COVID-19 Vaccine Decision-making Factors in Racial and Ethnic Minority Communities in Los Angeles, California

Key Points

Question  What factors do members of multiethnic communities at high risk for COVID-19 infection and morbidity in Los Angeles County, California, cite as influencing vaccine decision-making and acceptability?

Findings  In this qualitative study, 70 participants from racial and ethnic minority communities in Los Angeles County described a complex vaccination decision-making process influenced by misinformation and politicization, deep apprehension related to historical inequity and mistreatment, access barriers related to social disadvantage, and a need for community engagement and trusted messengers.

Meaning  This study suggests that COVID-19 vaccine equity will require multifaceted policies and programming that respect community concerns and the need for informed deliberation, invest in community-based engagement, improve accessibility and transparency of information, and reduce structural barriers in vaccination.

Importance  The COVID-19 pandemic has had disproportionate effects on racial and ethnic minority communities, where preexisting clinical and social conditions amplify health and social disparities. Many of these communities report lower vaccine confidence and lower receipt of the COVID-19 vaccine. Understanding factors that influence the multifaceted decision-making process for vaccine uptake is critical for narrowing COVID-19–related disparities.

Objective  To examine factors that members of multiethnic communities at high risk for COVID-19 infection and morbidity report as contributing to vaccine decision-making.

Design, Setting, and Participants  This qualitative study used community-engaged methods to conduct virtual focus groups from November 16, 2020, to January 28, 2021, with Los Angeles County residents. Potential participants were recruited through email, video, and telephone outreach to community partner networks. Focus groups were stratified by self-identified race and ethnicity as well as age. Transcripts were analyzed using reflexive thematic analysis.

Main Outcomes and Measures  Themes were categorized by contextual, individual, and vaccine-specific influences using the World Health Organization’s Vaccine Hesitancy Matrix categories.

Results  A total of 13 focus groups were conducted with 70 participants (50 [71.4%] female) who self-identified as American Indian (n = 17 [24.3%]), Black/African American (n = 17 [24.3%]), Filipino/Filipina (n = 11 [15.7%]), Latino/Latina (n = 15 [21.4%]), or Pacific Islander (n = 10 [14.3%]). A total of 39 participants (55.7%) were residents from high-poverty zip codes, and 34 (48.6%) were essential workers. The resulting themes included policy implications for equitable vaccine distribution: contextual influences (unclear and unreliable information, concern for inequitable access or differential treatment, references to mistrust from unethical research studies, accessibility and accommodation barriers, eligibility uncertainty, and fears of politicization or pharmaceutical industry influence); social and group influences (inadequate exposure to trusted messengers or information, altruistic motivations, medical mistrust, and desire for autonomy); and vaccination-specific influences (need for vaccine evidence by subpopulation, misconceptions on vaccine development, allocation ambiguity, vaccination safety preferences, the importance of perceiving vaccine equity, burden of vaccine scheduling, cost uncertainty, and desire for practitioner recommendation).

Conclusions and Relevance  In this qualitative study, participants reported a number of factors that affected their vaccine decision-making, including concern for inequitable vaccine access. Participants endorsed policy recommendations and strategies to promote vaccine confidence. These results suggest that support of informed deliberation and attainment of vaccine equity will require multifaceted, multilevel policy approaches that improve COVID-19 vaccine knowledge, enhance trust, and address the complex interplay of sociocultural and structural barriers to vaccination.

Increasing COVID-19 vaccine uptake is essential to reducing COVID-19 disparities, but it requires understanding the process and needs within vaccine decision-making. Vaccine decision-making, including deliberation, describes weighing the pros and cons of vaccine efficacy and safety and is a normal, appropriate response to any new treatment or intervention.¹ In the US, racial and ethnic minority communities have the highest risk of COVID-19 morbidity and mortality yet report lower vaccine confidence and lower receipt of the COVID-19 vaccine.^2-5 Medical mistrust, rooted in historical and contemporary racism, has lowered vaccine confidence in racial and ethnic minority groups.^6-10 However, vaccine uptake is influenced by more than mistrust, including socioeconomic and health inequity.^1,8,9,11

