Full LCH Report to Washington State Department of Health

Latino Center for Health: Report to Washington State Department of Health

Latinx Perceptions and Attitudes regarding COVID-19 vaccines and Vaccines in General

January 17, 2024

The Latino Center for Health, an interdisciplinary research center at the University of Washington, conducted and completed a qualitative study of 25 telephone interviews with Latinx individuals across Washington state to ascertain their perceptions and attitudes regarding COVID-19 vaccines. One interview question also asked about their perspectives regarding vaccines in general. This body of work, including this report, was commissioned by the Washington State Department of Health (DOH). Data collection took place from the period of Nov. 15 – Dec. 20, 2023. The sample consisted of Latinx adults ranging in ages from 25 to 54 years old. They lived in diverse regions of the state in Western, Central and Eastern Washington, including rural communities. Fifteen women and 10 men participated, nearly all of whom spoke Spanish.

This report reveals important findings pertaining to Latinx attitudes towards COVID-19 vaccines and their motivations in seeking vaccination. While these findings are not generalizable, they provide critical insights that can help inform the DOH’s planned media campaign to the diverse Latinx community in Washington state.

Though the crest of the pandemic has subsided, the need for COVID-19 vaccinations persists, due to the on-going emergence of new variants, relaxed standards of masking, and the elevated health risks that remain. Leading experts posit additional contributing factors, namely, not enough people are accessing treatments or getting vaccinated as well as waning immunity in the overall U.S population.^1.Currently, nearly 1500 individuals in the country die per week due to COVID-19.² This number represents significant mortality signaling the importance of vigilance in taking steps for protection and safety.^.

Research has identified that Washington state’s Latinx communities were disproportionately impacted by the COVID-19 pandemic with Latinx individuals experiencing higher infection, hospitalization and death rates compared with Whites.⁴

As of January 8, 2024, COVID booster rates among Latinos in WA are the lowest among racial/ethnic groups, with only 5.5% having received the most recent booster, compared to 18.1% of non-Hispanic Whites.⁵Recent research conducted by the Latino Center for Health indicates that vaccine hesitancy among Latinos is fueled by persistent concerns regarding vaccine efficacy, safety, and cost.⁶

This corpus of national and state research provides clear rationale for conducting this survey study of Latinx adults in Washington state.

Methods

The study’s method was to conduct 25 individual interviews in either English or Spanish language by an undergraduate research assistant whose first language is Spanish. The interviews took 20-30 minutes to complete in the language preferred by the respondent. Prior to commencement of data collection, study researchers obtained approval from the University of Washington’s Institutional Review Board Human Subject Division. The application contained recruitment material, consent information, and the survey questions. These were all approved by IRB and the study was deemed low risk of harm to participants. Representatives from the WA State Department of Health and its collaborating partner, C+C, also reviewed the survey questions and provided input and suggested edits to the interview guide before it was finalized. The research assistant translated the interview guide into Spanish and this was reviewed by team members of the Latino Center for Health.

Recruitment efforts consisted of e-mailing community partners, Latino Center for Health Board Members, and select stakeholders with information about the project and a flyer for distribution that contained a phone number to call if interested in learning more about the qualitative study. The flyer was available in English and Spanish languages. The trained research assistant reached out to interested community members who called the posted number, describing the interview process further and scheduling with those who consented.

Interviews were conducted over the phone and recorded for transcription purposes. Participants were asked for verbal consent to continue with the recorded interview before any questions were asked. Interviews were later transcribed, and original recordings were deleted. Three of the interviews were conducted in English, while the other twenty-two were conducted in Spanish. Participants were compensated for their time in the form of a $40 gift card sent either electronically or by mail.

Thematic analsysis of transcribed responses was then conducted by the Principal Investigator. Major themes were identified and reported. Potential differences based on gender, language and residence in an urban or rural community were examined for each question and reported if significant differences were found. Additionaly, two questions, questions four and seven, were quantitative in nature and frequencies of responses were reported. This report highlights and synthesizes the responses to each of the interview questions developed for this study. Please see the Appendix for the full interview guide that was administered to the Latinx adult participants.

Question 1. What is your opinion about the use and effectiveness of COVID-19 vaccines?

