Racial differences in institutional trust and COVID-19 vaccine hesitancy and refusal

The COVID-19 pandemic has claimed the lives of more than 600,000 people in the United States alone and more than 4 million people globally [1, 2]. Despite the availability of three vaccines in the United States and mass vaccination campaigns, the rate of vaccination has stagnated and decreased from peak vaccination rates in February 2021 [3]. Strategies on the state and local levels to increase vaccination rates vary greatly following initial national goals to vaccinate the most vulnerable populations. Current vaccination programs have fully expanded to populations 12 years and older. Factors that potentially play a role in vaccine hesitancy and refusal, such as political affiliation, perceived threat of COVID-19, trust in the vaccine itself, and trust in public institutions involved in vaccine production and distribution [4‐7] influence both the ongoing COVID-19 pandemic and responses to future public health crises. Demographic factors, particularly ethnicity and socio-economic status also impact vaccine hesitancy [8].

Furthermore, racial disparities in vaccination rates are of increasing concern, as racial and ethnic minorities have been disproportionately affected by COVID-19 in both severity of infection and mortality rates [9‐12]. As of July 2021, approximately 61% of White Americans reported being vaccinated, but only 15% of Hispanics, 9% of Blacks, 6% of Asians and 9% who fall into other racial categories [1]. Racial disparities in vaccine rates are influenced by institutional trust. Institutional trust such as trust in the government and scientific/medical community are significant factors in promoting preventative health behaviors such as compliance with lockdowns and vaccination uptake [13‐15]. Low institutional trust was associated with lower likelihood of vaccination in a study conducted in Italy [16]. In the United States, government’s ineffectual early response to the pandemic and inconsistent messaging from the scientific community at the start of the COVID-19 pandemic have been cited by some as justification for their lack of trust in the available COVID-19 vaccines [17].

Medical mistrust encompasses a broad spectrum of mistrust, including the overall health care system, medical research and researchers, health care providers, insurers, and public health officials. This mistrust can lead to under-utilization of health care services, a lack of satisfaction with available services or providers, low adherence to medical advice, and reduced compliance with recommended health behaviors [18, 19]. Racial disparities and other impacts of racism have been linked to rates of medical mistrust [20‐22]; as such, higher perceived discrimination correlates with higher medical mistrust [23, 24].

The need to address trust in order to mitigate the continued impact of COVID-19 especially in minority communities already impacted by health disparities has been recognized in recent literature [25, 26]. However, the relationship between institutional mistrust and vaccine hesitancy deserves more attention [27, 28], especially in relation to the COVID-19 pandemic. Trust in public health figures such as Dr. Fauci has been associated with higher likelihood to vaccinate or encourage others to vaccinate [29]. Public health professionals acknowledge that mistrust of both health care services and messaging is a major barrier to effectively engaging minority communities in prevention efforts [30, 31]. Given this limited data, further research is needed to understand the impact of trust on current rates of COVID-19 vaccination.

This study examines racial/ethnic differences in vaccine hesitancy and refusal, ethnic/racial differences in institutional trust, and the impact of institutional trust on vaccination behavior. Institutional trust was divided into two categories: trust in the government’s response to the COVID-19 pandemic and trust in members of the scientific community. Based upon the findings of previous studies, we hypothesized that lower trust in the government would be associated with vaccine hesitancy, while higher trust in the scientific community would predict greater willingness to receive the COVID-19 vaccine. Additionally, based upon previous literature that indicates high rates of medical mistrust in the African American community, we hypothesized that African Americans would report lower trust in the scientific community and higher rates of vaccine hesitancy than other racial/ethnic groups in the sample.

Wave 8 of RAND’s American Life Panel (ALP) Omnibus 2000 survey was fielded from March 1st – April 1st, 2021. The ALP is a probability-sampled internet-based panel study designed to represent U.S. adults age 18 and older (for details, please see https://​www.​rand.​org/​research/​data/​alp/​panel.​html). Informed consent was obtained from all study participants. Data for the current study was collected using items the authors included as part of the Wave 8 Omnibus 2000 survey. Responses to author included items were fielded between March 8th – 19th, 2021 and analyses were conducted in June 2021. All data collected using ALP participants are made available to researchers who register with RAND following a 12-month embargo; data for the current study can be found at: https://​alpdata.​rand.​org/​index.​php?​page=​data&​p=​showsurvey&​syid=​569. Of the 3391 invited panelists, 2080 (61.3%) responded. The final sample contained 52% women, (M = 51.1 years old; SD = 15.6 years); 75.2% White, 12.2% Black, 7.4% Other, 3.4% Asian or Pacific Islander, 1.9% American Indian or Alaskan Native; 18.2% Latinx; 62.7% with educational attainment of an associate degree or less, 44.2% with a combined family income of $59,999 or less during the previous 12 months, an average household size of 2.82 people (SD = 1.50), and 94.1% covered by some form of health insurance. All study materials and procedures were approved by the Kennesaw State University IRB (OHRP # IRB00001469) and the RAND Human Subjects Protection Committee and the study was conducted in accordance to the Declarations of Helsinki.

