Introduction

COVID-19 has presented a conundrum for medical anthropology. The pandemic has both highlighted and exacerbated existing issues in health systems,¹ and the inconsistency and inequality of responses has demonstrated that health cannot be separated from the social, economic, and political environment. However, there has been frustration among anthropologists that analyses of the pandemic have primarily focused on social-behavioral sciences and have mostly not led to deeper reflections on structural inequalities and the political economy of health.² One significant aspect of the responses and debates has been COVID-19 vaccines. From the perspective of critical medical anthropology, vaccination is an excellent example of the extent to which public health issues can be understood as a mirror of societal preoccupations and the relationship with the state, revealing “the impacts of socio-cultural, economic, and (geo-)political particularities concerning the acceptance and rejection of a vaccine.”³ As the interdisciplinary UK-based Vaccine Confidence project argues, “a vast majority of the challenges around vaccine confidence have little to do with the vaccines themselves. Rather, the vaccine confidence challenge is a window into the broader issues of our polarized, mistrustful society.”⁴

During COVID-19, the global issues around vaccination were amplified, with intense debate over the ethics of mandatory vaccination and human rights.⁵ Vaccines and vaccination have been characterized, through morally polarized and often politically opposing viewpoints, either as the vehicle to a sinister level of state control or as an expression of societal compassion over individual liberty. The concepts of “vaccine confidence” or “resistance,” “vaccine (in)equality” and “(in)equity,” took on new relevance in the context of an unprecedented vaccination drive that targeted multiple populations simultaneously, albeit within highly differing contexts. Southeast Asian nations, in particular, have been the target of multiple vaccine diplomacy efforts by China, the United States, and even Russia.⁶ But while studies suggest that this region has the highest COVID-19 vaccination acceptance rates worldwide,⁷ disparities across socioeconomic groups are pronounced.⁸ Furthermore, the region’s highly diverse cultural, linguistic, and religious landscape makes a one-size-fits-all public health approach almost impossible, often described by health implementors as “cultural barriers” to vaccination.

However, to medical anthropologists, this terminology is resonant of an excuse to shift responsibility rather than tackling the complex power relationships, underlying inequities, and substandard care that may lead to poor relationships between populations and health providers. Instead, by reframing culture as the dynamic mediator of embodied experience,⁹ one can better understand the lived realities of people’s everyday encounters with health services. This is evident in Laos, where in a population of less than eight million people, there are more than 150 ethnolinguistic groups and a rich religious tapestry that weaves together Theravada Buddhist and animist traditions against historical Hindu influences, colonial and contemporary forms of Christianity, and a small Muslim population.¹⁰ Central to this is the interplay between belief, faith, and trust, which in local languages can be expressed as a single term, khuam seua (Lao) or ntseeg (Hmong), demonstrating how these concepts are interlinked and difficult to separate.¹¹

This paper examines trust in vaccines in Laos among the Hmong, an ethnic group whose healing epistemologies are rooted in animism and who are also converting to Christianity in rapidly increasing numbers, while the majority of healthcare staff are from the lowland Buddhist majority. We explore how vaccination intersects with or contends with local notions of immunity and cosmologies of protection but argue that this is not the main factor influencing confidence in vaccines, as these epistemologies of healing are flexible and pragmatic in incorporating different approaches to curing illness. In order to understand the root causes, it is necessary to consider patterns of distrust associated with their history, and the embodied experiences of inequity enacted through Hmong peoples’ experiences with health services.

We then dissect the characterization of the Hmong by healthcare workers as “vaccine-resistant,” showing how this term is erroneous because it suggests an active and fixed opposition to vaccines. Instead, by addressing underlying issues rather than blaming and shifting responsibility, it would not be a big leap to arrive at “vaccine confidence.” The unique conditions of the pandemic and the drive to vaccinate an entire population brought many people into contact with the health sector for the first time, especially elderly people. For vaccination teams, this prompted the utilization of village, family, ethnic, and religious structures as part of a broader approach to building trust and increasing local ownership through community engagement and local governance. This also encouraged greater awareness of relational care, effective communication, and cultural sensitivity among health actors. Trust in vaccines is therefore not based on abstract concepts but is highly relational and so can be intentionally developed.

Methods and Field Sites

Data for this paper were collected both before and during the pandemic among Hmong communities and healthcare actors through a variety of methods that draw on the authors’ experiences of applied medical anthropology and public health. In 2017, a study on barriers and facilitators to immunization was conducted (by the third author) in four Hmong-majority villages in both rural and urban areas of Vientiane Province. Semistructured interviews in Hmong language were used to collect sociodemographic information, experiences, and perceptions of vaccination from families and caregivers, with the assistance of a Hmong university student who was already known and trusted within these communities. The study also incorporated insights from informal conversations with health workers who were based in Hmong communities. During 2020–22, the first, second and fourth authors were involved in designing and implementing CONNECT, an initiative aiming to build trust and local governance for essential healthcare and COVID-19 responses, including vaccination. Data were collected through interviews with government and WHO staff and community members, with observation and feedback shared through WhatsApp groups. In 2023, a study was conducted (by the first author) through interviews and focus group discussions with 106 people aged between sixteen and ninety-two in six majority Hmong ethnicity villages in Xieng Khuang Province in northern Laos who had recently been the target of COVID-19 vaccine efforts. Interviewees included villagers, village authorities, village health volunteers, ethnic and religious leaders, and health center and local government staff, with the aim of identifying the factors that influenced vaccine uptake and whether the intervention methods had impacted vaccine acceptance. Informal conversations with young Hmong Christians living in Vientiane Capital were also drawn on for this paper.