Responses varied among the respondents from expressing a lack of confidence in the effectiveness of COVID-19 vacccines to viewing these vaccines as important and having full confidence in their effectiveness. Overall, five respondents expressed clear negative remarks towards COVID-19 vaccines and one respondent was neutral. Several of these respondents named a variety of side effects, including nausea, vomiting, skin turing red and experiencing very strong pain where the vaccine was injected as contributing to their negative perspective. In addition, several of these respondents revealed that fear and the lack of certainty regarding the safety of the COVID-19 vaccines and conflicting information about them as reasons for their negative view. Along with the newness of the disease and the experience of a global pandemic, this group of respondents felt unsure about what information to believe.

“Honestly, since the virus is new, we had never heard of the coronavirus. There was too much information circulating, both for and against it. In the end, I didn’t know what was true and what was false.”

Noteworthy is that all of respondents with negative views were residents of urban communities in WA state. Thus, all respondents from rural communities held more positive views about the use and effectiveness of the COVID-19 vaccines.

Most respondents viewed COVID-19 vaccines in a postive light.

“The vaccines are very important for our health and protection. I believe that they are very effective, and I consider them to be very worthwhile.”

Indeed, protecting self, family and community were seen as key benefits of obtaining COVID-19 vaccines. For example, many respondents revealed that COVID-19 vaccines are very necessary and helpful in building immunity.

“I think COVID vaccines are good, and they are effective in preventing severe COVID-19. It’s the best option for personal protection and to protect those around us.”

Question 2. Have you ever received any COVID-19 vaccine? Yes/No

Nearly all respondents revealed that they have received the COVID-19 vaccine. Only two indicated that have not received the vaccine. Despite this almost uniform action of obtaining the vaccine, several respondents revealed having an initial hesitancy. A recurring theme in this regard was the newness of the vaccine—with much unknown fueling a lack of confidence about the vaccine’s effectiveness as well as a deep concern regarding its side effects and long-terms effects. These respondents wanted more information. In spite of initial hesitancy among several respondents, they eventually chose to receive the COVID-19 vaccination.

“Initially I was skeptical about if vaccines really work. But as time went on, I did some research and I felt more confident after that. I wanted to protect my family, especially my mom who is very susceptible to respiratory diseases. Also, the well-being of my community.”

Question 2.1. Can you name the top two reasons that influenced you in that decision?

Thematic analysis of the responses revealed protection as the overwhelming principal reason for obtaining the vaccine: to protect family, friends, and community, including those with whom they worked.

“I did it to protect myself, my family, and my community from this new virus.”

Some respondents revealed that they did not want to get sick themselves and because it was required at their place of employment as reasons for obtaining the vaccination. These were the second top reasons that influenced the decision of the respondents to obtain the COVID-19 vaccination. A few respondents remarked that fear of contracting COVID-19 was a motivating factor. One respondent revealed that they were motivated because their children suffered depression due to not being in contact with other children during the pandemic.

Question 2.2. Have you received or are you considering getting the current 2023-24 updated COVID-19 vaccine? Why or why not?

The vast majority of respondents indicated that they have received the updated COVID 19 vaccine (5 respondents) or are considering obtaining it (12 respondents). Again, personal protection and protection of family were identified as principal motivators. Nevertheless, it is important to note that many of this group of respondents revealed that while they are inclined to get the updated COVID-19 vaccine they have not yet done so.

Five respondents reported that they have not received the most current COVID-19 vaccine. Of these respondents, only two answered question #1 in the negative.

Both respondents who revealed that they were unsure if they would seek to get vaccinated, voiced the need for more information.

This area is important to consider and address in a media campaign to the Latinx community. Hesitancy persists with regards to COVID-19 vaccinations. This must be acknowledged. Also, there exists a need to provide clear information about the vaccines, what they will do in terms of health safety, and possible side-effects.

Question 2.3. What does it mean to be up-to-date on your COVID-19 vaccine?

Findings revealed a strong consensus among the respondents with regards to their understanding of what it means to be up-to-date with your COVID-19 vaccination. Staying protected from the new variants, getting new boosters, and being informed about updated vaccinations were the primary responses provided.

“Being up-to-date with the latest information about vaccines and the accessibility rate nationwide also about the latest countries that are accepting the vaccines.”

“Getting the new vaccines in a way to protect oneself from the variants.”

“Getting all the boosters that become available.”

