Exploring the Continuum of Vaccine Hesitancy Between African American and White Adults: Results of a Qualitative Study

"To some extent, the degree of hesitancy differed by race just as the reasons for hesitancy about the flu vaccine varied by race."

This study draws on the concept of vaccine hesitancy to understand the persistence of racial/ethnic disparities between African American and White adults with regard to adult immunisation against seasonal influenza. In the United States (US), African American adults are significantly less likely to be immunised for seasonal influenza than White adults: During the 2015-16 flu season, the Centers for Disease Control and Prevention (CDC) estimated that 37% of Black adults were vaccinated compared to 45% of White adults. The specific factors driving this disparity continue to elude scholars.

The paper begins by exploring vaccine hesitancy, which the World Health Organization (WHO) defines as delay in acceptance or refusal of vaccines, despite availability of vaccination services. WHO points out that vaccine hesitancy is complex and context specific, varying across time, place, and vaccines. It includes factors such as complacency, convenience, and confidence (hereafter, the Three Cs). The researchers see this framework as providing broader sensitising constructs that attempt to incorporate social and contextual factors and potentially capture the wider scope of vaccine hesitancy. In this context, the research questions are: What is the difference in the degree of vaccine hesitancy between African American and White adults related to seasonal influenza immunisation? What impact do cultural, attitudinal, and social differences have on vaccine hesitancy? Are the vaccine narratives of both African American and White adults accurately reflected in the Three Cs framework?

The study relied on a thematic content analysis of qualitative data, including 12 semi-structured interviews, 9 focus groups (N=90), and 16 in-depth interviews, for a total sample of 118 (N=118) African American and White adults. A coding scheme combining both inductive and deductive codes was utilised to identify themes related to vaccine hesitancy. Significant themes around each of the Three Cs were fully developed into written memos combining theoretical definitions with illustrative quotes (included in the paper).

Data revealed a continuum of vaccine behaviour from never-takers, sometimes-takers, and always-takers, with significant differences between African Americans and Whites. Each C had an influence in both directions, with some elements contributing to greater vaccine hesitancy and some attitudes contributing to greater vaccine acceptance.

• Complacency contributed to low vaccine acceptance with both races. The majority of complacent non-takers perceived a low susceptibility and low severity of seasonal influenza as justifications to forgo vaccination. However, what appeared to be complacency did not always lead to non-vaccination; more passive vaccine takers didn't have a strong opinion on the vaccine, but when external circumstances made vaccination an option, they accepted it.
• Among sometimes-takers and always-takers, convenience was often cited as a reason for their behaviour, while never-takers of both races were more likely to describe other reasons for non-vaccination, with convenience only a secondary explanation. However, for African Americans, cost was a barrier. Takers described accessible location, low cost, and encouragement through workplace policies as the most common convenience-related reasons for vaccination. Widespread availability in pharmacies, grocery stores, and pop-up clinics made the vaccine very accessible.
• It was in the context of confidence that racial differences emerged more starkly, and cultural, social, historical, and attitudinal factors had the most significant impact. The researchers observed 3 major areas related to confidence: trust/distrust of the vaccine, trust/distrust of the agencies that produce the vaccine, and a more generalised sense of trust/distrust that stems from traditions. A major challenge to vaccine confidence is the fear of side effects, which was widespread across participants. Whether such fear stems from a personal experience, an account from friends and family, or from a rumour, it was found to have a strong, negative impact on trust in the flu vaccine and vaccine confidence overall. Distrust in pharmaceutical companies was universal among many participants - young and old, male and female, White and African American. In the absence of a strong family tradition supporting vaccination, many individuals, especially from older generations, refused to consider a flu shot now. This is especially true among African American families, where distrust of the medical establishment was the norm. For the African American vaccine takers, they were aware of the concerns within their community and yet they made an active choice to trust.

The researchers reflect on these qualitative findings, noting that they yield "a broad continuum of behaviors and beliefs that was unwieldy and not easily distilled into discreet categories based on either behavior or belief. In practice, the Three Cs can reflect some of the complexity but the wide range of variability between populations and the overlap between the Three Cs leaves room for debate and growth. Some would note the potential overlap with key concepts such as susceptibility, severity and barriers from the Health Belief Model [HBM]. We found a number of factors that are associated with complacency, and in the HBM framework, would be described as low perceived susceptibility and low perceived severity. However, by considering the Three Cs, we also discover passive placement of vaccine opportunities in the path of some complacent individuals, results in vaccine uptake. More traditionally, a HBM approach would lead us to target changing individual susceptibility and severity, which is more difficult, and potentially failing to address vaccine opportunities and convenience."

In conclusion: "The [Three Cs] framework, though not a natural fit for the data, does provide some insight into the differential sources of hesitancy between these two populations. Complacency and confidence clearly impact vaccine behavior, often more profoundly than convenience, which can contribute either negatively or positively to vaccine acceptance. The Three Cs framework is a useful, but limited tool to understanding racial disparities. Understanding the distinctions in those cultural factors that drive lower vaccine confidence and greater hesitancy among African Americans could lead to more effective communication strategies as well as changes in the delivery of vaccines to increase convenience and passive acceptance."