General perceptions about COVID-19.

Focus group participants reported that Latine communities were hard hit by COVID-19, thus took it seriously from the onset of the pandemic. Many participants knew people (family members or friends) who had died or experienced serious illness from COVID-19. Though there was general recognition that COVID-19 was less threatening over time, some (e.g., farmworkers) still viewed it as a serious matter. As highlighted by a focus group participant:

Well, okay. I was saying that COVID is still a worrisome topic because, well, it hasn’t disappeared 100 percent. Right? It’s still–it’s latent. But in the community, it feels like it’s being managed with more tranquility or with more confidence, vaccines. (Focus Group (FG) 0728-NC statewide, virtual)

Focus group participants reported that many Latines do not trust, are discouraged from using, and have difficulty accessing and navigating the U.S. healthcare system, especially for non-English speakers and for those who are accustomed to healthcare systems in other countries. This was reported in a focus group:

Why the distrust? Because–because as Hispanics, that’s how our culture is. It’s simply–we’re from countries where there are no public services and public services are very deteriorated. And here, when–and we come with that mentality of, “I’ll go to the doctor only when I feel sick, not when I’m okay. I won’t go to a routine exam, because I don’t need it, because I’m not sick. So, our mentality and our culture teaches us that…Our culture teaches us not to trust, it teaches us not to go to the doctor, it teaches us to not accept things because before, in the past, they were being used to do medical or clinical studies to create medications–certain people, communities were used in certain countries. So, all of that shot off here in the United States, and let’s not forget about our countries, where there was also chaos. (FG 0615-Forsyth County, NC, in-person)

Notably, participants reported that Latine communities fear using public health services given experiences with racial/ethnic discrimination, anti-immigration rhetoric, and policies and laws that discourage or restrict access. Participants reported that publicity around policies, such as Section 287(g) of the Immigration and Nationality Act and the Secure Communities program,(35) sanctuary city status,(36) and “public charge” (term used by U.S. immigration officials and the media for individuals considered likely to become dependent on the government for subsistence(37)), reduced perceived access to and discouraged use of COVID-related services, as noted:

I don’t know people who found it difficult, but I know many people, especially Latinos, who don’t know that they can get home tests at home. I don’t know if this is because they think or are afraid that they’ll be denied because of their status, some of them who don’t have documents. And they think they can’t get them. And that’s one of the questions that many people have who think they can’t get them because they’re undocumented. And I don’t know if that’s an obstacle for them. (FG 0623-NC statewide, virtual)

Participants also reported many Latines hold concerns that seeking services might expose them/family members to immigration enforcement actions or negative legal consequences related to immigration status.

Barriers to testing, vaccination, and booster uptake.

Many barriers to COVID-19 testing, vaccination, and booster uptake were reported. Participants shared that many Latines distrusted the information received during the onset of the pandemic (especially since little was available in Spanish). This contributed to the circulation of misinformation and myths about COVID-19. Some participants reported hearing that COVID-19 did not exist and was an invention to control and confine people, or that the virus was created intentionally to make people sick and then sell them vaccines. Participants reported various forms of vaccine-related misinformation (e.g., fertility issues and microchips) from several sources, including friends, religious leaders, and media. Media, both social and traditional forms, fueled misinformation; one provider stated that many Latines, particularly young people, were getting information from social media that the vaccine was “dangerous”, not tested, or did not prevent COVID-19. This was discussed frequently, including in a focus group:

I watched a lot of TV and heard a lot on social networks that vaccines were a chip that was implanted in you, that it was part of a government strategy to keep you under control, mainly to keep you under control. So that was my fear. Many comments were made and they related it to biblical things, which was the mark of the devil, many things that happened. (FG 0623- NC statewide, virtual)

Participants also reported that initially there was not enough known about vaccines which contributed to doubts about safety and efficacy.