“Getting the latest, most current vaccine approved.”

Question 3. What is your primary source of information for staying updated with news overall?

Social media platforms such as Facebook and Instagram were the sources most commonly reported. Other sources identified to a lesser extent included local media, radio and TV, and friends and neighbors. A few respondents mentioned Information from news gained from the internet on their phones, newspapers, and Twitter as well.

Analysis revealed no significant differences between urban and rural respondents or men and women with regards to reliance on radio and TV as their sources of information for news. Across demographics, this sample of respondents appear to be well-versed in the use of social media platforms.

Question 3.1 Is there a specific TV show or social media account that you listen to or read more frequently?

Many respondents indicated that they do not have a specific TV show or social media account that they listen to or read more frequently. As one respondent stated, “If I am interested in something specific, I search on Google or other engines.”

Several did mention specific sources such as CNN, Univision, and Telemundo.

It is important to note that several respondents highlighted the importance of local programs and news.

“No specific one. I mainly focus on local programs or things that my community shares on social media.”

Despite the fact that the majority of the interviews were conducted in Spanish, only a few participants noted their preference for Spanish language sources.

“I mainly listen to Spanish radio stations. On Instagram, I follow the page of the state health department.”

Question 4. What sources of information do you seek out or use when it comes to staying informed about COVID-19?

This question allowed for a quantitative analysis as respondents were asked to answer yes or no to a variety of information sources they use to stay informed about COVID-19. The graph below reveals that doctors are the near unanimous source of information sought out by respondents with regards to COVID-19. Other sources of information identified include social media, local health department and promotoras (community health workers). Each of these sources garnered slightly more responses than TV news. This finding is important as it signals that Latinx adults utilize information that is made available and disseminated through local health departments of the WA State Department of Health. This suggests that the state and local health departments are a trusted source for health information.

Findings reveal the significant role and impact that health fairs have. Information from flyers obtained at health fairs were identified as an important source of information by nearly two-thirds of respondents (64%). Such local approaches are integral to the dissemination of COVID-19 information. This approach is one that the DOH should make use of as part of its campaign.

When asked to identify their top three sources of information, respondents’ answers reveal a different picture. While doctors remained the primary source of information and headed the ranking of top three sources of information by the respondents, nearly half of the respondents included TV news, the local health department, and the Centers for Disease Control and Prevention as among their top three sources of information. Only four respondents included social media as among their top three sources and the same number of respondents identified radio.

This ranking of the top three sources of information clearly signals that the provision of health-focused news from local and national health entities (health department and CDC) are primary sources for this study’s sample of Latinx adults, even among those who are Spanish-speaking.

Findings reveal the opportunity and importance to educate physicians and care providing organizations as they are crucial sources and viaducts of disseminating up-to-date information regarding COVID-19 and vaccinations to the Latinx community. Such educational and training efforts should be informed by and congruent with the Latinx value of personalismo, embodying a trusting and personal approach in the care of the patient.

A noteworthy finding is the fact no respondent named promotoras or clergy as among their top 3 sources of information. This may seem surprising because these leaders are highly valued in the community. However, data reveals that they are not sought-after entities with regards to COVID-19 information. Based on this data, they should not be priority avenues with regards to the planned media campaign by DOH.

Another consideration for the DOH is based on one respondent’s remarks.

“I like brochures because later, when I’m at home relaxed, I read them and can review the information and who wrote them to see if they can be trusted.”

This response suggests that providing flyers or handouts to read at one’s convenience without pressure can be a helpful and useful tool.

Question 5. What are beliefs and conceptions/perceptions towards COVID-19 vaccines that you have found or heard about in your community?

This question is an important one as it surfaced robust responses. Negative and mixed views (both negative and positive) dominated the responses. Only four respondents identified only positive perceptions in the community. These beliefs centered on the effectiveness of the COVID-19 vaccine and the protection it provides.

Many of respondents’ answers to this question touched upon earlier themes identified such as the concern for side effects. Some side effects they were concerned the vaccine might result in included weight gain, “making women broader”, dizziness, tremors, and other side effects that are irreversible. One respondent expressed concern that you will be charged for the vaccine if you delay obtaining it.

“Others say that these vaccines don’t work because they still get COVID-19, so many believe that vaccines don’t really help.”

