Overcoming COVID-19 Vaccine Hesitancy in Minority Communities

Minority communities are among the hardest hit by the COVID-19 pandemic in the United States, but have lower rates of vaccination than other groups. As of March 11, 2021, the majority of patients who have received at least 1 dose of a COVID-19 vaccine are White (67%); only 9% are Hispanic, 7% are Black, 5% are Asian, 2% are American Indian or Alaska Native, and <1% are Native Hawaiian or Other Pacific Islander.

In a recent webinar hosted by The American Journal of Nursing, nursing experts examined the causes of and strategies to overcome vaccine hesitancy in Black, Hispanic, Orthodox Jewish, and other underserved patient populations.

Vaccine hesitancy often stems from misinformation about vaccine efficacy and safety, lack of trust in the government and pharmaceutical companies, fear of deportation among undocumented immigrants, as well as inaccessible vaccination sites in underserved communities. Some patients wonder if COVID-19 death rates have been inflated for political purposes, if the disease is really that bad, and whether the benefits of the vaccine outweigh the risks of serious adverse effects.

Kristen Choi, PhD, MS, RN, emphasized the importance of giving the public clear and accurate information and trusting that they can handle, in some cases, complicated information. When administering the COVID-vaccine, clinicians should ask patients about their concerns and take the time to explain how and why the vaccines work, anticipated side effects, and what is happening in the body when side effects occur, she said.

Patients may need to be reassured that none of the COVID-19 vaccines currently in use contain a live virus and cannot cause COVID-19, said Dr Choi, who is an assistant professor of nursing and public health at the University of California, Los Angeles. Also, some patients believe a common conspiracy theory that the mRNA vaccines (Pfizer and Moderna) will alter their DNA, which is not the case.

Facts to counter concerns on vaccine safety were presented by Janell Routh, MD, MHS, of the Centers for Disease Control and Prevention (CDC) and are linked here.

Racism and the COVID-19 Pandemic

In Black communities and other communities of color “we are dealing simultaneously with a pandemic of racism in this country that is rooted in antiblackness and this country’s refusal to reconcile its very racist past,” said Sheldon D. Fields, PhD, RN, CRNP, FNP-BC, AACRN, FAANP, FNAP, FAAN, associate dean for equity and inclusion and research professor at The Pennsylvania State University College of Nursing.  

“The unrest that we all witnessed last summer sparked by the death of George Floyd that led to the rise of the Black Lives Matter movement to the witnessing of the insurrection on January 6, 2021, of our nation’s capital by a white supremacist mob, all feeds into the narrative that tells Black people that their lives matter less,” said Dr Fields, who is also the first vice president of the National Black Nurses Association (NBNA). “So the question then becomes, why should I trust the government?”

In response, the more than 100 chapters of the NBNA “have been meeting with people where they are,” including in rural areas, to offer a trusted voice and to educate patients on facts related to the vaccines, Dr. Fields said.  

Dr Fields is not surprised that vaccine rates are low in the Black community. Using New York City as an example, Dr Fields explained that mass vaccination sites were placed in the suburbs of the city that are not easily accessible to minority populations. The movement to increase vaccine supply at pharmacy retail chains also is not effective to reach minorities as pharmacies are more often located in white neighborhoods, he said.

“The issue of pharmacy deserts in a lot of brown and Black communities is very real,” Dr Fields said. Even a pharmacy that is 5 miles away may not be accessible to someone without transportation. Also, the race/ethnicity of vaccination teams often does not mirror the population in minority communities, which can be a barrier to vaccine uptake.

“We’ve got to take this to the people,” Dr Fields said. He also stressed the importance of leveraging kinship networks in the Black community. “So if not for yourself, then [get the vaccine] for others around you.” And if patients absolutely won’t get a vaccine, then he uses messaging about respecting the community with masks, hand washing, and social distancing. 

He suggested setting up vaccination sites at Historically Black Colleges and Universities, predominantly Black churches, and other places of faith with open parking lots (for social distancing) and other trusted entities such as federally qualified health centers, which are often located in Black and other underserved communities. To overcome transportation-related barriers, use mobile vans and offer home visits, he suggested.

Vaccine Hesitancy Among Hispanic Patients and Undocumented Immigrants

In the Hispanic community, limited English speaking skills and poor health literacy are substantial barriers to vaccination, said Gina Miranda-Diaz, DNP, MS/MPH, APHN-BC, H-O, Certified Contact Tracer, Fellow New York Academy of Medicine (FNYAM), policy and legislation chair of the National Association of Hispanic Nurses-New Jersey Chapter. Additionally, undocumented immigrants have concerns about having their information gathered into a system where they might be sought out or deported.

