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Abstract

Canada achieved COVID-19 vaccination coverage of 83.2% in the total population (at least one dose). However, only 49.6% of Canadians completed the primary series plus one booster (which defines one as fully vaccinated). Inconsistent uptake of COVID-19 vaccines impeded pandemic response and led to increased demands in a stretched health care system. To advance pandemic preparedness, a critical understanding of vaccine access and hesitancy is needed. We undertook a scoping review to identify the primary reasons for vaccine hesitancy in Toronto's East Asian, Black, and Eastern European diaspora. A total of 5548 articles were retrieved from PubMed, OVID, JSTOR, ERIC and 27 and 43 from Google Scholar and Google respectively. De-duplication left us with 42 relevant sources for data extraction, including 19 news articles, 9 commentaries, 11 pieces of grey literature and 3 peer reviewed articles that were not identified via academic databases. Our review results revealed four factors for COVID-19 vaccine hesitancy among East Asian, Black, and Eastern European diasporas in Toronto: (a) access barriers; (b) mistrust; (c) racism; and (d) misinformation. These factors can create conditions of re-racialization by stereotyping entire ethnoracial groups or convincing members of these groups to become vaccine skeptics.

Keywords

vaccine hesitancy COVID-19 Toronto racialized Black East Asian Eastern European

As a pandemic response, COVID-19 vaccination plays a crucial role in reducing the negative impact on the health of vulnerable groups and the health care system.^1–3 While diligent use of masks, judicious social distancing, and structured ventilation are integral for successful management of this airborne virus, COVID-19 vaccines are a necessary component of this multilayered approach because of their proven ability to prevent severe outcomes such as hospitalization and death and to minimize the risks of long COVID.^4–6

From the start of Canada's vaccination campaign in mid-December 2020 to September 25, 2022, there were 2,305,933 recorded cases of COVID-19, 108,218 hospitalizations, and 20,861 deaths.⁷ The unvaccinated accounted for 47.6% of these hospitalizations and 47.6% of the deaths, respectively.⁷ Comparatively, hospitalizations and deaths for the fully vaccinated were 22.2% and 23%, respectively.⁷ Confirmed COVID-19 deaths in Canada by vaccination status from December 14, 2020, to September 25, 2022, are two times higher among the unvaccinated than the fully vaccinated, with hospitalizations roughly equal.⁷

A mathematical modeling study concluded that COVID-19 vaccines have saved 19.8 million lives globally in their first year of existence.⁸ Canadian public health officials and researchers estimate that, in the absence of mandates and vaccines, 800,000 lives would have been lost in Canada alone.^9,10 A Public Health Ontario report revealed that the COVID-19 vaccine demonstrably prevented Omicron deaths among the elderly and thus avoided a “catastrophic” scenario.¹¹ Yet despite Canada's comparatively successful pandemic response, vaccine hesitancy remains a public health challenge. The health risk of vaccine hesitancy, especially among the elderly, was illustrated in Hong Kong, which was COVID-free before 2022, yet by mid-March 2022, low vaccination rates led to the highest COVID-19 death rate in the world along with burgeoning hospitals and a flurry of geriatric suicides.^12,13

In addition to the prevention of avoidable deaths from COVID-19, mass vaccination also decreases the pressure on a public health system overwhelmed by COVID-19 hospitalizations and demands of critical care, leaving only a limited number of intensive care unit (ICU) beds and contributing to staffing shortages and burnout among health care providers.^14,15 In early 2022, Ontario had a pandemic backlog of 1,000,000 surgeries¹⁶ with an excess mortality rate of 76.8 per 100,000 compared to a COVID-19-reported mortality rate of 66.4 per 100,000.¹⁷ A recent study concluded that risk of infection for the vaccinated was considerably higher around unvaccinated people.¹⁸ With 6.7 million unvaccinated people in Canada despite scientific evidence of vaccine effectiveness, there is a critical need to understand vaccine hesitancy.¹⁵ To address this need, we conducted a scoping review on the primary reasons for COVID-19 vaccine hesitancy among the Black, East Asian, and Eastern European diaspora in the Greater Toronto Area (GTA).

We chose to focus the review on these three communities based on emerging needs identified by community commentators engaged in pandemic response. Based on said needs, our review question was: What contributed to COVID-19 vaccine hesitancy among the Black, East Asian, and Eastern European diasporas in Toronto? These ethnic communities were selected for the following reasons.

First, East Asian communities were the most affected at the beginning of the pandemic due to early cases in East Asia and previous experiences with SARS in Canada. Previous collective experiences in East Asia enabled them to mobilize infrastructure for various control measures (eg, masking, isolation, distancing, testing, vaccination).¹⁹ Moreover, the anti-Asian COVID-19 pandemic racism that emerged in Canada and the United States echoed the scapegoating in Toronto during the 2003 SARS outbreak and thus offers a precedent for similar sentiments in COVID-19 Canada.²⁰

Second, we chose Black communities because early data showed inequities of infection by neighborhoods in the City of Toronto, with more cases affecting Black neighborhoods.²¹ Indeed, late 2020 statistics from Statistics Canada revealed that COVID-19 death rates were twice as high in Canadian neighborhoods with considerable racialized populations, and that Black people had the highest rates of COVID-19 infection and vaccine hesitancy.²²

Finally, Eastern European diasporic communities were selected because their health and health practices are a severely understudied phenomenon. They represent an interesting liminal subject between White-identification and strategic racialization, and whose pre-migration countries are notoriously vaccine hesitant.^23,24

Methods

In this scoping review, we used the framework pioneered by Arksey and O’Malley, who suggest a five-stage practice for scoping reviews: (a) identify a searchable topic; (b) find relevant studies; (c) choose pertinent studies; (d) table the collected data; and (e) compile and report the results of the collected data.²⁵ We also drew from Levac, Colquhoun, and O’Brien's emphasis on connecting conclusions to the overall aims of the study and discussing prospective ramifications for various kinds of research and practice.²⁶ We decided to use these frameworks because they were foundational in guiding scoping reviews in health sciences, especially in terms of community engagement in knowledge synthesis and dissemination. We also used the PRISMA-ScR checklist²⁷ to ensure that we have completed the relevant items.

