Addressing Mistrust About COVID-19 Vaccines Among Patients of Color
Authors: Douglas J. Opel, Bernard Lo, Monica E. Peek
Journal: Annals of Internal Medicine (2021)

Ideas and Opinions9 February 2021Addressing Mistrust About COVID-19 Vaccines Among Patients of ColorFREEDouglas J. Opel, MD, MPH, Bernard Lo, MD, and Monica E. Peek, MD, MPH, MSDouglas J. Opel, MD, MPHUniversity of Washington School of Medicine, Seattle, Washington (D.J.O.), Bernard Lo, MDUniversity of California, San Francisco, San Francisco, California (B.L.), and Monica E. Peek, MD, MPH, MSUniversity of Chicago, Chicago, Illinois (M.E.P.).Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-0055 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail "The health care system has failed me and my family many times before. Why should I believe this vaccine will be any different?" Clinicians may feel ill-equipped to address concerns about the coronavirus disease 2019 (COVID-19) vaccine that are rooted in the sociopolitical mistrust of communities that experience health disparities, discrimination, and structural injustice in their everyday lives. Current recommendations for talking to patients about COVID-19 vaccines do not provide specific guidance on how to discuss mistrust (1). We suggest specific strategies and language that clinicians can use to address mistrust of COVID-19 vaccines among racial and ethnic minorities.Reducing COVID-19 vaccine mistrust is a national priority. Mistrust of COVID-19 vaccines is widespread, particularly among people of color. Only 18% of Black Americans and 40% of Latinx Americans trust that a COVID-19 vaccine will be effective (2). Even fewer trust that it will be safe. The impact of this mistrust is alarming: Fewer than half of Black Americans intend to get vaccinated against COVID-19 (3).Mistrust in COVID-19 vaccines must be addressed to reduce the disproportionate burden of COVID-19 morbidity and mortality among people of color. This mistrust is multifactorial and is not restricted to concerns about COVID-19 vaccine safety and efficacy. It is rooted in a history of unethical medical and public health experimentation involving communities of color, as well as structural inequities in government institutions (for example, police, criminal justice, child welfare, and public schools). As a result, a primary strategy to decrease mistrust has been to leverage trusted community leaders to engage communities of color in public health campaigns.Clinicians can play an important role in mitigating mistrust of COVID-19 vaccines. The personal clinicians of Black and Latinx patients, regardless of clinician race, remain trustworthy sources of COVID-19 vaccine information (4). Although race-concordant patient–clinician relationships may nurture trust among patients of color and may even facilitate information-seeking behaviors about COVID-19 (5), most patients of color do not have a race-concordant clinician. Addressing COVID-19 vaccine mistrust can be a powerful way for any clinician to convey an openness to discussing patient concerns about COVID-19 vaccination and also an interest in patients' lived experiences with structural injustice.These discussions with patients about COVID-19 vaccines can occur now as an important part of health promotion and counseling. Initiating these discussions early can start the process of building trust in COVID-19 vaccines among patients of color. Anticipate the possibility of a multivisit process, rather than a single discussion.Four specific communication strategies may help promote trust among patients of color about COVID-19 vaccines. First, lead with listening. Patients, particularly those from marginalized communities, desire health care interactions in which their experiences are heard and validated. Consider beginning the COVID-19 vaccine conversation with an open-ended invitation for the patient to share their perspective, such as "You may be hearing a lot about COVID vaccines. Tell me what you think about them." Doing so can also help avoid erroneous assumptions about a patient's self-identity or experience.This approach differs from standard vaccine communication practices for well-established and routinely recommended vaccines. For these vaccines, starting the conversation with the implicit assumption that vaccination will happen, such as "You're due for your tetanus booster today," has been associated with increased vaccine uptake. For COVID-19 vaccines, however, which have, to date, been made available only through an emergency use authorization, a more appropriate approach is to facilitate shared decision making.Second, tailor responses to patient concerns. If patients respond to an invitation to share their perspective about COVID-19 vaccines either equivocally (such as "I'm not sure.") or negatively (such as "Those vaccines aren't for me."), do not provide reassurance prematurely. Doing so may be ineffective if it is done before listening to and exploring the patient's concerns in detail. Rather, engage with the patient nonjudgmentally and collaboratively. Motivational interviewing (MI) techniques can facilitate this engagement (6) (Table, top) and have been found to be effective in improving vaccine