Participants reported that religious institutions were an important source of COVID-19-related information. While some churches supported and promoted protective measures, others had leaders who viewed COVID-19 prevention methods as a threat to religious practice through restricting congregational meetings and temporarily closing church facilities. This underscored the myths about how COVID-19 is a lie intended to distance people from churches/God. Both focus group and interview participants stated that some churches suggested COVID-19 is a sign of the end of the world and thus people should not accept preventive measures because God will protect them, as highlighted:

We saw so many things, I’m sorry to say it, but at the church level, they–they caused a terrible scandal, like, “They’re shutting down our churches. They don’t want us to gather. That’s all a lie.” I believe in God and this is what a pastor told me, “Sister, if you believe in God, nothing–this is a lie. None of this will happen. God will protect you. The blood of Christ will protect you.” There’s a–there was a–an imminent and latent emergency in the community and people continued to not believe it due to our culture being the way it is. (FG 0615-Forsyth County, NC, virtual)

Similarly, an interview participant reported:

There were very few pastors who heeded the plea. Because they thought, “This is a lie. What they want is to remove us from gathering in churches. What they want is–” One of them–I heard so many comments. One of them said, “This is from the devil because what they want is to prevent us from continuing to adore our Lord and serving him the way we do.” Another one said, “Sister, get–do you believe in God? Get on your knees and ask for his forgiveness because this is an exaggeration. This will pass. God has revealed it to me and nothing is going to happen.” Others said, “This shall pass with fasting and prayer. We all have to fast together. And–and that’s what we have to do.” There were so many of them stating this in the churches and then the Hispanic community would say, “No, what you guys are telling us is a lie. We’re not going to believe or accept it. (Interview (I) 0705-Winston-Salem, NC, woman, virtual)

While participants reported that most Latine community members hold more science-based views, these rumors are part of the general context that situates attitudes about and creates barriers to COVID-19 testing, vaccination, and booster uptake.

Participants reported that language-related barriers affect testing, vaccination, and booster uptake. Participants noted that home test kit instructions did not always include Spanish-language instructions, as reported by an interview participant, “At first home tests didn’t have Spanish instructions, so we created a video on social that was a hit” (I 0512-Raleigh, NC, woman, virtual). In addition, testing and vaccination sites without Spanish-speaking staff or Spanish-language information were described as missed opportunities to provide culturally congruent services by participants:

I saw many people in the pharmacy who don’t speak English. Many of them didn’t have a car. Many didn’t know where to go. It’s very easy because many people–the answer to know which website to go to, how to fill out the application, because in [urgent care clinic] you have to put your name, why you go there, if you have insurance. And it costs them a lot of work if it’s in English. Many times I had to translate and help them fill out the forms online, send them to the address and help them get there. I think someone who doesn’t speak English is going to have a hard time knowing where to go. (FG 0707-Forsyth County, NC, in-person)

Latines living in urban areas reported more access than those living in rural areas, including farmworkers, to Spanish-language information and health services.

Focus group participants noted other staffing challenges, including perceived discrimination. Participants shared being offered one option for the type of vaccine they could receive (i.e., the one dose Johnson and Johnson vaccine) while perceiving that White clients were offered multiple types of vaccine in the same location. The focus group comprised of farmworkers discussed this in depth:

In the city where we live is a farming town. The closest city is [city]. Only Americans live in that city, retired gringos, in [city]. And that city had all the resources, all the tests. For example, there you had to go to the closest cities to take the test. And the agricultural towns were the last ones, why, because we’re immigrants, because we’re agricultural, and we don’t matter so much. We don’t have social security. No. I think there’s that. And they didn’t test you in [city] if you weren’t from [city]. If you came from [town] to [city] to take the test, they said no because it’s not your county. It had to be the people of [city] first. (FG 0827-Hendersonville, NC, farmworkers, in-person)

Based on these negative experiences, participants were less willing to return for additional vaccine doses/boosters. This included how experiences with the immigration process influenced accessing health services, as highlighted:

There is a lot of mistrust, misinformation, tied to how people are treated while immigrating…they just got stuck in an arm at some detention facility, don’t know what it was. (I 0510-Wilmington, NC, woman, virtual)

Other logistics served as barriers. Participants reported confusion among Latine communities about whether identification or other documentation were required for testing or vaccination/boosters. Participants described how early in the pandemic Latine communities experienced substantial difficulties accessing sites that provided timely and affordable testing. Due to work/school schedules and location as well as technological and transportation issues, participants reported that services remain difficult to access during standard business hours.

