How We Feel: COVID-19 Pandemic Experiences among Intergenerational Cambodian, Laotian and Vietnamese Americans in San Francisco

Background: The COVID-19 pandemic has exacerbated many social determinants of health and barriers to health care for Southeast Asian Americans. Objective: The objective of this study is to understand the impact of the COVID-19 pandemic on Southeast Asian American communities’ health care utilization and need for support. Methods: This cross-sectional, multiple methodology study administered surveys and conducted focus groups with 78 participants (≥14 years) across generations and Cambodian, Laotian, and Vietnamese ethnicity in partnership with the Southeast Asian Development Center in San Francisco, California between July and September 2021. Results: We identified two themes in health care utilization: 1) language and technology barriers were magnified during the pandemic, while telehealth options increased access options; 2) fear of anti-Asian violence deterred participants from public outings and activities; two themes in the role of community and community centers: 1) intergenerational support facilitated health care access; 2) community centers provided crucial social services; two themes in COVID-19 prevention: COVID-19 safety precautions contributed to interpersonal conflict and financial stress and 2) lack of linguistically accessible COVID-19 information and services posed challenges to COVID-19 testing and vaccination. Conclusions: Despite the challenges posed by the duality of the COVID-19 pandemic and fear of anti-Asian violence, Southeast Asian Americans persisted with resilience to seek health services with intergenerational support and the guidance of community centers. This highlights the need for further expansion of culturally relevant, linguistically accessible, and trauma-informed health interventions and enhanced support for community-based organizations in advancing health for these underserved populations.


METHODS
The study utilized a mixed research methodology to investigate community experiences and perceptions towards health care utilization and the impact that fear of anti-Asian violence had on health-seeking behaviors during the COVID-19 pandemic between July and September 2021.

Study design/setting
The study was conducted in the San Francisco Bay Area, a region with a total population of more than 7.7 million people, of which approximately 27% are Asian American. 21n March 2020, the Bay Area was the first major metropolitan area in the US to enact public health orders against the spread of COVID-19 and has maintained a relatively low record of COVID-19 cases throughout the pandemic compared to other metropolitan areas. 22,23e collaborated with the Southeast Asian Development Center, a nonprofit community organization that serves Cambodian, Laotian, and Vietnamese communities in San Francisco Bay Area.Southeast Asian Development Center provides a variety of services, including youth programs, workforce development services, translation services, and basic needs resource navigation.Community leaders of each generational group and ethnicity identified potential participants for the study.We recruited 78 participants based on their age (14 years or older) and selfidentification as Cambodian, Laotian, or Vietnamese.The participants were grouped into focus group cohorts by generational status (first-generation, born elsewhere, and immigrated to the US after childhood, or secondgeneration, born and/or lived primarily in the US since childhood) and by ethnicity (Cambodian, Laotian, or Vietnamese). 24Participants were offered a gift card as an incentive for study participation.Each participant was limited to participating in one focus group to ensure fair distribution of limited participation incentives to all interested participants.
The study was granted approval by the Stanford University Institutional Review Board (May 12, 2021, #60712).Informed consent was obtained from all

POPULAR SCIENTIFIC SUMMARY
• First-generation participants across ethnicities (Cambodian, Laotian, and Vietnamese) faced similar barriers to health care access and utilization, such as language and technology barriers, compared to differences between ethnic groups.• During the COVID-19 pandemic, anti-Asian violence and discrimination facilitated fear and anxiety that deterred the behavior and activities of first-generation Southeast Asian Americans.• Community-based organizations, such as community and cultural centers, provide vital services and support to the Southeast Asian American community by advocating for community needs, providing valuable resources and language support, and disseminating essential information to community members.
Davis Chhoa et al.
Southeast Asian American COVID-19 experiences individual participants included in the study, and written informed consent was obtained from parents or guardians of participants who were under 18 years of age.

