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Balasuriya L, Santilli A, Morone J, et al. COVID-19 Vaccine Acceptance and Access Among Black and Latinx Communities. JAMA Netw Open. 2021;4(10):e2128575. doi:10.1001/jamanetworkopen.2021.28575
What factors are associated with facilitating and obstructing COVID-19 vaccine acceptance and access among Black and Latinx communities?
This qualitative study of 72 participants who identified as Black and/or Latinx identified 3 themes to understanding factors associated with facilitating or obstructing COVID-19 vaccination: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access.
These findings suggest that community-informed insights may inform health care strategies to maximize vaccine acceptance and access in communities hardest hit by the COVID-19 pandemic.
Black and Latinx communities have faced disproportionate harm from the COVID-19 pandemic. Increasing COVID-19 vaccine acceptance and access has the potential to mitigate mortality and morbidity from COVID-19 for all communities, including those most impacted by the pandemic.
To investigate and understand factors associated with facilitating and obstructing COVID-19 vaccine access and acceptance among Black and Latinx communities.
Design, Setting, and Participants
This community-partnered qualitative study conducted semistructured, in-depth focus groups with Black and Latinx participants from March 17 to March 29, 2021, using a secure video conferencing platform. Participants were recruited through emails from local community-based organizations, federally qualified health centers, social service agencies, the New Haven, Connecticut, Health Department, and in-person distribution of study information from community health workers. A total of 8 focus groups were conducted, including 4 in Spanish and 4 in English, with 72 participants from a diverse range of community roles, including teachers, custodial service workers, and health care employees, in New Haven, Connecticut. Data were analyzed from March 17 to July 30, 2021.
Main Outcomes and Measures
Interviews were audio-recorded, transcribed, translated, and analyzed using an inductive content analysis approach. Themes and subthemes were identified on the acceptability and accessibility of the COVID-19 vaccine among participants who identified as Black and/or Latinx.
Among 72 participants, 36 (50%) identified as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx and 56 (78%) identified as women and 16 (22%) identified as men. Participants described 3 major themes that may represent facilitators and barriers to COVID-19 vaccinations: pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access.
Conclusions and Relevance
The findings of this qualitative study may impact what health care systems, public health officials, policy makers, health care practitioners, and community leaders can do to facilitate equitable uptake of the COVID-19 vaccine. Community-informed insights are imperative to facilitating COVID-19 vaccine access and acceptance among communities hardest hit by the pandemic. Preventing the further widening of inequities and addressing structural barriers to vaccination access are vital to protecting all communities, especially Black and Latinx individuals who have experienced disproportionate death and loss from COVID-19.
More than 99% of deaths from COVID-19 are now among unvaccinated individuals.1,2 Black and Latinx communities experience 2-fold the rate of death due to COVID-19 compared with their White counterparts, and factors rooted in structural racism continue to impede equal access to health for all.3,4 Striking racial and ethnic disparities also exist in COVID-19 vaccination rates and vaccine access.5-7 As of July 2021 in the US, among individuals who have received 1 dose of the vaccine, 58.9% were White, 16.1% Hispanic, and 9.3% were Black, which lags behind national racial and ethnic representation.8
Data continue to show lower vaccination coverage in Black and Latinx communities, even as the supply of COVID-19 vaccines outpaces demand.8-12 Additionally, COVID-19 cases continue to increase as variants surge and vaccination rates stagnate, making it imperative to understand barriers to vaccine acceptance and access.8
While summary statistics and aggregated process data are ubiquitously available, these data merely reflect challenges without providing deeper community-informed insights into the drivers associated with vaccination disparities and the approaches necessary to overcome such obstacles. Additionally, studies have shown that attitudes and perceptions regarding COVID-19 vaccines are variable. Thus, it is imperative to understand community perspectives reflective of the current state of affairs in which 3 COVID-19 vaccines exist. Accordingly, our study aims to investigate and understand what factors are associated with facilitating and obstructing COVID-19 vaccine acceptance and access among Black and Latinx communities to directly inform strategies to improve vaccination rates.