Search Strategies and Inclusion Criteria

We began our search in March 2022 using a multipronged approach. Given the recent nature of SARS-CoV-2, we anticipated a paucity of peer-reviewed articles for a review focused on the Black, East Asian, and Eastern European diasporic communities in Toronto. Our inclusion criteria were English language full-text sources on vaccine hesitancy and COVID-19, published between December 2019 and December 2021, focused on Toronto, Ontario, and Canada, respectively, as well as a selection of Anglosphere countries: the United States, the United Kingdom, Australia, and New Zealand. We conducted basic searches in PubMed, OVID, JSTOR, and ERIC specified as “peer review only” if the limit option was available (eg, in the case of ERIC). We selected our timeframe because it bookends published research between the discovery of SARS-CoV-2 in December 2019 and the December 2021 rollout of COVID-19 vaccine third doses in Ontario. Initially, we used the specified four databases to search for English language peer-reviewed literature about diasporic vaccine hesitancy in Canada, focusing on Ontario and, more specifically, Toronto. Upon recognizing that COVID-19 was a novel phenomenon and peer-reviewed Canadian articles with GTA-focused sources were nonexistent, our team discussed and decided to expand the search to include studies from countries with similar historical and/or sociocultural contexts as Canada, that is, White settler societies with racialized immigrant populations, or immigrant-sending Eastern European countries. The results were imported into EndNote and checked for duplicates. Furthermore, given the limited sources of primary studies on SARS-CoV-2 and vaccine hesitancy at the time of the search, we went beyond the selected academic data bases to include Google Scholar, a web crawl search engine, to locate potential peer-reviewed studies and research reports in Canada. In addition, we searched Google News for news articles, blogs, and podcasts about vaccine hesitancy in Toronto's ethnic diasporas. Google News enabled us: (a) to keep our search timely by maximizing the number of news articles; (b) to avoid grey literature overlap with Google Scholar; and (c) manage voluminous results. In using Google Scholar and Google News, we were able to identify news stories, commentaries in news mediums, and grey literature. We surveyed the first ten pages of every keyword search for relevant GTA-centric and Canada-based sources. These genres provided us with current, affective, and prescriptive sources uniquely relevant to our review question, and they revealed the lived COVID-19 contexts for Canada, Ontario, and the GTA. All searches were conducted in March 2022, using combinations of the following keywords separated by Boolean modifiers: COVID-19; vaccine hesitancy; Toronto; Ontario; Canada; immigrant; diaspora; migrant; Eastern European; Eastern Europe; Black; African; Black people; ERIC was not responsive to Boolean modifiers, so searches were repeated without them and produced more results.

A total of 5590 articles based on our search terms were retrieved from the four databases and imported into EndNote to identify and remove duplicated articles. Duplicated articles numbered 5,348, with the reasons for that as follows. Our academic database searches for Toronto, Ontario, and Canada did not retrieve any results, so we searched Anglosphere countries such as the United States, United Kingdom, Australia, and New Zealand to see if we could expand the study. These searches also yielded nothing. However, our Google Scholar and Google News searches produced a generous amount of timely news articles and some scholarly sources for Toronto, Ontario, and Canada, respectively—more than enough to conduct a scoping review. We thus agreed to focus our scoping review on GTA and Canada-based sources as originally planned. Since we decided to abide by protocol, we followed through with all the academic database searches using the same order and chronology of keywords for every search strategy save for ERIC. This predictably produced numerous overlapping results, numbering in the presence of thousands of duplicates. After deduplication, there were 242 articles. The authors met and discussed the inclusion/exclusion criteria in detail, and randomly chose, screened, compared, and discussed four sources to ensure agreement in determining inclusion/exclusion. The lead author then carefully screened the titles and abstracts of the 242 articles and found that they did not square with our review question. Other team members were not able to engage in the detailed screening due to the heavy demands of their pandemic response duties. When we used Google Scholar to expand our search, we found another 27 sources but only 6 discussed vaccine hesitancy in Canada. The different experiences gleaned from these news stories and commentaries reflect popular concerns and inform community-based decision-making. Our search unearthed 43 Google News sources on vaccine hesitancy in Canada among Black, East Asian, and Eastern European communities, 36 of which were included as they focused on or mentioned Toronto.^21,22,^28–61