Survey data collection and analysis
The objectives of the surveys were to obtain descriptive data to characterize study participants and to collect quantitative data about participants' experiences of healthcare access and utilization.Participants completed an anonymous survey in English or in Khmer (Cambodian), Laotian, or Vietnamese with the assistance of a translator.The survey questions were adapted from standardized questionnaires and other published studies and were tested and revised for clarity before administration. 25,26The survey included questions about participant demographics, health care utilization, and access to COVID-19 testing and vaccination in the last 12 months prior to survey participation (Tables 1 and 2).

Focus group data collection and analysis
The objectives of the semi-structured focus groups were to collect qualitative data on participants' perspectives and experiences on how the COVID-19 pandemic affected their health care access and utilization and the impact that fear of anti-Asian violence had on health-seeking behaviors.The focus groups were conducted in-person or remotely via Zoom based on the pandemic health restrictions, interpretation needs, and preferences of participants, and lasted 30-90 min each.The first-generation focus groups were conducted in-person to offer language interpretation to limited English proficient participants, to address limited technology skills, and to facilitate participant comfort in a familiar community space.The second-generation focus groups were conducted remotely via Zoom to provide increased flexibility and convenience to participants with school, work, or childcare responsibilities.Six firstgeneration focus groups were conducted in-person at community spaces, while nine of the second-generation focus groups were conducted remotely (Table 3).The first-generation focus groups were co-facilitated by the lead author of the research study and a community leader from each ethnic community who were fluent in English and Khmer, Lao, or Vietnamese, respectively.The community leader in each first-generation focus group offered live interpretation of focus group questions and responses between the first author (DC) and participants at the in-person focus groups.The second-generation focus groups were facilitated virtually by the first author (DC) of the research study without interpretation as all second-generation participants were fluent in English.
The focus groups were audio recorded, transcribed, and checked for quality and completeness.The codebook utilized for qualitative analysis was developed using both deductive and inductive approaches based on the data and an adapted health services framework and was iteratively refined until the team agreed on the final codebook (Figure 1). 27,28Themes were then mapped and interpreted.The coding software, Dedoose, was used to organize and facilitate the qualitative analysis process.
First-generation participants ranged in age from 35 to 82 years (mean age 63.8 years, SD 11.1 years) (Table 1).The median ages of first-generation participants from each ethnic group were 67 years (Cambodian), 68 years (Laotian), and 61 years (Vietnamese).The average number of years since immigration to the US was 22.9 years (SD 14.6 years).All first-generation participants spoke their origin country's language as their primary language and only 28% of first-generation participants had a self-reported 'well' or 'very well' English proficiency.Sixty-two per cent of first-generation participants rated their current health status as fair or worse (28% poor, 34% fair) (Table 2).Eighty-two per cent of first-generation participants had been tested for COVID-19 at least once, and among those, 21% had tested positive for COVID-19.Ninetyeight per cent had received at least one COVID-19 vaccine.
Second-generation participants ranged in age from 14 to 50 years (mean age 25.3 years, SD 12.5 years) (Table 1).The median ages of second-generation participants from each ethnic group were 22 years (Cambodian), 40.5 years (Laotian), and 15.5 years (Vietnamese).Among second-generation participants, 61% were born in the United States.Fifty-five per cent of second-generation participants speak English as their primary language and 87% report 'well' or 'very well' English proficiency.Ten per cent of second-generation participants rated their current health status as fair or worse (    When asked about barriers to accessing health care, firstgeneration participants overwhelmingly described difficulties with language access and technology barriers (Table 4).While many first-generation participants expressed that remote or staff interpreters were generally available when accessing medical services, the quality and convenience of language access varied throughout the health care process and by clinic and native language spoken.Participants who - 1st generation Vietnamese participant 'Sometimes the translator is not there, so it's different from in-person, especially for people who don't read or write, so they really prefer an in-person translator.
Online [translators], some of them are good.But some of them because we are the Lao ethnicity, sometimes they get someone from another ethnic group from Laos that can speak other dialects.It doesn't make sense and they have to stop right there.People from Laos, there's many different ethnic groups.The problem is that they ask for someone who speaks Lao, but they don't know that there are different dialects.They just get someone from Laos and then they speak different dialects, so then they have to cancel [the appointment] because ethnic language differences'.
- 1st generation Lao participant 'I also saw like issues in terms of like language barriers and stuff when I was trying to book appointments for like my dad who like needed like mental health services.There were no providers who spoke Cambodian so finding him resources was difficult'.
- 2nd generation Cambodian participant One, the language barrier and two, I don't know how to use the iPhone to access appointments for the doctor or social services.When I ask my children, they seem to be busy or not available, so I have to go around and look for social services, but many of the social services don't have Lao-speaking staff or interpreters, and many places are closed.We rely on Lao Seri Association for support.We ask Lao Seri to help us with translation, and if they are not available, then we ask our children for help.It's up to seniors to ask for the services'.
- 1 st generation Lao participant 'I noticed for my parents like I help them make some of their appointments.
[At] the beginning of the pandemic they were not able to go to the doctors often they should have and, like my dad is diabetic so he has like a specialized doctor and yeah they were were scared of if they went to the doctor's office that they would like to have more interaction, or like those are like places where they like our higher chances of catching COVID so they definitely didn't want to go, then, and then like they don't know how to use Telehealth so that wasn't really an option for them.Now, I think, as soon as doctors have like limited capacity there.They're still kind of not able to see their doctors as often but it's more frequent than before'.
- 2nd generation Cambodian participant Theme 2: Community centers provided critical social services to first-generation participants 'I want to thank you for the opportunity to have this space to reflect on the pandemic and health and the Lao community.I've actually been less engaged in a lot of community in this past 17 months.We usually do a cultural festival in collaboration with a Southeast Asian group here in the city, but we had to do virtual this past year and we canceled this year because of the new delta variant'.
- 2nd generation Lao participant 'We use the temple as a mental health and stress-reducing place.The monks can speak Lao, Thai, and Cambodian, so we believe it and can do medications.It helps us maintain our physical health.When physical health gets better, the mental health gets better too.The spirituality is important for healing too.In the past, they could invite the monks to do a blessing ceremony at the temple or home, but during COVID-19, they could not do it.We tried going to the temple and the temple limited people and closed like everywhere else People got stuck for a long time.Only recently have they opened again for limited number of people and people need to be vaccinated.Information that we have for the community, the temple is the best place to share information with people.The monks there can speak our language and they have traditional techniques to talk to people, and people tend to sit down and listen, meditation, so that's also supportive of their well-being'.
- It's still very dangerous, but I felt more reassured [after their recoveries.]When I was able to get the vaccine, I felt a lot better and felt a lot more protected.Now, when I learned that there's the delta variant, I realized that it's still not that safe, so we need to take precautions like wearing masks and other things'.

