Health literacy, information access and COVID-19 vaccination hesitancy among foreign-born persons in Sweden – a focus group interview-study

Background Lower rates of COVID-19 vaccination have been observed in individuals with an immigrant background, yet if this relates to barriers to obtaining reliable information is unknown. This exploratory interview study investigated health literacy and information access as determinants for vaccination hesitancy towards the COVID-19 vaccine among foreign-born individuals in Sweden. Methods and findings We used purposive sampling to recruit foreign-born adults from low- and middle-income countries and health guides and doulas who were assigned to spread COVID-19 related information in immigrant-dense urban areas. Data were collected using semi-structured focus group interviews, which were transcribed verbatim and analysed according to systematic text condensation. Ten participants were included who were gainfully employed as health guides/doulas, or in other jobs, full-time students, or housewives. Four main themes emerged: 1) Limited health literacy, 2) Consequences of not using official Swedish information, 3) Decision-making on COVID-19 vaccination, and 4) Suggestions to improve information dissemination effectiveness. The lack of health literacy in official institutions, health care personnel and recipients alike led to little use of official information. Instead, most participants relied on social media, social contacts and international media, through which a lot of contradictive and negative information about the vaccine was spread. The decision to get vaccinated or not was a process fraught with insecurities about the effectiveness and side effects of the vaccine, which was balanced against wishing to be protected and contributing to the battle against COVID-19. Suggestions for information dissemination improvements from the participants were to produce multilingual information and to increase the use of transmission through social interaction with trusted persons and platforms. Conclusions An inadequately adapted information outreach prevented some members of the society from making fact-based decisions about getting vaccinated. Several suggestions for improving dissemination were brought forth that can be tested in future communication strategies. Why was this study done? People with an immigrant background have consistently displayed a lower vaccination uptake than the general population. This study investigated aspects of health literacy, information access and vaccination hesitancy in foreign-born individuals in Sweden. What did the researchers do and find? Few participants accessed official information about the COVID-19 vaccine, mainly because of poorly adapted information outreach, language barriers and not knowing Swedish institutions. Instead, they turned to a multitude of other sources from which conflicting and inaccurate information was spread, lowering their confidence in the COVID-19 vaccine. What do these findings mean? In the case of national emergencies, important public health information does not reach everyone equally, obstructing the possibility for some to make an information-based decision on how to protect their health. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Yes ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study has been approved by the Swedish Ethical Review Authority (2022-02942-02). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data are not publicly available. Anonymized data are available upon reasonable request from the first author and pending fulfilment of legal requirements.