COVID-19, Vaccination, and Ethnicity in Laos

Laos suffered relatively few early impacts from COVID-19 – during the first year of the pandemic, there were fewer than forty cases and no deaths, although the effect of restrictions was felt through economic slowdown and disrupted access to essential health services. The COVID-19 vaccine rollout was at first very successful, with people eagerly awaiting the arrival of the first doses, which were highly publicized on social media with ceremonial handovers from donors.¹² Residents joined long queues in the blazing sun in April 2021, just before the second wave of COVID-19 began, posting proud photos of themselves posing with “I’ve been vaccinated” signs and giving the thumbs-up with needles in their arms. At least in urban Vientiane Capital, there was a strong sense of collective pride that Laos was instigating a faster vaccination program than many of its neighbors (most notably Thailand).¹³ This demand for vaccines increased after the second wave hit, and people began to become resentful over the frequent running out of doses, crowding at vaccination stations, and the fear of catching the disease while waiting. Many people did not return for a second dose, perhaps due to a perception that too much vaccine was bad for the body or general fatigue of hearing about COVID-19. The percentage of fully vaccinated people plateaued, and soon, Laos began to lag behind other ASEAN states in vaccination statistics. Considering the logistics of reaching the entire population of Laos and the lack of resources in the health sector, this was not surprising. The main burden of vaccination (both routine childhood vaccination and extra mass immunization campaigns such as COVID-19) in rural areas falls on health center staff. With many villagers unable or unwilling to bring their children to health centers, staff conducted immunization outreach in often hazardous conditions, only to find that residents had gone to the fields with their children, especially during rice planting season. Health centers are often understaffed and lack reliable cold storage for vaccines. Staff struggle with late or nonexistent salaries and are frequently reliant on only one motorbike to transport both themselves and vaccines to villages. COVID-19 vaccination also required them to reach new populations, especially elderly people who had little previous contact with health services and migrant workers.¹⁴

The faltering progress of vaccination also reflected preexisting patterns of poor trust in health services, especially among certain groups of people. Some of these issues were specific to COVID-19; stories circulated through social media, Thai television, and local gossip told of side effects and deaths from vaccination. People doubted the quality of vaccines that had been produced quickly, and among elderly people especially, fear that the vaccine would exacerbate underlying health conditions limited uptake. There was also suspicion over a previous clause in the consent form that stipulated that the government bore no responsibility for any adverse effects of the vaccine.¹⁵ In fact, many health and local government staff lacked confidence about the safety of vaccination and so were unable to explain the benefits or gave explanations like “this will introduce the virus into your body,” which added to people’s fear. Poor communication and ineffective methods of disseminating information also contributed to a lack of trust; villagers described how they sometimes received conflicting information about the timing of doses from different health staff, causing them to believe neither.

However, beyond the specific circumstances of the pandemic, the vaccination rates followed a common pattern. While by June 2022, Vientiane Capital had over 90 percent of the population fully vaccinated against COVID-19, other areas were as low as 50 percent, especially difficult-to-access mountainous areas that are home to peoples like the Hmong. Despite the complex nature of ethnicity in Laos, all those who are not described as lao loum (lowland Lao, encapsulating a range of Lao-Tai groups) are termed ethnic minorities. The Hmong are a Sino-Tibetan group, part of the Hmong-Mien ethnolinguistic family who originated from southern China and started to settle in Laos in the nineteenth century; there are now an estimated half a million people who identify as Hmong living in Laos, amounting to 9 percent of the total population. Their patrilineal clan system is still of great social importance, especially through the unsettled years after their involvement in the “Secret War” between the United States and the Vietnamese and Lao communist forces that led to the establishment of the Lao People’s Democratic Republic (Lao PDR) in 1976.¹⁶

In Laos the Hmong are often still referred to as lao soung (highland dwellers) and have typically practiced shifting agriculture, cultivation of domestic animals, hunting and foraging, and growing opium poppies as a cash crop. Through migration and resettlement, the Hmong now live throughout Laos, including a large population in the capital, Vientiane, and the southern lowlands – as well as overseas, mainly in the United States and France. Although in many places, their lifestyles are not notably different from their Lao Buddhist neighbors, pervasive stereotypes of “otherness” persist, such as patriarchal family structures, including polygamy, unwillingness to assimilate, and resistance to state power.¹⁷ Hmong women still have lower levels of education and Lao language proficiency compared to other groups, as well as the highest number of adolescent pregnancies. Hmong children have one of the lowest vaccination rates in Laos – in 2017, less than 30 percent of those aged up to three years old were fully vaccinated¹⁸ compared to almost 60 percent of lowland Lao children of the same age.¹⁹ Given this context, it is not surprising that health staff claimed that they were unable to reach or convince many Hmong people to receive the COVID-19 vaccines. Healthcare staff commonly lamented that “Hmong are difficult,” “Hmong don’t listen to us,” or even that they were frightened of violent reprisals if they pressured them to be vaccinated.