This response highlights the need to continue to educate the Latinx community due to misunderstandings of the role of the COVID-19 vaccine and what it does and does not do. Efforts to provide clear messaging and education remain crucial. As one respondent indicated:

“Many misconceptions about the importance of COVID-19 vaccines persist. People are not knowledgeable about the vaccine, the dose that should be administered, how it should be administered or even about the accessibility of vaccines.”

Another respondent noted that the community is worried about getting vaccinated because they think that the vaccine gives you COVID-19.

Fears based on lack of knowledge or understanding is revealed in this statement.

“Many people think it’s not safe because they don’t know the vaccines well and what they contain. They don’t want to be injected with something they don’t know.”

A lack of understanding of the COVID-19 vaccine is further illuminated in this statement by a different respondent.

“Many had very mild COVID-19 symptoms and don’t understand why they should get vaccinated; they don’t see the point.”

Several respondents voiced notions of conspiracy and fear of government control within the Latinx community.

“Others say the government wants to control you.”

“That government won’t let you do certain things like using public transportation, going to the theater, or attending school.”

“The government is injecting a chip in you.”

“I’ve heard people say that it’s all a lie and that the entire pandemic is to reduce the number of people in the world, especially in our community.”

These findings highlight the importance to recognize and address the fears and mistrust that exists within the Latinx population in Washington state. Findings emphasize a clear need for trusted messaging of concrete evidence of the effectiveness of the COVID-19 vaccine and boosters.

“Due to distrust, Latinos are likely to be among the last to use a vaccine. According to how we see others fare with the vaccines is how we decide whether we can use it or not.”

“Some do not believe in vaccines and say that you will get sick upon receiving it. I would say that 30% of the community does not have much trust in vaccinations.”

This notion of seeing the reactions/side effects experienced by others was supported by another respondent. It is something that the DOH should recognize and address in its media campaign efforts.

“Seeing people in the community have a positive experience with a vaccination would bolster confidence.”

New findings also emerged through our thematic analysis. One respondent remarked that COVID-19 vaccines are “sometimes not very accepted in our Latino community.”

Findings revealed a new theme—misinformation–as communicated in several responses to this question. The reflected theme of misinformation in the respondents’ answers calls for continued efforts in providing information through trusted sources to combat misinformation and disinformation that remain from the earliest introduction of the COVID-19 vaccine.

Though only one respondent made the following remark, it is noteworthy as it reveals racial bias.

“Sometimes, I feel like because we are from another ethnic group, we have to give money for these things.”

Question 6. What message or information would make you more inclined or motivated to get a vaccination?

The top themes identified were: accessibility (“That it is free and accessible in the area”), safety (“Crucial to highlight that they are safe for children”), and protection (“That they protect against complications from COVID-19”). These top three factors were mentioned by 11 respondents each. Eight respondents indicated that family was a key motivating factor.

Several respondents made clear what type of messaging from DOH should emphasize.

“A message that emphasizes the need to protect the family and everyone else, not just ourselves.”

“That vaccines are safe and that there are entire vaccinated families who are doing well.”

Another respondent provided valuable insight regarding content of messaging that should be made.

“An advertisement on the radio or TV saying that they are safe, and everyone can get them, and that they are free is important.”

One respondent stated:

“I feel that there’s nothing specific that can sway me one way or another. Vaccinating myself is a personal decision, and I believe that as long as there is enough information about the vaccines, that’s sufficient.”

Another respondent provided the following helpful ideas:

“Workshops in the community; clear, detailed info about vaccines—what do they contain, what they do, possible side effects, more info about vaccines for children in school.”

Question 7. Now, I am going to ask you about how much you agree or disagree with a series of statements about vaccines in general, not just COVID-19 vaccines. For each statement, there are five options: strongly disagree, disagree, agree, strongly agree, or ‘I’m not sure.’ How strongly do you agree or disagree with the following statement?