The Yale Institutional Review Board deemed this study exempt from approval because participation would not put the participant at risk if responses were shared outside the research, per institutional policy. Informed consent was obtained prior to each focus group. This study is reported following the Consolidated Criteria for Reporting Qualitative Research (COREQ) reporting guideline.
We conducted a community-partnered qualitative study with participants from Black and Latinx communities in New Haven, Connecticut, as part of a Centers for Disease Control and Prevention Racial and Ethnic Approaches to Community Health grant. This grant was provided to the Community Alliance for Research and Engagement (CARE) to address disparities in COVID-19 vaccinations. We partnered with 3 key community organizations and stakeholders, including CARE, the New Haven Health Department, and Cornell Scott Hill Health Center (a federally qualified health center). Through weekly online meetings from February to April 2021, representatives from each group aided in adapting the interview guide, creating a codebook, participant recruitment, and interpretation of findings. The interview guide (Box), coding, and thematic analysis were also informed by the World Health Organization (WHO) Measuring Behavioral and Social Drivers of Vaccination Increasing Vaccination model.13 The interview guide was pilot tested and adapted by our community partners to ensure questions were informed by the community and asked in plain language.
What are your thoughts and feelings about the COVID-19 vaccine?
If you got a call today that someone was offering the vaccine, what would you think about getting it or not getting it?
What, if anything, has been helpful in learning more about the vaccine?
Where do you get trusted information from in your community?
What, if any, challenges do you, your family, or people you know face in getting the COVID-19 vaccine?
Is there anything else you would like to add that we might not have asked you about?
We held 8 semistructured in-depth focus groups (4 in Spanish and 4 in English) over a secure video conferencing platform (Zoom; Zoom Video Communications) between March 17 and March 29, 2021. At that time in New Haven, individuals older than 44 years were eligible for vaccination. To remove technological barriers, participants were able to join by video or phone. Focus groups consisted of 3 to 12 participants and lasted 60 to 90 minutes, and participants were compensated with $30 gift cards. Informed consent was obtained before each focus group, and participants were aware of the study goals.
Focus groups were used because they are a valuable tool for gathering information on attitudes and beliefs about behaviors.14 Interactions between participants were also a valuable way to generate data on understanding behaviors, particularly where sociocultural factors may influence health behaviors.14 Given the timeliness of the COVID-19 pandemic and our project being embedded within a community vaccination effort, focus groups afforded us the ability to collect a higher quantity and breadth of response on an accelerated timeline necessary to inform community vaccination efforts.
Groups were conducted in English (by L.B., J.A., A.N., and B.M.) and Spanish (by L.B., A.M., C.F.-A., and G.V.), audiotaped, and professionally transcribed in their respective languages. Owing to technical challenges, 1 group was not audiotaped; this interview was analyzed from contemporaneous notes, but it was not used for direct quotes. Spanish focus groups were professionally translated to English. Meetings occurred with the study team and community partners 1 to 2 times a week to review the data and ensure that thematic saturation was reached prior to concluding focus groups. Thematic saturation was defined as when a thorough understanding of participants’ perspectives were represented, and no new themes were subsequently found.15
Participants were recruited through emails from local community-based organizations, federally qualified health centers, social service agencies, the New Haven Health Department, and through in-person distribution of study information by CARE community health workers. Eligible participants were current New Haven residents identifying as Black and/or Latinx. Those who did not meet this criteria were unable to participate. A convenience sampling was used.