uptake among those who voice reluctance (7). These techniques can also be used to explore and address COVID-19 vaccine concerns rooted in structural injustice (Table, bottom), complementing other suggested COVID-19 communication approaches (8). Of importance, a clinician's vaccine recommendation, a factor associated with increased uptake (9), can be integrated with MI. For instance, consider asking permission to make a recommendation and, if granted, stating, "In my view, the benefits of COVID-19 vaccination outweigh the risks. I am strongly recommending these vaccines to my patients."Table. COVID-19 Vaccine Communication Strategies for the Clinical Encounter to Help Address MistrustThird, briefly describe the regulatory and development processes surrounding COVID-19 vaccines using accessible language. There may be confusion about and negative connotations with terms used to describe the vaccine regulatory process (10). The term "emergency use authorization," for instance, may lead to misunderstanding or exacerbate mistrust. Patients may believe that a new vaccine, for instance, has been authorized "emergently" before any data could be reviewed, harking back to days of experimentation on enslaved people, indigenous people, prisoners, immigrants, and unknowing Black Americans. Consider simple factual statements that avoid confusing terminology, such as "The FDA has authorized these vaccines now after reviewing a lot of evidence carefully" (see also the bottom part of the Table).Lastly, acknowledge uncertainty. The shortage of COVID-19 vaccines is unprecedented, and delivery schedules are changeable. There is much not yet known about COVID-19 vaccines, particularly regarding their long-term safety, their effect on transmission of severe acute respiratory syndrome coronavirus 2, and their efficacy against new strains. Acknowledging uncertainty creates transparency, and transparency is key to facilitating trust during public health emergencies.COVID-19 vaccines are not routine vaccines, nor are these routine circumstances. This past year has laid bare harsh health disparities and structural injustice in the United States, activating and exacerbating mistrust among people of color. Clinicians need to address this mistrust to help patients at highest risk for COVID-19 gain the benefits of COVID-19 vaccines. Prioritizing these discussions now in routine clinic visits, even over other health maintenance or stable chronic disease management issues, may help increase the acceptance of COVID-19 vaccinations and improve health outcomes among persons of color.References1. Centers for Disease Control and Prevention. Talking to recipients about COVID-19 vaccines. 2 November 2020. Accessed at www.cdc.gov/vaccines/covid-19/hcp/talking-to-patients.html on 7 December 2020. Google Scholar2. COVID Collaborative; UnidosUS; NAACP. Coronavirus Vaccine Hesitancy in Black and Latinx Communities. 2020. Accessed at https://static1.squarespace.com/static/5f85f5a156091e113f96e4d3/t/5fb72481b1eb2e6cf845457f/1605837977495/VaccineHesitancy_BlackLatinx_Final_11.19.pdf on 7 December 2020. Google Scholar3. Funk C, Tyson A. Intent to get a COVID-19 vaccine rises to 60% as confidence in research and development process increases. Pew Research Center; 3 December 2020. Accessed at www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/ on 14 December 2020. Google Scholar4. Hamel L, Kirzinger A, Muñana C, et al. KFF COVID-19 vaccine monitor: December 2020. Kaiser Family Foundation; 15 December 2020. Accessed at www.kff.org/coronavirus-covid-19/report/kff-covid-19-vaccine-monitor-december-2020/ on 15 December 2020. Google Scholar5. Alsan M, Stanford FC, Banerjee A, et al. Comparison of knowledge and information-seeking behavior after general COVID-19 public health messages and messages tailored for Black and Latinx communities: a randomized controlled trial. Ann Intern Med. 2020. doi:10.7326/M20-6141 MedlineGoogle Scholar6. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. Guilford Pr; 1991. Google Scholar7. Dempsey AF, Pyrznawoski J, Lockhart S, et al. Effect of a health care professional communication training intervention on adolescent human papillomavirus vaccination: A cluster randomized clinical trial. JAMA Pediatr. 2018;172:e180016. [PMID: 29507952] doi:10.1001/jamapediatrics.2018.0016 CrossrefMedlineGoogle Scholar8. VitalTalk. COVID collaborative resources. 2021. Accessed at www.vitaltalk.org/topics/covid-collaborative-resources/ on 22 January 2021. Google Scholar9. National Vaccine Advisory Committee. Recommendations from the National Vaccine Advisory Committee: standards for adult immunization practice. Public Health Rep. 2014;129:115-23. [PMID: 24587544] CrossrefMedlineGoogle Scholar10. Liu BF, Quinn SC, Egnoto M, et al. Public understanding of medical countermeasures. Health Secur. 