Immigrant populations are eager to be vaccinated but the barriers are steep, including lower rates of technology literacy and how well they speak English.
This article was published on Tuesday, March 23, 2021 in Kaiser Health News.
In late February, a week after Virginia launched a centralized website and call center for COVID-19 vaccine preregistration, Zowee Aquino alerted the state to a glitch that could prove fatal for non-English speakers trying to secure a shot.
Callers who requested an interpreter on its new 1-877-VAX-IN-VA hotline would be put on hold briefly and then patched through. Then the line would automatically hang up on them.
It was a startling discovery for Aquino, a community health manager, and her colleagues at NAKASEC Virginia, a nonprofit that works with Asian Americans across the state. The glitch was a "direct barrier to access," she wrote to senior state officials, "and must be addressed immediately."
But that wasn't the only problem. Only two languages were offered when callers dialed in — "press 1 for English" or "press 2 for Spanish." But Virginia is home to speakers of many other languages — Chinese, Korean, Vietnamese, Arabic, Mongolian, Amharic and dozens more — who would need the help of translators to get their place in line for a vaccine.
"There's so much attention to, let's translate flyers, right? We're like, what's the point of translating a flyer that says you can call 'VAX in VA' and we have all these languages, when the phone line doesn't work consistently, or it's not even set up well for non-English, non-Spanish-speaking populations?" said Sookyung Oh, the group's Virginia director.
Concerns about equity have loomed large in the nation's mass COVID vaccination effort. Distribution of doses has been spotty among underserved populations, many of whom have been hit disproportionately by COVID hospitalizations and deaths. As Aquino found, barriers to vaccinating those groups begin with providing basic information about the shots and getting people registered.
Several individuals in interviews said the immigrant populations they work with, including Asians and Latinos, are eager to be vaccinated. But the barriers are steep, including lower rates of technology literacy and how well they speak English, if at all.
"Especially in stressful situations, they are not trying to struggle through English," said Oh, who described trying to secure a vaccine appointment for her mother — a Korean woman who lives in Philadelphia — as a "complete clusterf***" because the city's registration portal isn't available in that language.
President Joe Biden announced this month that by May 1 the federal government would launch a website and new call center to help people find vaccine appointments, but officials have declined to elaborate on whether the website will be translated into non-English languages and which languages will be available through the call center. A spokesperson for the Department of Health and Human Services did not respond to questions about language access.
Approximately 5.3 million U.S. households have limited English proficiency, according to the U.S. Census 2019 American Community Survey. And, it found, nearly 68 million people speak a language other than English at home.
The CDC's website for COVID-19 vaccine information is comprehensively translated into four languages: Chinese, Korean, Spanish and Vietnamese. The federal agency has drafted other flyers about vaccines, but which languages the materials are available in varies considerably. A "Facts about COVID-19 Vaccines" flyer is translated into nearly two dozen languages, including Arabic, French, Tagalog, Russian, Somali and Urdu. Other documents are not translated at all; if they are, Spanish is the most common translation.
"It's really concerning that the information is not available in different languages," said Bert Bayou, director of the Washington, D.C., chapter of African Communities Together, which works with immigrants across the metropolitan area.
Virginia in mid-February released a centralized online preregistration system and a new hotline for vaccinations, a full month after residents 65 and older and those with certain medical conditions could register for appointments. As of mid-March, the state health department's portal could be translated only into Spanish, spoken by nearly 8% of the state's population. Similarly, the District of Columbia's vaccine preregistration website that launched this month was initially available only in English, although officials were working to have it translated into additional languages before the month is out.
Any agency that fails to inform limited-English speakers of how to access their services — in this case, vaccinations — could be found to have violated federal laws that prohibit discrimination in healthcare on the basis of race, color, national origin and other factors, said Mara Youdelman, a managing attorney at the National Health Law Program, a civil rights advocacy organization.
"If they launch a website and they choose not to have it translated into multiple languages, I would say at a minimum that they should have some taglines on the webpage about where to get more information," Youdelman said. Even beyond the law, making the vaccination process as accessible as possible to non-English speakers is "the necessary thing to do and the right thing to do."
Otherwise, she said, "we're not going to reach the herd immunity we all want and need to get life back to normal."
Fairfax County, the most populous county in Virginia, maintained its own registration portal, but officials only on March 15 launched a Spanish registration website, two months after the state significantly broadened vaccine eligibility. In the interim, Spanish speakers had been directed to download a PDF questionnaire, and then call a phone line to relay their information for an eventual appointment. Roughly 14% of the county's population identifies as Spanish-speaking, according to the 2019 American Community Survey.