When we combined these 36 Google News sources with the 6 sources from our Google Scholar search, we were left with a timely sample of 42 sources that focused on vaccine hesitancy in Toronto in the context of broader Canadian trends. Of these 42 sources, 19 were news articles,^{22,30,32,33,35,37,}^40–42^,44–53 9 were commentaries/op-eds,^{28,31,36,38,39,}^54–57 11 were various kinds of grey literature,^{21,29,33,43,50,}^59–64 and 3 peer-reviewed sources from Google Scholar.^65–67 As such, we met as a team to collaboratively develop the data extraction form. Since only three out of the 42 sources included in this review were peer-reviewed articles, we had to test the relevance and usability of common scoping review categories such as author, year, location, study population, methods, and results. After many revisions, we developed a form that consisted of the categories of citations, locations, types, purposes, and sources. Three team members tested the relevance and usability of the form by extracting data from a small number of sources first to assess the fit, challenges, and discrepancies. In addition, we used the NVivo software to help organize and manage the diverse data during extraction. The lead author imported all 42 sources into NVivo, organized them by the categories of news articles, commentaries, peer-reviewed articles, and grey literature. The team read the 42 sources using an iterative approach to generate multiple high-level themes on vaccine hesitancy. These themes were then discussed in team meetings and refined to four categories: access barriers, racism, misinformation, and mistrust. In addition, we generated subcodes that were linked to the respective population, for example, access barriers (Asian); access barriers (Black); access barriers (Eastern European). These codes and subcodes were applied to all 42 sources in NVivo and code reports were generated to facilitate team discussion and thematic analysis. During thematic analysis, we reviewed the coded excerpts of the sources to explore how they relate to one another and to identify patterns across the different types of sources.⁶⁸

Results

A total of 42 sources met the inclusion criteria (see Figure 1) and are organized by types, purposes, sources, and themes addressed across four tables in our supplementary files. Out of these 42 sources, three were academic studies in Canada—two quantitative studies and one qualitative study on vaccine hesitancy (see supplemental Table 3). The two quantitative studies sampled fractions of the Canadian population—Anglophone Canada⁶⁵ and Saskatchewan,⁶⁷ while the qualitative study presented a content analysis of tweets from Canadian Twitter.⁶⁶ These studies provided some broad Canadian trends within which to situate those sources exploring vaccine hesitancy in Ontario and, more specifically, Toronto. Eleven sources fell under the category of grey literature: a sponsored essay for an anti-racism foundation,²⁹ two science briefs,^58,59 two reports,^21,62 a policy proposal,⁴³ one news release,³³ a podcast interview,⁶⁰ a blog,⁶⁴ a research study,⁶³ and a rapid review⁶¹ (see supplemental Table 4). Most of the sources were news articles and commentaries (eg, op-eds or first-person accounts of vaccine hesitancy). Nineteen were news articles from a variety of Canadian media (eg, CBC, Global News, The Toronto Star)^{22,30,32,34,35,37,}^40–42^,44–52,53 (see supplemental Table 1), and nine were commentaries and first-person accounts from several news sources^{28,31,36,38,39,}^54–57 (see supplemental Table 2). The news articles and commentaries were particularly useful as they provided important urban context and lived texture for understanding COVID-19 policies and vaccine hesitant responses.

Figure 1.
Search results.

Analysis of these 42 articles generated four themes that shape vaccine hesitancy among our three Toronto ethnic diaspora communities: (a) access barriers; (b) mistrust; (c) racism; and (d) misinformation. These themes were based on a total sample of 57,989. The findings related to (a) access barriers are derived from 19 studies that addressed this theme,^21,22,^28–31^{,33,35,40,42,44,45,47,51–53,58,63,67} which draw conclusions from a sample of 31,122 (see supplemental Tables 1-4). Of these studies, 3 did not mention the sample, 11 were news articles, 2 were commentaries, 1 was a peer-reviewed article, and 5 were grey literature. The findings related to (b) mistrust are derived from 29 studies that addressed this theme,^21,22,^30–32^{,34–42,45,46,49,50,52,54,55,57,59–62,64–66} which draw conclusions from a sample of 34,885 (see supplemental Tables 1-4). Of these studies, 5 did not mention the sample, 14 were news articles, 7 were commentaries, 2 were peer-reviewed articles, and 6 were grey literature. The findings related to (c) racism are derived from 11 studies that addressed this theme,^21,22,34,^37–39^{,41–43,46,56} which draw conclusions from a sample of 6811 (see supplemental Tables 1-4). Of these studies, 2 did not mention the sample, 6 were news articles, 3 were commentaries, and 2 were grey literature. Finally, the findings related to (d) misinformation (conspiracy theories) are derived from 13 studies that addressed this theme,^{21,22,29,31,34,39,40,43,44,48,49,60,67} which draw conclusions from a sample of 16,079 (see supplemental Tables 1-4). Of these studies, 2 did not mention the sample, 6 were news articles, 2 were commentaries, 1 was a peer-reviewed article, and 4 were grey literature.

Our evidence does not support all four reasons in relation to all three populations referred to. For example, the four identified themes for Eastern European communities, despite some compelling insights, are based on limited evidence available at the time. Moreover, although we identified access barriers and mistrust across all three communities, there was more evidence available to support our thematic claims for Black diaspora communities, with mistrust more prominent among Black communities. Finally, there was some evidence that spoke to the effects of misinformation on all three communities.