Continued
Davis Chhoa et al.
Southeast Asian American COVID-19 experiences spoke Khmer or Lao observed long wait times for an available interpreter at clinics compared to Vietnamesespeaking participants.First-generation participants highlighted the differences between speaking and being literate in their native language and perceived barriers in completing health care forms or understanding written communications about their health care.Most firstgeneration participants relied on their families, friends, or community centers for language assistance if interpretation or translation services were unavailable.Many first-generation participants shared frustrations with the technological skills needed to obtain health care and highlighted the need for tech literacy to utilize patient portals or check-in kiosks in clinics.First-generation participants faced further technology barriers to accessing health services during the COVID-19 pandemic when most ambulatory and elective medical care abruptly shifted to remote, telehealth services.Some participants relied on family members to help them participate in telehealth visits, while other participants deferred their health care until clinic appointments were available again.Even if participants were able to access telehealth visits, some participants preferred clinic visits to be able to be physically examined and decreased their trust in health care providers on telehealth visits.
Second-generation participants shared challenges of navigating health insurance and transportation barriers.Many participants' lack of knowledge about health insurance processes and the logistical burden of navigating health insurance plans created barriers to utilizing health services.Among participants who were uninsured, some described hesitancy to seek medical care due to fear of exorbitant medical bills.In addition, participants highlighted the unreliability of public transportation and financial burden of transportation deterring them from seeking medical care.Some suggested their preference for telehealth visits if available to overcome transportation barriers.