Because vaccine acceptability is strongly associated with vaccine uptake, understanding factors that influence the multifaceted vaccine decision-making process is critical to narrowing COVID-19–related disparities in racial and ethnic minority communities. It is essential to consider the factors that influence COVID-19 vaccine acceptability and how the decision-making process may differ from other vaccines. These factors link to unique perceptions of disease risk and context, such as one’s emotional state and sociopolitical and environmental influences.^12,13 Therefore, aspects unique to the COVID-19 pandemic, including the ongoing sociopolitical contexts, mistrust, economic instability, and mental and health challenges, add to the complexity of the vaccine decision-making process.¹⁴ Given the multilevel nature of vaccine concerns, an inquiry into the commonalities between marginalized groups is required to tailor community engagement approaches.^14-18

This study explores barriers to and facilitators of COVID-19 vaccine readiness reported by members of disproportionately affected multiethnic communities in Los Angeles County (LAC), California. Exploration of factors in the decision-making process for COVID-19 vaccines can inform public health and policy initiatives for equitable vaccine distribution.

We used community-engaged qualitative methods to better understand factors that contribute to vaccine deliberation and acceptability in racial and ethnic minority groups at high risk for COVID-19 infection and morbidity in LAC. Los Angeles County is a uniquely fitting setting to address these questions—it is the most populous and 1 of the most diverse counties, has among the highest number of COVID-19 cases and deaths, and COVID-19–related morbidity and mortality disproportionately affect racial and ethnic minority individuals and high-poverty communities.¹⁹ The UCLA Institutional Review Board approved the study, and we obtained verbal informed consent from all participants. Although focus group facilitators, moderators, and participants used their personal names within the virtual focus groups, all personal identifiers (names and workplaces) were removed from transcripts by the professional transcription company before analysis. We report our findings using the Standards for Reporting Qualitative Research (SRQR) reporting guideline.^20,21 A critical and radical paradigm²² and community-partnered research methods guided this study. Local community partners and a community advisory board collaborated on study design, recruitment, interpretation, and dissemination.

Between November 16, 2020, and January 28, 2021, we conducted 2-hour virtual focus groups with LAC residents using Zoom.²³ We recruited individuals virtually through telephone, video conferencing, and email outreach to community partners and networks from communities that face a high risk of COVID-19 morbidity and mortality attributable to race and ethnicity, age, essential worker status, and residential area (median household income <$40 000, 2010 US Census).^19,24,25 Eligible participants self-identified as American Indian, Black/African American, Filipino/Filipina, Latino/Latina, or Pacific Islander. Focus groups were stratified by race and ethnicity as well as age (≥50 years, <50 years, or mixed age). Of 144 candidates screened, 6 were ineligible because of self-reported White race and ethnicity, and 13 were excluded because of insufficient numbers for a specific racial and ethnic focus group (ie, <3). We ordered and sequentially recruited from the remaining 125 eligible participants by race and ethnicity as well as age, prioritizing essential workers and residents of low-income zip codes. Of 81 invited to participate, 70 participated in 13 focus groups (4-6 per group).

A semistructured focus group guide was developed from previous qualitative vaccine acceptability studies^26-29 with input from community organizations. Question domains on COVID-19 vaccines included concerns, risks, benefits, information sources, trusted entities, barriers, and recommendations for improving access (Box). Participants were asked to contribute as both individuals and experts representing their families and communities.

Box Section Ref ID

We provided partner organizations with a study description to assist with recruitment. We also described how research outcomes might benefit their respective organizational missions, including strategic planning about COVID-19 education.