English	Spanish
Statement 1: There are ways to access vaccines convenient for my work and family schedule, including mobile, school, and community-based vaccine clinics and pharmacies that are open seven days a week or in the evenings.	Afirmación 1: Hay formas de acceder a vacunas convenientes para mi horario laboral y familiar, incluyendo clínicas de vacunación móviles, en escuelas y comunidades, así como farmacias abiertas los siete días de la semana o en las noches.
Statement 2: Most vaccines (including COVID and Flu) are available to children and adults in Washington at no- or low cost. There are easy-to-access programs to cover the cost, regardless of insurance status.	Afirmación 2: La mayoría de las vacunas (incluyendo las de la COVID y la gripe) están disponibles para niños y adultos en Washington sin costo o a bajo costo. Hay programas de fácil acceso para cubrir los costos, independientemente del estado del seguro médico.
Statement 3: Natural immunity isn’t enough to protect individuals and communities from serious diseases, so we need a boost from vaccine immunity to help keep everyone safe.	Afirmación 3: La inmunidad natural no es suficiente para proteger a individuos y comunidades de enfermedades graves, por lo que necesitamos un impulso de la inmunidad a través de las vacunas para ayudar a mantener a todos a salvo.
Statement 4: By getting routine and seasonal vaccines, I’m giving myself extra protection but maybe more importantly, I’m helping protect everyone in my family.	Afirmación 4: Al vacunarme regularmente y en temporada, me estoy brindando una protección adicional, pero quizás más importante aún, estoy ayudando a proteger a todos en mi familia.

This graph shows the frequency with which the respondents agreed or disagreed with the four statements regarding vaccines in general. Nineteen respondents agreed or strongly agreed with statement one. Twenty respondents agreed or strongly agreed with statement two. No respondent disagreed with statements three and four. Twenty-two respondents agreed or strongly agreed with statements three and four.

The chart below reflects the same information. While very few respondents disagreed with the first two statements, indicating that they felt that there is convenient access to vaccines and availability at no-cost, it should be noted that for each of these two statements, four respondents reported, “I’m not sure.”

In comparison, for statements three and four, there was a higher number of respondents who strongly agreed, supporting that belief that we need a boost from vaccine immunity to help keep everyone safe and that protection of family is keenly important. This finding emphasizes that the themes of safety and protection, not just for self but for the family, including children and older adults, should be primary themes in an effective media campaign.

	Strongly disagree	Disagree	Agree	Strongly Agree	I’m not sure
Statement 1	0	2	12	7	4
Statement 2	0	1	12	8	4
Statement 3	0	0	11	11	3
Statement 4	0	0	12	10	3

Statement 1 Notes:

One participant who disagreed with Statement 1 indicated that she had trouble finding appointment availability.

Statement 2 Notes:

One participant chose “strongly agree” for Statement 2 but later said “I like the statement but I am not sure if that’s actually right here in WA.”

The respondent who disagreed with Statement 2 stated, “I don’t believe that all vaccines are available for free because I have friends who have had to pay.”

CONCLUSION

This study provides valuable insights into the perspectives of Latinx adults and the sources of information they access to inform them about COVID-19 and vaccines in general. The main themes identified in this study serve as important guideposts to inform the planned media campaign of the Department of Health.

Throughout the pandemic, many Latinx individuals struggled with divergent communication and misinformation regarding the COVID-19 disease and vaccination options and their side effects. Concerns persisted about the effectiveness and side effects of the vaccinations. Similar concerns and fears remain and impact the Latinx community today.

The need to continue to communicate clear and trusted information in English and Spanish. Study findings point to the importance of Identifying trustworthy sources of information and then strategically prioritize them. For example, though promtoras are effective and instrumental in helping Latinx individuals navigate health care systems, respondents did not highly rank them as sources of information regarding COVID-19 and its vaccinations. In addition, findings from this study emphasize the importance of addressing the family and not just the individual. This is congruent with the cultural value of familismo within the collectivist culture of the diverse Latinx community. Thus, images of family members getting vaccinated and smiling with the knowledge that they are protecting themselves from serious consequences of COVID-19 and promoting health for themselves and their community should be well-utilized in media efforts to the Latinx community.

Summarizing here, the main themes identified by participants include:

Protection of Family: Most participants stated that their primary motivation for getting vaccinated was the protection of their families.

Fear of Vaccine Side Effects: A significant number of participants expressed that in their communities, the predominant fear was the potential side effects of vaccines. Some participants refrained from getting the COVID vaccine due to these fears, believing that vaccines could make them more susceptible to other illnesses.