In Virginia, many immigrants are left with the heavily promoted VAX-IN-VA hotline, where access to interpretation services was uneven. The state eventually added a "press 3" menu option for help in a different language — although the "press 2" and "press 3" prompts are spoken in English — that allowed non-English and non-Spanish speakers to more easily connect with interpreters in more than 100 languages.
Yet their needs often fall to the back of the line because the languages are so discrete and, after Spanish, there's no "obvious" third language that's prioritized, Oh said. Census data shows that more than 1.3 million Virginians speak a language other than English at home, including about 310,000 who speak Asian and Pacific Island languages and 295,000 who speak Indo-European languages.
A state spokesperson said that, upon reviewing call logs, in some situations the callers were the ones who may have hung up while on hold, and other times call center agents may have accidentally hung up. Records showed that this occurred fewer than 10 times, mostly all during the first week.
"We had a small handful of issues but looking forward we have not uncovered any ongoing issues," Vaccinate Virginia spokesperson Dena Potter wrote in an email. She did not respond to questions about whether state officials planned to translate Virginia's preregistration portal into other languages and whether the system might violate federal civil rights laws.
Nationally, Asian Americans have had lower COVID mortality rates than other minorities, including Black and Latino Americans. However, there are troubling signs that underscore the urgency to boost vaccination rates. According to data compiled by the American Public Media Research Lab, the four-week period between early February and early March was the deadliest stretch of the pandemic for Asian, Latino, white and Indigenous Americans. Roughly 3,730 new deaths were reported among Asian Americans. Among Hispanics, 16,780 new deaths were reported.
To figure out whether they're eligible and to get vaccine appointments, non-English speakers rely on the clinics that treat them, English-speaking friends and family, and other nonprofits that serve immigrant communities. Without reliable information across languages, health centers and other nonprofits worry about what fills the void: Rumors and false information proliferate not only on U.S. social media platforms but apps like WhatsApp and WeChat used around the world.
"They're not your Facebook and your Instagram chats," said Andrea Caracostis, CEO of the HOPE Clinic in Houston, a federally qualified health center that treats patients from at least 60 countries. "I think language issues and misinformation from abroad is going to erode a lot of the work that we do."
The Houston area is home to one of the largest Vietnamese populations in the country. In late January, the clinic prioritized Vietnamese seniors for shots after receiving about 500 doses from the city. To make it happen, Caracostis said, they partnered with local Vietnamese doctors, nurses and even medical students to help. Clinic staff members translated immunization release forms before patients showed up.
"It's going to take a village," she said.
Groups are assembling teams of volunteers to make preregistration calls and appointments, and setting up pop-up registration sites in church parking lots in poorer neighborhoods.
"You can answer questions right on the spot," said Wanda Pierce, co-chair of Arlington County's Complete Vaccination Committee, a 40-plus-person group formed to ensure equitable distribution of vaccines in that Virginia suburb of Washington. County officials have organized preregistration pop-ups, typically done alongside other services for low-income residents, such as clothing and food distribution. A recent pop-up held at Macedonia Baptist Church, a Black church in a lower-income area of the county, saw a handful of limited-English speakers preregister for vaccines, according to organizers.
Recent polling has found that vaccine hesitancy is dipping among minority groups; however, they are still more likely to take a "wait and see" approach than white Americans. And many are struggling to secure appointments.
A March poll from KFF found that among adults who have gotten at least one dose of vaccine, 39% said someone else had helped them find or schedule an appointment. Hispanic adults were more likely than white adults to say they did not have enough information about where or when they could get vaccinated.
Spanish-language needs and outreach to Latinos haven't been adequately prioritized, said Luis Angel Aguilar, the Virginia state director of CASA. In addition to language access, "there's not enough communication and information now on where and who to call," he said.
"It's so easy for people to give up and say, 'You know, I tried,'" added Nancy White, president of the Arlington Free Clinic, which treats low-income minorities and counts Spanish, Mongolian and Amharic speakers among its patients.
The clinic, instead of signing up patients through Virginia's preregistration portal, is using its own system to get its patients vaccinated since the clinic receives an allocation of doses directly from the county. After an early pilot program to vaccinate seniors 75 and older, Arlington Free Clinic this month began vaccinating people 65 and up and those with chronic medical conditions. It relies on over 100 volunteer interpreters to help patients navigate the healthcare system.
"You can do it," White said of getting around language issues, "but it takes a lot of time and a lot of manpower."
“It's really concerning that the information is not available in different languages.”
Bert Bayou, African Communities Together
Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.
Concerns about equity have loomed large in the nation's mass COVID vaccination effort.
Distribution of doses has been spotty among underserved populations, many of whom have been hit disproportionately by COVID hospitalizations and deaths.
Barriers to vaccinating those groups begin with providing basic information about the shots and getting people registered.