To enhance congruency between researchers and participants, in all but 1 focus group, either the moderator, trained as the facilitator, or a community partner, self-identified with the group participants’ race or ethnicity. Each group began by restating the study’s purpose and emphasizing the importance of community voices for understanding COVID-19 vaccine acceptability to shape public health policies. We facilitated an icebreaker where moderators and participants described their community and feelings on the pandemic. Two focus groups were conducted in Spanish, and the other 11 were conducted in English. Several research team members attended each focus group to ensure consistent use of the focus group guide and prompts, facilitate debriefing, and record field notes. Recordings were deidentified, translated, and transcribed by a professional transcription service. Each participant received a $100 gift card and completed an online demographic and attitudes survey.

We analyzed transcripts using a critical realist,³⁰ reflexive, 6-phase thematic analysis approach^31,32 in Atlas.Ti (ATLAS.ti Scientific Software Development GmbH). Two experienced coders (S.L.C. and L.N.M.) reviewed the transcripts and field notes to develop a preliminary codebook, then tested and amended the codebook’s initial practicality after the coding of 2 transcripts. The coders reached iterative consensus on the evolving codebook, code definitions, and coding approach and used memos to document thematic evolution throughout the analysis. Triangulation was achieved by reviewing the field notes, holding iterative discussions with all moderators and facilitators, and sharing preliminary results at community partnered meetings to validate perspectives.

We used the Vaccine Hesitancy Matrix (VHM), developed by the World Health Organization Strategic Advisory Group of Experts on Immunization Vaccine Hesitancy Working Group,^33,34 to categorize prominent themes shared commonly across all racial and ethnic groups and most focus groups. The VHM categorizes vaccine hesitancy determinants into contextual influences (historical, sociocultural, environmental, health system or institutional, and economic or political factors), individual and group influences (personal, social, and peer environment), and vaccine- or vaccination-specific issues (vaccine or vaccination factors).^13,34,35 Although various vaccine hesitancy definitions, determinants, measures, models, and terms exist,^36-39 including arguments for inclusion or exclusion of vaccine social determinants,⁴⁰ the VHM provides a multifaceted picture of vaccine acceptability. The VHM accounts for factors other than hesitancy and vaccine refusal, such as vaccination program design, allowing for systems-level⁴¹ perspectives in COVID-19 vaccine decision-making.

A total of 13 focus groups were conducted with 70 participants (50 [71.4%] female). We conducted 3 American Indian focus groups (n = 17), 3 Black/African American groups (n = 17 participants), 2 Filipino/Filipina groups (n = 11), 3 Latino/Latina groups (n = 15), and two Pacific Islander groups (n = 10). A total of 39 participants (55.7%) were residents from high-poverty zip codes, and 34 (48.6%) were essential workers. A total of 31 (44.3%) were employed full time, and 13 (10.0%) were unemployed and 8 (11.4%) retired. A total of 37 (52.9%) reported they were likely or very likely to receive the vaccine when available. Demographic characteristics and survey responses are given in Table 1 and eTables 1 and 2 in the Supplement.

Participants described influences in their vaccine decision-making process. We organized results using the VHM constructs, reporting themes, subthemes, and quotes in Table 2. The specificity and comprehensiveness of the VHM worked well to frame results by accounting for interrelated socioeconomic and contextual factors occurring during the COVID-19 pandemic. Notably, most of the resulting themes portray dimensions within potential vaccine inequity for each VHM category.

Participants described conflicting vaccine information in the news, social media, and from leaders, likely stemming from an absence of factual information, misinformation, and a scarcity of trusted messengers or sources. A Latino/Latina participant (focus group 12) explained, “These kinds of decisions should be informed decisions after getting information from authentic sources of information.”

Specific examples of unethical historical or contemporary research affecting one’s community negatively influenced trust in COVID-19 vaccine research. Consequentially, many expressed hesitation about being among the first to be vaccinated, and several expressed fears of experimentation. A Black/African American participant (focus group 5) described a “general unease,” which others endorsed because of previous unethical research, mistreatment, experimentation, or discrimination. Participants requested acknowledgment, empathy, and understanding of current and historical events that led to their communities’ mistrust.

All groups expressed deep concerns about potential inequity in vaccine management, distribution, access, and quality. Participants feared receiving differential treatment, projecting that well-resourced communities, White people, and the “rich and powerful” (Filipino/Filipina participant from focus group 1) would be the first to receive a vaccine and would receive higher-quality or better treatment during vaccination.