Theme 2: Fear of anti-Asian violence deterred participants from public outings and activities.
Across ethnicities and generations, participants highlighted the impact that fear and anxiety about anti-Asian violence has had on their daily lives and healthseeking behaviors (Table 4).Participants mentioned several incidents of physical assault towards community members they personally knew.Both first-generation and second-generation participants expressed that fear of anti-Asian violence occurring to themselves or their families has created a sense of 'hyper-awareness' when going out in public.First-generation participants mentioned that they would alter plans to go out earlier during the day or when a family member could accompany them or would employ strategies to avoid being identified as Asian.In contrast, second-generation participants were unlikely to change medical appointments or plans deemed necessary but maintained vigilance when out in public.Second-generation participants expressed greater concern about older community members being victims of anti-Asian violence than their own personal safety.

Domain 2: The Role of Community and Community Centers Theme 1: Intergenerational support facilitated health care access prior to and during the COVID-19 pandemic
Intergenerational community was an underlying theme that spanned multiple topics and was discussed by both first-and second-generation participants (Table 4).Firstgeneration participants heavily relied on younger family members for language interpretation and help with - 1st generation Vietnamese participant 'I am depressed and under stress because my family stays together during shelter-in-place and we're overcrowded, so that makes us more depressed.Along with financial problems and worrying about everything to be safe because of all of the changes.We have to buy more supplies.I have to negotiate and balance family relationships.We have to come together for discussions and we're more depressed and under stressed.Even getting things back to normal is difficult because of the COVID pandemic.We're afraid of the virus'.- 1st generation Lao participant 'I think it was just a blessing in a weird way because I was working multiple part time jobs before the pandemic, so I didn't have a lot of time with family.So in terms of the pandemic itself, it was a concern in the beginning, worrying about getting sick.But luckily, we stayed COVID free as a family and we were able to get out everyday for a few hours after they were distant learning and explore San Francisco and do new activities to keep busy.It was a positive in that respect but it was scary because nobody wanted to get sick, so we were always wearing masks and trying to avoid crowds'.- 2nd generation Lao participant Theme 2: The lack of linguistically accessible COVID-19 information and services posed challenges to COVID-19 testing and vaccination 'It's been convenient for me because my daughter takes me.My daughter makes the appointment and drives me through the drive-thru.A lot of seniors have someone escort them to get tested or vaccinated because they are afraid because they don't speak the language.[blinded organization names] assist people to vaccine sites and COVID tests'.- 1st generation Lao participant 'I just wanted to add that I do like that for getting tested and everything was easy like I was able to like ship it to myself, instead of going out somewhere.But I felt like it was easy for myself, but for my parents I don't think they would have been able to figure out how to get a vaccine and like schedule like sign up.If I didn't do it for them, I don't know if they would have been able to so I feel like that was like a good thing for myself that everything was online, but for them, I don't know if they would have been able to do things by themselves'.- 2nd generation Cambodian participant Davis Chhoa et al.
Southeast Asian American COVID-19 experiences during the first phase of the COVID-19 pandemic (March 2020 to July 2021), we found deleterious effects of the pandemic on health care utilization.Our findings highlighted participants of the same generational status faced similar barriers to health care access and utilization compared to differences based on ethnicity (e.g.firstgeneration participants across ethnicities faced similar barriers and second-generation participants across ethnicities faced similar barriers).Furthermore, the fear of anti-Asian violence overshadowed and shaped the experiences of many participants.However, intergenerational support ameliorated the experiences of first-generation participants and community centers were vital to supporting the community during a tumultuous time.The experiences of Southeast Asian Americans need to be uplifted and recognized to improve the health outcomes of a historically overshadowed community.Generational differences in cultural, linguistic, and technological factors need to be considered when serving Southeast Asian Americans.The findings from the study are crucial to advancing health equity among Southeast Asian Americans and can be mapped to the Center for Disease Control and Prevention's framework for '10 Essential Public Health Services' (Figure 2). 29hroughout the pandemic, the fear of anti-Asian violence permeated every aspect of life for many community members.The majority of first-generation Southeast Asian Americans resettled in the US as immigrants and refugees from genocide, war, persecution, and poor living conditions in Southeast Asian homelands and refugee camps. 24The heightened atmosphere of anti-Asian violence and xenophobia may resurface experiences of trauma and violence that the firstgeneration participants previously fled, intensifying fear of anti-Asian violence against themselves and their families.Many participants highlighted how their general fear of COVID-19 illness was further compounded by fear of anti-Asian violence leading them to limit public outings and to practice hypervigilance in public settings.This fear and anxiety contributed another barrier to accessing medical resources and prevented many from carrying out necessary day-to-day activities including exercise, running errands, and using public transportation.Given the history of war and trauma experienced by Southeast Asian Americans, further harm and distress to community members must be prevented by advocating for resources to promote community safety and healing, such as expanded access to mental health services and trauma-informed care. 30he expansion of culturally relevant mental health resources will allow community members to process trauma and minimize the perpetuation of intergenerational trauma onto younger generations. 