Black Americans Cite Low Vaccine Confidence, Mistrust, and Limited Access as Barriers to COVID-19 Vaccination

Following the development and rollout of COVID-19 vaccines in late 2020, researchers, policymakers, and community leaders expressed concern about the low levels of confidence in COVID-19 vaccines among Black Americans across the United States. Although vaccination rates have increased over time, Black Americans are still being vaccinated at lower rates compared with other racial or ethnic groups (Figure 1).

This Study

To identify approaches to increase vaccine confidence and uptake among Black Americans, RAND Corporation researchers conducted a national survey of 207 Black participants in November 2020. The team also conducted in-depth interviews with 28 Black participants from December 2020 to March 2021. The in-depth interviewees comprised 23 participants who responded on the survey that they would not get the vaccine when it became available and five community stakeholders who represent different Black organizations and subcommunities, including people living with HIV, sexual and gender groups, and immigrants. In the interviews, participants gave their perspectives about how to encourage vaccine confidence and increase vaccination among people in Black communities. The study was conducted in partnership with a national advisory board of eight community stakeholders.

	Black Americans	U.S. population
Received one dose	23.3%	51.7%
Fully vaccinated	19.7%	42.3%

SOURCE: Centers for Disease Control and Prevention, "COVID Data Tracker," webpage, 2021.

Main Findings

The study produced two overarching findings that speak to the current crisis and may offer lessons to inform a proactive response to future public health crises.

Vaccine confidence has improved among Black Americans, but mistrust plays a role in holding down vaccination rates. Mistrust of the vaccine stems directly from historical and ongoing discrimination and racism experienced by Black communities and can be conceptualized as an adaptive coping response to such experiences. The authors found that vaccine-related mistrust is a multifaceted construct that includes distrust of health care and health care providers (to be equitable), the government (to provide truthful information), and the vaccine itself (to be safe and effective). Table 1 provides details on key areas of mistrust expressed by survey participants.

The national discussion of confidence issues has masked access problems. Although there has been considerable attention paid to the issue of mistrust and vaccine confidence among Black Americans, increasing confidence has shifted the spotlight to barriers to access as a reason for persistently lower vaccination rates. Specific access challenges noted by study participants at the beginning of the vaccination rollout included the following:

• the distance to vaccine site was too far or there were insufficient vaccination sites in one's community
• lack of transportation to available vaccination sites (e.g., poor public transportation infrastructure or lack of access to private transportation)
• lack of high-speed internet access and/or internet literacy or lack of English literacy required to locate and schedule appointments
• work- and child care–related issues and other scheduling challenges, particularly in the case of a two-dose vaccine and when managing side effects.

Recommendations

The authors made several recommendations based on their own survey and interview data and discussions with the study's national advisory board. At the outset of the vaccine rollout, when issues of low confidence and limited access became apparent, community stakeholders across the country took the lead to develop their own tailored solutions. Later, as vaccination rates leveled off, national initiatives further aimed to reduce access barriers. It is perhaps not surprising then that the recommendations developed by the authors to increase vaccine confidence and access overlap with those that are already being implemented in communities across the United States.

Solutions for increasing vaccine confidence include the following:

• Acknowledge that systemic racism has contributed to an understandable and justified response of mistrust before providing information about the vaccine.
• Develop clear, layperson-oriented, transparent messaging that (1) is tailored to specific subcommunities within the broader Black American community and (2) acknowledges both what we know and what we do not know about the vaccine, particularly when conducting outreach to marginalized subcommunities, such as people living with HIV, sexual and gender minorities, and immigrant communities.
• Provide opportunities for open dialogue with scientists and health care providers who can answer questions.
• Identify trusted messengers by community, including trusted public health officials and Black doctors, who can work with local leaders to disseminate information together.
• Leverage the power of social networks, including friends and family who have been vaccinated, who can discuss their vaccination experiences and reasons for getting vaccinated with their peers.

Solutions for increasing vaccine access include the following:

• Add medical (e.g., clinics, primary care providers) and nonmedical (i.e., community-based) vaccination sites in underserved communities.
• Build on existing resources in communities, such as trusted community-based organizations that already provide resources and human resources who are already trained in health-related fields.
• Simplify and streamline access (e.g., provide transportation, do not require appointments, allow appointments to be made by phone, meet people where they live and work).
• Collect and publicly release good data on COVID-19 risk, vaccination, and vaccine efficacy by subgroup, including by race or ethnicity and by other vulnerable groups (e.g., sexual and gender minority groups, immigrant communities, those without English proficiency, people with insecure housing status)—recognizing that there is great diversity in Black communities and that cultural norms, experiences, and beliefs about health care may differ by subcommunity.
• Use vaccination (and the 15-minute waiting period following vaccine administration) as an opportunity to screen for health conditions and increase health care and social service access.
• Create authentic partnerships between communities and public and medical officials.

It is worth noting that, as with the challenges noted in the findings, these solutions will need to be multifaceted and focus on building long-term capacity and engagement.

Key Takeaway

To improve Black Americans' confidence in COVID-19 vaccines, and in public health initiatives more generally, health care organizations and the U.S. public health system need to undertake efforts to become more trustworthy. Being honest about historical and ongoing discrimination and working with communities to provide equitable, accessible care can significantly contribute to such efforts. These steps will improve the health care system's response not only to the current public health crisis but also to future crises.

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Topics

• African American Populations
• Community Health and Well-Being
• Coronavirus Disease 2019 (COVID-19)
• Neighborhood Influences on Health
• Racial Equity
• Vaccination