Several social determinants of health were identified as barriers to vaccine access (availability and quality of translation services as well as limited technology or internet access to register), vaccination accommodations (limited transportation, a lack of employment benefits, including paid time off for vaccination, or adverse effects), or vaccine eligibility (uninsured or undocumented). An American Indian participant (focus group 10) described a “logistical nightmare” to access transportation for vaccination.

Participants described political influences in vaccine development and pharmaceutical companies’ interests, motives, and profits. A Filipino/Filipina participant (focus group 9) described limited “trust in politics” as a barrier to vaccination.

Many felt compelled to consider receiving the vaccine to protect themselves or others but expressed uncertainty because of insufficient information, including a lack of opportunities to discuss vaccine concerns. Facing this dilemma, many wanted to wait. Participants desired notification and communication about the COVID-19 vaccine from their medical practitioners, local health centers, and community leaders. A Pacific Islander participant (focus group 2) explained, “There’s definitely some key leaders in each of our communities. Some of them may be faith leaders.”

Participants desired outreach strategies that promoted altruistic vaccination motivations, including how the vaccine may “protect us all” from infection to themselves or communities (Latino/Latina participant in focus group 8). Participants were optimistic about the potential of reducing stress as well as infection risks and desiring a return to social and cultural norms.

Some participants described medical mistrust, worried about overmedicalization, or referenced past medical experiences, including medical errors, mistreatment, and racism in health care. As such, participants requested sensitive, respectful, and equitable treatment during vaccination.

Some worried that vaccines would become mandatory and expressed a desire for autonomy “to be respected” around informed decision-making, particularly given the current uncertainties regarding themselves or their community’s safety (American Indian participant in focus group 4).

Many expressed a belief that the vaccine clinical trials primarily included healthy, young, and White participants. They wanted to see clinical trial demographic characteristics and evidence of the vaccine’s effectiveness and safety outcomes, requesting data representing the same racial and ethnic community, age group, and health conditions. A Black/African American participant (focus group 5) stated interest in “any data that’s connected with some of the conditions that are prevalent in our community.”

Because of the development of multiple vaccines, participants questioned whether they should wait for future iterations with improved safety and efficacy profiles. Participants questioned the rapid vaccine development process and whether the scientific or testing process had been rushed. A Black/African American participant (focus group 12) asked, “Is this like the rough draft?”

The allocation process seemed unclear, including notification and requirements, insurance coverage, or out-of-pocket costs. A Pacific Islander participant (focus group 2) stated that uncertainties are “tied to not having enough information.”

Preferences for vaccination location included familiar or local sites instead of a mass vaccination site with long lines or crowds that would increase COVID-19 exposure risk. Additional site concerns included a lack of accommodations for disabled, elderly, or immobile people. Others worried large sites would lack proper medical attention to monitor adverse effects with too much “room for error” (Latino/Latina participant in focus group 13). Although local, familiar sites were preferred, participants worried about vaccination infrastructure within underresourced communities (ie, a trusted site may lack suitable freezers for vaccine storage).

Participants emphasized the importance of equitable vaccine allocation in their communities but feared certain groups would be left behind, including “low-income, homeless,” bedridden, or incarcerated individuals (Latino/Latina participant in focus group 13).

Dual-dose vaccine schedules were seen as an additional burden for families or caregivers, those “having to take all the kids,” those with limited transportation access, or those with other mobility obstacles (American Indian participant in focus group 4).

Participants with underlying health conditions or concerns expressed a desire for a practitioner recommendation for vaccination. A Pacific Islander participant (focus group 7) explained, “I would first ask the doctor if I’m able to… I’ll trust him and go wherever he says.”

Participants offered and endorsed recommendations or strategies for improved vaccine confidence and accessibility (Table 3). Recommendations include using community engagement, improving empathetic bidirectional deliberation, ensuring timely access to critical information, promoting altruistic and culturally congruent messaging, increasing data transparency, translation, and data collection for diverse populations, and increasing accessibility through navigational and logistical vaccination support.