Nurses can help address vaccine hesitancy among minority patients by listening to patients’ concerns and pointing them to credible sources of information rather than listening to word of mouth or inaccurate sources (Table), said Dr Miranda-Diaz, who also is a New Jersey state-licensed health officer, licensed home health aide instructor, and president/CEO of Hudson Consultants LLC.

Table. COVID-19 Vaccine Resources for Patients

The Black Coalition Against COVID

The National Black Nurses Association

National Association of Hispanic Nurses

COVID-19 Prevention Network

Vaccine Finder

CDC Covid-19 patient resources

State-specific federally qualified health centers Provide vaccines to patients with Medicaid, on a sliding scale, and often free of charge regardless of immigration status

Many patients do not understand that the vaccine is free, Dr Miranda-Diaz said. While there may be administration costs involved in vaccine administration, patients who cannot afford these fees should be directed to facilities or clinics — such as federally qualified health centers — offering no-cost vaccines, she noted.

Also, President Biden “has said that he would not allow federal agents to be anywhere near the vaccinating centers,” Dr Miranda-Diaz noted. “People who want to get vaccinated do not have to reveal their immigration status and we have to go where they are.”

Dr Miranda-Diaz agreed with Dr Fields about the need to rethink the strategy of increasing vaccine supply at chain pharmacies to reach underserved communities. “Let nurses or practitioners who can get a mobile unit get out there put these vaccines in arms,” she said.

“Poverty, your inability to speak English, your immigration status should not be a cause of death,” she said.

Vaccine Hesitancy Among Orthodox Jewish Communities

Blima Marcus, DNP, RN, ANP-BC, OCN, works with cancer patients in primarily ultra-Orthodox Jewish communities in New York City. Like other vulnerable communities, her patient population is targeted by well-funded antivaccine organizations that know how to strengthen mistrust that may already be inherent in the population, she said.

Dr Marcus outlined 3 main concerns expressed by Orthodox Jewish patients:

1. What is in the COVID-19 vaccine?
2. Is the vaccine toxic?
3. Does the vaccine actually work?

“Some people try to fit narratives that resonate better with them, such as wondering if COVID death numbers are real or if they are somehow inflated and whether patients died from COVID or with COVID?,” said Dr Marcus, who is a nurse practitioner in ambulatory oncology as well as adjunct professor at Hunter College-Bellevue School of Nursing, City University of New York. She saw similar concerns during the measles outbreak among Orthodox Jewish communities in New York and New Jersey that started in October 2018.

In response to distrust stemming from initially confusing messages on mask wearing, Dr Marcus tells patients that this is one of the first times in history where we are watching science evolve “and it is messy.” As new evidence emerges, the CDC has had to backtrack and change recommendations. “When the [initial] recommendation was made not to mask, that was before we knew that asymptomatic transmission occurred. There was a delay in learning,” she said.

She emphasized the importance of having people from within the community become advocates or vaccine ambassadors. These trusted advocates can endorse scientific information when educating community members. Dr Marcus also is founder of the Engaging in Medical Education with Sensitivity (EMES) initiative.

Dr Marcus also uses cautious optimism to encourage vaccination in her oncology patients, many of whom “have isolated for over a year now refusing to leave their homes except for coming into the clinic for chemotherapy and appointments. They are the ones I’m giving messages of future hope of getting to a place where they can see their grandchildren and where they can feel less afraid.” Most of her oncology patients have received the vaccine, she said.

“The fatality rate [from COVID-19] for cancer patients is close to 20% to 25%, so definitely get the vaccine,” she said.

Fighting the Infodemic on Social Media

Misinformation on Twitter, Instagram, and Facebook continues to be a pronounced barrier to COVID-19 vaccination uptake. Nurses, who are often seen as trusted sources of information, can play a key role in arming the public with evidence-based facts and helping patients overcome vaccine hesitancy, the presenters said.

“Allowing lie after lie without breaking in and saying, ‘Hold off, this is false. And here’s a good resource you can read,’ is very important for the lurkers who may be reading along, but have not been yet given a rebuttal,” Dr. Marcus said. She suggests offering scientific information in a respectful response to help battle misinformation online.

However, Dr Marcus also knows when to cut her losses. “It is so important to keep that respect and step back when you feel you can no longer engage in good faith and be useful to the conversation,” she said.

References

Disseminating Facts, Dispelling Myths – Building COVID Vaccine Confidence in Communities. February 26, 2021.

Centers for Disease Control and Prevention. Vaccines and immunizations: training and education resources. Accessed March 12, 2021. www.cdc.gov/vaccines/covid-19/training-education-resources.html

This article originally appeared on Clinical Advisor