Promoting COVID-19 Vaccination Equity

March 18, 2021

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

As COVID-19 vaccines are rolled out across the United States, there is an urgent need to increase vaccination rates among people of color, and primary care providers may be an important part of the answer.

Black and Brown people are disproportionately likely to be essential workers, live in environments that do not permit physical distancing, and lack access to healthcare—factors which contribute to higher risk of infection and poorer outcomes. Yet vaccination among Black Americans lags far behind white Americans in the 16 states that collect data by race.

While the causes are many and complex, one factor is Black Americans are less likely to believe that vaccines are safe and effective. This lack of confidence in the medical establishment, the natural consequence of centuries of maltreatment by healthcare institutions, is often referred to as “medical mistrust.” While the Tuskegee syphilis experiments of the mid-20th century are frequently cited in this context, racism in healthcare is decidedly not a thing of the past. As Jessica Jaiswal, Behavioral Public Health Scientist at the University of Alabama, writes, medical mistrust may be better described as “inequality-driven mistrust among communities that have been made vulnerable by historical and ongoing structural inequities.”

With COVID-19, public health leaders find themselves in the quandary of trying to rapidly foster trust in a vaccine among the very people who’ve long been deceived, harmed, and neglected by the systems that produced and are delivering it.

Findings from our research with Black women who’ve been involved in the criminal legal system may help inform vaccination efforts, particularly as Black people are disproportionately burdened by the criminal legal system in the United States. We examined trust in healthcare systems and primary care providers among 193 Black women in Oakland, California, who were insured through Medicaid, had a primary care provider they could identify by name, and had a history of incarceration or probation. While women in the study reported a low level of trust in “healthcare organizations” writ large, they had a high level of trust in their individual providers.

Using the LaVeist Medical Mistrust Index, we found the majority of women “agreed” or “strongly agreed” with statements such as, “Patients have sometimes been misled or deceived by healthcare organizations” and “When healthcare organizations make a mistake, they usually cover it up.” On a scale that ranged from 1 (lowest trust) to 4 (highest trust), the mean score was 2.0.

By contrast, we found a substantially higher level of trust in individual providers. Using the Wake Forest Physician Trust Scale, we found that over two-thirds of women “agreed” or “strongly agreed” with statements such as “You completely trust your doctor’s decisions about what treatment is best for you” and “Your doctor only thinks about what is best for you.” On a scale that ranged from 10 (lowest trust) to 50 (highest trust), the mean score was 37.

These findings suggest that primary care providers may play an important role in the provision of COVID-19 vaccines to people with inequality-driven mistrust in the healthcare system. Equipping providers with resources to discuss vaccine-related concerns with their patients and to administer the vaccine to them personally could go a long way towards facilitating vaccine acceptance.

In order to reach the groups most vulnerable to COVID-19, we must utilize strategies that recognize the legacy of racism and mistrust in medical institutions. Making vaccines available in primary care settings, and building on ongoing, positive relationships with providers in those settings, is one way to increase vaccine acceptance and protect the health of Black Americans.

This work is supported by the National Institute on Minority Health and Health Disparities (grant #R01MD010439).

**Feature photo obtained by standard license on Shutterstock.


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Jennifer Lorvick

Jennifer Lorvick, DrPH, is a Senior Public Health Scientist in the Community Health and Implementation Research Program at RTI International. She specializes in community-based research with marginalized populations. Her most recent work explores healthcare utilization by women impacted by the criminal legal system.


Jordana HembergJordana Hemberg, MPH, is a Public Health Analyst at RTI International within the Community Health and Implementation Research Program. She serves as Associate Project Director on NIH-funded research working with marginalized populations in community-based settings.




Megan Comfort, PhD, is a Senior Research Sociologist in the Youth, Violence Prevention, and Community Justice Program at RTI International. Her work focuses on the health and wellbeing of people involved in the criminal legal system and their family members.

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