I mentioned it to someone working in the Union municipality and I said, ‘This is happening. Have you been concerned about the people in the fields?’ Which is the same part of the county. They’re in the North Carolina zone, but those people are left over there. I mean, I took it upon myself to go see what was going on. And I would ask them. Because they were Latinos. ‘Hey, sir, have you gotten the vaccine? Have you gotten tested?’ ‘Oh, no.’ Because they’re camps. Now, what happened? That [name] County can’t go into those camps because they’re private property. But there’s a reality that’s very…that scared me, because they’re still working for North Carolina agriculture. They’re located there in the camps, but it’s like they don’t count as normal civic life. I mean, that’s what I experienced and it pained me so much. Because I think, people outside of the camp had access to take their truck, their bus and go get tested or get the vaccine and those people couldn’t. (FG 0714-Mecklenburg & Union Counties, NC, virtual)

Barriers were further highlighted in interviews:

The use of technological means is still a problem. In her organization, people can call and help you make appointments. But many people cannot use technological means. That is why health promoters are important because they assist people in everything they need and give them a follow-up. (I 0706-Durham/Carrboro, NC, woman, virtual)

The implications of a positive test result are barriers for testing. Overall, Latines perceive tests as a reliable means of assessing COVID-19 infection, some were unsure of the procedures were required (e.g., isolation) with a positive result and were concerned about missing work. While some focus group participants reported getting tested as part of requirements to go back to work/school, others stressed that many Latines have jobs without sick leave protections or where they feel that the employer would hold COVID-related absences against them.

The community is not interested in getting tested because they cannot go to work if the test results are positive. The test doesn’t help them get paid for those days of isolation in their jobs. They cannot afford to miss work and not get paid; they must keep working to feed their family. Many workplaces tell them that even with COVID, they come to work if they don’t have symptoms. All the sectors where undocumented people work in the same situation; they don’t offer them any benefits. They don’t get paid if they don’t show up to work. Also, Latinos can’t isolate themselves because they have to go out in person to do their shopping; they don’t have access to a credit card because they don’t have social security, so they don’t have Amazon, nor do they have access to make purchases online, they go to the store directly. (I 0720-Raleigh, NC, woman, virtual)

Similarly, a focus group participant stated:

Our community doesn’t have health insurance. And our community is–the majority are undocumented, so they work–if they work one hour, that’s the hours’ worth of pay they’ll be getting. So, they didn’t want to stop working. Another thing was that employers didn’t want to let their employees go get tested, much less let them go, because they’d lose their workforce, and their businesses would go down. (FG 0615-Forsyth County, NC, virtual)

Further, the living situation of some Latine families did not easily accommodate recommended isolation practices and some participants described a lack of awareness of sources of, or eligibility for, aid that were available to address these concerns, as discussed:

Previously at my job you needed a negative test to return to work. If you’ve taken the test, they must know the day you did it, and you have to send the result when you have it. Many people don’t get tested and they don’t want to know because they need money for food, rent, and anything else. (FG 0623-Statewide, NC, virtual)

Participants also worried about side effects. Some focus group participants reported that they (or someone they knew) had a negative reaction after their initial vaccine and did not get further doses/boosters:

One person who was vaccinated and one who was not, if they both got sick at the same time, in my experience, the person who had been vaccinated was sick for more days and had more fever and more time in bed. And the person who wasn’t vaccinated was better in a few days, maybe with a little fever. But I also have a family member who had the first vaccine and was in the hospital, got infected with COVID and was in the hospital for seven days even though he was vaccinated. He only got one vaccine because he got COVID and he didn’t want the other one anymore. (FG 0707, Forsyth County, NC, in-person)

Side effect concerns resulted in some parents not vaccinating their children, even if they themselves had received the vaccine and experienced no side effects as reported by an interview participant:

Sometimes adults get vaccinated but don’t want to vaccinate their children. They are worried about side effects on their children; some rumors that the vaccines will leave them with infertility. (I 0808-Siler City, NC, woman, virtual)

Knowledge was low about availability of and eligibility for boosters (e.g., changing availability by age). Many participants questioned the need for boosters (e.g., frequency and different intervals from flu shot). As such, participants reported lower willingness to receive boosters when made available, as noted:

Not all people are putting on boosters. Many people think they are no longer necessary because they have already gotten sick with COVID-19. (I 0719-Greenville, NC, woman, virtual)

Facilitators of testing, vaccination, and booster uptake.