Trust in Vaccines Derived from Others’ Experiences: Many participants mentioned that early in the pandemic, their motivation to get vaccinated stemmed from observing others in their community who had received the vaccine without issues. Conversely, some participants cited distrust in the vaccine based on adverse reactions or side effects experienced by someone in their community or family.

Reassurance for Family Safety: Most participants expressed the need for reassurance regarding the safety of vaccines, particularly for their family members, especially children and older adults.

Based on this study’s findings, investing in education about vaccines, what do they do and how do they work is a clear approach that should be undertaken by the Department of Health. Providing clear information that vaccines do help to prevent complications from COVID-19, but do not prevent contracting COVID-19 is also important. In addition, as previously noted, the themes of safety and protection of family should be central messages.

Interviewer Observations

Below are a two observations and recommendations of the interviewer who had direct contact with the participants through administration of the study’s interview guide.

The study guide questions were mostly clear and well-understood. The majority of participants had no difficulty understanding the questions. Only rarely did they seek additional prompts or explanations.

Regarding the test messages, in some instances these messages may not have been well understood by some respondents. Some questioned if they were ranking based on whether they think the statement is factually correct versus whether the message’s power to motivate them to obtain vaccines.

Recommendations

Future testing of messages should consider a refined approach to that would eliminate any semblance of ambiguity and ensure the capture of reliable information. Developing statements that are theory-informed would bring enhanced clarity.

Allocating more time for the recruitment process is advised to help ensure an even more diverse sample, including more male participants and individuals from rural communities.

REFERENCES

1. Kekatos, M. (Jan. 10, 2024). Why are 1500 Americans still dying from COVID every week, ABC news. Accessed: January 13, 2024).

2. Kekatos, M. (Jan. 10, 2024). Why are 1500 Americans still dying from COVID every week, ABC news. Accessed: January 13, 2024).

Latino Center for Health, University of Washington (2021). Vaccination Rates Among Washington State’s Latinos Are Improving, But Challenges Remain. https:// latinocenterforhealth.org/ wordpress_latcntr/wp-content/uploads/2021/10/ DRAFTv2_VaccinationRatesOctober2021.pdf).

influenza vaccination data. (n.d.). Washington State Department of Health. https://doh.wa.gov/data-statistical-reports/health-behaviors/immunization/influenza-vaccination-data Accessed January 17, 2024.

Morales, L. (2024). Long COVID Among Latinos in Washington State. Unpublished manuscript. Latino Center for Health, University of Washington.

Acknowledgements

Dr. Gino Aisenberg, co-Director of the Latino Center for Health, was Principal Investigator of this study. In the writing of this report, Andrea Cabrera, Research Project Coordinator of the Latino Center for Health, and Luisana Valero, Student Assistant with the Latino Center for Health, also made significant contributions and are co-authors of this report.

APPENDIX

LCH DOH Qualitative Interview Script—COVID-19 and Test Messages

Thank you so much for taking the time to talk with me today. My name is Luisana, and I am a Research Assistant for the Latino Center for Health at the University of Washington. The Center is working with the WA State Department of Health to understand the perspectives and attitudes of Latinos towards vaccines and to inform the media campaign messaging of the Department of Health. There are no right or wrong answers.

Your responses to this interview are confidential and will not be shared with anyone outside the research team. This interview is completely voluntary. You may choose not to answer any questions you prefer not to answer. The interview will take approximately 30 minutes and we will send you a $40 gift card after completing the interview as a thank you for your participation and compensation for your time. The focus of these interview questions is on COVID-19 vaccines.

What you say to us is important, so we’d like to take notes. To make sure our notes correctly represent what you say, we would also like to take a sound recording. The recording is confidential and will not be shared with anyone outside of the Latino Center for Health. We will destroy the recording in January 2024. If you have no objections, we’ll proceed with the questions.

Thank you for being willing to share your experience. We hope that we can take what you share to the WA Department of Health to help us understand better the needs and desires of your community.

Before we start with the main portion of the interview, I would like to ask if you could answer a few short-ended questions about yourself. You may decline to answer any of these.

What is your preferred language?

What is your opinion on the use and effectiveness of COVID-19 vaccines?

I know this can be a sensitive topic, but we welcome and respect all types of perspectives. Please share your honest thoughts and feelings about the use of COVID-19 vaccines and their effectiveness..

