COVID-19 vaccination intention and behavior in a large, diverse, U.S. refugee population

Abstract

Introduction: Refugees often face increased risk of exposure to COVID-19 due to their disproportionate representation in the essential workforce and crowded household conditions. There is a paucity of data about risk factors for under-immunization for COVID-19 among refugees.

Methods: Refugees were surveyed in two phases that corresponded to before and after wide availability of COVID-19 vaccines. Participants were asked about their attitudes, and perceptions about COVID-19, previous acceptance of vaccines, sources utilized to obtain trusted health information, and intent to get vaccinated. The overall participant vulnerability was assessed using the social vulnerability index. In-depth semi-structured interviews were completed with key stakeholders through snowball sampling.

Results: Of 247 refugees, 244 agreed to participate in the initial survey. Among those, 140 (57.4%) intended to get vaccinated, 43 (17.6%) were unsure, and 61 (25%) did not intend to get vaccinated. In the follow up survey, all 215 who were reached, agreed to provide information about their vaccination status. Among those respondents, 141 (65.6%) were either vaccinated or expressed intent to do so, and 74 (34.4%) remained hesitant. We did not observe any significant correlation between socio-demographic variables, country of origin, and vaccination status/intent. Among those who initially intended to get vaccinated, nearly 1 in 5 changed their mind and decided to forego vaccination, and among those who initially did not plan getting vaccinated, 1 in 3 changed their mind and got vaccinated. Fears related to the vaccine, concerns that the vaccine is religiously prohibited, "wait and see" how others did with the vaccine, communication and transportation barriers were commonly cited as reason not to get vaccinated.

Conclusions: Over a third of refugees in our study were hesitant to get vaccinated. Refugees desired additional education about the benefits and safety of vaccines along with easier access to vaccination clinics in their communities.

Keywords: COVID-19; Hesitancy; Refugee; Vaccine.

Fig. 1

Change of vaccination intent and readiness between December 2020-April 2021. Participants were approached for survey participation during self-reported COVID-19 testing. The initial survey included 244 participants. Follow up survey took place when COVID-19 vaccines became widely available in April 2021. Out of 244, we were able to reach 215 refugees for a follow up survey.

Fig. 2

Map of social vulnerability index among survey respondents and their vaccination status/intent Syracuse area, New York. The social vulnerability index ranges from 0 to 1, with higher values indicating a community is more vulnerable. The SVI was previously associated with increased COVID-19 risk, and more vulnerable counties had lower vaccine coverage. The SVI combines fifteen measures from the US Census including measures of socio-economic status and household density into a single index. Geocoded households were matched to census tracts and compared the SVI among vaccine hesitant and vaccine accepting participants using R version 4.0.3. We then conducted an analysis of variance of the SVI by vaccination intent in April of 2021 showing that vaccine hesitant refugees lived in more socially vulnerable neighborhoods than their accepting counterparts.

Fig. 3

Social vulnerability of survey respondents by their vaccination intent/status. The social vulnerability index ranges from 0 to 1, with higher values indicating a community is more vulnerable. The SVI was previously associated with increased COVID-19 risk, and more vulnerable counties had lower vaccine coverage. The SVI combines fifteen measures from the US Census including measures of socio-economic status and household density into a single index. Geocoded households were matched to census tracts and compared the SVI among vaccine hesitant and vaccine accepting participants using R version 4.0.3. We then conducted an analysis of variance of the SVI by vaccination intent in April 2021 showing that vaccine hesitant refugees lived in more socially vulnerable neighborhoods than their accepting counterparts.

Fig. 4

Vaccination intent/status among respondents by country of origin before and after wide COVID-19 vaccines availability. Initial survey included 244 foreign-born adults who presented for COVID-19 testing between December 2020 through March 2021. A follow-up survey was conducted in April 2021 among 215 initial participants to inquire about their COVID-19 vaccination status. There were no significant differences at the country level and vaccination intent (p = 0.08, Fisher exact test).