Because this was a community-partnered study, we developed COVID-19 vaccine information guides based on the most common questions and concerns described in this study and shared them with all participants. Preliminary results and vaccine-related information were shared with participants, community partners, public health officials, and policymakers through community presentations.

This qualitative study identified factors associated with COVID-19 vaccine decision-making across different racial and ethnic low-income communities in LAC. Themes included fear of differential vaccine treatment, mistrust from unethical research or mistreatment in medicine, inadequate vaccine evidence and information, inequitable allocation and accessibility, and inadequate community engagement efforts. To enhance acceptability and accessibility, disseminating critical information from trusted messengers about population-specific vaccine safety data and providing navigational support to address structural barriers were suggested by participants.

Consistent with prior COVID-19 vaccine acceptability qualitative research, we found information gaps, concerns about the vaccine’s rapid development, and an absence of scientific evidence translated for diverse communities.^11,42-45 Culturally centered care and practitioner recommendations may help promote vaccine acceptability, trust, and combat misinformation.^6,46,47 However, a previous study⁴⁷ found that racial and ethnic minority populations are less likely to receive practitioner recommendations for vaccinations. More recent evidence⁴⁸ suggests inadequate in-language education on COVID-19 information and prevention. Comprehensive messaging of crucial information, particularly about vaccine safety⁴⁹ and efficacy, is needed to make informed decisions and requires critical investment in trusted messengers, including physician recommendations.^1,14 In particular, our study expanded informational needs to include outcomes data relevant to minority communities, such as population-based participant data in vaccine clinical trials and, when available, effectiveness outcomes by age, race and ethnicity, or chronic disease. Addressing these needs will be particularly important for racial and ethnic minority groups who already face health disparities and fear COVID-19 vaccine adverse effects.

Participants voiced concerns about systemic inequality across the vaccine development and distribution continuum, from clinical trial participation to allocation to mistreatment during vaccination. A previous study⁵⁰ found historical discrimination influences mistrust of health care, including vaccine hesitancy. Furthermore, influences from systematic and institutional mistrust, including widespread uncertainty stemming from the pandemic and recent social justice movements, can create additional obstacles for vaccine uptake.^42,51-57 A lack of equity, transparency, or outreach to repair breaches in trust may further erode confidence in the COVID-19 vaccine and health care more broadly.

Because racial and ethnic minority communities are disproportionately affected by social factors that worsen COVID-19–related disparities,^9,43,58,59 it is critical to identify the societal conditions and harms that lead to these unique vaccination barriers.^8,9,11 Participants in our study highlighted the difference between equity and equality in vaccine distribution, often referencing concerns about personal, family, or community members who might have difficulty accessing the vaccine without additional attention to availability and cost of transportation, technology assistance, access to medical recommendations, time off from work, and more. Unfortunately, many of these misgivings were realized in the early phases of the vaccine distribution, which has been marred by allocation and uptake disparities, resulting in the underrepresentation of racial and ethnic minority individuals, low-income communities, and essential workers.⁶⁰

The recommendations from study participants to improve vaccine acceptability and accessibility in their communities can support building long-term trust in health care, the scientific process, and public-facing governmental and institutional systems. A multipronged approach to building vaccine acceptability in disenfranchised communities will require local, community-centered actions and activities that develop an understanding of hesitancy, build trust, promote deliberation, and translate findings to national initiatives and policy improvements. National funding initiatives, such as the National Institutes of Health Community Engagement Alliance and Rapid Acceleration of Diagnostics, have promoted community engagement to reduce COVID-19 disparities by developing and disseminating prevention strategies, including clinical trial participation and vaccine or therapeutic uptake.^61,62

This study has limitations. Its primary intent was to describe common needs and potential areas for intervention for COVID-19 vaccine rollout in high-risk communities in LAC; thus, we did not compare or quantify specific differences across racial and ethnic groups or by age. Future comparative research should examine differences among communities to elucidate how best to tailor interventions. Our findings may not be generalizable to other high-risk groups or geographic areas. Virtual participation requirements may have led to a selection bias against those with limited telephone or internet access, although we offered tablets and Wi-Fi access. This study started before vaccines received US Food and Drug Administration emergency use authorization and ended before vaccines became widely available.⁶³ During the study period, COVID-19 vaccine knowledge and awareness shifted. However, findings provide real-time insight into community knowledge, concerns, questions, hopes, and barriers related to the COVID-19 vaccines, potentially future vaccines, and therapies.