Have you ever received any COVID vaccine? Yes/No
- If yes:
  - Can you name the top 2 reasons that influenced you in that decision?

(Note: these are f/u prompts: Perhaps the desire to protect your family, friends, community, personal health protection, fear of hospitalization, easy to get vaccine, trust that it is safe, because it was a mandate, all possible options are welcome.

Have you received or are you considering getting the most current 2023-24 updated COVID-19 vaccine? Why or why not?
1. What does it mean to you to be “up to date” on your COVID-19 vaccine?

If no:
- Can you name the top 2 reasons that influenced you in that decision?

(Note: these are f/u prompts: For example, it could be the you don’t believe vaccines are safe, fear of side effects, you don’t have confidence in their effectiveness, don’t think that the risk of getting COVID-19 is that high, concern that the vaccine affects your fertility, concern that vaccines cause autism, or the difficulty to get the vaccine due to your work schedule, or lack of transportation to get to appointment for vaccination. Feel free to be honest, all possible reasons are welcome and accepted.

What is your primary source of information for staying updated with news overall?
- Options: TV, radio, Facebook, Twitter, Instagram, WhatsApp group chats, text messages, telegram, newspaper, or other.
  - Is there a specific tv show, or social media account that you listen to or read more frequently?

What sources of information do you seek out or use when it comes to staying informed about COVID-19? Please answer yes or no to each of the following prompts.
- Options:
  - CDC guidelines ___Yes ___No
  - What the local health department said ___Yes ___No
  - What you heard on TV news ___Yes ___No
  - What a leader of your community said ___Yes ___No
  - What the priest or pastor said ___Yes ___No
  - What the school said ___Yes ___No
  - What a flyer said at a health fair ___Yes ___No
  - What your doctor said ___Yes ___No
  - What a promotora de salud said ___Yes ___No
  - What you heard on the radio? ___Yes ___No
  - What you learned from social media? ___Yes ___No
  - What a neighbor told you ___Yes ___No

Of these trusted sources of information you indicated, what are the top 3 messengers you actually trust for COVID-19 related information? e.g. information from the radio, doctors, church leaders, community leaders, promotoras de salud, schools?

What are beliefs and conceptions/perceptions towards COVID-19 vaccines that you have found or heard about in your community? (F/U prompts if needed: For example, they prevent hospitalizations, they make people sick, they cost too much, COVID-19 vaccines are good for my family and community.

What message or information would make you more inclined or motivated to get a vaccination? (F/U prompt: For example, if you saw a picture of a family receiving the vaccine or heard a radio announcement explaining how COVID-19 vaccines are safe for children, that vaccines are available free of cost, are available at a time that is convenient for you, would that or anything similar motivate you to get vaccinated?

Now, I am going to ask you about how much you agree or disagree with a series of statements about vaccines in general, not just COVID_19 vaccines. For each statement, there are five options: strongly disagree, disagree, agree, strongly agree, or ‘I’m not sure.’

Do you have any questions?

How strongly do you agree or disagree with the following statement? (strongly disagree, disagree, agree, strongly agree, I’m not sure)

Statement 1: There are ways to access vaccines convenient for my work and family schedule, including mobile, school, and community-based vaccine clinics and pharmacies that are open seven days a week or in the evenings.

___Strongly Disagree ___Disagree ___Agree. ___ Strongly Agree. ___I’m not sure

Statement 2: Most vaccines (including COVID and Flu) are available to children and adults in Washington at no- or low cost. There are easy-to-access programs to cover the cost, regardless of insurance status.

___Strongly Disagree ___Disagree ___Agree. ___ Strongly Agree. ___I’m not sure

Statement 3: Natural immunity isn’t enough to protect individuals and communities from serious diseases, so we need a boost from vaccine immunity to help keep everyone safe.

___Strongly Disagree ___Disagree ___Agree. ___ Strongly Agree. ___I’m not sure

Statement 4: By getting routine and seasonal vaccines, I’m giving myself extra protection but maybe more importantly, I’m helping protect everyone in my family.

___Strongly Disagree ___Disagree ___Agree. ___ Strongly Agree. ___I’m not sure

That concludes the questions we have for you today. Thank you for your participation!

Do you have any additional questions or thoughts you would like to share with us? We sincerely appreciate your participation and the insights you have provided; your time and commitment are highly valued by our team.