31As carriers of past trauma, it is likely that the Southeast Asian American community may continue to be affected by the fear of anti-Asian violence, even after the COVID-19 pandemic era.As the United States moves forward from the COVID-19 pandemic, the public health infrastructure needs further assessment and to 'investigate, diagnose, and address health hazards and root causes' such as impacts of racism and discrimination on mental health outcomes. 29he majority of Cambodian, Laotian, and Vietnamese Americans fled war-torn homelands in the late twentieth century and resettled across the United States.Southeast Asian Americans have some of the lowest median household incomes and education attainment rates compared to other Asian American subgroups. 32At the beginning of the pandemic, there were large reductions in non-emergent health services as well as racial or ethnic and income disparities between users of in-person care and telemedicine when many health systems reduced services.The reduction and shift to telehealth during the pandemic limited health care access to those who could navigate telehealth visits, which typically required stable internet connection, English proficiency, and technology literacy, and often excluded many first-generation participants.While COVID-19 services such as testing and vaccination were eventually available in their communities, similar barriers posed to utilizing non-COVID-19 health services such as language and technology were still hindering Southeast Asian Americans from accessing the services without support.Telehealth options helped many participants access health services during the pandemic, but exacerbated barriers for others without the language or technological skills needed to utilize telehealth services. 33hile technology can be imperative to addressing health disparities, technology must be intentionally developed to serve the needs of vulnerable communities.Without the support of second-generation family members and community centers, many first-generation participants would not have been able to utilize telehealth services, leading to health care access delays and worse health status.
Culturally relevant and linguistically accessible health services need to be prioritized throughout the entire process of health care utilization, especially during emergent times, to ensure that the most vulnerable populations can access quality health care.In terms of language access, all first-generation participants identified a language other than English as their primary language and had limited English proficiency.While studies examining disparities in health access among Asian Americans during the pandemic are limited, a federally qualified health center in Oakland, California, found that 49% of the 1,297 Asian American participants surveyed indicated that they could not find a place to get tested during the summer of 2020. 25One year later, partnerships with community-based organizations in the San Francisco Bay Area have made COVID-19 testing services more readily accessible for underserved communities, including linguistic access. 34Participants reported differences in the availability and quality of language interpretation services among Khmer, Lao, and Vietnamese language needs.Among the first-generation participants, Khmer and Laospeaking participants were less likely to be able to read their native language script compared to Vietnamese participants, limiting the effectiveness of translated written language.The varied language access experiences of our first-generation participants highlight the need for expanded language access in non-medical settings and throughout the process of health care utilization (e.g.medical documents, patient portals), as well as more reliable, quality access to language interpretation in medical settings consistent with Title VI of the Civil Rights Act. 35Without ensuring culturally relevant and linguistically accessible services, limited English proficient patients will be hindered from receiving quality care.In order to expand assurance of health equity, language and technology barriers need to be considered to 'expand equitable access' to health services. 29sian Americans are not a monolith and cannot be considered an aggregate.Therefore, community programs and interventions need to be tailored to the needs of each community.This suggests the value of community and community-oriented health among Southeast Asian Americans and the potential of pursuing community-led health interventions in advancing health for Southeast Asian Americans.Despite the uncertainty of the pandemic, fear of anti-Asian violence, and exacerbated barriers to health care access, many participants strived to maintain their health and continued to utilize health services as much as possible.There was a strong, reciprocal relationship of care and concern between generations regarding each generation's health and safety, reflective of the interdependent, communityoriented values shared by many Southeast Asian Americans.Community and cultural centers have been and continue to be vital for providing basic resources and information to community members, especially for many first-generation community members.For many of these community members and their families, community centers provide key services, such as language interpretation, resource navigation, and the sharing of essential information, and intricately understand the needs of the communities they serve.The continued support and expansion of community-based organizations through increased funding and institutional support are pivotal to improving the health of underserved Southeast Asian American communities.In the process of advancing health equity, policy development must 'strengthen, support, and mobilize communities and partnerships' such as community-based organizations and the key roles they play in their communities. 29ur study revealed the lived experiences of Cambodian, Laotian, and Vietnamese participants and showcased on-going challenges that need to the addressed to improve health care access and ultimately health outcomes for these communities.While the COVID-19 pandemic certainly exacerbated longstanding

