Portrait of French-speaking minorities with respect to vaccination against COVID-19

Background The coronavirus disease 2019 (COVID-19) vaccination campaign highlighted the requirement to better understand the needs of different populations. French-speaking minorities (FSMs) have greater difficulty accessing quality care in French, and this problem was exacerbated during the COVID-19 pandemic. Objective The aim of this survey was to develop a descriptive portrait of the health needs of FSMs in relation to the COVID-19 vaccination campaign by describing their vaccination status, attitudes and beliefs compared with English-speaking majorities. Methods A survey was conducted among eligible participants using convenience sampling. Data measurement includes a descriptive statistical comparison using analysis of the variance, univariate logistic regressions and a two-proportions z-test. Results Of the 1,505 respondents (554 FSMs vs. 951 English speakers), the FSMs have an average age of 51.4 years and 89.2% are Canadian citizens. Vaccination of children was preponderant among English speakers (74.2% vs. 86.3%), including against COVID-19 (58.6% vs. 73.9%). A higher proportion of FSMs had gotten vaccinated in order to obtain a vaccine passport (39% vs. 29.3%). Among the unvaccinated, FSMs were more likely to question the efficacy of vaccines (60% vs. 36.4%). Canadian citizen FSMs with higher education could be divided in relation to the vaccine regimen. Conclusion This survey revealed differences between FSMs and the English-speaking majority in their perceptions of vaccine efficacy, particularly vaccination of children, and a polarization of attitudes/beliefs among FSMs according to certain sociodemographic factors.


Introduction
The coronavirus disease 2019 (COVID-19) vaccination campaign highlighted the requirement to better understand the needs of different Canadian populations during a pandemic. The lack of data on the needs of linguistic minorities (1-3) had a significant impact on vaccine uptake and trust in healthcare institutions (4,5).
based on up-to-date evidence. An existing survey (19) explores some relevant areas, but does not provide a breakdown by language, at least not in publicly available data. This survey, carried out between May 1 and June 30, 2022, aims to describe the health needs of FSMs in relation to the COVID-19 vaccination campaign through the lens of vaccination status, attitudes and beliefs, and provides for a comparison with English-speaking majorities.

Methods
This article was written according to the guidelines of Improving the Quality of Web Surveys: The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) (20).

Population, time and place
The survey was conducted over an eight-week period ending on June 30, 2022, among FSMs and English speakers outside Québec, Canada. The study defines FSMs as residents outside Québec whose preferred language is French, and Anglophones as residents outside Québec whose preferred language is English. Given the rapid evolution of the pandemic, convenience sampling was used.

Link to the research objective
The descriptive portrait of FSMs vis-à-vis the COVID-19 vaccination campaign includes the collection of sociodemographic data, vaccination status, attitudes and beliefs.

Development of the survey questionnaire
The questionnaire (Supplemental material, Survey) was designed by the research team based on a validated survey (19) by Statistics Canada. To meet the requirements of the study, questions dealing with language, attitudes and beliefs were added before conducting a pilot study with 30 participants drawn from the mailing list of Léger Marketing Inc.

Sampling technique
Participants were recruited primarily via the sampling strategy, the mailing list of Léger Marketing Inc. and Canadian Francophone organizations (Supplemental material, Survey invitation letter). The sample was created taking into account the response rates for each age category and the quotas required to obtain a representative sample. Representative quotas were established for age, gender and province. The sample was sent out strategically to ensure representativeness. For example, attention was focused on the 18 to 24 age group, as these respondents are generally harder to reach, while less attention was paid to the 65+ age group, as they are conversely much easier to reach. This required constant attention to the quotas defined in the survey platform, while ensuring random selection. An invitation letter, a consent form and the questionnaire were distributed to those who met the inclusion criteria.

Informed consent
The study was approved by the University of Ottawa Research Ethics Board (H-02-22-7648). A consent form had to be completed by participants prior to conducting the survey.

Optimizing response rates
The survey was made available on FocusVision Decipher (Forsta, 2022) and on the LEO mobile app (Léger Marketing Inc., 2020), in addition to being widely distributed via the social networks of the University of Ottawa Faculty of Medicine's Francophone Affairs. Participants were invited to share the survey, allowing snowball sampling to be used to optimize the response rate.

Measurement
Data measurement was carried out in accordance with two research questions designed to identify 1) the vaccination status, attitudes and beliefs of FSMs compared with English speakers, and 2) the sociodemographic characteristics of FSMs in relation to vaccination status, attitudes and beliefs.
Sociodemographic data includes: province/territory of residence, age, gender, income, education, marital status, ethnicity, citizenship and health status. Vaccination status includes COVID-19 vaccine doses, willingness to follow the recommended vaccine regimen, and vaccination of children (ages 5 to 11 years). Attitudes include reasons for uptake and hesitancy, as well as trusted sources of information. Beliefs include vaccine safety, perceived risks and efficacy, health practices and social responsibility.