Access Barriers

In the context of vaccine hesitancy, access is more than the availability of vaccines. The COVID-19 pandemic worsened inequalities for many ethnoracial communities in Canada, including a lack of easy access to plain language information, barriers to accessing services in non-official languages, and a lack of paid sick days for quarantine.⁵¹ According to the Institute of Clinical Evaluation Sciences (ICES), racialized neighborhoods in Toronto were especially hard hit.^53,69 This includes neighborhoods such as Thorncliffe Park, Regent Park, and Northwest Toronto.^44,45,53 Those with the highest concentration of racialized people had the lowest vaccination rates, Black and Southeast Asian populations among them.^53,69 As one community concerned leader put it, there are “so many barriers,” from vaccine-empty pharmacies in Northwest Toronto to essential workers lacking time off to get vaccinated.⁵³ Language barriers and inaccessible science communication are anecdotally expressed by one East Asian first-generation intergenerational family,²⁸ a lone source that demonstrates a clear need for language support at Asian-focused pop-up clinics where, early in the vaccine rollout, government COVID-19 vaccination messaging was mostly delivered in English.^42,70 This evidence is buttressed with other evidence from the global East Asian diaspora that also illustrates how language barriers may create tension within Asian families, making it more difficult to find accurate COVID-19 information.^29,71 There is nonetheless a paucity of research about how language operates as an obstacle to credible information access for the Toronto Asian diaspora despite this problem being observed by some members early in the vaccine rollout. For example, a family-operated health supplies store in Toronto's Chinatown was often inundated with customer questions about the vaccine, but with few answers and no literature in their first language.³⁰ These barriers have real consequences on communities, with the Kensington-Chinatown neighborhood at one point reporting less than 54% of people 18 and older receiving a vaccine.³⁰ Moreover, other sources, including one representing the East Asian community, underscore how a person's immigration status can complicate one's ability to access a COVID-19 vaccine.^35,47 Yet despite language barriers, most Chinese ethnic media endorsed masking, isolation, online education, and vaccination, thus fully embracing public health recommendations on COVID-19.^31,72 Moreover, Toronto's East Asian communities have attempted to solve accessibility issues themselves, with groups such as Friends of Chinatown Toronto (FOCT) working with neighborhood clinics to organize outreach, contact volunteers, engage in door-to-door discussions, translate information, use ethnic theater and music to assuage vaccine fears, and advertise Asian-centered pop-up vaccine clinics.^30,42,71,73

Strong evidence points to access as a prominent issue in Toronto's Black diaspora. The Black Scientists Task Force conducted 20 town hall meetings from February 2021 to June 2021, where 40% to 50% of its participants identified as “vaccine hesitant” with up to 15% saying they would not get vaccinated.^21,58,63 The task force concluded that Black health care and essential workers were at high risk for COVID-19 due in large part to the lack of paid sick days, poverty line incomes, and the intimate and exposed nature of such work.^21,22 Indeed, most of Toronto's Black and racialized laborers work blue collar and/or low wage service sector jobs with a significant amount of Black and racialized women in the stress-inducing health or home care sector.²¹ Much of this employment was precarious, with some people living “hand to mouth”,^21,22 a situation echoed by a Canadian study that identified financial instability as a general indicator of vaccine hesitancy.⁶⁷ Moreover, pharmacy oversight also left Black communities underserved while they endured vaccine queues, appointment obstacles, internet barriers, and time-chewing work schedules.²¹ Despite being higher risk for COVID-19 infection and severe illness, only 56.6% of Black Canadians were open to being vaccinated versus 76% in the overall population.^22,52 In late 2020, Black African and Caribbean people scored highest in both COVID-19 infections and vaccine hesitancy, facts attributable in part to access barriers.^22,33

In terms of access barriers to pandemic response in Toronto's Eastern European diaspora, we could identify only one article, which flagged efforts to overcome language barriers by disseminating COVID-19 facts in Ukrainian.⁴⁰ There were no sources that substantively reported or explored access barriers in these communities.

Mistrust

Several reasons for COVID-19 vaccine mistrust were revealed by an analysis of Twitter profiles in Canada, with 48.3% discussing vaccine safety and the alleged harms of the vaccine, 32.4% exhibiting skepticism over vaccine development, and other tweets expressing COVID-19 vaccine mistrust due to medical legacies targeting marginalized groups.⁶⁶ Our evidence revealed that there are varying degrees of COVID-19 vaccine mistrust among different ethnoracial communities as well as general mistrust in the health care system based on their unique experiences. A March 2021 Statistics Canada report indicated that vaccine mistrust in many East Asian communities was low compared to Toronto's Black diaspora, with 50.9% of Chinese respondents stating that they were unlikely to get a vaccine compared to 77% for Black Canadians.^32,34,74 Drawing on his interviews with the clinical director of the Chinese and Southeast Asian Legal Clinic in Toronto and the executive director of the Migrant Workers Alliance for Change, Nick Boisvert suggested that undocumented migrants might avoid accessing vaccination given their precarious immigration status and associated concerns about privacy at vaccine clinics.³⁵ Our review also found one first-person account where the narrator, a former “anti-vaxxer” of Filipino background, equated medical intervention with faithlessness,³⁶ an admission that revealed the important role Toronto faith leaders can play in persuading mistrustful members of racialized communities to get vaccinated.⁵⁵ Thus, there was some evidence that language barriers and inefficient vaccine rollouts informed mistrust, but this occurred alongside East Asian ethnic media (eg, Chinese) exhibiting pro-science stances with regards to masking and vaccination.^{30,31,42,70,74} This was a position shared by recent immigrants, 75% of whom intended to get the COVID-19 vaccine in late 2020.⁴⁹ Indeed, one study demonstrated that East Asian participants felt their infection risk was very high and that COVID-19 restrictions were not sufficiently restrictive.⁶⁵

