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COVID-19 Vaccine Decision-making Factors in Racial and Ethnic Minority Communities in Los Angeles, California

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What factors do members of multiethnic communities at high risk for COVID-19 infection and morbidity in Los Angeles County, California, cite as influencing vaccine decision-making and acceptability?

Findings  In this qualitative study, 70 participants from racial and ethnic minority communities in Los Angeles County described a complex vaccination decision-making process influenced by misinformation and politicization, deep apprehension related to historical inequity and mistreatment, access barriers related to social disadvantage, and a need for community engagement and trusted messengers.

Meaning  This study suggests that COVID-19 vaccine equity will require multifaceted policies and programming that respect community concerns and the need for informed deliberation, invest in community-based engagement, improve accessibility and transparency of information, and reduce structural barriers in vaccination.


Importance  The COVID-19 pandemic has had disproportionate effects on racial and ethnic minority communities, where preexisting clinical and social conditions amplify health and social disparities. Many of these communities report lower vaccine confidence and lower receipt of the COVID-19 vaccine. Understanding factors that influence the multifaceted decision-making process for vaccine uptake is critical for narrowing COVID-19–related disparities.

Objective  To examine factors that members of multiethnic communities at high risk for COVID-19 infection and morbidity report as contributing to vaccine decision-making.

Design, Setting, and Participants  This qualitative study used community-engaged methods to conduct virtual focus groups from November 16, 2020, to January 28, 2021, with Los Angeles County residents. Potential participants were recruited through email, video, and telephone outreach to community partner networks. Focus groups were stratified by self-identified race and ethnicity as well as age. Transcripts were analyzed using reflexive thematic analysis.

Main Outcomes and Measures  Themes were categorized by contextual, individual, and vaccine-specific influences using the World Health Organization’s Vaccine Hesitancy Matrix categories.

Results  A total of 13 focus groups were conducted with 70 participants (50 [71.4%] female) who self-identified as American Indian (n = 17 [24.3%]), Black/African American (n = 17 [24.3%]), Filipino/Filipina (n = 11 [15.7%]), Latino/Latina (n = 15 [21.4%]), or Pacific Islander (n = 10 [14.3%]). A total of 39 participants (55.7%) were residents from high-poverty zip codes, and 34 (48.6%) were essential workers. The resulting themes included policy implications for equitable vaccine distribution: contextual influences (unclear and unreliable information, concern for inequitable access or differential treatment, references to mistrust from unethical research studies, accessibility and accommodation barriers, eligibility uncertainty, and fears of politicization or pharmaceutical industry influence); social and group influences (inadequate exposure to trusted messengers or information, altruistic motivations, medical mistrust, and desire for autonomy); and vaccination-specific influences (need for vaccine evidence by subpopulation, misconceptions on vaccine development, allocation ambiguity, vaccination safety preferences, the importance of perceiving vaccine equity, burden of vaccine scheduling, cost uncertainty, and desire for practitioner recommendation).

Conclusions and Relevance  In this qualitative study, participants reported a number of factors that affected their vaccine decision-making, including concern for inequitable vaccine access. Participants endorsed policy recommendations and strategies to promote vaccine confidence. These results suggest that support of informed deliberation and attainment of vaccine equity will require multifaceted, multilevel policy approaches that improve COVID-19 vaccine knowledge, enhance trust, and address the complex interplay of sociocultural and structural barriers to vaccination.

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Article Information

Accepted for Publication: July 23, 2021.

Published: September 30, 2021. doi:10.1001/jamanetworkopen.2021.27582

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Carson SL et al. JAMA Network Open.

Corresponding Author: Savanna L. Carson, PhD, Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1100 Glendon, Ste 1820, Los Angeles, CA 90095 (scarson@mednet.ucla.edu).

Author Contributions: Dr Carson had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Carson, Casillas, Castellon-Lopez, Morris, Barron, Ntekume, Vassar, Norris, Dubinett, Garrison, Brown.

Acquisition, analysis, or interpretation of data: Carson, Casillas, Castellon-Lopez, Mansfield, Barron, Ntekume, Landovitz, Vassar, Garrison, Brown.

Drafting of the manuscript: Carson, Casillas, Castellon-Lopez, Mansfield, Morris, Ntekume, Vassar, Garrison, Brown.

Critical revision of the manuscript for important intellectual content: Carson, Casillas, Castellon-Lopez, Mansfield, Barron, Ntekume, Landovitz, Vassar, Norris, Dubinett, Garrison.

Statistical analysis: Carson, Mansfield.

Obtained funding: Carson, Vassar, Norris, Dubinett, Brown.

Administrative, technical, or material support: Carson, Casillas, Castellon-Lopez, Mansfield, Morris, Barron, Ntekume, Vassar, Garrison, Brown.

Supervision: Carson, Casillas, Landovitz, Vassar, Norris, Brown.

Conflict of Interest Disclosures: Drs Carson, Brown, Morris, Castellon, Casillas, and Garrison and Ms Vassar reported receiving grants from the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Science, and the UCLA Oversight COVID-19 Research Committee during the conduct of the study. Dr Ntekume reported receiving grants from the National Heart, Lung, and Blood Institute, the National Center for Advancing Translational Science, and the UCLA Oversight COVID-19 Research Committee during the conduct of the study. Dr Landovitz reported receiving grants from the National Institutes of Health during the conduct of the study and personal fees from Gilead Sciences, Merck Inc, Roche, and Janssen outside the submitted work. Dr Norris reported receiving grants from the National Heart, Lung, and Blood Institute during the conduct of the study and grants from National Center for Advancing Translational Science, National Institute on Aging, National Institute of Diabetes and Digestive and Kidney Diseases National Institute of General Medical Sciences, and National Institute on Minority Health and Health Disparities outside the submitted work. No other disclosures were reported.

Funding/Support: This research is supported by grant 21-312-0217571-66106L from CEAL/STOP COVID-19 CA, grant UL1TR001881 from the National Center for Advancing Translational Science, and grant OCRC 20-51 from UCLA.

Role of the Funder/Sponsor: The supporters of this study had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The study participants, our Community Advisory Board, the UCLA Community Consultants Panel, and our community partners supported recruitment or provided feedback on preliminary results. We thank the diverse communities we come from and are embedded within that shape, influence, and guide our research approach in culturally congruent ways.

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