Participants reported increased comfort with testing and vaccination procedures among Latine communities:

Many people–for example, home test… The same thing happened with my daughter. She watched the nurse practitioner how she did it, she just left it at that. And she said, ‘It’s not painful.’ And she said, ‘It’s not if we do it carefully.’… If we teach how to do it, maybe people will lose that fear of what they’re going to put in my nose and whatever. (FG 0623-NC statewide, virtual)

The availability of home testing as well increased education and communication about vaccine safety and efficacy in supportive clinical environments were factors identified as enhancing access and uptake. This was noted in a focus group:

And we said, we must have our family safe, and if they’re telling us–because we investigated in several clinics listening–this is safe. I didn’t hear that they were vaccinated and died, at least not around me. (FG 0827-Hendersonville, NC, farmworkers, in-person)

Participants commented that the availability of Spanish-language information was greatly improved from the onset of the pandemic. This was highlighted in one focus group:

We along with several groups were working in that part and we provided documentation in Spanish, because the state didn’t have anything in Spanish yet. So, in order to explain to the families we also, for example, comics to make it easier for families to understand about Covid and all that and we took things through organizations they trust. (FG 0714-Mecklenburg & Union Counties, NC, virtual)

Participants also reported increased ease when receiving services from personnel who spoke Spanish or from known and trusted institutions, such as churches or clinics, as reported:

We have long term history at our clinic, so Spanish speaking families trust the place. We are working to be proactive. We called patients, didn’t wait for them to come to clinic. And if kids come into clinic, then the whole family could get vaccinated in the pediatric clinic. (I 0713-Winston-Salem, NC, woman, virtual)

External requirements were a vaccination facilitator. As one interview participant commented: “For people to get vaccinated and tested, they should make it mandatory. Vaccines and tests should be required in work and study places: (I 0621-Greensboro, NC, man, virtual). When vaccines were initially available, employers’ requirements were a strong motivator. Notably, these experiences differed by participants’ immigration status (e.g., legal permanent residents vs. temporary workers). Farm workers reported feeling more isolated and more beholden to their employers, so the choices of the employer (obligating them to get the vaccine or not providing them opportunities to get vaccinated) often dictated their behaviors. More recently, social event and travel requirements motivated individuals to get vaccinated; participants reported they wanted to get back to “normal” and thus motivated to get vaccinated. This was discussed frequently, including:

First of all, because they would say it at work. My idea was to work, but well, no… I need to have the vaccine and second of all, because we were going to travel and they were requesting it at the airport, at restaurants. (FG 0726-Mecklenburg County, in-person)

Participants emphasized the crucial role of peer influence and support. For many Latines, if someone they knew had been vaccinated and had a positive experience, they were more likely to seek vaccination. This was especially true if a community leader had been vaccinated, highlighting the important role of informal community leaders. The important role of peer influence was described:

But if you’re someone who is scared and you do want to get vaccinated, I’d say, ‘Well, let’s go. I’ll go with you so you feel comfortable and so you don’t feel alone.’ So, ‘I’ll keep following up with you. Let’s go to the next appointment.’… For example, my own family didn’t want to get vaccinated, so I had to say, ‘Look, nothing happened to me. I’m still here. I didn’t transform,’ because, well, there was that topic of the zombies. So–[laughter] yeah, that part. (FG 0728-NC statewide, virtual)

Another facilitating factor included worry about becoming seriously ill or hospitalized. Latines with personal experiences with COVID-related morbidity/mortality were especially motivated to engage in prevention behaviors, such as:

I did know a person who had Covid and was hospitalized for about six months. Then he had other complications because he was already an old person. And he was left with many sequelae. He was left with after-effects. And many people have sequelae after Covid. That’s why it’s better to get vaccinated. (FG 0726-Mecklenburg County, in-person)

This resulted in one interview participant suggesting, “One strategy is sharing stories of families affected by COVID, having conversations about the importance of vaccination” (I 0613-Charlotte, NC, woman, virtual). In addition, some who had initially avoided vaccination got the vaccine after they had been sick with COVID-19 to avoid future illness.