Faith in Immunity: Healing Epistemologies and Religion

From a religious perspective, the Hmong can be described as animist, with a complex system of spirit beliefs and ancestor worship. Traditionally, they recognize that illness can be a result of external natural forces such as accidents and infectious diseases, heredity, metaphysical imbalance, weather, stress, and reckless behavior. Hostile spirits, ancestors, spells, violations of taboos, and souls wandering from the body are also associated with ill health.²⁰ Hmong herbal medicine made from wild and cultivated plants is popular both among Hmong people and other ethnic groups and is sold in markets.²¹ Shamans play a central role in village life and decision-making, and houses have an altar for protection from spirits. Rituals, including animal sacrifice, are widely utilized for spiritual illness and as techniques to strengthen and protect the person from invasive forces as part of a broader cosmology. It is notable that these traditions have remained an influential part of Hmong immigrant communities’ lifestyle and approaches to health outside of Asia, such as in the United States.²²

To what extent does vaccination conflict with Hmong epistemologies of healing? None of the people interviewed either before or during COVID-19 mentioned this as a factor influencing attitudes toward vaccines. However, a Hmong student living in Vientiane Capital commented, “Hmong believe in superstition, even not going to a hospital or using services like vaccination. They believe that our great grandparents’ spirits will protect us, so we don’t need to.” This sentiment was echoed by many health staff in explaining the low vaccination rate in Hmong communities both in Laos and among first- or second-generation Hmong Americans. In 2019, during a resurgence of the measles outbreak in Laos, approximately 90 percent of cases recorded were among children in Hmong communities. This was attributed to the low level of vaccination coverage, difficulties in accessing vaccination, lack of knowledge about vaccination, socioeconomic inequalities, and “linguistic and cultural barriers.”²³ In the same area, a study on antibodies of various vaccine-preventable diseases noted a significantly “lower seroprotection in those who follow animism, as compared to Buddhism,” meaning that childhood vaccination was lower among animist groups such as the Hmong.²⁴ Measles outbreaks have also commonly been recorded among Hmong communities in the US,²⁵ as well as other conflicts between Hmong immigrant families and biomedical healthcare.²⁶ Key to these explanations is the claim that “cultural barriers” prevent the acceptance of biomedical interventions such as vaccination by Hmong families.

This assumption is problematic on several levels. First, it may cause important structural issues and inequities to be overlooked, as discussed later. Second, it assumes that culture is fixed and unchanging. It is important to remember that healing epistemologies tend to be flexible and pragmatic and can also incorporate biomedical explanations or render them meaningful. Even if some illnesses are understood to have spiritual causes with spiritual cures, others are categorized as organic diseases requiring a different type of intervention, such as in the case of malarial fevers in southern Laos, which are classified symptomatically and treated with herbal medicines.²⁷ This point is demonstrated in the behavior of the Akha, a Tibeto-Burman group also living in the northern highlands of Laos. The Akha are known for their complex pantheon of ritual healing practices and rules for childbirth and postpartum practices in which babies are considered especially vulnerable to the spiritual dangers of the outside, thus making contact with vaccinators more challenging. However, anthropologists have argued that this belief in spirits does not necessarily pose a barrier to the use of modern medicines, as the Akha prefer to utilize as wide a combination of different methods as possible, especially when in doubt as to the cause of illness.²⁸ Indeed, while the correlation of health-seeking behavior with ideas about causation is often overexaggerated,²⁹ the Akha have been convinced by the improvement they have observed in children’s health since the arrival of vaccines.

