Introduction

In Canada, immigrants (i.e., individuals born outside of Canada) represent approximately 23% of the population [1]. Despite constituting a considerable proportion of the Canadian population, research suggests that immigrants, particularly older immigrants, face unique and complex challenges in accessing and receiving vaccinations and that immigrant status is associated with lower vaccination rates [2–8]. This is particularly concerning, as older age is a risk factor for the incidence and severity of various infectious diseases, such as influenza, pneumococcal disease, and shingles [9–12].

Of note, in 2025, adults aged 65 years and older in Canada were recommended by the National Advisory Committee on Immunization (NACI) to receive an influenza vaccine every year and a single pneumococcal vaccine in their lifetime [11,13], and in 2023, adults aged 50 years and older were recommended to receive two doses of the herpes zoster (shingles) vaccine in their lifetime [12]. Influenza and pneumococcal vaccinations are publicly funded for those aged 65 years and older across all provinces and territories in Canada, while shingles vaccination is publicly funded in Ontario, Quebec, Prince Edward Island, and Yukon, among which only Prince Edward Island provides the vaccine for free as per NACI recommendations for adults aged 50 years and older [14]. However, national estimates from 2023 suggest that influenza and pneumococcal vaccination coverage among adults aged 65 years and older were 70.2% and 54.7%, respectively, while only 38.8% of adults aged 50 years and older had received at least one dose of the shingles vaccine [15]. Studies also indicate that vaccination coverage in immigrants is lower by 2.4% for influenza, 10.7% for pneumococcal disease, and 3.8% for shingles, compared to non-immigrants [5,6], presenting a need to address these disparities in vaccination experienced by immigrants.

However, it is important to recognize that immigrants are not a homogeneous group. Different communities have distinct histories, linguistic, cultural, and social norms, as well as pathways to migration that influence health behaviors, including vaccination. Since vaccination decision-making and vaccine hesitancy are vaccine-, context- and culture-specific [16–19], research should account for the heterogeneity among immigrant communities. Understanding the unique experiences, facilitators, and barriers faced by specific immigrant communities is essential to developing tailored and culturally appropriate strategies to improve vaccine uptake.

An older immigrant community that remains heavily overlooked and understudied with respect to vaccination is the Korean immigrant population, one of the largest racial minoritized groups in Canada according to the 2021 Census [20]. This population continues to grow rapidly as well. Between 2001 and 2021, the number of individuals who self-identify as Korean more than doubled, increasing from 101,000–218,000, of which over 60% were born in Korea [20,21].

According to a study conducted using 2003–2009 Canadian Community Health Survey data, Korean adults aged 65 years and older reported lower, although not statistically significant, coverage of influenza vaccination than those of other ethnic groups with the exception of Latin American, West Asian/Arab, and Black older adults [22]. This was the only study in the Canadian context that reported vaccination coverage among Korean older adults, but was not specific to Korean immigrant older adults. Similarly, a study conducted using 2009–2012 REACH US Risk Factor Survey reported that Korean American adults aged 50 years and older reported lower influenza vaccination coverage than those of other ethnic groups with the exception of Non-Hispanic Black adults, and that Korean adults aged 65 years and older reported lowest coverage of pneumococcal vaccination among population groups analyzed [23]. Other studies on vaccine willingness and healthcare service use among Korean adults in North America, primarily conducted in USA and focusing on COVID-19 vaccinations, suggest that Korean adults are less willing compared to other Asian adults to get vaccinated and less likely to access and utilize healthcare services, and that various barriers negatively impact Korean immigrants’ health and healthcare utilization, such as lack of social support, language difficulties, geographic constraints, and economic challenges [19,24–26].

