Covid-19 Vaccine Hesitancy and Under-Vaccination among Marginalized Populations in the United States and Canada: A Scoping Review

Abstract

Background Amid persistent disparities in Covid-19 vaccination and burgeoning research on vaccine hesitancy (VH), we conducted a scoping review to identify multilevel determinants of Covid-19 VH and under-vaccination among marginalized populations in the U.S. and Canada. Methods Using the scoping review methodology developed by the Joanna Briggs Institute, we designed a search string and explored 7 databases to identify peer-reviewed articles published from January 1, 2020–October 25, 2022. We combine frequency analysis and narrative synthesis to describe factors influencing Covid-19 VH and under-vaccination among marginalized populations. Results The search captured 11,374 non-duplicated records, scoped to 103 peer-reviewed articles. Among 14 marginalized populations identified, African American/Black, Latinx, LGBTQ+, American Indian/Indigenous, people with disabilities, and justice-involved people were the predominant focus. Thirty-two factors emerged as influencing Covid-19 VH, with structural racism/stigma and institutional mistrust (structural)(n = 71) most prevalent, followed by vaccine safety (vaccine-specific)(n = 62), side effects (vaccine-specific)(n = 50), trust in individual healthcare provider (social/community)(n = 38), and perceived risk of infection (individual)(n = 33). Structural factors predominated across populations, including structural racism/stigma and institutional mistrust, barriers to Covid-19 vaccine access due to limited supply/availability, distance/lack of transportation, no/low paid sick days, low internet/digital technology access, and lack of culturally- and linguistically-appropriate information. Discussion We identified multilevel and complex drivers of Covid-19 under-vaccination among marginalized populations. Distinguishing vaccine-specific, individual, and social/community factors that may fuel decisional ambivalence, more appropriately defined as VH, from structural racism/structural stigma and systemic/institutional barriers to vaccination access may better support evidence-informed interventions to promote equity in access to vaccines and informed decision-making among marginalized populations.

“Going vaccine hunting” : Multilevel influences on COVID-19 vaccination among racialized sexual and gender minority adults—a qualitative study

“…In sum, the broader structural and social contexts that emerged as foundational to the COVID-19 vaccination experiences and perspectives of individuals occupying intersectional marginalized identities support the need for critical assessment and reconceptualization of “vaccine hesitancy” 14 , 28 , 29 and trust in vaccination. 64 Nevertheless, much of the burgeoning research on COVID-19 vaccine hesitancy among racialized populations appears to elide the latter part of the definition: “delay in acceptance or refusal of vaccination despite the availability of vaccination services ” 17 (p.4163) [emphasis added].…”

“…A semi-structured interview guide was developed based on published reviews and studies of vaccination and vaccine hesitancy 14 , 34 , 35 and informed by a social ecological framework. 36 The latter conceptualizes multilevel influences on health and wellbeing, including structural, social and community, and individual levels.…”

“…Nevertheless, several studies indicate higher levels of vaccine hesitancy and undervaccination among marginalized populations, along with rampant misinformation and the politicization of COVID-19 and measures to control it. 14–16 Defined as a delay in acceptance or refusal of vaccination despite the availability of vaccination services, 17 vaccine hesitancy has been identified as a substantial threat to global health. 1 Greater COVID-19 vaccine hesitancy has been described among Black and other racialized populations in Canada 18–20 and the U.S. 21–24 in contrast to White populations, although with inconsistent findings.…”

Acceptability of a future HIV vaccine: A rapid scoping review

“…Important message targeting strategies include (1) translating the message into the languages spoken by different populations, (2) addressing questions and concerns about the vaccine prevalent among their members, (3) disseminating the message through “opinion leaders” these populations consider to be knowledgeable and trustworthy, 35,70,73 and (4) having members of the different populations participate in the design and evaluation of different message versions. 12 Fifth, messages should encourage engagement and shared decision making, by inviting people to ask healthcare providers questions about the vaccine and also recommending that they consult close family and friends when making the decision to vaccinate or not. Sixth, messages should counteract the “reactance” caused by prescriptive advice, which some people perceive as a challenge to their freedom to choose.…”

“…As seen with COVID-19 vaccines, vaccine hesitancy is real and pernicious. 10–12 Persuasive health communication can be an effective tool in reducing hesitancy, and thereby maximizing HIV vaccine uptake and coverage. A prerequisite for such communication is exploring factors that influence HIV vaccine decision making, with special attention to attitudes and beliefs toward vaccination among potential recipients.…”