Therefore, to what extent does religion really influence the use of vaccines in Laos, especially among non-ethnic Lao communities? While animist practices among highland ethnic groups are usually described in opposition to modern medicine, there has been surprisingly little attention paid to the role of other and newer religions, such as evangelical Christianity. The Catholic Church was established during the colonial period in the mid-nineteenth century, and older churches are found across Laos, but Protestantism is relatively recent, with the advent of evangelism after the new constitution in 1991, which proclaims religious freedom.³⁰ Two denominations (the Lao Evangelical Church and the Seventh Day Adventist Church) are officially recognized by the state, with others operating covertly. Proselytizing by foreign nationals is officially prohibited, but this policy is not always enforced when the practice is combined with humanitarian aid. Conversion rates are especially high among the Hmong; while there is little data available from Laos, in neighboring Vietnam, more than a third of the million Hmong citizens have become Protestant.³¹

Health staff in areas with high conversion rates highlighted a link between Christianity and vaccine refusal. For example, in rural Savannakhet Province, one health worker recalled that only a sixth of the approximately 6,000 Christians in the area had received the COVID-19 vaccine. Even among urban, educated families, this was explained as a factor against vaccine acceptance. One twenty-five-year-old Lao woman from Vientiane said, “My younger sister became Christian. She’s always pushing me and saying, ‘No need to get the booster, somebody got it and died,’ but I don’t know what evidence she has.” Some denominations were said to be more difficult to convince than others; a female Hmong ethnicity doctor in Vientiane Province described how only those who go to church on Saturday “absolutely do not want to hear about vaccination and say that vaccines give disease. Parents say that if vaccination was mandatory to go to school, they would disallow their children from going to school.” These “Saturday people” most likely belong to the Seventh Day Adventist Church established in Laos in 1973, which in 2010 was recorded as having around 1,000 members in Laos but has since likely increased substantially.³² Although there is apparently no doctrinal opposition to vaccines by the Church, whose leaders have released statements supporting COVID-19 vaccination,³³ it does advocate for the sanctity and purity of the body, such as a strict kosher/vegetarian diet and the avoidance of intoxicants and premarital sex. According to health staff, this extended to a rejection of “chemical” medicines in some cases. One health center nurse described how when she went to the church to administer vaccinations, people reacted angrily and refused medical treatment for their sick children, telling health staff they would pray instead.

Whether or not the church directly prohibits vaccination, it is clear that religious leaders have a big impact on people’s choices. According to one Lao male health official from Vientiane:

They [religious leaders] have the power to speak to the community and are respected. In Huaphan there was one case where the Christian leader told people not to get vaccinated and even not to use other health services, so they don’t go to the health center.

However, conversations with village leaders in Xieng Khuang Province showed that this was by no means a universal situation, especially in religiously mixed villages. One fifty-six-year-old Hmong male village leader commented, “There are four Christian families in our village, but they have good solidarity and got vaccinated.” Other villagers pointed to the contrast in lifestyle between Christian and animist Hmong, who “are vegetarian and don’t follow our traditions,” as the reason why they were harder to reach out to and, therefore, perhaps did not receive information about vaccination. Indeed, none of the Christians interviewed made any link between religion and vaccination, which suggests this might be an externally imposed perception.

It is also important to reflect on whether “belief” really has any ontological weight independent of practice. These newer religious epistemologies might appear to be diametrically opposed to the Hmong belief in multiple souls, and especially the Adventist prohibition on blood products in contradiction to the ritual sacrifices that are required by the spirits. However, just as Buddhism in Laos has incorporated many preexisting animist practices, it is likely that the absorption of monotheistic beliefs into the existing spiritual landscape is cumulative, flexible, and circumstantial.³⁴ Indeed, it is common practice for Hmong teenage boys to temporarily adopt Buddhist practices in order to be ordained as novices for the purpose of receiving monastic education and learning English. A thirty-five-year-old Hmong woman living in Vientiane described how her actions did not always appear to be congruent with her self-identification as Christian:

Right now, for Hmong people, sometimes we believe in ghosts, believe in Jesus, believe in Buddha also. Even if we believe something different from our grandparents, we cannot say, and if they pass away, we have to make sacrifices for them.

Like many others, she emphasized how actions were strongly predicated by family, ethnic, and religious power structures, including whether to vaccinate, above the notion of belief.

The Body Politic and Embodied Inequities

The question whether religion directly influences vaccine use among the Hmong is a deeper and arguably more important issue – the embodied experience of othering underlying both identities. While Christianity is tolerated in Laos, it is not encouraged. Accusations of persecution, such as evictions and imprisonment, especially in rural areas, are regularly made by international religious groups and media, although there is little independent reporting to support these.³⁵ In Vietnam, Christian conversion has been described as a way of connecting to the global Hmong diaspora and an expression of resistance,³⁶ as well as a perceived alternative path to progress instead of the state-led development agenda.³⁷ It is notable that some areas in Laos such as Xaysomboun Province with low vaccination rates and outbreaks of diseases like measles are also home to rebel Hmong factions. Indeed, some health educators had suggested that vaccine refusal was a political statement and a deliberate strategy of some of their supporters to “exaggerate rumors to stir up disobedience,” making health workers reluctant to go there.³⁸

While there is probably some truth behind this accusation, and the circulation of rumors about deaths from COVID-19 vaccination was cited as a major reason why many people were unwilling to receive it themselves, this statement also demonstrates a tendency to shift responsibility to the Hmong for their low vaccination rates. Through interviews and group discussions with Hmong villagers in Xieng Khuang and Vientiane Provinces, a more nuanced story emerged of ongoing inequity within their interactions with health services, much of which revolved around pregnancy, childbirth, and children’s health, including vaccination. Women described their struggles with communication and the experience of feeling that their needs and concerns were ignored, leading to low trust in the health system. In one group discussion in Xieng Khuang Province, the following stories were shared by women:

It was rice planting season, and my son was sick. I came from far away in the rice fields to bring him to the health center, but the doctor was angry with me; she asked me why I didn’t come in the morning. And then they didn’t have any medicines. Another time, I went there and the staff ignored me, even though I knocked on the door and went to their house, so I had to return home.