First, a preliminary codebook was made a priori based on the WHO Measuring Behavioral and Social Drivers of Vaccination Increasing Vaccination model by a psychiatrist (L.B.) a nurse scientist (J.M.), a vaccination outreach research assistant (J.A.), a social worker and researcher (A.S.), and a community health worker (C.F.-A.). This codebook was adapted and informed by our community partners as coding progressed. Coding and analyses were performed using inductive content analysis, in which essential concepts from interview data were iteratively coded and compared to extract themes.16 Three of us (L.B., J.M., and J.A.) independently performed line-by-line inductive coding to identify initial codes using the online software Dedoose, then collectively analyzed codes, grouping similar codes into subthemes and then larger themes.16 The final list of subthemes and themes were agreed on by majority consensus among authors (L.B., A.S., J.M., and J.A.). To ensure the themes and subthemes accurately represented the data and the community’s experience, triangulation was used, in which the we discussed and examined final themes with community partners.17
A total of 79 participants agreed to take part in the study, of whom 7 did not attend and were categorized as nonparticipants. Our final study sample was 72 participants, with 36 (50%) identifying as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx; 56 participants (78%) identified as women and 16 (22%) identified as men (Table 1). Participants were largely from 3 age categories: 50 to 64 years (34 participants [47%]), 30 to 49 years (24 participants [33%]), and 18 to 29 years (13 participants [18%]). Employment backgrounds reflected the diversity of the New Haven community, including teachers, custodial service workers, and health care workers. Vaccination status of participants is noted in Table 1.
Identified themes centered around trust and addressing barriers to vaccine access. They were categorized into 3 key themes: (1) pervasive mistreatment of Black and Latinx communities and associated distrust; (2) informing trust via trusted messengers and messages, choice, social support, and diversity; and (3) addressing structural barriers to vaccination access. Table 2 lists illustrative quotes representative of these major themes and subthemes.
Participants shared that the lingering legacy from historical mistreatment, in addition to present-day mistreatment, contributed to distrust and impacted acceptance of the COVID-19 vaccine. Disparate death rates from COVID-19 and other medical conditions, as well as ongoing experiences of their voice being “thrown away” and ignored, impacted COVID-19 vaccine acceptance.
The lasting legacy from historical mistreatment and the concern for potential reoccurrence were cited as factors influencing vaccination. A participant shared that events, such as the Tuskegee syphilis study, fostered concern for recurrent mistreatment related to COVID-19 vaccines. They remarked, “The Tuskegee experiment information in your head…that actually pulled a certain group of Black Americans and did this to them…are they setting certain vials away…to give when a Black person sits down?”
Participants shared experiences of unequal death from the medical system that contributed to fears of interacting with the health care system and getting vaccinated. One participant shared, “People die from childbirth, regular colds…they’re just ignored…so, I feel that’s a huge part of moving with getting this vaccine.” Another participant expressed that vaccine concerns were related to the disparate death rates from COVID-19 in African American communities. “Knowing a lot of disparities that are with African Americans in health and seeing just the different reactions that people have with COVID[-19]…I feel like there’s just as much risk in allowing yourself to kind of get COVID[-19] as much as getting a vaccine.”
Participants frequently cited pervasive and ongoing mistreatment of Black and Latinx communities by the health care system as factors influencing vaccine acceptance. Mistreatments included perceptions of having their opinion “thrown away” and having their voice go unheard by the health care system. These experiences were then related to COVID-19 vaccinations. One participant explained, “I had to fight my way to get certain things done for my health. They don’t take you seriously sometimes…that kind of contributes to the fear of wanting to get vaccines.”
Receiving information from trusted messengers, consistent messaging, fact-based information, and transparent and continued messaging informed feelings of trust in the COVID-19 vaccine. Having choices in the vaccination process, social support, and seeing diversity at the vaccination site influenced confidence and feelings of reassurance related to getting vaccinated.
Participants wanted information from trusted messengers who were reliable sources to them. “People who know the community, people who know me, I think that’s the deciding factor that would make me actually want to get it,” said a participant.
Participants repeatedly expressed that consistent messaging was needed regarding the COVID-19 vaccine, as inconsistencies in messaging fostered confusion and lack of trust. A participant said, “It’s all confusing because none of them have the same message…makes it harder to believe anything.” Another participant remarked that “conflicting messages can be very confusing…it also adds to the mistrust.”
