Vaccination rates lag in communities of color, but it's not only due to hesitancy, experts say

It started with the op-eds. Even before COVID-19 vaccines were widely available, newspapers' opinion pages warned that some Black people would be hesitant to get the shot. Those columns often referenced the infamous 1930s Tuskegee Syphilis Study, during which doctors withheld treatment from Black men with syphilis, as evidence of lingering well-founded mistrust that might drag down vaccination rates in the Black community.

That theory wasn't just fueled by newspapers. Former President Barack Obama and former NBA player Charles Barkley both referenced Tuskegee during an April NBC special to encourage Black Americans to get vaccinated. "I’m telling all my friends, 'Yo man, forget what happened back in the day,' every Black person, please go out and get vaccinated," Barkley said.

While early polls indicated that Black Americans were less inclined to get vaccinated than other racial groups, by spring 2021 those polls had shifted dramatically, showing a steep rise in the proportion of Black people who wanted to get the vaccine. Despite that shift and despite newer polls reflecting that Black people were not more hesitant than other groups, the narrative that hesitancy was the primary vaccination barrier in the Black community persisted, even making an appearance during an April "Saturday Night Live" skit, widely derided by critics for promoting stereotypes.

But experts say the narrative that Black people, and communities of color more widely, are more vaccine hesitant, may not be the whole story. Instead, they argue, lack of access to vaccines and structural barriers are also hurting vaccination rates in these communities. There's a risk to perpetuating that single-story narrative, they say. Overemphasizing hesitancy diverts attention away from policies that could fix those access problems and hinders the U.S. vaccine distribution strategy at large.

'Hesitancy hotspots' tend to be in less diverse areas

"We had been hearing that vaccine hesitancy was a barrier to getting minorities, specifically Black and Latino communities vaccinated," said Dr. Jorge Caballero, a clinical instructor at Stanford Medicine and co-founder of the group Coders Against COVID. "The more data that we have, the less that assertion is actually supported."

One important data point, according to Caballero, are recent estimates from a U.S. Census Bureau survey, conducted in April, that explored which Americans were most likely to say will "probably," "probably not," "are unsure," "will definitely not get a vaccine" or "who do not plan on receiving all the required doses."

In that survey, 60% of individuals who expressed vaccine hesitancy self-identified as white. Moreover, four out of five counties with vaccine hesitancy above the national average had predominantly white populations.

The definition of vaccine hesitancy itself is somewhat murky. The Centers for Disease Control and Prevention refers to hesitant people as those who indicate in surveys that they would "probably not" or "definitely not" receive a COVID-19 vaccine when it's available to them. The World Health Organization defines hesitancy as a "delay in acceptance or refusal of vaccines despite availability." But other experts argue that it blames and shames people who aren't vaccinated yet, and doesn't reflect people's lived experiences, which tend to be more nuanced than their feelings about getting vaccinated at a given point in time.

"The actual narrative should be that as a group, white Americans are more hesitant to get vaccinated than non-white Americans," Caballero said.

New surveys have bolstered that case.

According to the latest U.S. Census Bureau data, which broke down attitudes toward the COVID-19 vaccine by race, white and Black adults were similarly wary about getting vaccinated. An estimated 12% in each group said they would "definitely not" or "probably not" get a vaccine when it was available to them, compared to 10% of Hispanic adults who responded that way.

Although similar proportions of adults are estimated to be hesitant, Black and Hispanic adults are less likely than white adults to actually be vaccinated, according to Kaiser Family Foundation data. Across states that report race and ethnicity data for vaccinations, the percentage of white people who've gotten at least one vaccine dose (39%) was 1.5 times higher than the rate for Black people (25%) and Hispanic people (27%), as of May 3, the foundation found.

An April ABC News/Washington Post poll found that intent to get vaccinated rose across demographic groups since January, with the steepest rise seen among Hispanic respondents (+16 points) and Black (+11 points) respondents, followed by white (+5 points) respondents. According to the same poll, Hispanic respondents (81%) were most likely to say they were already vaccinated or were inclined to get vaccinated, followed by Black (75%) and white (72%) respondents.

Reading between the lines, "Latinos are the least hesitant group, but they're also the least vaccinated," Caballero said. "That underscores the notion that access is the problem, not hesitancy."