Hmong mother, aged twenty-nine

I went into labor and went to the health center, but they told me they didn’t have [the] equipment, and I had to go to the provincial hospital to give birth, but it was too late. If we forget our family book [meaning they cannot use health insurance], they give us expensive medicines that we have to pay for. But if we bring the book, they just tell us there are no medicines.

Hmong mother, aged twenty-four

Others felt that some Lao staff members discriminated against Hmong people; one woman from another village commented, “Some Lao staff don’t pay attention to Hmong children, even after we brought them many times; also, when they check the body of pregnant women they share personal details with others. Their behavior is not appropriate for sick people.”

Stories like this are not unique to the Hmong; across all sectors of Lao society people regularly complain about the attitudes of health staff. Lack of emphasis on counseling skills and relationship-building in medical education combined with poor working conditions and salary lead to low motivation to fully engage with service users.³⁹ However, the experiences shared by Hmong families in relation to vaccines were markedly more negative, especially for “SIA” (supplementary immunization activities) for diseases such as measles or COVID-19 when vaccinators tried to reach a large number of people at once, often with little or no explanation or choice given. One thirty-eight-year-old Hmong woman from a village in Vientiane Province described her difficult experience with child vaccination:

The health staff should tell us about vaccination and let us decide whether we want our children to be vaccinated or not. Not just come and inject our children without any information. We sometimes think that they bring chemicals to kill our children, so we are scared.

A forty-one-year-old Hmong man in Vientiane Province described how some of the fears of vaccines started:

My aunt’s lovely little daughter had a high temperature after vaccination, and one night later did not stop crying and felt ill. My aunt took her to the hospital again in the morning, and the nurses examined her. They said there were measles in her body and used some medicines to inject her. She died after a few minutes.

As shown here, there was also confusion over whether the cause of death was due to a vaccine or another injection. There is no specific vocabulary to designate vaccination in the Hmong language. The term txhuaj nkaug refers to both “vaccination” and “injection,” or more generally just txhuaj (medicine) is used. The absence of communication and information from the health staff in such situations aggravates the situation, along with the impression that there is little value given to Hmong lives. For example, one Hmong grandmother in her seventies from Vientiane Province said:

My sister-in-law had a fever, so my son took her to the hospital nearby. The doctor used some medicines to inject her, and then they came back home, and she died after an hour. But the doctor did not care about the death (they said, do not worry; people die). So, since that day until now, we [have been] afraid of vaccines and all kinds of medicines.

Many stories were told of health staff who were not held accountable; the man who described how his aunt’s “lovely little daughter” had died after vaccination further complained about the lack of empathy and responsibility that the family encountered:

The nurses said nothing [and] took no responsibility for the death. No care – the nurses just noted the name of the dead person in the registry book. For Hmong people like us, we cannot say anything. Even when we have an idea, or we need to change something, they do not follow what we have said.

Another young mother (aged twenty-two, Hmong) from Vientiane Province complained about physical and emotional pain experienced during encounters with vaccinators:

I have seen the nurses; they used their strong arms, and so when they inject the children, it hurts them, and they cry. Then, the nurses scold the children and ask why they are crying. And, after the vaccination, the children’s arms are inflamed, and [they] have blisters where they were injected. We need them to change their habits and be kind to us Hmong people.

Therefore, vaccine refusal can also be understood as an expression of resistance, reflecting the tension between a marginalized population and those in power. Indeed, while all interactions with health staff have the potential to be traumatic, especially experiences around childbirth, vaccination is notable in that it can be viewed as an act of harm against people who are not sick. As Nancy Scheper-Hughes and Margaret Lock propose in the notion of the “body politic,” the body is also a site of social and political control,⁴⁰ and therefore physical and emotional pain associated with vaccination may also be understood as the embodied experience of structural violence. In the case of the Hmong people, negative experiences with the health system also reflect sociopolitical structures that perpetuate inequity in their daily lives. From a health systems perspective, the consequential fear or unwillingness to receive vaccination or use other services then leads to a higher burden of disease and preventable deaths among mothers and children, continuing the cycle of embodied inequities.

