Perspective

Addressing Vaccine Hesitancy in BIPOC Communities ! Toward Trustworthiness, Partnership, and Reciprocity

List of authors.
  • Sandra C. Quinn, Ph.D.,
  • and Michele P. Andrasik, Ph.D.

Article

The devastation of the Covid-19 pandemic has been rippling through Black, Indigenous, and People of Color (BIPOC) communities throughout the United States. The Centers for Disease Control and Prevention has reported horrifyingly disproportionate age-adjusted rates of cases, hospitalizations, and deaths. Black Americans have had hospitalization and death rates 9 times as high as those for White Americans; American Indians and Alaska Natives have seen 9 times as many cases and 4 times as many deaths as White Americans; and Latinx/Hispanic Americans have faced 3 times as many deaths as their White counterparts.1 Simultaneously, the United States has been reeling from police shootings, Black Lives Matter protests, and an emboldened White supremacist movement that perpetrated the January 6, 2021, attack on the U.S. Capitol. As national surveys continue to report hesitancy in BIPOC communities over receiving Covid-19 vaccines, the social, economic, and political backdrop helps us understand the experiences and circumstances that feed that hesitancy.

For BIPOC communities, such hesitancy is rooted in both the historical and contemporary contexts of systemic racism, marginalization, and neglect that shape daily life today. Moreover, historical experiences with research abuses ! from the U.S. Public Health Service Syphilis Study at Tuskegee to the more recent case in which blood samples from members of the Havasupai Tribe were improperly used for research ! have established doubt and skepticism about the trustworthiness of science, research institutions, and government that are not easily overcome. Furthermore, persistent racial bias and the dearth of BIPOC clinicians in the health care system are well documented. In a national survey of 1643 adults, evenly split between Black and White respondents, Quinn and colleagues examined the impact of this lack of diversity on behavior with regard to influenza vaccination and found that perceived racial fairness in the health care setting increased trust in influenza vaccines and vaccine uptake, whereas experiences of discrimination in the health care setting decreased trust, increased perceived risk of side effects, and reduced uptake.2

Although BIPOC communities have important reasons to be hesitant, increasing reports of disparities in vaccine access throughout the country point to broader systemic challenges, such as inequitable distribution of doses, failure to place clinics in sites accessible to BIPOC communities, and underinvestment in health care providers and services in BIPOC communities. Reliance on Web-based vaccine-registration systems has disadvantaged communities with less access to technology, and real barriers such as work obligations and limited childcare options reduce their ability to chase vaccination appointments. Several systematic reviews3,4 have provided evidence that systemic racism and provider bias are associated with poor patientCprovider communication and interactions, lower quality of care, and negative health outcomes. These ongoing challenges prompt an urgent need to address the inequities in access proactively to avoid turning the vaccine rollout into one more example of ongoing unfair treatment, providing additional evidence to confirm beliefs that the U.S. health system is fraught with structural racism.

It is essential to remember that hesitancy doesn¨t mean refusal, and in fact, skepticism can be protective for BIPOC communities. However, we believe it¨s time to shift the focus from a sole emphasis on changing hearts and minds among members of BIPOC communities to ensuring that institutions are trustworthy, transparent, and engaged with communities during the vaccine rollout. Making our institutions ! particularly health care, public health, and government ! more trustworthy will require listening to community voices, preparing public health and health care organizations to respectfully engage with BIPOC communities, and becoming more client-centered, including viewing hesitancy and barriers to vaccine uptake through the eyes of members of the BIPOC community.

A primary path toward trust and confidence is relationship building. In too many situations and circumstances, BIPOC communities are asked to ^help us solve the problems in your community. ̄ Long-standing and reciprocal relationships between medical and research institutions and BIPOC communities are largely nonexistent. The relationships that do exist are generally short-lived, often enduring only as long as grant funding lasts. For health care and public health institutions to build a reputation of trustworthiness, partnerships rooted in bidirectional communication, capacity building, and reciprocity are required. Environments that center on relationships allow for mutual learning, provide opportunities for sharing stories, engender understanding, prepare organizations to respectfully engage community members, and increase the capacity of all partners in their efforts to navigate institutional, organizational, and community spaces.

Building relationships requires actively listening to others¨ stories and ensuring that all partners are provided an opportunity to articulate the challenges, barriers, and facilitating factors they have encountered in their work. The shared understanding and insight gained can create a strong foundation for developing a collective public health response, but this understanding must be accompanied by the sharing of resources.