Access, not attitude, may also be hurting vaccination rates

A great deal about what we know about Americans' attitudes toward COVID-19 vaccination comes from polls and surveys, and how pollsters ask those questions matters, according to Stefanie Friedhoff, a professor and senior director at the Brown University School of Public Health.

"A lot of polls that are currently assessing and asking people about their intent to get vaccinated don't ask about structural factors that might be influencing this decision," Friedhoff said.

Instead, Friedhoff explained, the questions are framed through a behavioral lens that focuses on whether people are willing to get vaccinated, as opposed to whether they're able to do so. "For many people, it's much more complex."

When a Kaiser Family Foundation survey asked about vaccination concerns among those who weren't already vaccinated or who were planning to get the vaccine as soon as they could, lack of access to convenient vaccines and missing work were bigger problems for Black and Hispanic respondents than for white ones.

"Hesitancy means you have all the information about the vaccine, you know that you could easily get it and you just choose not to," Friedhoff said. "Where we're at right now, it's actually not as easy to get it as people make it sound."

More than half of Black and Hispanic respondents said they were worried about missing work because of vaccine side effects and roughly a third in each group expressed concern about being unable to get the vaccine from a trusted place.

Compared to 5% of white respondents who said it would be difficult to travel to vaccination site, 20% of Black and Hispanic respondents listed getting to a vaccine site as an obstacle.

"Today, 90% of Americans now live within five miles of a vaccination site," President Joe Biden reiterated during his address to a joint session of Congress last week.

But Caballero says living within five miles doesn't always mean easy access.

"If you live within five miles of the vaccine site and it doesn't actually have vaccine doses available, that's not helpful," Caballero said. "That's what we're seeing in the data, that there are plenty of vaccination sites on paper, but boots on the ground, there are no doses available."

Even in places where there are doses available, being five miles away from a vaccination site doesn't address reality in a city like Houston, which lacks strong public transportation, Friedhoff pointed out. If you don't have a car, you're not going to walk to a vaccine site five miles away in the Texas heat.

Officials acknowledge that although most Americans live within five miles of a vaccine site, in many cases the vaccine will have to be brought to their door or provided by an organization they trust. To that end, the administration has turned hundreds of local community health centers into vaccination sites and provided grant money to nonprofits already working with disadvantaged neighborhoods.

"Easy and convenient and free," Andy Slavitt, the White House COVID-19 response coordinator, said during a Wednesday press briefing. "That’s what we’re focused on in this next phase."

'If we don't look for the structural barriers, we can't fix them'

None of this is to suggest that there's no bad blood between communities of color and the medical establishment, experts point out. Discrimination in medicine remains a concern, with racial and ethnic minorities receiving less accurate medical diagnoses, less pain management and ultimately having worse health outcomes than white Americans.

In turn, Black adults (24%) were most likely to say they wanted to "wait and see" before getting a COVID-19 vaccine, compared to white (16%) and Hispanic (18%) adults, according to the March KFF survey.

But emphasizing hesitancy instead of access is looking at the problem backward, Friedhoff explained. Instead of focusing on the patient and how to change their mind about vaccines, the focus should also include the health care system making it easier for people to get shots, ensuring workers get paid time if they feel sick after being vaccinated and offering childcare support.

In addition to vaccination campaigns driven by trusted community organizations, other logistical improvements could include extended and weekend vaccination hours; more walk-up vaccinations; and staff on hand to answer questions about what to expect when getting vaccinated.

While the one-shot Johnson & Johnson vaccine has been promoted as a good option for people who don't have easy access to vaccination sites, Caballero noted that solely offering the J&J vaccine to minority communities might also be an issue. Giving people a choice of which vaccine to get avoids the perception that certain communities are being treated differently or have fewer options, he said.

"What we can do is avoid anything that would amplify that concern," Caballero said.

But all these strategies are more logistically complicated than telling Americans that everyone who wants a shot can get one. "I think we are erring too much on the side of convenience for public health officials instead of convenience for the community," Caballero said.

"We have entire communities that are not hesitant, but just don't have access," he added. "The thesis does not support over-pivoting on hesitancy when we have low-hanging fruit."

Or as Friedhoff noted, "If we don't look for the structural barriers, we can't fix them."