Participants shared that fact-based information helped combat misinformation. One participant said, “We need to develop a platform where the positive part of the vaccine can be spreading because there’s so much negative in social media.”
Participants shared an appreciation for transparent and continued communication with the community as a way to facilitate engagement with health care practitioners and receive accurate information. “I feel like there’s just that level of transparency that’s needed between health care professionals and providers to communities like this,” said a participant. It was repeatedly expressed that communication needed to be continued with the community. A participant voiced, “The more we can have this discussion and just be honest with one another, I think the better it’s going to be.”
Participants shared that having a sense of personal choice facilitated confidence in the vaccination process. “There was a list of the different vaccines, and I checked the one that I wanted…I had a choice,” highlighting that there was a choice in vaccine manufacturer that was transparently listed. Another participant shared their experience about having choices in the vaccination process. They noted, “It just made me feel relieved that I had a choice of which lane I could go to.”
Support during the vaccination process, including receiving guidance for signing up and having family or community support during the vaccination, was frequently cited as a facilitator. One participant commented, “If they see a neighbor go with them…I see somebody else is in the same boat as I am, then I don’t feel so scared.” Another vaccinated participant shared with an unvaccinated participant, “I want to go with you…where it would give her some strength and some confidence.”
Participants were reassured by seeing a diverse group of individuals at the vaccination site. One participant said, “When I got in there, seeing the diversity, it made me feel better.” Another participant appreciated seeing a diverse range of professionals in line for the vaccine and said, “When I went inside and seen all the policemen, doctors all in line…and I’m looking like, okay…must be for real.”
Multiple structural barriers were identified by participants as impacting their vaccination access, including concerns about vaccine supply in Black and Brown communities being impacted by White communities, “going in circles” in the sign-up process causing fatigue, and insurance concerns. Vaccinations at schools and workplaces, with community partners and with support in Spanish, were shared as avenues to address barriers to vaccine access.
Participants shared experiences of feeling that vaccine availability was limited in Black and Brown communities and that supply was being commandeered by White communities. One participant commented that “You hear about the White people that are going to the Black and Brown communities and cutting the line.”
Participants described inaccessible and fatiguing sign-up processes that obstructed access to vaccine appointments. One participant said, “The numbers that they were giving were not working numbers…they kept going around in circles.” Another participant stated: “You follow all these steps, and when you get to the end, it says, ‘Pick a time,’ and it goes, ‘no time available.’”
Participants shared it was important to know that insurance was not required for vaccinations. One participant proceeded to educate the focus group about this fact. “If you do have insurance, great, but if you don’t, it’s not a worry.” Another participant noted, “People are afraid to go get vaccinated, because many think that they are going to be charged to their health insurance.”
Participants shared that having vaccines offered through schools and workplaces and with trusted community partners facilitated vaccination. One participant noted, “It was super easy for me because the clinic was at my school…it’s right here, no excuse.” Another participant expressed that their workplaces partnered with a trusted community organization and this served as a facilitator in getting vaccinated. “With my employer…we’re working on a partnership to get vaccinated…and I got my appointment within the next week.”
Support in Spanish is needed in every step of the process, including educational information and at the vaccination sites themselves. One participant commented that their family member did not speak English and “A lot of the information that he may have heard about the vaccine and COVID- probably came off of Univision.” Another participant shared with other participants that “There are always people who speak Spanish…do not be afraid to go.”
This qualitative study on COVID-19 vaccine acceptance and access among Black and Latinx participants identified 3 themes with critical implications for equitable uptake of the COVID-19 vaccine. Themes included pervasive mistreatment of Black and Latinx communities and associated distrust; informing trust via trusted messengers and messages, choice, social support, and diversity; and addressing structural barriers to vaccination access. Our findings call for creating more trustworthy health care systems that are able to approach vaccine acceptance and access through the lens of equity, informed by the communities they serve. Listening and responding to the community’s needs to improve COVID-19 vaccine acceptance and access and to inform policy recommendations must remain at the forefront (Table 3). Our participants’ experiences underscore tenets of the WHO Measuring Behavioral and Social Drivers of Vaccination Increasing Vaccination model, highlighting the importance of thoughts and feelings related to trust, addressing structural barriers impeding access, and social processes, including social support, all of which may influence motivation to vaccinate.