Theme 1 :
Language and technology barriers were magnified during the pandemic for first-generation participants, while telehealth options increased access options for second-generation participants

Table 3 . Focus group cohorts.
Figure 1.Adapted conceptual framework of Asian American immigrant health utilization during COVID-19 pandemic.

Table 4 . Themes and representative quotes. Domain 1: Utilization of Medical Services During COVID-19 Pandemic Theme 1: Language and technology barriers were magnified during the pandemic for first-generation participants, while telehealth options increased access options for second-generation participants
'I have to try my best and try to understand the information or read by myself.If it's something that I don't understand, I have to ask friends or other people around me to help translate.I can read a little bit of English, so I can try.However, for other people who don't read, speak, or write English at all, so there is no way at all for them to access those services.Government agencies do typically have Vietnamese interpretation options, but other services outside of government services doesn't have the same guarantee'.

Theme 2: Fear of anti-Asian violence deterred participants from public outings and activities
'One thing I feel is that I want to exercise, but I'm worried that someone will push me and cause me to hit my head on the ground, so I'm afraid to do so.During this time, my eyes have also been worsening … and It's been difficult to go back and forth to the doctors.I want to go exercise here and there, but my kids tell me 'Mom, don't go!Be careful because they might push you and break your skull open!' I've been very worried'.- 1st generation Cambodian participant 'I never dare to go out by myself, I always have to ask someone to go out with me.When I go out, I try to hide everything by wearing sunglasses, masks, and a huge hat and cover everything so that they don't recognize that I am Asian when I take the bus or am walking on the street.If my phone rings, I don't dare to pick it up because I'm afraid of people hearing when I talk and know that I am speaking an Asian language and am Asian'.- 1st generation Vietnamese participant 'I don't think I was like scared for myself, I was more scared of like the Asian Americans and like my community and like my family members, and so, if, like my mom would like want to walk in the neighborhood alone like I would get scared.yeah I wasn't really like worried about myself, I was just more worried about like the people my community and my family members'.

The Role of Community and Community Centers Theme 1: Intergenerational support facilitated health care access prior to and during the COVID-19 pandemic
'It has been very difficult for my situation.
1st generation Lao participant 'It depends on the need, what type of services is needed and what information I need to access different services.Usually, I come to the community center to get information and from there, if I need to get tested, they tell me where I should go, or if I need to go to the doctor, they help me make an appointment, or if I need to apply for something.It depends on the need, but usually help comes from the community center'.
- 1st generation Vietnamese participantDomain 3: COVID-19 PreventionTheme 1: COVID-19 safety precautions, such as shelter-in-place and personal protective equipment (PPE) policies, contributed to interpersonal conflict and financial stress among participants 'At first, I had the same feeling as what everyone else just shared.I was very scared when going out.I wasn't sure if people would have COVID and spread it to me, so I have been very scared.Later, some of my friends were COVID-positive, and they were able to recover after staying home.That made me feel a bit better.