Conversely, much evidence revealed that Toronto's Black diaspora exhibited high levels of vaccine mistrust, with 30% showing vaccine hesitancy as of March 2021²² due in part to a durable memory of historical injustices.^21,34,46,62 Where there was trust, it was invested in Black health care providers and local organizations.^21,75 The town hall survey showed that at least half of the vaccine hesitancy exhibited by Black Torontonians was the result of mistrust in the health care system and vaccine safety,²¹ a general concern given that 14% of Toronto residents were considered vaccine-hesitant as of August 2021 with those still unvaccinated citing side- and long-term effects of the vaccine as concerns as well as mistrust of its quick development.⁵⁷ Indeed, the main reason for vaccine hesitancy was “historical mistrust with medical sciences and governments,” which, along with discrimination, were unique reasons for vaccine hesitancy among Black communities.²¹ A National Collaborating Centre for Determinants of Health (NCCDH) paper concluded that Black vaccine hesitancy is “rooted in histories of oppression, systemic anti-Black racism in health systems and society, and the legacy of unethical medical research conducted in Black communities”,⁶²^(p.16) with classic examples being the notorious Tuskegee Syphilis experiment and Henrietta Lacks’ cell abduction.^22,54 Yet medical injustice is not simply a relic of the past for Black communities; it still occurs today. These histories have created “a sense of cautiousness when Black communities are approached about accepting a new treatment or vaccine”,⁶² especially pronounced in the United States,⁴⁶ yet evident in Toronto with the existence of an Instagram account called Black Mother Collective (BMC).³⁷ BMC is a platform for Black women to express concerns about the COVID-19 vaccine as well as skepticism about the health care system. This skepticism is based on evidence of health disparities experienced by Black communities, such as the high prevalence of preterm births among Black women and low flu vaccine uptake among Black Ontarians^37,38,76,77—interesting facts given that pregnancy vaccinations generally were low.⁵⁰ One source explained how the internalized and durable fear of medical institutions exhibited by many Black Canadians is the product of decades of systemic, institutional, and interpersonal racism,³⁹ as many studies have demonstrated.^78–81 The impact of this fear is illustrated by the tragic death of Leonard Rodriquez, a Black personal support worker, whose fear of hospital treatment was so acute he refused appropriate care and subsequently died because of his perception that “white people don’t like us”.³⁹ Given these obstacles, some have proposed that a “decentralized”⁴⁵ strategy for vaccine communication and distribution that leans on faith, community leaders, and family physicians as co-designers of vaccine practices that, for example, use Afrocentric approaches,⁵² is a more effective way of combatting vaccine hesitancy among immigrants and people of color.⁴⁵ This means providing opportunities to more Black medical professionals and emphasizing community-based education over mandatory COVID-19 vaccination policies and strategic incentives,⁵⁴ recommendations affirmed by Toronto's Wellesley Institute.⁶¹ The Wellesley Institute concludes that building vaccine trust among racialized communities requires using demonstrably effective strategies⁶⁴ such as trust-tailored communication and resource provision while avoiding incentive-based and punitive approaches.⁶¹

There are some similarities, but which need to be qualified, between Black peoples’ mistrust of vaccines and the vaccine hesitancy articulated by members of Toronto's Eastern European diaspora. We discovered two pieces of evidence that reveal mistrust-informed vaccine hesitancy among this demographic, particularly Ukrainian and Polish people, to be fueled by traumatic experiences living under communist and/or fascist states and/or working as exploited migrant laborers in Canada.^40,60 One source focused on long-term care homes in Toronto's West End, while the other shared the views of Mary Oko, the chair of the Copernicus Lodge Family Council, an advisory body made up of family members, friends, and others who advocate on behalf of long-term care residents at Copernicus Lodge.^40,60 Indeed, reported Eastern European vaccine hesitancy was evident in Ukrainian, Lithuanian, and Polish long-term care homes in Roncesvalles and Etobicoke and especially among a significant percentage of unvaccinated staff.⁴⁰ Yet some argue that the claim that the experience of living under totalitarian Soviet Bloc countries cultivated hesitancy in the diaspora—an experience defined by propaganda, allegedly shoddy products, and mandated vaccinations—is speculative and contradictory.⁴⁰ For example, some deny that this could be a “widespread issue” thirty years after the fall of communist regimes.⁴⁰ Regardless, there's little research about vaccine hesitancy among Toronto's Eastern European diaspora, a compelling demographic given the prevalence of vaccine mis/disinformation in pre-migration countries.⁸²

Racism

Racialized and low-paid peoples carry the bulk of Ontario's COVID-19 infection and sickness, with 70% of all cases in Toronto impacting them as of May 2021.⁵⁶ Our study revealed racism to be a reason for vaccine hesitancy, especially among East Asians and Black people. While there are many points of comparison between these two groups, there are also important differences.

Some of our sources revealed that, since the beginning of the pandemic, East Asian Canadians have been explicitly and implicitly targeted as “responsible” for COVID-19.^41,83 A 2020 Statistics Canada study stated that Asian Canadians were more inclined to report how COVID-19 has led to disproportionate spikes in “harassment or attacks based on race, ethnicity or skin colour”.,⁸⁴^(p.5) Many of those identified as Chinese perceived an increase in racialized harassment and physical assault, evident in cities such as Vancouver.^41,85 A subsequent 2022 study on racial discrimination experienced by Asian Canadians supports our review findings, affirming the negative mental health effects of such racism.^41,85 Moreover, the gendered nature of such racism was laid bare, with Asian women reporting 60% of racist incidents according to national data collected by Project 1907.^41,86 In spring and summer 2021, pop-up vaccine clinics in Toronto that prioritized underserved East Asian communities were confronted with “vaccine vultures” looking for another dose while some clinics had staff unprepared to serve residents with English language barriers—a systemic failure on top of incidents where East Asian vaccine seekers were spoken to in racist tones.^42,71,87 One source revealed how anti-Asian sentiment compelled some in the East Asian diaspora to perform mask hesitancy out of a fear they might be seen as guilty by association regarding the virus; some people even removed their masks on public transit and in grocery stores for this reason.⁴¹ The threat of physical violence was very real for many Asian Canadians in a historical conjuncture where discourses of the “yellow peril” reemerged alongside those about an insidious “Chinese disease,” often uttered from the mouths of politicians, and which did not abate as late as two years into the pandemic.^41,42,83,88

