Article Text

Download PDFPDF
Health promotion and public health
Addressing health beliefs in vaccination policies to increase uptake among older adults from ethnic minority backgrounds
  1. Dorothy Afriyie
  1. Nursing Research, Imperial College Healthcare NHS Trust, NIHR, London, UK
  1. Correspondence to Dorothy Afriyie, Research Nursing, Imperial College Healthcare NHS Trust, NIHR, London W2 1NY, UK; d.afriyie{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Commentary on: Bhanu C, Gopal DP, Walters K, et al. Vaccination uptake amongst older adults from minority ethnic backgrounds: a systematic review. PLoS Med 2011; 18(11):e1003826. doi: 10.1371/journal.pmed.1003826

Implications for practice and research

  • Healthcare professionals should tailor vaccination education to address people’s health belief models to minimise hesitancy.

  • An empirical study exploring the health beliefs and other factors influencing vaccination uptake among older adults from minority ethnic backgrounds.


Vaccine hesitancy is high among individuals from ethnic minority backgrounds (EMB). Globally, an age-based vaccination approach was implemented during the initiation of the COVID-19 vaccination.1 In this approach, older people were prioritised to receive COVID-19 vaccination since older adults were prone to contracting the disease as well as experiencing severe morbidity and mortality from the virus. This was more so in older EMB adults than similar-aged Caucasians. Despite availability of COVID-19 vaccines, vaccination uptake was low in EMB adults compared with their white counterpart.1 This study by Bhanu and colleagues identified systemic, patient-related and governance-level as factors related to lower vaccination uptake among older EMB populations.1


A systematic review and convergent synthesis was used in this study. Literature search was done on seven academic databases widely opened from inception to 15 July 2021. Eligibility was subjected to empirical studies focused on adult aged ≥65, from EMB focusing on their perceptions, beliefs and attitudes towards vaccinations. The authors carried out data screening using Rayyan, Qatar Computing Research Institute (QCRI) an online systematic review software and also used Mixed Method Appraisal Tool to assess the risk of bias. Qualitative and quantitative data were integrated using a convergent synthesis approach. Results from selected studies (qualitative/quantitative/mixed methods) were converted into qualitative findings using thematic analysis.


In all, 28 relevant studies conducted between 1997 and 2020 were included in the final analysis. There were 17 quantitative survey, 8 interview studies, 2 mixed-methods studies and 1 case–control study. Eighteen of the studies were conducted in the USA in English or Spanish with 10 other studies conducted in Asia, Europe, South America and Africa. The studies explored the views from a mixed group of EMBs, including African American, Hispanic, Hong Kong Chinese, Japanese and Brazilians. A total of 28 262 EMB adults with a mean age of 69.8% and 63.2%, women were included across the studies reviewed. The review revealed major determinants at the health system, patient and operational policy levels acted as barriers or facilitators for vaccine uptake among older EMB adults. Mistrust of the healthcare system and misconceptions of vaccine adverse events were all identified as barriers, Whereas some facilitators for vaccine uptake included knowledge of vaccines and how they work and recommendation for vaccination by a trusted health professional.


This study used thematic analysis to systematically examine EMB adults’ perceptions towards vaccination. This review largely included studies mainly across the USA; therefore, findings may not be applicable to other adults in other settings. Nonetheless, ethnic groups are considered to share a common ancestry and culture.1 The studies were on influenza and pneumococcal vaccination; however, these can be comparable to the COVID-19 vaccination.1 In this current COVID-19 pandemic, the UK data revealed that 86% of adults from white background had received COVID-19 vaccine at the time of data collection, compared with 55% of black cohort although adults from EMB were affected significantly.2 This indicates the relevance of engaging adults from EMB to facilitate vaccination uptake. The study revealed that vaccination strategies should revolve around healthcare providers, patients and policy to ensure adequate impact, efficacy and equity.1

This study is important because it identifies relevant barriers to be addressed as well as facilitators who can be capitalised on to improve vaccine uptake among EMB adults. Vaccination will play a significant role in controlling the COVID-19 pandemic and; therefore, it is important to address vaccine hesitancy, while picking up lessons for future disease control interventions. Since the study identified multilevel factors acting as barriers to vaccine uptake, it draws attention to the need for multidisciplinary approaches in addressing and tailoring health education, health policies and implementation underpinning the health beliefs of EBM adults, instead of the usual ‘one-size-fits-all’ approach for expediency. A study by Mohammed and colleagues identified that health education programmes tailored on people’s beliefs improve their adherence to care.3 Therefore, vaccination approaches should focus on the beliefs, challenges and context of EMB adults to promote equity, successful spread of policies and adherence.

Ethics statements

Patient consent for publication

Ethics approval

Not applicable.



  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.