2017;15:194-206. [PMID: 28388223] doi:10.1089/hs.2016.0074 CrossrefMedlineGoogle Scholar Comments 0 Comments Sign In to Submit A Comment Guglielmo M. Trovato*, MD, PhD; Simon D. Taylor-Robinson**, MD, FRCP FWACP; Paulo Alberto De Souza Lopes***, BSc and Ahmed A. A. Suliman****, MD*The School of Medicine. University of Catania. Catania, Italy. **Dept Surgery and Cancer. Imperial College London. London. United Kingdom ***Department of Medicine, UAI Universidad Abierta Interameri18 February 2021 COVID-19 VACCINES MISTRUST COMPOUNDED BY FAKE-NEWS, INEQUALITIES AND BIASES. TO THE EDITOR: As a group of Medical Professionals from around the world, we found the recent article published in your journal on the mistrust of the medical profession with respect to the COVID-19 pandemic by black and ethnic minority populations in the United States particularly interesting and stimulating. [1] The key issue in the article by Opel and colleagues is the elegant analysis of the roots of such mistrust in the medical profession, well identified as multifactorial and not restricted to concerns about COVID-19 vaccine safety and efficacy. It seems to be rooted in a history of unethical medical and public health experimentations, involving communities of color, in addition to structural inequities in healthcare provision and representation in governmental institutions in the United States. [1] The current disparities in access to reliable and timely diagnostics and treatment add to this feeling of resentment and mistrust. [2] This issue was identified recently when considering the response to emerging infectious disease threats.[3] We are reminded of the lack of universality in the COVID-19 pandemic preparedness, given that most of the written paradigms emanate from the Global North.[3] The active non-inclusion of black and ethnic minority populations is of great concern, not only in the United States, but also in other countries of the Global North with mixed populations, such as the United Kingdom. We believe that the medical profession in the developed world has done little to increase the confidence of the population groups concerned. However, the situation is quite different in much of Africa and Latin America, where the request for protective vaccinations is strongly desired by the local populace, and actively supported by an engaged medical profession. An area not highlighted by Opal and colleagues is the use social media to maximize vaccine confidence and uptake. [4] In our opinion, the medical profession misses a huge opportunity to reach all parts of society if social media platforms are not engaged by government and by professional medical bodies. Globally, there remains willingness to be vaccinated. [5] This advantage should not be lost, using well-calibrated media strategies targeting all sectors of the population, both in the United States and in other countries with mixed populations, such as in Europe, where ethnic minorities remain reluctant to engage with the medical profession. REFERENCES. 1. Opel DJ, Lo B, Peek ME. Addressing Mistrust About COVID-19 Vaccines Among Patients of Color. Ann Intern Med. 2021 Feb 9. doi: 10.7326/M21-0055. Epub ahead of print. PMID: 33556271. 2. Escobar GJ, Adams AS, Liu VX, Soltesz L, Chen YI, Parodi SM, Ray GT, Myers LC, Ramaprasad CM, Dlott R, Lee C. Racial Disparities in COVID-19 Testing and Outcomes : Retrospective Cohort Study in an Integrated Health System. Ann Intern Med. 2021 Feb 9. doi: 10.7326/M20-6979. Epub ahead of print. PMID: 33556278. 3. Paules CI, Eisinger RW, Marston HD, Fauci AS. What Recent History Has Taught Us About Responding to Emerging Infectious Disease Threats. Ann Intern Med. 2017;167:805-811. doi: 10.7326/M17-2496. PMID: 29132162. 4. Patten D, Green A, Bown D, Russell C. Covid-19: Use social media to maximise vaccine confidence and uptake. 2021;372: n225. doi: 10.1136/bmj.n225. PMID: 33500243. 5. Caserotti M, Girardi P, Rubaltelli E, Tasso A, Lotto L, Gavaruzzi T. Associations of COVID-19 risk perception with vaccine hesitancy over time for Italian residents. Soc Sci Med. 2021; 272:113688. doi: 10.1016/j.socscimed.2021.113688.. PMID: 33485215. Author, Article, and Disclosure InformationAuthors: Douglas J. Opel, MD, MPH; Bernard Lo, MD; Monica E. Peek, MD, MPH, MSAffiliations: University of Washington School of Medicine, Seattle, Washington (D.J.O.)University of California, San Francisco, San Francisco, California (B.L.)University of Chicago, Chicago, Illinois (M.E.P.).Acknowledgment: The authors thank Sean O'Leary, MD, MPH, for his input on the top part of the Table and Barbara Pahud, MD, MPH, and Doriane Miller, MD, for their input and critical review of the bottom part of the Table.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-0055.Corresponding Author: Monica E. Peek, MD, MPH, MS, 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637; e-mail, mpeek@medicine.bsd.uchicago.edu.Current Author Addresses: Dr. Opel: University of Washington School of Medicine, 1900 Ninth Avenue, M/S: JMB-6, Seattle, WA 98101.Dr. Lo: University of California San Francisco School of Medicine, 1701 Divisidero Street, Fifth Floor, San Francisco, CA 94115.Dr. Peek: 5841 South Maryland Avenue, MC 2007, Chicago, IL 60637.Author Contributions: Conception and design: B. Lo, D.J. Opel, M.E. Peek.Drafting of the article: B. Lo, D.J. Opel, M.E. Peek.Critical revision for important intellectual content: B. Lo, D.J. Opel, M.E. Peek.Final approval of the article: B. Lo, D.J. Opel, M.E. Peek.This article was published at Annals.org on 9 February 2021. 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