Anti-Black pandemic racism was mentioned or addressed in several sources and often understood as systemic and institutional and very much connected to access barriers, which facilitated a culture of mistrust.^21,22,34,^37–39^,46,43 Participants in the Black Task Force town hall meetings had many grievances, all revolving around an obvious lack of attention towards high-risk Black neighborhoods with regards to testing, vaccination, and the risks Black people experience in essential service jobs.²¹ The acuteness of this racialized neglect was brought to the light during the first year of the pandemic when “the estimated COVID-19 mortality rate for Black and racialized communities was an average of 35 deaths per 100,000 compared to an average of 16 deaths per 100,000 for the non-racialized population”.,²¹^(p.25) By December of 2020, Black people in the GTA made up 21% of reported COVID-19 cases while only making up 9% of the population.⁴³ Such disproportionate health inequity was also reflected in global vaccine disparities, with many in the Toronto Black diaspora concerned about family members in Africa, the Caribbean, and Latin America, regions that had received hardly any doses of the vaccine compared to the vaccine gluttony in the Global North.^21,^89–91 Anti-Black racism revealed itself in access barriers and a long history of medical mistrust, from underserved hot spots and lack of paid sick leave to the prevalence of preterm births and traumatic stories of medical experimentation.^21,22,37,59

Eastern Europeans straddle the liminal space between occasional racialization and mainstream Whiteness that does not leave them subject to racism in the same way as visible minorities.⁹² Our review was limited by an absence of articles discussing the racialized nature of Eastern European vaccine hesitancy. There are some studies that explore vaccine hesitancy in the United Kingdom among the Polish diaspora, an unusually racialized group in the United Kingdom and one subject to racist harassment by far-right politicians such as Nigel Farage, but these were not part of our scoping review given the focus of our research question.⁹³

Misinformation

All three ethnic communities exhibited varying degrees of susceptibility to vaccine misinformation, but the reason for this susceptibility differed. Several news articles expressed sentiments of exclusion from mainstream health knowledge by marginalized people, which compelled them to look for vaccine information online and on social media platforms.^{21,31,43,49,67} Within the global East Asian diaspora, much COVID-19 misinformation was spread via Asian-based e-platforms such as WeChat.^29,94,95 Yet, according to one source, most Chinese-Canadian ethnic media took pro-science positions on COVID-19.³¹

There was evident COVID-19 vaccine misinformation in Toronto's Black diaspora, from “guinea pig”,^21,22 “lab rat” conspiracy theories, and the myth that the vaccine is a genocidal “mark of the beast,” to the belief that vaccination changes DNA or implants surveillance technologies.³⁹ These conspiratorial fears were also held by some immigrants and refugees.⁴⁸ Some of these conspiracies have been expressed on urban radio, like Toronto's G98.7, specifically its current affairs flagship show “Grapevine,” and spread by vaccine-hesitant community activists via WhatsApp.⁴⁴ Indeed, ethnic and social media played a part in the dissemination of misinformation, with some spreading misleading messages and persuading community activists and health care workers to hedge on life saving vaccines.^31,34,39,44

The one reason for vaccine hesitancy with regards to the Eastern European diaspora that we had the most persuasive evidence for was misinformation. Members of the Eastern European diaspora exhibited susceptibility to vaccine misinformation via historical mistrust that some argue was learned under totalitarian regimes.⁶⁰ Op-ed writers in some ethnic media outlets, such as Russian Express, tarred Canadian authorities and statistics.³¹ Some argued that Russian-speakers abhor mass vaccinations because of allegedly bad quality vaccines that halted childhood immunization, and that the inheritance of Soviet propaganda makes them unusually suspicious of Canadian authorities despite some doubts raised by ethnic organizations such as the Ukrainian Canadian Congress.^31,40 These claims were buttressed by those working in Eastern European long-term care homes in Toronto's West End.^40,60

Discussion

Our review focused primarily on literature from timely news articles, commentaries, and grey literature since they captured the immediacy of the COVID-19 pandemic and reflected issues that people in our respective ethnic communities were concerned about, as well as three relevant peer reviewed sources from Google Scholar, a web-based search engine. The results revealed how the historical and structural violence of a colonial, capitalist, and White supremacist patriarchy manifested in the early pandemic conjuncture by racializing and subordinating different pandemic ethnoracial communities in different degrees. Our results revealed four reasons for vaccine hesitancy: (a) access barriers, including occupational, cultural, language, neighborhood-based, and socioeconomic obstacles; (b) mistrust, be it historical, medical, or political; (c) racism at the interpersonal, institutional, and systemic level; and (d) misinformation (such as conspiracy theories) circulated via various media platforms. COVID-19 vaccine access was compromised by inequitable distribution of resources and unfair social welfare policies.^69,96,97 These access barriers were especially evident in Black communities, although neighborhood-based neglect and language barriers were also prevalent among the East Asian diaspora.^21,30,42,70 Only one source identified language obstacles in a Toronto Eastern European community by describing a Ukrainian Canadian Congress effort aimed at disseminating COVID-19 vaccine facts in the Ukrainian language.⁴⁰ No other source broached the theme of access barriers for this demographic. For many in the Black diaspora, access barriers were part of a historical continuity of deeply racist and unethical treatment, double standards, and subpar care^39,62 that made some people susceptible to vaccine misinformation peddled by unscrupulous anti-vaxxers who instrumentalized such historical traumas for their interests.⁹⁸ Misinformation increased vaccine hesitancy among racialized peoples in a steadily vaccinated society,^58,59 which may expose them to more racism as a demographic perceived as culturally averse to vaccination, thereby strengthening racism as a negative social determinant of health. The desire to blame the “culture” of racialized groups for alleged inattentiveness to COVID-19 has been flagged and studied by South Asian Canadian scholars, who conclude that factors such as disproportionate representation in high-exposure essential services and cohabitation in multigenerational homes increase COVID-19 risks—concerns worth exploring across other ethnoracial groups.^99,100