Building Gradients of Trust: the CONNECT Approach and Relational Care

As shown in these stories, a fundamental issue influencing the interactions between the people providing and receiving vaccines, especially in Hmong communities, was the lack of trust on both sides. One person conceptualized this mistrust as a long-term, intergenerational issue: “Trust runs through generations – if parents don’t trust, their children won’t get vaccinated.” While religious factors are certainly influential, these are not an origin of mistrust but rather emplaced within the broader sociopolitical context and power structures; indeed, shared mistrust can also shape and bond social groups.⁴¹ Furthermore, as argued earlier, healing epistemologies are flexible and allow for adaptation to new categories and methods. This is an important point because focusing on the explanation of “cultural barriers” absolves the system of responsibility and does not allow for agency on either side.

Trust in the health system is a difficult concept to define – but a significant part of this is constructed within interactions between the healthcare provider, the person receiving care, and their family and social networks, especially in Laos, where relationships and reputation are paramount.⁴² In the case of mass vaccination campaigns like COVID-19, there is also a clear link with trust in the state, especially as government officials may be involved in these interactions. When asked about the most important thing to be aware of when speaking to Hmong people about vaccination, this aspect was widely emphasized. A representative from the Lao Women’s Union in Xieng Khuang stated, “You must be sincere and honest always; only one lie can break trust forever.” A community engagement specialist from Vientiane likewise commented, “Based on my experience working with Hmong, if they trust you, they’ll do whatever. But if they don’t trust you, it’s impossible.” However, trust is not an all-or-nothing ideological conviction; it is a gradient, relational, and can be increased or decreased through intentional actions, as demonstrated in the following story.

In early 2021, before the second wave of COVID-19, we initiated ethnographic community engagement field research conducted by master’s students from the Lao Tropical and Public Health Institute in rural Bokeo Province in northern Laos, which showed how much the lack of trust influenced health service use.⁴³ From this, the Community Engagement Network for Essential Healthcare and COVID-19 responses through Trust (CONNECT) Initiative was created through a collaborative and iterative process by WHO and the Lao PDR Ministries of Health and Home Affairs. Using COVID-19 as “an opportunity,” it aimed to utilize the temporary window of attention and funding given to healthcare to address deeper issues within primary healthcare, as well as assisting with COVID-19 preparedness and responses. Targeting actors at multiple levels, it aimed to develop stronger local governance for health through empowering local government to support community-led actions. Using a “grounded theory” approach toward developing a health intervention in which hypotheses and subsequent actions were founded on long on-the-ground experience and research in Laos, it also drew on ethnographic, participatory action and decolonizing research methodologies in its development.

Key to this approach is a series of participatory workshops that bring together village authorities, community members, health staff, and local government officials to explore and listen to the experiences, perspectives, and capacities of each and then develop a concrete action plan based on the mutually agreed priorities in the symbol of an Orange Tree (fig. 1). All actions are centered around the principle of relationship- and trust-building; key principles include the concept of a “positive approach,” which refers both to the atmosphere and facilitation style in managing points of sensitivity or possible conflict and also to the focus on identifying existing resources and capacities and past successes rather than “lack,” as is common in development projects. Second, the concepts of “good questions” and “listening to feelings” are promoted by facilitators who are encouraged to be open-minded and curious and practice active listening in order to learn and build relationships. Activities such as community mapping help to facilitate and emphasize these principles as the participants together learn about community priorities and resources, such as transportation to health facilities and the support needs of the most vulnerable members like pregnant women, the elderly, and migrants. The workshops also focus on practical learning – taking part in exercises that generate deeper reflection rather than verbal explanations – and on inclusivity and reducing the power differential, especially through awareness of gender, ethnicity, and hierarchies. Stories of successful outcomes have included more women giving birth in facilities and better support for quarantined families; a visual example of this was a sign that appeared on gates asking for “love and support” rather than stigmatizing families with the virus (fig. 2). People using services described how they felt more respected and better treated by health staff after the workshops.⁴⁴

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CONNECT workshop activity with community members and health staff, May 2021

Citation: Asian Medicine 19, 1 (2024) ; 10.1163/15734218-12341548

Photo by Elizabeth Elliott

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Sign on the gate of the house of a family in quarantine due to COVID-19 infection. It reads, “Give love and support to affected families”

Citation: Asian Medicine 19, 1 (2024) ; 10.1163/15734218-12341548

Source: Ounkham Souksavanh

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The success of the CONNECT approach then led the government to use it to address the faltering levels of COVID-19 vaccine uptake in a movement termed Talumbon, which can be translated as channeling attention and resources to an urgent issue. This incorporated planning workshops with local government and vaccination outreach, followed by daily remote supportive supervision using an online dashboard to measure statistics. In Xieng Khuang Province, the need was judged especially urgent as the National Games were to be held there in December 2022, along with a number of other events, such as Hmong New Year, which would bring together large numbers of potentially unvaccinated people. Along with a general campaign across the province, twenty-five villages were identified as being “difficult” by local authorities and requiring support from the CONNECT team – almost all had a majority Hmong population and included some Christian families. During the Talumbon outreach, the number of people in these twenty-five villages who received the vaccine for the first time increased by almost seven times compared to previous visits.⁴⁵,⁴⁶