While data on the burden of vaccine-preventable diseases on Korean older adult immigrants are not available, given that NACI recommends older adults receive influenza, pneumococcal, and shingles vaccines [11–13], but that Korean immigrants have lower vaccination willingness and healthcare service use [19,24–26], there is a pressing need to better understand the decision-making processes of Korean immigrants, to inform tailored strategies to improve vaccine uptake and hesitancy. Qualitative studies are particularly well suited to address the “how” and “why” of vaccination behaviours and decision-making processes within specific contexts and immigrant communities as it enables an in-depth exploration of these complex processes [27,28].

To address these gaps, we conducted a qualitative descriptive study to gain an in-depth understanding of influenza, pneumococcal, and shingles vaccination experiences and decision-making among Korean immigrants aged 65 years and older in Canada. The specific objectives of this study were to: 1) explore vaccination experiences of older adult Korean immigrants in Canada, including their attitudes, perceptions, and perspectives on vaccination, focusing on influenza, pneumococcal, and shingles vaccination; and 2) identify factors that facilitate or hinder uptake of influenza, pneumococcal, and shingles vaccines among older adult Korean immigrants in Canada. Findings of our study will inform evidence-based, culturally appropriate, and targeted strategies to improve vaccine uptake in this understudied population. Furthermore, while this study focuses on older adult Korean immigrants in Canada, the findings have broader relevance for global public health. In 2022, 43,000 Korean citizens emigrated to OECD countries such as the United States, Canada, and Japan [29]. The considerable size of Korean diaspora around the world highlights the need for increased efforts to better understand the health of Korean immigrants [30]. While the findings from this study are specific to Canada, they may be applied to other countries with similar vaccination policies and cultural contexts.

Methods

We report study methods and findings in accordance with the standards for reporting qualitative research (SRQR) guidelines.

Results

A total of 30 Korean immigrants aged 65 years and older residing in Montreal or Toronto participated in semi-structured interviews, at which saturation was reached (Table 1). One interview was conducted via videoconference and all others were conducted in-person. The interviews lasted between 40 and 110 minutes (mean of 61.5 minutes). Most participants resided in the Toronto area, were married or living with a partner, identified as Christian, and had completed college or university-level education. Almost all study participants reported having a family physician. At the time of the interview, 10 participants (33.3%) reported having received all three recommended vaccines, 9 (30.0%) reported having received two of three vaccines, 7 (23.3%) reported having received one of three vaccines, and 4 (13.3%) reported having received none of the vaccines. All interviews were conducted in Korean.

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Table 1. Sociodemographic characteristics and vaccination statuses of study participants.

https://doi.org/10.1371/journal.pgph.0005538.t001

Fig 1 presents the results of this study.

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Fig 1. Summary of themes and sub-themes by SEM category.

Intrapersonal factors represent individual characteristics (e.g., knowledge, attitudes, behaviours, etc.). Interpersonal factors include social networks and support systems. Institutional factors refer to social institutions with organizational characteristics and rules that govern the social institutions, as well as interactions with such social institutions. Community factors encompass relationships between organizations, institutions, and informal networks. Public policy factors include laws and policies.

https://doi.org/10.1371/journal.pgph.0005538.g001

Discussion

This qualitative descriptive study explored the influenza, pneumococcal and shingles vaccination experiences and decision-making processes of older adult Korean immigrants in Canada. Consistent with established frameworks of vaccination [16,17], our findings indicate that vaccination decisions are driven by the complex interplay of various intrapersonal-, interpersonal-, institutional-, community-, and policy-level factors. Within the different SEM layers, the most commonly reported motivators of vaccination were perceived disease risk to themselves and others (intrapersonal), family and peer norms (interpersonal), healthcare provider recommendation (institutional), church support (community), and government recommendations (policy), among which perceived disease risk to themselves and others was the most commonly reported motivator while healthcare provider recommendation was cited as the most important. Conversely, concerns about vaccine safety was the most common and important reason for not getting vaccinated, consistent with findings previous literature on factors influencing vaccination and vaccine hesitancy among immigrant and migrant populations [7,8,35,36].