In our review, several of the identified reasons for vaccine hesitancy intersect with one another but in different degrees for the different communities. A Toronto Asian legal clinic director highlighted how those with precarious status may choose not to get vaccinated if required to disclose health information³⁵ while neighborhoods such as Kensington-Chinatown were underserved by Toronto's vaccination rollout early in the pandemic.^30,42,71,73 “Yellow peril” and “Chinese disease” discourses reemerged with COVID-19 and discouraged some from abiding by COVID-19 protocols.⁸³ Moreover, several news articles and an op-ed illustrate how language barriers complicated vaccine acceptance, with one source inferring that this may push some towards alternative vaccine-suspicious sources via WeChat, a Chinese social media platform that, as subsequent studies have shown, became a hub of misinformation.^41,69,95 Racist pandemic discourses targeting Asians reveal a systemic racism that affects all racialized communities in different ways (eg, the enslavement of Black peoples; the construction of Asian Canadians as perpetual foreigners; the systematic genocide of Indigenous peoples).¹⁰¹ As a result, even though some of our evidence reveals an interpersonal element to anti-Asian racism under COVID-19 that differentiates it from the deep structural marginalization that defined the Black experience, it nonetheless stems from the same violent history of systemic racism.^41,83 Yet East Asian vaccination was very high at the time of our review. There are several plausible explanations. Our review shows that Chinese ethnic media generally supported COVID-19 mitigation,^31,102 while community members translated COVID-19 information and staffed pop-up clinics.^24,32 Furthermore, community resilience and organizing in the form of the Black Action Task Force, FOCT, and Chinatown Business Improvement Area necessitated by vaccine rollout tardiness and neglect, highlight how access barriers are policy choices situated within a history of state indifference towards racialized communities.^103,104 Moreover, there are community approaches that can (and do) mitigate these barriers.^27,59,64

There is very little information about Toronto's Eastern European diaspora with regards to the COVID-19 pandemic, the nature of their integration in Canadian society, and dynamics in responding to health crises. A couple of sources have identified mistrust of the COVID-19 vaccine by some Eastern European communities in Toronto as an afterlife of communist cynicism, a cynicism with real traumatic roots and one that reveals an inheritance of mistrust in some ways analogous to that harbored by many in the Black diaspora. Of course, access barriers for the Eastern European diaspora lack the media coverage of Black and East Asian vaccine hesitancy. What little evidence exists hints at a need for translated COVID-19 information, and there does exist documented racism against Eastern Europeans, especially Poles, elsewhere in the Anglopshere.⁹³ Yet there is at least some evidence of misinformation-induced vaccine hesitancy in the Toronto Russian diaspora, sometimes presented in Russophobic terms as part of a geopolitical game of cyber warfare.¹⁰⁵ The discourse of “race,” then, with regards to Eastern Europeans is not entirely absent.

Limitations

These results must be cautiously interpreted and several limitations should be taken into consideration. First, given this study is a scoping review, we did not undertake a risk or bias evaluation of the studies included in this review. Subsequent research on this topic should think about conducting a systematic review across several academic databases to spotlight and examine the impact of access barriers, mistrust, racism, and misinformation on our three ethnoracial groups, especially Eastern Europeans. Second, we conducted research for this review in March 2021, a time where there was little published about this topic. As a result, we focused primarily on news articles and commentaries while including some relevant available grey literature and peer-reviewed sources. This provided key urban context and affective detail for understanding COVID-19 policies and vaccine-hesitant responses among select racialized groups in the GTA. With the emergence of a more expansive literature base since our searches, future research should consider focusing on peer-reviewed sources and grey literature. Third, only one reviewer instead of two reviewers, a common approach used in scoping reviews, was involved in the screening. Other team members had demanding pandemic response duties and could not partake in detailed screening. Succeeding research must equitably divide screening labor and integrate contingency plans for such demands.

Conclusion

Our thematic analysis of news articles, commentaries, grey literature, and three relevant peer-reviewed sources generated four reasons for vaccine hesitancy: access barriers, mistrust, misinformation, and racism. These reasons, whether on their own or intersecting with one another, can create circumstances for re-racialization by willfully stereotyping entire peoples or misinforming them to become vaccine doubters and science-phobes, thereby doubly stigmatizing them by race and vaccination status in a way that nourishes mistrust in a system now armed with another problematic rationale for indifference. Yet these same reasons can also spur diaspora communities to engage in solidaristic practices of resilience that bring together scholars, activists, health care workers, and the disenfranchised.

