Background
The COVID-19 pandemic unleashed catastrophic damage to human populations worldwide including almost seven million reported deaths.1 A global effort to curb the pandemic led to the development of a number of COVID-19 vaccines by different countries including Pfizer–BioNTech (US-Germany), Moderna (US), Oxford–AstraZeneca (UK), Sinopharm and Sinovac (China) and Sputnik (Russia). With 70.5% of the world population having received at least one dose of a COVID-19 vaccine by September 2023,2 the successful global COVID-19 vaccination programmes have played a crucial role in containing the virus. On 5 May 2023, the WHO declared an end to COVID-19 as a global health emergency, more than 3 years after the pandemic was first declared on 11 March 2020.3
Despite this remarkable success, there are still a large number of people across the world who are COVID-19 vaccine hesitant.4–6 Vaccine hesitancy, defined as ‘delay in acceptance or refusal of vaccination despite availability of vaccination services’ has been identified by the WHO as a global health threat.7 Studies in the USA, UK and Australia suggest that vaccine hesitancy is particularly salient among ethnic minorities who already experience health disparities due to systematic and structural inequalities.8–13 Information and communication emerged as key issues because exposure to vaccine misinformation, the lack of clarity in vaccine-related information and mistrust of healthcare systems have been identified as causes of vaccine hesitancy.14–16 Ethnic minority communities are found to be disproportionately affected by COVID-19, experiencing higher rates of morbidity and mortality and greater adverse socioeconomic consequences.17 18 While there are some studies focusing on Black and South Asian communities,12 14 19 there are no in-depth studies on Chinese communities in the UK, the ethnic group which has the second highest level of vaccine hesitancy.10 At the end of 2020, COVID-19 vaccine acceptance rates of UK-based Chinese people were estimated between 52% and 57%, significantly lower than that of the general population (76%).12 20–22 According to the latest 2021 census data, 445 646 Chinese people lived in England and Wales, constituting one of the largest non-EU ethnic groups.23 Given its relatively large size, the Chinese communities’ vaccine hesitancy and potential low uptake could increase the risk of virus transmission within its communities and the risk of prolonging the pandemic for the whole society. However, UK-based Chinese communities are largely invisible in the COVID-19-related public health literature. Limited existing literature on vaccine hesitancy is mostly based on survey research that only provides snapshots of broad trends and patterns and included few samples from the Chinese communities.6 21 24 25 A survey-based study conducted in China in March 2020 while the vaccines were still being developed reports high levels of willingness to accept COVID-19 vaccination among the Chinese public due to strong beliefs about the efficacy of COVID-19 vaccines and the perceived large impact of the pandemic.26 It also identifies vaccination information based on doctor’s recommendation, vaccine convenience and price as important factors affecting people’s vaccination intention.26 The significance of the findings is limited to the specific mainland Chinese context in which strong disease control and public health measures were taken by the authorities. Outside China, few qualitative studies are available to shed light on the complex, multilayered factors and determinants of people’s vaccine hesitancy. Existing literature identifies exposure to vaccine misinformation and the lack of clarity in vaccine-related information as causes of vaccine hesitancy which indicates that communication and information is a key factor shaping people’s attitudes towards and perceptions about vaccination.14–16 23 Therefore this study fills this important research gap and adds value and new knowledge to enquiries into ethnic minority health by focusing on under-researched UK-based Chinese communities. It aims to answer the following research questions:
What is the understanding of and attitudes towards COVID-19 vaccines within Chinese communities in the UK?
What informs their understanding of and attitudes towards COVID-19 vaccines and how?
Study design
The study draws on an interpretive research paradigm which aims at understanding the subjective and socially situated human attitudes and behaviour. In contrast to positivism, a paradigm which seeks to identify the one objective truth, the interpretive paradigm seeks to uncover multiple subjective ‘truths’ that are ‘socially constructed by humans in everyday interaction’.27 This study is also informed by community-based participatory research. A Chinese community member working group advised the design, conduct, reporting and dissemination plans of our research. The main empirical part of the study is based on in-depth focus groups with Chinese community members of varied sociodemographic backgrounds which explore their subjective experiences and understanding of COVID-19 vaccination. Focus groups are best suited for generating a rich understanding of participant experiences and beliefs by creating a process of sharing and comparing among participants.28 They have also been widely used to explore people’s behaviours and underpinning motivations.28 This paper reports on findings from focus group discussions during which we explored participants’ overall understanding of and attitude towards the COVID-19 vaccines, the sources of information about the vaccines and levels of (dis)trust in these sources of information.
Patient and public involvement
In December 2020, a patient and public involvement (PPI) group from the Chinese community organisation, Wai Yin Society, engaged in discussions with the corresponding author regarding vaccine hesitancy within the community, identifying it as an urgent health concern. In early 2021, the authors and Wai Yin Society submitted an application for a co-design project to investigate the Chinese community’s understanding of COVID-19 vaccines and to promote vaccine uptake, drawing on the PPI group’s experience. On receipt of research funding, a project working group comprising the original PPI group members was set up. The group members were asked to assess the burden and time required to take part in the working group. They participated in three project meetings at the research design stage, data analysis stage and impact delivery stage to advise on the research questions, method (focus group), participant recruitment methods, the design of our COVID-19 vaccine promotional materials (eg, videos of Chinese speaking doctor debunking COVID-19 vaccine misinformation) and our public-facing research dissemination plan (eg, public screening of video and Q&A with Chinese-speaking doctors). The PPI group was not involved in participants recruitment. Members of the working group were given a £60 gift voucher as a token of appreciation.