Our finding that healthcare provider recommendation is one of the most important determinants of vaccination in older adult Korean immigrants is consistent with previous research on vaccination decision-making among older adult and immigrant populations [2,56–60]. During interviews, participants also reported a desire to spend more time with and receive sufficient information to guide vaccination decision-making from healthcare providers who lacked the time and resources to educate them. Previous research suggests that immigrants often lack vaccine information and awareness [8,35,61], and that healthcare providers are immigrants’ primary source of vaccination information [57,58]. As such, immigrants’ limited knowledge and awareness about vaccines, combined with the central role of healthcare providers as sources of vaccination information, may explain the participants’ specific desire to spend more time with their healthcare providers to receive guidance on vaccination.

Government recommendation was also a commonly cited reason for vaccination among participants. Many reported high levels of trust in the Canadian government and expressed their desire to adhere to government recommendations on vaccination. Participants compared the poverty, government corruption, and conflict experienced during their time in Korea to their current experiences with the government in Canada and reported that such experiences from Korea have fostered their trust in and gratitude towards the Canadian government. While gratitude is a common emotion reported by immigrants [62–64], it is possible that due to the historical and political contexts leading up to the participants’ immigration to Canada, this emotion is particularly relevant to Korean immigrants aged 65 years and older. The participants’ feelings of gratitude and indebtedness likely contributed to their trust in the Canadian government and desire to adhere government vaccination recommendations.

We found that religion and religious service attendance play important roles in vaccination decision-making processes of older adult Korean immigrants. Study participants reported that their social circles mostly existed in their church communities, which not only served as their primary source of vaccine information, but also actively recommended and motivated participants to get vaccinated. During interviews, many participants described having “faith” in vaccines, and that they would be “committing a sin” by not getting vaccinated and potentially acquiring a contagious disease that they would then spread to others. Our findings are consistent with previous research that suggests that religiosity and religious service attendance are associated with improved health outcomes [65–67], as well as preventative healthcare use and behavior [68,69]. Faith-based organizations can play a critical role in effective dissemination of public health and vaccination campaigns, as demonstrated during the COVID-19 pandemic [70], to addressing vaccine hesitancy, vaccine uptake, as well as vaccination disparities in marginalized and underserved populations [70–72]. While estimates of religious denominations are not available among immigrants from Korea in Canada, data from the U.S. suggest that approximately 59% of Korean Americans self-identify as Christian [73]. Therefore, our findings suggest that religion can be an important leveraging factor that can be taken advantage of to improve vaccination coverage in older adult Korean immigrants.

In our study, participants were generally very willing to get vaccinated and expressed a sense of obligation to do so. However, despite their high vaccination willingness, vaccination coverage rates were not very high, and many conveyed conflicting thoughts and feelings about vaccine effectiveness and safety. For instance, all participants agreed that vaccines help prevent disease or mitigate symptom severity. However, many also questioned whether vaccines are truly effective and safe. This is consistent with previous research showing that while vaccine hesitancy and willingness may be closely linked to uptake, they are not equivalent to uptake [16,74].

Of the three vaccinations examined in our study, the vaccination rate among participants was highest for influenza, followed by shingles and pneumococcal disease. This is in contrast to the results from a recent national vaccination coverage survey among the general adult population in Canada, which indicated that among older adults, vaccination rates are highest for influenza, followed by pneumococcal disease and shingles [15]. During our interviews, many participants mentioned knowing or having heard of people who had suffered from shingles, which motivated them to seek vaccination. High levels of awareness about and uptake of the shingles vaccine observed among participants may be reflective of what Korea has experienced in recent years – the high burden of herpes zoster infection, an increased awareness about the disease and vaccine following the 2022 presidential election in Korea during which public funding of the vaccine was used as an election strategy, subsequent efforts of multiple regional jurisdictions to provide free shingles vaccination, and competitive shingles vaccine marketing strategies employed by pharmaceutical companies [75–77]. Research on health practices and behaviors of immigrants suggests that immigrants maintain close ties with their places of origin and that their health-related behaviors and decisions are transnational [25,78–80]. The transnational ties of study participants may have contributed to their high awareness of shingles disease and vaccine. This highlights the importance of accounting for immigrants’ connections to their countries of origin and therefore the epidemiology of diseases and vaccine uptake, awareness, and ongoing and previous vaccine promotion efforts of their countries of origin when designing interventions to increase vaccination coverage.