Findings from the present study suggest that there are racial differences in vaccine hesitancy and vaccine refusal, and significant ethnic differences (Latinx vs non-Latinx identity) in vaccination rates at the time of this study. Additionally, there are racial differences in trust of the scientific community where lower trust in the scientific community was a stronger indication of higher vaccine hesitancy and refusal in the study sample. Trust in the government’s response was not indicative of vaccination status within the sample, differing from some previous research on government trust and COVID-19 behavioral compliance in other countries [16] and studies of government trust and vaccine intention in previous pandemics [15]. Further research needs to be conducted to understand why members of the African American community, Latinx communities, and those identifying as Other express higher vaccine hesitancy than Whites and Asians. The study also identified American Indian/Alaska Native members of the sample as having the highest vaccine refusal rate compared to other groups, as well as the lowest level of institutional trust. In the study, we did not differentiate between tribal governments, which have high vaccination rates [35], and U.S. state or federal governments. Little research has focused on this community and their concerns throughout the pandemic, with most efforts focused on creating health infrastructure on reservations to mitigate the spread of COVID-19 [36].

Approaches to addressing vaccine hesitancy may need to be markedly different within different communities. Razai and colleagues [37] identify the five Cs that impact vaccine uptake: confidence in vaccine safety and efficacy, complacency regarding COVID-19 infection risks, convenience of access, communication, and context. Listening to communities to determine the root causes is an important strategy moving forward. Conducting community-based research, such as focus groups embedded within specific communities, can tease out more specific reasons given for vaccine hesitancy. Given ethnic differences in vaccine rates, all five of the “Cs” need to be analyzed to determine if there are greater structural barriers to vaccination such as time off from work, easy access to vaccination sites, and language barriers, or issues with vaccine confidence and complacency. Vaccine hesitancy may be addressed by increasing confidence in the vaccine, discussing concerns about side effects, and highlighting vaccine efficacy in preventing COVID-19 and reducing the severity of COVID-19 infection [38, 39].

Trust of the scientific community was the strongest predictor for already receiving at least one dose of the COVID-19 vaccine at the time of study, suggesting that strategies to increase trust of the scientific community can be employed to address vaccine hesitancy. Results also suggest that members of the scientific community including doctors, researchers, and other health care professionals may be viewed as credible messengers by community members. Opel, Lo, and Peek [40] have outlined vaccine communication strategies to address mistrust during clinical encounters. These strategies address historical injustices and personal feelings of distrust. Such strategies are vital, especially in communities that have historically been excluded from medical care and scientific research such as American Indians and African Americans. Historical incidents of oppression cannot be ignored in efforts to build trust between community partners and medical providers. Increasing health literacy and understanding of the scientific process through which vaccine development takes place is another important element of increasing trust.

Given the rapid spread of misinformation regarding COVID-19 on social media platforms, social media can also be an effective vehicle to address different aspects of mistrust. Debunking misinformation and increasing media literacy and health literacy can also contribute to improved trust [41, 42]. Drawing on scientists’ and medical professionals’ expertise when creating short video clips in language for non-experts can combat misinformation and make the vaccine development process more transparent for the hesitant. For example, Louisiana State University tweeted a three-minute video, titled “Dr. Catherine O’Neal Sets the Record Straight,” discussing the rise of COVID variants, using a football training metaphor to explain how scientists developed MRNA vaccines quickly via available technology; the video has over 3500 likes on Twitter [43]. Explaining the changing recommendations regarding COVID-19 protective behaviors throughout the pandemic can also counter the current lack of trust impacting vaccine acceptance. Discussions within communities regarding the scientific process can increase understanding of why messaging changes as new information became available.

All approaches to address trust should be community-based and involve partnerships between community stakeholders and trusted members of the medical community. Community-based initiatives that engage local members of medical communities with other community leaders to start dialogues on past causes of medical mistrust in minority communities, especially within Native American and African American communities, is necessary. Community leaders who are viewed as trusted and credible messengers within their communities should have equal partnerships with public health agencies in decision making regarding vaccine distribution sites and campaigns, with plenty of time leading up to the vaccine drive to address concerns among the vaccine hesitant.