Analysis
Descriptive statistics were calculated and analyzed using SPSS (version 22.0). Continuous variables were presented as means and standard deviations, and categorical variables as totals and/ or percentages. Analyses of variance (ANOVA) were performed to examine significant differences in continuous variables. Univariate logistic regressions were performed to determine the associations between FSMs and English speakers, and also sociodemographic variables with vaccination status and belief. The findings are presented as odds ratios (OR) with 95% confidence intervals (CI), as well as the likelihood chi-squared statistic. A two-proportions z-test was performed for multiple-response questions to compare proportions between groups; the Bonferroni correction was used for multiple comparisons. A p-value of less than 0.05 indicates a statistically significant difference.

Findings
The sample comprised 1,505 participants: 554 FSMs and 951 English speakers. The findings include a 100% response rate for each participant, giving n=554 (FSMs) and n=951 (English speakers). The sociodemographic data are presented below ( Table 1).      to get vaccinated to protect themselves against serious illness (83% vs. 72.6%, p<0.001). The higher the level of education, the more likely it was that article publication dates would be consulted to validate information (40% vs. 24%, p=0.008) and that scientific professionals would be regarded with confidence (76% vs. 56%, p<0.001).

Beliefs Differences between French-speaking minorities and English speakers
FSMs frequently disagreed with the efficacy of herd immunity ( Table 4).

Summary of key findings
The survey highlights three findings of interest: a polarization of attitudes/beliefs according to citizenship and education, vaccine uptake for a return to normal, and significant hesitancy concerning vaccination of children.

Comparative analysis
Compared with English speakers, FSMs show a polarization of attitudes/beliefs according to certain sociodemographic characteristics. Among FSMs, Canadian-born citizens with a higher education were more likely to completely disagree or agree with the recommended vaccine regimen. This trend is noted by other studies in high-income countries (17). The literature indicates that mixed attitudes may stem from inconsistent information from official sources (21-24), becoming a risk to communication and patient disregard for medical care (25).
According to the literature, the prospect of a "return to normal" is strong motivation for vaccine uptake (4,21). Although FSMs generally doubted its efficacy, they mainly got vaccinated to obtain the vaccine passport and to protect themselves against serious illness, especially in the case of men. Given the inconsistency of information, also felt among healthcare professionals (25), FSMs were not always able to count on the news and relied on the recommendations of government agencies, promising a return to normality thanks to vaccination (24,26).
Although FSMs are often described as an older population (7,27), this survey was designed to be representative of all FSM generations. Despite the low representation of French-speaking parents with young children, vaccination hesitancy for children is of particular interest. Vaccine hesitancy (COVID-19 and other diseases) for children is more pronounced among FSMs, who are less likely to follow the vaccine regimen, unless they have a high income. In a broader context, the efficacy of COVID-19 vaccines in children has been widely disputed in literature (17,28).
The problem of childhood vaccination, which existed prior to the emergence of COVID-19 (17) and led to parental vaccine hesitancy during this pandemic (28), could be caused by suboptimal physician-patient communication (4,29). The finding of this study could indicate greater inaccessibility for linguistic minorities. We hypothesize that the current shortage of family physicians in rural and urban settings (30,31), and by extension a lack of accessibility to bilingual health professionals, could contribute to an exacerbation of the problem of vaccination of children during a health crisis. Vaccination of children and parental hesitancy should be the subject of further research to pursue this line of thought and optimize access to care.

Strengths and weaknesses
Considering the rapid evolution of the virus and of health recommendations, the study has some conceptual and methodological limitations. Media saturation and collective exhaustion made participation less appealing and influenced the sampling technique that was selected, resulting in a sampling bias caused by a convenience sample. Despite the strategy employed by Léger Marketing Inc., it is difficult to ensure the representativeness of FSMs and English speakers, as well as the potential for statistical generalization of the findings. Furthermore, the survey presents a portrait of FSMs for a given period, rather than according to a specific situation during the pandemic. The time elapsed between the data collection period and the comparative analysis must also be considered a bias for the representativeness of the findings. Despite this, the study met its objective and thus contributed to the active offering of French-language health services.

Impact
This survey provides health professionals with the relevant information they need to tailor their communication with patients who are faced with a vaccination choice. The findings also point to the need for new studies establishing a portrait of FSMs in order to better address their vaccine needs.

Next steps
By filling the knowledge gap regarding vaccination against COVID-19, this data could help improve access to information and, consequently, help adapt the training of health professionals for a therapeutic alliance based on trust.

Conclusion
Although difficult to generalize, this survey did reveal significant differences between FSMs and English speakers in their perceptions of vaccine efficacy, particularly vaccination of children, as well as a polarization of the attitudes/beliefs of FSMs according to certain sociodemographic factors. The findings imply a requirement to better understand the overall needs of FSMs in order to improve access to information and care in French.