A key finding of this qualitative study was pervasive mistreatment of Black and Latinx communities, rooted in structural racism, that influenced acceptance of COVID-19 vaccines. Tragedies ranging from the US Public Health Services Syphilis Study at Tuskegee to recently reported disparities in maternal mortality and COVID-19–related mortality fueled untrustworthiness in the COVID-19 vaccine and health care systems. Our participants’ perspectives are supported by systematic reviews providing data exemplifying that systemic racism and health care bias are associated with negative health outcomes and lower quality of care.18,19 Discrimination and inequitable treatment of Black and Latinx communities by health care systems further drive untrustworthiness related to COVID-19 vaccinations.6,20 Health care systems and public health organizations must understand and address the forces of structural racism that perpetuate disparities in COVID-19 vaccinations and health inequities.9,21,22
Informing trust via trusted messengers and messages, choice, social support, and diversity is critical to fostering trustworthiness and vaccine acceptance.6,23-27 Trusted messengers include individuals regarded as credible by their community, such as health care professionals, faith leaders, and community stakeholders. Public health agencies and health care systems stand at an opportune time to form authentic, long-standing, and mutually beneficial alliances with trusted messengers and key community stakeholders to help broker trust based on the community’s earned reliability and respect. Partnerships with trusted messengers, communities, and their stakeholders can serve as conduits to deliver accurate, consistent, and transparent messaging from trusted sources, which has been cited as an effective tool for increasing vaccine acceptance and other beneficial health behaviors.6,23,24,28-31 The community holds the expertise of what their needs are and what interventions are likely to succeed. Health care systems often hold valuable resources that benefit the community if used effectively.31 Combining such strengths are critical and have been successful against tobacco use (eg, the national “Truth” campaign) and with the Vaccinate with Confidence program, a framework that promotes protecting communities, empowering families, and stopping myths.28-30,32,33
Offering choice in the vaccine process was perceived as facilitating a sense of control and influencing willingness to receive a COVID-19 vaccine.34 Choice should be offered in as many aspects of the vaccination process as possible to facilitate trust and transparency. This includes choice in vaccine manufacturer, a mix of community and health care–based vaccination sites, and allowing individuals to choose the lane and chair they select to be vaccinated in at the time of vaccination.
The influence of social support is a known tool in increasing behaviors to vaccinate.35-38 The support of family, friends, and one’s local community are critical to vaccine acceptance, as decisions related to health behaviors are often drawn from patterns within small communities.39 Additionally, vaccination sites should reflect the diversity of the population, including race, ethnicity, and profession, which is imperative to fostering trust. Equally important is ensuring that equitable and inclusive care is delivered to all.
Structural barriers underscore the narrative of inequitable access to COVID-19 vaccinations and point to the larger health care system changes needed to ensure equity. Vaccine distribution patterns must be analyzed and reassessed to ensure distribution is adequate and consistent to communities with the highest social risk indices and those hardest hit by the pandemic.40,41 To further remove barriers, mobile clinics, same-day clinics, and walk-in vaccination sites in easily accessible and trusted locations can be used.42 If sign-up systems must be used, ensure multimodal access.43-46 Highlighting the no-cost nature of the vaccine and removing documentation requirements are essential to eliminating barriers.46 We stand at a time when overcoming vaccination barriers will not only determine whether disparities in outcomes for Black and Latinx communities are worsened but also determine whether vaccination efforts are able to sufficiently mitigate the progression of the pandemic through variants in the coming year.6
This study has some limitations. Our study intentionally included participants who identified as Black or Latinx from a medium-size city. Experiences may not represent that of other communities, such as rural populations or other racial and ethnic populations. Our study provides the perspectives of both Black and Latinx communities, and nuanced perspectives of each individual community may not be captured. Findings may be susceptible to social desirability bias. We did not include segmentation by age, vaccines status, or occupation, and required the use of video conferencing software owing to pandemic social distancing precautions, which may change levels of participation compared with in-person groups.