The community engagement efforts of the COVID-19 Prevention Network (CoVPN), led by the National Institute of Allergy and Infectious Diseases (NIAID)-funded networks, provide one model for community partnership. The CoVPN has worked to ensure that communities have the resources they need to make informed decisions about participation in Covid-19 vaccine trials in the short term, and about vaccine acceptability and uptake in the long term. These efforts are grounded in frequent and ongoing discussions with long-standing community partners to ensure that our understanding of community fears and uncertainty is accurate and to share challenges and obstacles faced in our efforts and work together to identify strategies for overcoming them.

Questions and Answers Used in Train-the-Trainer and Community Education.

These partnerships facilitated the early identification of materials required for building capacity among community members and health care providers by increasing knowledge about vaccines, clinical trials, and emergency use authorizations (EUAs). These materials are available in multiple languages and housed in an online Dropbox folder (tinyurl.com/COVID19Materials), easily accessible by all partners and disseminated widely in emails and webinar sessions. As new data and information emerged, we identified the need for train-the-trainer sessions for community health care navigators, clinicians, community leaders (such as religious and faith leaders, advocates, and barbers and stylists), and health department staff. These sessions focused on providing the facts about the Covid-19 vaccines available through EUAs. Each 2-hour session included an hour of didactic presentation covering vaccine science, safety, manufacturing, and questions and concerns frequently encountered in vaccine discussions (see table). The first hour concluded with an overview of available educational materials and a review of navigating the Dropbox folder. The second hour included a panel discussion, with CoVPN subject-matter experts answering audience questions.

From its beginning, the Biden administration has taken steps to begin to restore the trustworthiness of government for BIPOC communities who have suffered horribly during this pandemic. From its memorial service and the first presidential acknowledgment of the grief experienced by so many families, to the proposed American Rescue Plan and the reopening of enrollment in Affordable Care Act health care coverage, the administration has planted seeds to grow trust, possibly for the first time. The administration¨s Executive Order on Ensuring an Equitable Pandemic Response and Recovery and the COVID-19 Health Equity Task Force, led by Dr. Marcella Nunez-Smith, have placed critical issues front and center in the administration¨s response, addressing systemic challenges and calling for outreach to communities involving tailored communication and trusted local leaders. Ensuring that BIPOC communities have equitable access to Covid-19 vaccines and that the vaccines will be accepted when offered will take an enormous effort from governments at all levels, health care systems and clinicians, public health agencies, and communities themselves. This is a challenge we must meet.

We believe that authentic community engagement is essential to reducing vaccine hesitancy. Equally important is reframing the challenge of vaccine hesitancy in BIPOC communities to one of vaccine confidence. Working directly with these communities, let us acknowledge the collective fears stemming from past government actions and research abuses and engage in honest and authentic dialogue. By doing so, we can together issue a call for justice and meet that call by securing real access to Covid-19 vaccines to save the lives of BIPOC Americans.

Funding and Disclosures

Disclosure forms provided by the authors are available at NEJM.org.

This article was published on March 31, 2021, at NEJM.org.

Author Affiliations

From the Department of Family Science, School of Public Health, University of Maryland, College Park (S.C.Q.); and the HIV Vaccine Trials Network and Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, University of Washington, Seattle (M.P.A.).

Supplementary Material

References (4)

  1. 1. Hospitalization and death by race/ethnicity. Atlanta: Centers for Disease Control and Prevention, March 12, 2021 (https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/racial-ethnic-disparities/infographic-cases-hospitalization-death.html).

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  2. 2. Quinn SC, Jamison A, Freimuth VS, An J, Hancock GR, Musa D. Exploring racial influences on flu vaccine attitudes and behavior: results of a national survey of White and African American adults. Vaccine 2017;35:1167-1174.

  3. 3. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017;18:19-19.

  4. 4. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015;105(12):e60-e76.

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    Figures/Media

    1. Digital Object ThumbnailAudio Interview
      Interview with Dr. Michele Andrasik on promoting Covid-19 vaccine access and uptake by building relationships. (17:31)
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    2. Questions and Answers Used in Train-the-Trainer and Community Education.*
      Questions and Answers Used in Train-the-Trainer and Community Education.