What caused this significant change? Improved planning and coordination, involvement of village authorities, and support from local government all clearly had impacts, but this does not explain why people who had refused vaccination in the past would agree this time without being coerced. In particular, elderly people, as well as people with disabilities or other groups who were less visible or less able to access health services, made up a large proportion of those who were vaccinated for the first time. In answering this question, the vaccination team emphasized the importance of really listening to people’s perspectives and providing positive motivation to build confidence (fig. 3):

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Health worker speaking with an elderly woman about vaccination, Khammouane Province, February 2023

Citation: Asian Medicine 19, 1 (2024) ; 10.1163/15734218-12341548

Source: WHO/Enric Catala

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You have to listen to their opinions first and understand what matters to each person in their life to really touch their feelings and convince them to slowly change their mind. You can ask them, “Do you want to save your life, to stay longer for your family?”

CONNECT team member, female, aged thirty-eight, Vientiane Capital

This was backed up by stories shared by villagers; a sixty-eight-year-old woman in a wheelchair described her experiences when a team member visited her at home in her village in Xieng Khuang Province:

I saw on Facebook that people like me with chronic diseases might get really sick after vaccination, so I was very frightened. I haven’t been able to walk for five years, so I couldn’t go to the health center, but even when they came to my house, I still didn’t want to be vaccinated. The thing that changed my mind was talking one-on-one with her; she explained to me that even if I have a chronic disease, I can still get vaccinated. She waited with me to see if I was OK after the vaccine and called me two days later to ask how I was feeling. She’s so kind, like my daughter-in-law! My neighbor was also scared to get vaccinated, but I told her that I was fine and encouraged her to get it too.

Likewise, spending time with people, taking their concerns seriously, and building trust through taking responsibility and accountability for possible adverse effects were the factors that made a difference in the majority of cases. One team member shared this story:

We met one elderly man who told us that he was too old to use a vaccine that could be for somebody younger, but the real reason was that he felt scared because he believed one of his grandchildren had been harmed by vaccination. We sat with him and listened, and the village chief said to him, “It depends on you; it’s your choice. The reason why we are here is so that you can protect your health, not to force you.” Still, he was not convinced, so we went back with some of his friends from the village who had already been vaccinated, and they shared their experiences. He also wanted to check the vaccine bottle himself and asked for a letter from the district health office saying that they would take responsibility for helping him if he suffered any bad effects in the first week after receiving the vaccine. All of these things gave him confidence in us, and finally, he was happy to be vaccinated. We learned that it’s very important for the health staff, village, and local authorities to be honest and straightforward, show their care for people, respect their opinions, and provide confidence that they can call on them if they have any problems.

CONNECT team member, female, aged thirty-eight, Vientiane Capital

This story and many other similar ones contrast with the negative experiences of vaccination shared earlier by Hmong families. Fundamentally, the increase can be attributed not to a change in how people perceive vaccines or in cultural attitudes but to how the encounters and power hierarchy between government staff and community members played out. When each side was able to engage with and negotiate with the other on a more equitable level, there was a shift away from top-down and one-way habitual patterns of interaction between health implementers and Hmong people. Indeed, the political attention given to COVID-19 vaccines created an opportunity to demonstrate the effectiveness of relational care and good communication. Government staff commented on how this impacted how they understood the reality of community health issues:

I learned that we have to have good questions [and] not always be the person who has answers. We go to the community as a learner, not a teller, such as walking through the village and talking with people or eating together, so our relationship starts getting better. Sometimes, we may imagine one thing, but when we go there, we learn about the real picture.

Provincial health staff, female, aged thirty-four, Xieng Khuang

Others explained how the workshops had changed their perspective from the blame-driven and directive method they were used to:

These methods, like participatory observation and positive thinking, have opened up a new world for me. It’s completely different from anything we have done before; in the past, we just used one-way communication. It has helped me overcome some barriers and develop my skills so I can apply these in the future to help people express their ideas.

CONNECT team member, female, aged thirty-eight, Vientiane Capital

Roleplay and drama methods helped in the exploration of the best methods for encouraging elderly people to receive vaccination, as well as to develop empathy with the dilemmas they faced, such as in the story of “Mr. Joy,” in which his elderly parents refuse to get vaccinated because of their worries about underlying health conditions and the news aired on Thai TV, a staple in elderly people’s lives in Laos. As one workshop participant commented:

In the story of Mr. Joy, we thought about how we could help him and his family. We realized that we have to work as a team and [that] each of us has a role, but also that we share similar problems.

Lao Front representative, male, aged sixty-three, Vientiane Capital

Elderly people in Laos are also usually closely associated with religious networks. In Hmong communities, the clan leaders (singsao) are responsible for conducting rituals and have a strong influence on the actions of their clan members. One of the primary reasons cited for the success of the Talumbon was the inclusion of clan leaders in the vaccination outreach. One clan leader from Xieng Khuang, a seventy-year-old man, said:

People in my clan must do what I say because I am their leader, but I will also try to help them if they need to coordinate their work or if they are fighting. When the vaccinators came, I went with them to help explain. Thirty families in my clan agreed to be vaccinated, and five were not at home, but nobody refused.

