Where Past Meets Present: Indigenous Vaccine Hesitancy in Saskatchewan

"It would be misguided for any intervention, social media or otherwise, to ignore historical influences on Indigenous vaccine confidence."

Heightened vaccine hesitancy among Indigenous Peoples stems from a history of medical experimentation, forced or coerced sterilisation, residential school experiences, and unethical research, including by some of the institutions that promote vaccination. This research investigated COVID-19 vaccine hesitancy in a First Nations community in Canada and explored ways it can be overcome. It followed Indigenous research methodologies and a community-based participatory research design.

The project engaged an Indigenous community, Star Blanket Cree Nation, in Saskatchewan, Canada. Throughout the COVID-19 pandemic, Star Blanket Cree Nation's pandemic response team had been implementing a vaccination campaign. In the months between applying for funding and the commencement of research activities, this team found great success, with community members estimating vaccination rates exceeding 90%. Still, persistent refusers remained, and the Community Research Advisory Committee (CRAC) guiding this work determined that the project would still prove valuable to their community. The CRAC saw key sources of local vaccine hesitancy as information inaccessibility, medical misconceptions, historical mistrust, Traditions and Traditional healing practices, and perceived COVID-19 threat.

An Indigenous community-based health research lab at the University of Saskatchewan worked with Star Blanket Cree Nation to collaboratively develop a series of social media posts (interventions) to pilot on a community-run social media page in January and February 2022. The posts were all approved by the local CRAC composed of Elders, Knowledge Keepers, community research assistants, community members, and people with lived experience (hereafter, "co-researchers"). Social media interventions were developed to reflect contemporary and emerging research while relying on CRAC feedback and edits to account for cultural, historical, and local factors.

These posts tested different messaging techniques in a search for effective strategies. In total, six types of posts were developed: three investigating behavioural insights, or BI (with messaging around reciprocity, the availability heuristic, and anticipated regret - e.g., "The vaccines have been prayed over for our safety and are here to protect us and our community. Remaining unvaccinated is a personal choice, which is respected, but puts others at risk" - and three considering conspiracy theories (with messaging around memes and the victim motif, motives, and empathy - e.g., "Your concerns have been heard and these resources were developed to answer your questions!" Interventions were posted every Monday, Wednesday, and Friday at 13:00 local time until all posts had been made. A control post was included that simply stated, "Call the (community health centre) at (phone number) to inquire about getting vaccinated". The project compared piloted interventions to each other as well as to posts developed entirely by community.

The pilot period ran from January 31 2022 to February 14 2022, with each post having its likes, views, and comments recorded 1 week after posting. Among piloted posts and the control, the messaging strategies receiving the most likes included anticipated regret, reciprocity messaging, and empathy, while the most viewed were anticipated regret, the control, and reciprocity messaging. As a group, the community-developed posts outperformed the piloted posts in views, at a 5% level of significance, and in likes, at a 10% level of significance.

Qualitative data were also gathered at the end of the pilot in the form of sharing circles conducted with co-researchers, followed by culturally appropriate data analysis (Nanâtawihowin Âcimowina Kika-Môsahkinikêhk Papiskîci-Itascikêwin Astâcikowina procedure). (Starblanket et al., 2020) Sharing circles are similar to focus groups but differ in the sacred meaning they hold for many Indigenous cultures. Six major themes emerged from the circles and are discussed in the article, including: culture, fear, government COVID-19 responses, information consumption and exposure, community influence, and appeal of the vaccine-hesitant community.

The results demonstrated the importance of prioritising the exploration of an Indigenous community's self-determined solution before, or at the very least alongside, the exploration of external solutions. Further, it appears valuable to engage community members to see where culture may heighten hesitancy but also where it may be leveraged to the benefit of vaccine promotion. For example, traditional health practices emerged as one source of hesitancy; however, praying to, or over, the vaccine was mentioned multiple times as the catalyst to overcoming hesitancy. When attempting to overcome barriers, empathy is crucial, as legitimate vaccine fears exist; the CRAC's rejection of any definitive statements on vaccine safety is worthy of expansion. On this note, it is necessary to understand people and their beliefs to understand how to overcome hesitancy.

In addition, the study showed that the wider Star Blanket Cree Nation community has a powerful influence on vaccine confidence. Seeing relatives and friends get vaccinated spurred some to overcome their hesitancy. Reciprocity emerged as another theme, with one co-researcher stating that the clear message was, "the vaccines help and if you care, if you care for your fellow loved ones,... you'd get it". Messaging should avoid polarising vaccine-confident and vaccine-hesitant people to the point where the benefits of community influence are limited.

Co-researchers also discussed ways information could be used to promote vaccination. For example, they talked about the positive effect of educational pamphlets and pandemic response kits, provided by the community's pandemic response team and developed in partnership with the MSL. While statistics and medical information are valuable, one co-researcher noted that "people resonate with people, not with data", and another pointed to the importance of first-hand accounts and expert reports. In that vein, one proposed solution is a short documentary contrasting the lived experience of COVID-19 in a vaccinated person with that of someone who was not vaccinated.

In conclusion: "Overcoming vaccine hesitancy appears far too complex and individual to generate a universally effective vaccine promotion campaign. What works for one, may not for another, and what works at one time, may fail later. When it comes to helping someone overcome vaccine hesitancy, perhaps the only consistent 'best practice' is that, 'you really just have to listen to them, understand their...beliefs'."