COVID-19. In particular, younger and healthier participants tended to demonstrate lower levels of perceived susceptibility and perceived benefits and less willingness to get vaccinated. It should be noted that some participants who said they were not going to get vaccinated (a fifth of our sample) questioned the effectiveness of COVID-19 vaccines or worried about negative consequences of the vaccination based on misinformation widely circulated via social media. In analyzing the influence of perceived susceptibility and perceived benefits on immigrants’ willingness to get vaccinated, it is also important to understand how their exposure to information related to COVID-19 from news and social media sites in the U.S. and their country of origin as well as their social connections may have played a role. Our interviews show that the immigrants relied heavily on digital media sources in the U.S. and their country of origin and suggest that information from these sources may have served as a cue to action (i.e. vaccination). Cue to action is another key construct of HBM. Therefore, this study advances conceptual approaches to HBM and health information and provides much-needed empirical data on minority immigrants in this area of research.

While previous studies examined related topics for immigrants or racial minority groups (Gonzalez and Katz, 2016; KHademian et al., 2020; Richardson et al., 2012; Wang and Yu, 2015), few studies focused specifically on racial/ethnic minority immigrants and their online health information behaviors and vaccine willingness. In this sense, this study fills an important gap in the literature that currently lacks theoretical and empirical research on racial/ethnic minority immigrants’ online health information consumption and vaccine hesitancy. In particular, our findings highlight the importance of approaching the topic in a holistic manner by taking into account country of origin cultures and norms as well as those of the country of residence all in the context of the precarious social, economic, and health situations that racial/ethnic minority immigrants often face. Study participants often mentioned the importance of news media and social media content both from the U.S. and their country of origin in gaining health information online during the COVID-19 pandemic. Another aspect salient in the participants’ discussion of health information online was hateful messages on social media toward immigrants, particularly Asian immigrants, during the pandemic. In some cases, exposure to such hateful messages resulted in some participants wanting to stay away from social media. These findings suggest that it is important to take into account both cognitive and emotional dimensions of information seeking and consumption in understanding health behaviors of migrant immigrants or other marginalized populations.

Practical implications

Our research offers practical implications for those who work in the area of health communication, digital media messaging, and minority communication. Specifically, results from this study highlight the importance and urgency of media organizations, healthcare providers, policy makers and government entities taking measures to create a more productive information ecosystem related to health issues. Most of our participants reported being exposed to misinformation related to COVID-19 on social media. We found that some believed widespread misinformation such as COVID-19 vaccines resulting in genetic modifications or infertility (Reuters Fact Check, 2021). It is essential for relevant organizations to provide an information hub tailored for a particular immigrant population so that misinformation prevalent among that community can be more fully addressed. In addition, public health messaging during a crisis like COVID-19 should address both cognitive and emotional needs of underserved immigrant populations.

Policy makers and practitioners should devise measures for working collaboratively with racial/ethnic minority immigrant populations in correcting misinformation online. Our findings show that minority immigrant populations may be hesitant to correct misinformation they see on social media for fear of offending other people, ruining social relationships, or being harassed online. Misinformation, remaining uncorrected on social media, continues to affect a greater number of people. As minority immigrant populations tend to be more aware of particular pieces of information widely circulated within their community, including these populations in developing tailored and relevant messages and measures would be helpful. Such undertakings are especially important during public health crises where more people pay more attention to information from governmental and health agencies (Swire-Thompson and Lazer, 2020). In particular, when utilized effectively, social media channels can be helpful in disseminating truthful information and dispelling misinformation.

Limitations and future research

There are several limitations of the current study that need to be taken into account in future research in this area of research. First, the interview data in this study are based on a convenience sampling method. A larger study based on a random sampling approach would produce generalizable findings. Second, this study measured individuals’ perceptions and reported behaviors at one point of time. A longitudinal study analyzing perceptions or behaviors at multiple time points (e.g. different phases of the COVID-19 pandemic) will help understand how developments of the pandemic may affect their perceptions and behaviors related to the vaccination. Third, while our participants had a varying degree of educational attainment, overall they had a relatively high level of education. According to the American Immigration Council, over a fourth of immigrants typically have less than a high school diploma (Immigrants in the United States, 2021). Prior studies suggest that people with low education are more likely to believe misinformation and disinformation related to health information, are less likely to seek health information, and have low confidence in their ability to search for health information online (Richardson et al., 2012; Seo et al., 2016). Thus, future studies should consider including a larger sample of minority immigrants with lower education levels. Finally, we collected data from racial/ethnic minority immigrants residing in two neighboring states in the U.S. Midwest that had similar developments in terms of COVID-19. A comparative study analyzing states with different levels of infection and vaccination rates may offer insights as to how characteristics of states and developments of the pandemic within the state are associated with individuals’ health information consumption and vaccination willingness.

ORCID iDs

Annalise Baines https://orcid.org/0000-0001-9536-6010

Muhammad Ittefaq https://orcid.org/0000-0001-5334-7567

Footnotes

Author biographies

Annalise Baines (M.S. University of Kansas) is a doctoral student in the William Allen White School of Journalism and Mass Communications at the University of Kansas. Her research interests include environmental health communications, marketing communications, and digital and social networking platforms. Her research has been published in Vaccine, Vaccines, Newspaper Research Journal, and Frontiers in Communication.

Hyunjin Seo (Ph.D., Syracuse University) is Oscar Stauffer Professor in the William Allen White School of Journalism and Mass Communications at University of Kansas as well as founding director of the KU Center for Digital Inclusion. She is also a faculty associate at the Berkman Klein Center for Internet & Society, Harvard University where she was a resident fellow from fall 2018 to summer 2019. Her research examines how social collaborative networks facilitated by digital communication technologies affect social change at local, national and international levels. She has published over 50 peer-reviewed journal articles and book chapters in this and other related areas. She is also the author of Networked Collective Actions: The Making of an Impeachment (Oxford University Press, 2022), which examines intricate relationships between social institutions and agents during networked-facilitated political movements. Her research has been funded by various federal grant-making agencies and foundations including National Science Foundation, National Endowment for the Arts, Google, Ewing Marion Kauffman Foundation, and Kansas Health Foundation.

Muhammad Ittefaq is an Assistant Professor in the School of Communication Studies at James Madison University, Hairrisonburg, Virginia, United States. His research interests include global health communication, misinformaiton, vaccines, and emerging technologies.

Fatemeh Shayesteh (M.A. from University of Tehran, Iran) is a doctoral candidate in the William Allen White School of Journalism and Mass Communications at the University of Kansas. Her research focuses on social media, social change, and gender and sexuality.

Ursula Kamanga (Ph.D. University of Kansas) is an assistant professor in the Honors College at University of Nevada, Las Vegas. Her research interests include health communication, social media research, social media influences on health behavior, cultural influences on making health decisions, strategic communication, and community participatory research.

Yuchen Liu (Ph.D. University of Kansas) is an assistant professor at Cleveland State University. Her primary research interest is the use and effects of social media in the areas of strategic communication, public relations, and international communication. Her research has been published in Communication Research Reports, Science Communication, Global Environmental Change, and Environmental Communication.

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