Sampling and data analysis
Participants recruitment and data collection
In total 154 participants, 119 women and 35 men, took part in our focus groups between March 2021 and November 2021. Their ages ranged between 18 and 87 and their years of residence in the UK ranged from 6 months to 55 years. Participants were educated to different levels from primary school to PhD degree and worked in professional (eg, office worker, teacher, consultant, researcher) and semi-skilled jobs (eg, restaurants, takeaways, shop floor and hair salons). The rest were not in full-time employment as they were retirees, housewives and full-time students. The broad occupational classification was used in data collection to enhance anonymity and encourage participation and disclosure within the close-knit Chinese communities.
Participants were recruited from one northern and one Midland city in England which both have large Chinese communities. Chinese community members were broadly defined as adults who identify themselves as Chinese by ethnicity and who live permanently or temporarily in the UK. In the northern city, participant recruitment was facilitated by Wai Yin Society, one of the largest Chinese community organisations in the UK, from their existing groups and networks (eg, pregnant women’s groups, Tai Chi groups, mental well-being groups). In the Midland city, participants were recruited by two Mandarin and Cantonese-speaking research assistants at local community hubs (eg, Chinese churches, supermarkets, restaurants). The study additionally employed snowballing technique to recruit further participants from our participants’ social networks with the aim of forming natural focus groups. We asked participants from all ages and socioeconomic groups to share our study information with their friends and family who are likely to share the same socioeconomic and demographic backgrounds to ensure broad diversity within the study. Those who were interested were invited to contact the project team or our partner organisation, Wai Yin Society, for further information. Participants were provided with participant information sheets and informed consent forms. The focus groups were then formed on the basis of existing social networks in which participants already knew each other and shared similar socioeconomic and demographic characteristics including age, gender, migration history, occupation and language. For instance, focus group 7 (FG7) comprised mixed-gendered Mandarin-speaking young adults who are friends. While some work as professionals, others are postgraduate students (not in full-time employment). FG13 and FG27 comprised mixed-gendered Cantonese-speaking young and middle-aged adults who were friends and acquaintances. They were professionals who migrated from Hong Kong to the UK within the 2 years prior to the study. Once the minimum participant threshold (4) was reached, the focus group was organised at a mutually convenient time for participants. As the study took place when there was relatively high COVID-19 transmission, all focus groups were conducted remotely via Microsoft Teams, Zoom or WeChat (a Chinese instant messaging and social media app). The choice of the meeting platform was determined by participants’ preferences and accessibility to the platform. Participants were given a £10 gift voucher as a token of appreciation.
Based on our PPI advice, Cantonese, Mandarin or English were offered as language choices for the focus groups. Depending on our participants’ preference, focus groups were conducted in one of these three languages with the exception of group 26 in which a participant preferred to speak in both Mandarin and English. Cantonese was preferred by older participants who migrated from Hong Kong to the UK decades ago and used Cantonese as their main language for communication. Cantonese was also preferred by people recently migrated from Hong Kong to the UK. They were likely to be younger and had shorter residency in the UK. Mandarin was preferred by participants from mainland China and demonstrated strong ties with mainland Chinese media and family and friends. Although many different dialects are spoken in mainland China, because the media system is strictly controlled, the information that mainlanders accessed from the mainstream media is thought to be relatively homogeneous. In this study, the focus groups were moderated by at least one multilingual research assistant who conversed in participants’ preferred language in order to promote open, clear communication and disclosure. Wai Yin staff members involved in participant recruitment also attended the focus group to facilitate introductions and assist in building rapport between the participants and the researcher. In total 29 focus groups were conducted to reach data saturation at which point themes discussed in the focus groups began to be repeated and further data collection became redundant.29 30 For participant demographic information, group codes and group composition, please see table 1 below. Further information on aggregated group numbers can be found in online supplemental file 1. Focus group guide can be found in online supplemental file 2. The focus groups lasted on average 65 min and were audio-recorded. The recordings were then transcribed and all personally identifiable information was anonymised.
Data analysis
The focus group data were analysed based on the principles of thematic analysis. The analysis followed the four steps: Familiarising with the data, identifying codes and themes, coding the data and organising codes and themes.31 Three authors (QSG, ZG, DW) first read all transcripts to familiarise themselves with the data. The authors read the transcripts several times line by line deductively and inductively identifying a working coding framework constituted by key ideas and recurrent meta-themes in the data. The deductive coding was based on previous literature which identifies broad themes such as sources of information (eg, new media, traditional media, social media, word of mouth). The inductive coding process further developed the themes to subthemes based on the data, for instance, social media was further categorised into WhatsApp, WeChat, Weibo, Little Red Book, Douyin (Chinese version of TikTok) and so on. The coding framework was confirmed in six data analysis meetings involving all other authors (IS, CS, HZ) where new emerging themes were discussed and differences in coding were resolved. QSG, ZG and DW then coded all transcripts in using NVivo software. All authors discussed the selection of the key themes of the paper and quotes from the coded data to be included in thematic sections. A draft paper was sent to two participants who verified our findings before submission. Below we discuss three key interconnected themes from the data.