Health staff also found it useful to invite elders and religious leaders to attend workshops.

The Taloumbon district meetings invited religious leaders – not necessarily the village authorities but the elders whom people respect. These people have a lot of power to speak, so we try to get all of them to get involved to work together.

Provincial health staff, male, aged forty-four, Xieng Khuang Province

Religion was also significant in selecting the location of outreach. In Laos it is common for Buddhist temples to be used as vaccination sites, as they are usually built in an accessible and central location, in the open air with a level floor, which makes it easy for the vaccination team to set up and receive people. Churches, although less often used for this purpose, turned out to be useful for reaching people during service times. A CONNECT team member told the following story of her experience in Xieng Khuang Province (see also fig. 4):

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Church leader in Xieng Khuang Province who encouraged his community to be vaccinated

Citation: Asian Medicine 19, 1 (2024) ; 10.1163/15734218-12341548

Photo by Elizabeth Elliott

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In one village, the health center staff told us it had been very difficult to reach people in the past. Since most families in this village were Christian, we went there on a Sunday when they were all at church. We talked with the church leader to explain the benefits of vaccination and about the events that are happening in the province. He took a minute to think, then decided it was a good idea and talked to his members. We also asked the deputy provincial health officer to advocate to them – he’s Hmong, so he could talk to them in their own language, which is important for understanding and trust. Finally, all church members got vaccinated except one. The health center head was so impressed with this approach and said they would use it in future. In my observation, the church leaders aren’t against vaccination, but the issue has been [about] wrong information and poor communication.

CONNECT team member, female, aged thirty-eight, Vientiane Capital

While vaccination has provided the means for implementing and gaining political support for these approaches, hopefully, the impact will continue far beyond the pandemic and will become a more lasting change in how people engage with each other through the medium of health services. For example, in Xaysomboun Province, the team shared how one Hmong Christian woman with a significant village role was at first reluctant to take part in the CONNECT workshop but then changed her mind after participating and then requested to learn about some of the activities.

When I talked with her afterward, she said, “I will share what I have learned and try to advocate to the church members to get vaccinated. I’m sure if I can convince them, they will go.” A few weeks later, I talked to her and the pastor of the church. They will collect the names of target adults who have not been vaccinated, as well as the children under five [for routine vaccination] and pregnant women who need care.

CONNECT team member, female, aged thirty-eight, Vientiane Capital

As has been shown elsewhere, engaging with religious leaders repositions the assumption of their ideological opposition toward conceiving them as equal partners in a multisectoral approach to vaccination.⁴⁷ A provincial health official in Xieng Khuang described how church leaders had positively impacted vaccination rates among Christians in the past year by improving advocacy methods, such as inviting people to meet after church services for information sessions. Rather than dwelling on culture as a barrier, the CONNECT method encourages health actors to reimagine their approach by looking for the potential in each unique situation and understanding specific concerns and influences. This can lead to surprisingly rapid changes toward greater health equity, which will hopefully continue to be sustained. While it may not tackle all the deeper inequities embedded within Lao society, this is at least a step toward creating a more compassionate health system and a greater shared sense of ownership among those who are usually excluded.

Conclusion

In Laos, the outbreak of COVID-19 has both highlighted old issues like poor trust in the health system and brought new challenges like the goal to vaccinate an entire population, including elderly people in remote areas. While it is often assumed that local healing epistemologies present a barrier to vaccination, in practice, these are usually flexible and pragmatic. Religion is, however, an important factor in understanding how vaccination is perceived and experienced – not as a factor influencing choice but rather as one bound up with political identities and social worlds. Among the Hmong, taking part in animist and, to a greater extent, evangelical Christian practices positions the practitioners apart from lowland state power structures, which are reflected and accentuated through differing lifestyles and struggles with communication. This othering is reflected within the embodied inequities experienced by the Hmong through, at times, traumatic interactions with the state health sector, leading to mistrust in vaccines. “Vaccine resistance,” therefore, has less to do with subjective attitudes toward vaccines themselves but is rather what people may feel to be their only possible expression of agency by establishing boundaries against the further encroachment of state influence into their lives and bodies.

However, when approached from a different angle, awareness of religious influences and structures can be an important part of more effective and compassionate approaches to vaccination, especially for the elderly. Involving religious leaders and community networks, listening to local perspectives, taking concerns seriously and being accountable, and finding the best language to communicate have been proven to significantly alter how much vaccines are accepted in Laos. Empowering both sides with the possibility of changing how they interact and making informed and positive choices is an important step in changing longer-term dysfunctional patterns. These kinds of shifts show that trust in vaccines is not based on abstract concepts but is highly relational and so can be intentionally developed by addressing some of the underlying issues that influence how people interact with and perceive the state health sector.