The findings of this qualitative study suggest that key community-informed levers may have the potential to impact COVID-19 vaccine acceptance and access among communities hardest hit by the pandemic. These findings may impact public health initiatives and health care systems’ ability to reach Black and Latinx communities to increase equitable uptake of the COVID-19 vaccine and ensure health for all communities.
Accepted for Publication: August 4, 2021.
Published: October 13, 2021. doi:10.1001/jamanetworkopen.2021.28575
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Balasuriya L et al. JAMA Network Open.
Corresponding Author: Lilanthi Balasuriya, MD, Yale National Clinician Scholars Program, Yale University School of Medicine, 333 Cedar St, SHM IE-66, PO Box 208088, New Haven, CT 06510 (firstname.lastname@example.org).
Author Contributions: Dr Balasuriya and Mrs Santilli had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Balasuriya, Santilli, O’Connor Duffany.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Balasuriya, Morone, Ainooson, Mendiola-Iparraguirre.
Critical revision of the manuscript for important intellectual content: Santilli, Morone, Ainooson, Roy, Njoku, Mendiola-Iparraguirre, O’Connor Duffany, Macklin, Higginbottom, Fernández-Ayala, Vicente, Venkatesh.
Statistical analysis: Balasuriya, Ainooson.
Obtained funding: Balasuriya, Santilli, O’Connor Duffany.
Administrative, technical, or material support: Balasuriya, Santilli, Morone, Ainooson, Roy, Njoku, Mendiola-Iparraguirre, O’Connor Duffany, Higginbottom, Fernández-Ayala, Vicente, Venkatesh.
Supervision: Balasuriya, Santilli, Roy, O’Connor Duffany, Venkatesh.
Conflict of Interest Disclosures: Dr Santilli reported receiving grants from the Centers for Disease Control and Prevention (CDC) during the conduct of the study. Dr O’Connor Duffany reported receiving grants from the CDC during the conduct of the study and outside the submitted work. Dr Vicente reported grants from the CDC during the conduct of the study. No other disclosures were reported.
Funding/Support: This work was supported by the Community Alliance for Research and Engagement (CARE), a grant from the Racial and Ethnic Approaches to Community Health (REACH) at the Centers for Disease Control and Prevention (CDC), and the Yale National Clinician Scholars Program.
Role of the Funder/Sponsor: The funders assisted in the design and conduct of the study; CARE and the Yale National Clinician Scholars Program were involved in the collection, management, analysis, and interpretation of the data; and the funders had no role in the preparation, review, or approval of the manuscript or the decision to submit the manuscript for publication.
Additional Contributions: Ann Greene, BS (Yale National Clinician Scholars Program), assisted with mentorship regarding community partnered research and perspectives to consider regarding the history of New Haven, Connecticut, related to access to medical care. Ermonda Markaj, MPH (New Haven Health Department), provided perspectives on access to care in New Haven and reviewed themes in the context of addressing barriers in real-time in New Haven. Thomas Ficklin, MDiv (CARE community consultant), assisted in sharing information about the study and provided perspectives on access to care in New Haven. Maurice Williams, BA, MPA (Yale School of Medicine), assisted in sharing information about the study and provided perspectives on access to care in New Haven. Savanna Carson, PhD (UCLA Clinical and Translational Science Institute, Community Engagement & Research Program), and Arleen Brown MD, PhD (Community Engagement and Research Program of the UCLA Clinical and Translational Research Institute), shared their interview guide and institutional review board documentation for similar vaccine acceptance and access work happening in Los Angeles, California. No compensation was given for these roles, with the exception of Mr. Ficklin, who is compensated for his community consultation work.