COVID-19 Vaccine Acceptance and Access Among Black and Latinx Communities

IMPORTANCE 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. OBJECTIVE 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 NewHaven,Connecticut,HealthDepartment,andin-persondistributionofstudyinformationfrom 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. RESULTS Among 72 participants, 36 (50%) identified as Black, 28 (39%) as Latinx, and 8 (11%) as Black and Latinx


Introduction
More than 99% of deaths from COVID-19 are now among unvaccinated individuals. 1,2Black 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. 3,46][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][10][11][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. 8ile 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.

Methods
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.

Study Design
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. 13The interview guide was pilot tested and adapted by our community partners to ensure questions were informed by the community and asked in plain language.

Data Collection
We held 8 semistructured in-depth focus groups (4  Focus groups were used because they are a valuable tool for gathering information on attitudes and beliefs about behaviors. 14Interactions between participants were also a valuable way to generate data on understanding behaviors, particularly where sociocultural factors may influence health behaviors. 14Given 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 and Setting
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.).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. 16ree 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. 16The 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

Results
A total of 79 participants agreed to take part in the study, of whom 7 did not attend and were categorized as nonparticipants.

Pervasive Mistreatment of Black and Latinx Communities and Associated Distrust
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  Fact-based information "I think the data that they've been giving on the news has been very helpful about the number of vaccines [that] have been given and the reduction in hospital stays…they're giving us good data showing us that the vaccine is helping."

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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." Transparent and continued communication with the community "I think that direct conversation about the myths is good." 2 "I feel like there's just that level of transparency that's needed between healthcare professionals and providers to communities like this." 3 "The more we can have this discussion and just be honest with one another, I think the better it's going to be."

Subtheme: The Lasting Legacy From Historical Mistreatment
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?"

Subtheme: Disparate Death
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 "Was it just going to be all Black folks in there?And was I going to get back to that thought of, okay they're trying to do something to us, or that we got the contaminated vials….But when I got in there, seeing the diversity it made me feel better." 1 "I think for me, it would be because it would be other Black people actually getting vaccinated….There is power when you see actually someone who looks like you." 3 "It was kind of difficult for me to go inside because of the rumors and bad things that I heard about the vaccine.Then when I went inside and seen all the policemen, doctors all in line.…AndI'm looking like, okay…must be for real."Addressing structural barriers to vaccination access "Cutting the Line" and vaccine supply access "You hear about the White people that are going to the Black and Brown communities and cutting the line.They never be in that community otherwise but to get vaccinated." 2 "And one thing people have to look at now, who's some of the people in front of the line that want the vaccine?…I heard that people coming from Greenwich to New Haven to get the vaccine." 1 "Going in Circles": sign-up fatigue "The numbers that they were giving were not working numbers…they kept going around in circles." 2 "Finally, when you get it, you go through the process, you follow all these steps, and when you get to the end, it says, 'pick a time,' and it goes, 'no time available.'"4 "And I asked her if she had been able to get vaccinated elsewhere, and she said she was trying to call and they either didn't call her or they didn't have the slots available while she's not working."

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. 2) informing trust via trusted messengers and messages, choice, social support, and diversity; and (3) addressing structural barriers to vaccination access.Table2lists illustrative quotes representative of these major themes and subthemes.

Table 1 .
Demographic Characteristics and Vaccination Status of Study Participants a Other category includes food services, transportation services, factory workers, residential assistants, insurance verifiers, and customer services workers, among other employment.

Table 2 .
Study Themes, Subthemes, and Illustrative Quotes From Participants on COVID-19 Vaccine Acceptance and Access to fight my way to get certain things done for my health.…Theydon't take you seriously sometimes…that kind of contributes to the fear of wanting to get vaccines, wanting to do new medical things because it's like you've been put in so many different ways before in the past that you really just don't trust it." "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, but definitely not just any doctor."4"Whatgave me a lot of confidence in making the decision of whether to want to get it, is that my niece, I tell you, is a specialist and she told me that there are many studies that they did long before looking for the option of give a vaccine." 5 "Well, for me, I believe that religious leaders…I think they would listen more to that person." They didn't just say okay you go to this person.When the lanes opened up…they were like, just pick a lane…it just made me feel relieved that I had a choice of which lane I could go to.It wasn't just like go to the back of the room."

Table 2 .
Study Themes, Subthemes, and Illustrative Quotes From Participants on COVID-19 Vaccine Acceptance and Access (continued)

8
No insurance?No worry!"If you do have insurance, great, but if you don't, it's not a worry in back of peoples' heads." 3 "People are afraid to go get vaccinated, because many think that they are going to be charged to their health insurance."It was super easy for me because the clinic was at my school…it's right here, no excuse."4 "My work helped me, because they sent the initial email so that we could all get vaccinated, because we work with families in the community."8 "With my employer…we're working on a partnership to get vaccinated…and I got my appointment within the next week.…Ithad to do with the partnership, the partnership that my job had a partnership with.I think that was basically it, just knowing that the partnership that we had, it's been an organization that's been around for many, many years, and they do a lot of work in our community.I think that's what was more comforting to say, 'Okay, I think this is fine,' versus going to some drive-up parking lot saying, 'Come get your COVID[-19] vaccine.'" 4 "Having the vaccine sites at some of our local churches I think would make us feel more comfortable."1 Support in Spanish "He doesn't speak English.…So, a lot of the information that he may have heard about the vaccine and COVID[-19] probably came off of Univision and Telemundo."4 "There are always people who speak Spanish…do not be afraid to go to put it…the forms are given in Spanish too." -19 Vaccine Acceptance and Access Among Black and Latinx Communities 7JAMA Network Open | Public Health COVID