Mary Oko of Copernicus Lodge in Toronto, which serves the Polish and Lithuanian diaspora, organized a vaccine clinic, and worked with Toronto Public Health to vaccinate seniors and the broader Eastern European community. Our review revealed this kind of community outreach to be common across all three vaccine hesitant communities. Whether Copernicus Lodge, the FOCT and Chinese BIA, and the watershed study of town halls produced by the Black Scientist's Task Force on Vaccine Equity, there is a real need for, to quote Oko, a “customized approach to each community” with regards to vaccine hesitancy.⁶⁰ This is a novel area of inquiry for comparative diaspora studies, one that may benefit from scholarship that studies community resilience in the face of contagious diseases. A common thread across all three ethnic communities is the need for effective communication of clear and accessible information on vaccines; education that challenges mis/disinformation; reliable and neighborhood-specific data about vaccine hesitancy for targeted rollouts; and the importance of practices and policies collectively developed by affected communities, health care providers, and faith and community leaders. In other words, multisectoral practices and policies that share the common goal of empowering members of diasporic communities to make informed decisions based on vaccine science to combat vaccine hesitancy are needed.

We propose that subsequent research focus more on the interlocking reasons for vaccine hesitancy in Canada's ethnic diasporic communities, exploring the unique and similar reasons behind vaccine hesitancy. There is also the need for more neighborhood- and ethnic-specific data (especially regarding Eastern Europeans), and the study of the transnational effects of vaccine-phobic and anti-vaccination discourses in premigration countries. More accurate information to this effect can be collected via surveys, focus groups, in-depth interviews, and analysis of social media platforms as a means towards a more effective and ethical future pandemic response.

Supplemental Material

sj-docx-1-joh-10.1177_27551938251400901 - Supplemental material for Understanding COVID-19 Vaccine Hesitancy in Black, East Asian, and Eastern European Diasporic Communities in Toronto: A Scoping Review

Supplemental material, sj-docx-1-joh-10.1177_27551938251400901 for Understanding COVID-19 Vaccine Hesitancy in Black, East Asian, and Eastern European Diasporic Communities in Toronto: A Scoping Review by Rade Zinaic and Josephine Pui-Hing Wong in International Journal of Social Determinants of Health and Health Services

Supplemental Material

sj-docx-2-joh-10.1177_27551938251400901 - Supplemental material for Understanding COVID-19 Vaccine Hesitancy in Black, East Asian, and Eastern European Diasporic Communities in Toronto: A Scoping Review

Supplemental material, sj-docx-2-joh-10.1177_27551938251400901 for Understanding COVID-19 Vaccine Hesitancy in Black, East Asian, and Eastern European Diasporic Communities in Toronto: A Scoping Review by Rade Zinaic and Josephine Pui-Hing Wong in International Journal of Social Determinants of Health and Health Services

Footnotes

Acknowledgements

This scoping review is support by a Canadian Institute of Health Research Planning and Dissemination Grant [Ref# 183417] as well as two research assistants, Madelaine Woo and Edgar Ndogo, for reading an early draft and offering insights in an earlier incarnation of this project.

ORCID iD

Rade Zinaic

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Canada Research Coordinating Committee (grant # NFRFR-2019-00014) and the Canadian Institutes of Health Research (grant # PCS-183417).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Rade Zinaic (BA, MA, PhD) is a Postdoctoral Research Fellow at Toronto Metropolitan University in the Daphne Cockwell School of Nursing where he led a collaborative Canadian Institutes of Health Research (CIHR)-funded project with Josephine Wong on vaccine hesitancy among diaspora communities in Toronto titled “Engaging Community Stakeholders to Address Vaccine Hesitancy in Racialized and Diasporic Communities,” from which emerged an important Community Dialogue and Action Forum that brought together 40 community stakeholders from diverse ethnoracial backgrounds in the Greater Toronto Area to discuss vaccine hesitancy and ideas for pandemic preparedness. Zinaic has extensive experience working with diverse cohorts of university students across several different Ontario universities in disciplines ranging from sociology to legal studies. He has published on Eastern European issues in New Perspectives and Slavonic and East European Review.

Josephine Pui-Hing Wong (RN, BScN, MScN, PhD) has extensive experience in critical public health and public health access and equity practice frameworks. She designs and implements community-based action research to promote health equity among racialized and marginalized communities. During the 2003 SARS outbreak, Wong volunteered with a coalition to establish and co-lead the SARS Support Phone Line in response to community needs. She also led a COVID-19 rapid response study, Project PROTECH (2020-2022), to mobilize communities to address pandemic hate, increase access to accurate information, and implemented an online intervention to reduce the mental health stress of healthcare providers. Wong's research is supported by the Ontario HIV Treatment Network, Canadian Institute of Health Research, Movember Foundation, Global Alliance for Chronic Diseases, New Frontiers in Research Fund, Funds for Innovation and Transformation, and Public Health Agency of Canada.

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Supplementary Material

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Understanding COVID-19 Vaccine Hesitancy in Black,East Asian,and Eastern European Diasporic Communities in Toronto: A Scoping Review

Abstract

Keywords

Methods

Search Strategies and Inclusion Criteria

Results

Access Barriers

Mistrust

Racism

Misinformation

Discussion

Limitations

Conclusion

Supplemental Material

sj-docx-1-joh-10.1177_27551938251400901 - Supplemental material for Understanding COVID-19 Vaccine Hesitancy in Black, East Asian, and Eastern European Diasporic Communities in Toronto: A Scoping Review

Supplemental Material

sj-docx-2-joh-10.1177_27551938251400901 - Supplemental material for Understanding COVID-19 Vaccine Hesitancy in Black, East Asian, and Eastern European Diasporic Communities in Toronto: A Scoping Review

Footnotes

Acknowledgements

ORCID iD

Funding

Declaration of Conflicting Interests

Supplemental Material

Author Biographies

References

Supplementary Material