Understanding factors that influence the multifaceted decision-making process for vaccine uptake in vulnerable communities is critical for narrowing the racial and ethnic as well as socioeconomic disparities observed during the COVID-19 pandemic. Although this study highlights the continual unanswered need in the medical literature to determine the spectrum of mistrust and the interplay with health care decision-making,^64,65 members of these communities described wide-ranging structural barriers, disparate reasons for historical and contemporary trauma, and insufficient engagement for COVID-19 vaccine accessibility. Participants in this study identified interrelated factors that contribute to COVID-19 vaccine decision-making while emphasizing the importance of equitable access and the parallel need for community engagement in building long-term trust in health care, the scientific process, and public-facing governmental and institutional systems among historically and currently marginalized populations.

Accepted for Publication: July 23, 2021.

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.27582

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Carson SL et al. JAMA Network Open.

Corresponding Author: Savanna L. Carson, PhD, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon, Ste 1820, Los Angeles, CA 90095 (scarson@mednet.ucla.edu).

Author Contributions: Dr Carson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Carson, Casillas, Castellon-Lopez, Morris, Barron, Ntekume, Vassar, Norris, Dubinett, Garrison, Brown.

Acquisition, analysis, or interpretation of data: Carson, Casillas, Castellon-Lopez, Mansfield, Barron, Ntekume, Landovitz, Vassar, Garrison, Brown.

Drafting of the manuscript: Carson, Casillas, Castellon-Lopez, Mansfield, Morris, Ntekume, Vassar, Garrison, Brown.

Critical revision of the manuscript for important intellectual content: Carson, Casillas, Castellon-Lopez, Mansfield, Barron, Ntekume, Landovitz, Vassar, Norris, Dubinett, Garrison.

Statistical analysis: Carson, Mansfield.

Obtained funding: Carson, Vassar, Norris, Dubinett, Brown.

Administrative, technical, or material support: Carson, Casillas, Castellon-Lopez, Mansfield, Morris, Barron, Ntekume, Vassar, Garrison, Brown.

Supervision: Carson, Casillas, Landovitz, Vassar, Norris, Brown.

Conflict of Interest Disclosures: Drs Carson, Brown, Morris, Castellon, Casillas, and Garrison and Ms Vassar reported receiving grants from the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Science, and the UCLA Oversight COVID-19 Research Committee during the conduct of the study. Dr Ntekume reported receiving grants from the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Science, and the UCLA Oversight COVID-19 Research Committee during the conduct of the study. Dr Landovitz reported receiving grants from the National Institutes of Health during the conduct of the study and personal fees from Gilead Sciences, Merck Inc, Roche, and Janssen outside the submitted work. Dr Norris reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study and grants from National Center for Advancing Translational Science, National Institute on Aging, National Institute of Diabetes and Digestive and Kidney Diseases National Institute of General Medical Sciences, and National Institute on Minority Health and Health Disparities outside the submitted work. No other disclosures were reported.

Funding/Support: This research is supported by grant 21-312-0217571-66106L from CEAL/STOP COVID-19 CA, grant UL1TR001881 from the National Center for Advancing Translational Science, and grant OCRC 20-51 from UCLA.

Role of the Funder/Sponsor: The supporters of this study had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The study participants, our Community Advisory Board, the UCLA Community Consultants Panel, and our community partners supported recruitment or provided feedback on preliminary results. We thank the diverse communities we come from and are embedded within that shape, influence, and guide our research approach in culturally congruent ways.