Strategies and recommendations.

Participants described existing strategies and additional recommendations to support testing, vaccination, and booster uptake. Some strategies highlighted included use of familiar locations and spaces for the provision of services, as recommended:

Another thing is also that families are finding the vaccine through places they know or at churches or in different places they trust, so they are no longer afraid of that. (FG 0714-Mecklenburg & Union Counties, virtual)

Additional strategies included targeted mobile testing, extended hours, and walk-in appointments (and online appointment services) to address transportation, schedule, and technology-related concerns. The direct distribution of home tests attenuated many immigration-related concerns, and thus home testing is the preferred method.

Participants underscored the importance of culturally congruent education, communication, and service provision that addressed importance of testing, vaccination, and boosters in Spanish-by-Spanish speakers. For instance, one focus group discussed:

I would say that the information about the pandemic, people were getting it from–from social media. Right? From Facebook, from, I don’t know, from YouTube. I think some people…I received several videos, right? About the pandemic. So, social media, YouTube, and of course, information from friends and family. I think those are–you could summarize it that way, those were the three sources, basically. And I think a fourth one would be Univision and–if you only speak Spanish here, I think Univision was a very, very important source of information about the pandemic. …There were sectors within the pastors and within the churches that were in complete disagreement with all these [anti-vaccination] views. And they would encourage their congregants to get vaccinated, right? And a lot of pastors even went as far as letting their churches be used for vaccination events. (FG 0615-Forsyth County, virtual)

Participants also described the utility of sharing of personal stories of positive testing and vaccination experiences by other Spanish-speaking Latines. Communication avenues that were identified as useful included community leaders (e.g., supportive religious leaders), social media (e.g., moderated community WhatsApp and Facebook groups), Spanish-language media and services (e.g., Univision and call centers), and going door-to-door in high Latine census communities. For instance, one interview participants discussed the benefits of their group, “We utilize a very active WhatsApp group with community and neighborhood leaders, focused on six specific zip codes, to share COVID information and resources” (I 0607-Charlotte, NC, woman, virtual).

Given that Latine communities do not always trust government systems, participants reported that it was crucial to support community organizational capacity to improve service access, as reported:

That’s what we have to keep doing, try to keep educating our communities and keep giving them the right information… We’re here with you receiving information, and this same information we can share with people in the community outside to let them know the resources that exist for our communities. (FG 0623-NC statewide, virtual)

Participants highlighted the integration of community-based peer health navigators (who use natural helping) and more formally trained CHWs. Spanish-speaking Latine peer navigators and CHWs, connected to local clinics, organizations, and health departments, were identified as crucial in COVID-19 testing, vaccination, and booster uptake, as noted:

I recommend hiring health promoters, as other counties are doing…these promoters should be someone of Hispanic origin who comes out of their midst because they know the community. They could be students from the health area. The community’s leaders must be people with whom the community identifies and feels trusting. (I 0705-Winston-Salem, NC, woman, virtual)

CHWs devoted substantial efforts to educate Spanish-speaking individuals (e.g., community immunity and booster eligibility) and directly address misinformation. They also encouraged testing and vaccination sites to attend to factors that function as deterrents. For instance, they offered feedback to limit required information to the minimum necessary for public health reporting (e.g., name, address, and birthdate). CHWs described the development of a “know your rights” card for Spanish speakers specifying which types of identification were required for services and created Spanish-language videos about administering home testing and what to expect at testing and vaccination sites. To address immigration enforcement concerns, CHWs worked with local law enforcement to minimize presence at community sites.