The findings from our study suggest that repeated vaccination recommendations from healthcare providers may facilitate vaccination among older adult Korean immigrants. The study results also demonstrate the need to support healthcare providers in dedicating more time to vaccine discussions, particularly those that work closely with immigrant communities and are able to provide language-concordant care, to improve vaccination rates among older adult Korean immigrants. However, such one-on-one interventions may not be as feasible given the time and resource constraints. An alternative approach that circumvents this restriction could involve group educational sessions for older adult Korean immigrants in the Korean language and in Korean community settings (i.e., churches, Korean schools, Korean community associations, etc.), led by healthcare providers and in collaboration with religious leaders, as educational interventions for communities have been demonstrated to effectively improve vaccine hesitancy and uptake [56,81–83]. Furthermore, since the level of trust in government is very high in this population, our findings suggest that government-led public health campaigns could play a role in addressing knowledge gaps and vaccine safety concerns, ultimately helping to reduce hesitancy and increase uptake.

Our study is not without limitations. First, our sampling strategies were not random, which may have over-represented individuals with Canadian citizenship, higher education, and Christian faith compared to the overall older adult Korean immigrant population in Canada, potentially introducing bias into our findings. Second, we excluded individuals unable to pay for transportation or participate via videoconference, which may have biased the results. Third, we only recruited study participants from Toronto and Montreal. While approximately 40% of the Korean immigrant population in Canada reside in the two areas and Toronto is where the highest number of Korean immigrants reside in Canada [21], our findings may not be generalizable to older adult Korean immigrants living in other parts of Canada. Fourth, our study focused on understanding only influenza, pneumococcal, and shingles vaccination experiences and decision-making. Given the vaccine-specific nature of hesitancy and uptake [16,18], our findings may not apply to other recommended vaccines for older adults in Canada. Lastly, the study population was purposefully restricted to older adult Korean immigrants living in Canada to identify culturally-relevant and context-specific factors that drive vaccination decision-making processes in this population. While some findings may be relevant to other immigrant communities in Canada or Korean immigrants living in other countries with similar vaccination schedules, policies, and cultures, the restriction of our study population may limit the transportability of our findings.

Conclusions

In conclusion, we identified intrapersonal-, interpersonal-, institutional-, community-, and policy-level factors influencing influenza, pneumococcal, and shingles vaccination decision-making in older adult Korean immigrants in Canada. Overall, most participants were willing to get vaccinated, although hesitant about vaccines. Strategies to improve uptake in this population could involve reminding healthcare providers to give explicit and repeated recommendations for vaccinations, supporting healthcare providers or public health efforts to hold group educational interventions about vaccinations and provide vaccine information and knowledge, and working with faith-based communities to promote vaccinations. Our findings also highlight the importance of historical contexts of countries of origin and transnational ties in shaping immigrants’ vaccination decision-making and health decisions. Further studies among Korean immigrants of different age groups and in cities beyond Montreal and Toronto on their vaccination decision-making processes, reasons for non-vaccination, and potential strategies to improve vaccination coverage are needed for recommended vaccinations with low uptake rates as vaccination decision-making is context- and vaccine-specific.

Supporting information

Acknowledgments

We thank all study participants who shared their experiences during interviews. We would also like to thank the support of Korean community organizations, grocery stores, and churches in Toronto and Montreal. PL and AB are co-senior authors of this manuscript.