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Despite disparities in COVID-19 morbidity and mortality among marginalized populations, as predicted by the “inverse equity hypothesis”, with each innovation in COVID-19 treatments and vaccines, uptake is higher among wealthier and more social connected segments of the population, thereby exacerbating inequity. Amid persistent disparities in COVID-19 vaccination, we conducted a scoping review to identify multilevel determinants of COVID-19 vaccine hesitancy (VH) and undervaccination among marginalized populations in the United States.
Methods
We utilized the scoping review methodology developed by the Joanna Briggs Institute. We developed a search string and explored 7 databases to identify peer-reviewed articles published from January 1, 2020–October 31, 2021 (the initial period of U.S. COVID-19 vaccine availability), focused on (>50%) marginalized populations, and adults ≥18-years-old. Search results were uploaded into Covidence software and screened by teams of two reviewers. Data were extracted and determinants of VH categorized using the WHO “Vaccine Hesitancy Determinants Matrix” (structural, social/community, individual, and vaccine-specific). We combined frequency analysis and narrative synthesis to describe factors influencing COVID-19 vaccination among marginalized populations. Findings are reported according to PRISMA-ScR guidelines.
Results
The search captured 2,496 non-duplicated records, scoped to 50 peer-reviewed articles: 11 (22%) focused on African American/Black people, 9 (18%) people with disabilities, 4 (8%) justice-involved people, and 2 (4%) each on Latinx, people living with HIV/AIDS, people who use drugs, and LGBTQ+ people; 18 addressed more than one marginalized population (also including Asian people, immigrants/refugees, people experiencing homelessness). Structural factors (described in 44/50 articles) comprised medical mistrust (of healthcare systems, government public health, the pharmaceutical industry) and barriers in access due to unemployment, unstable housing, lack of transportation, no/low paid sick days, digital literacy/access, and lack of culturally and linguistically appropriate information. Social/community factors (36 articles) including trust in a personal healthcare provider (HCP), altruism, family influence, and social proofing mitigated VH. At the individual level (27 articles), low perceived COVID-19 threat and negative vaccine attitudes were associated with VH. COVID-19 vaccine-specific factors (40 articles) included vaccine safety, side effects, and efficacy.
Conclusions
We identified multilevel determinants of COVID-19 vaccination, with a preponderance of structural factors—logistical, financial, linguistic, cultural, and technological barriers in access, and systemic medical mistrust—associated with undervaccination. Approaches to undervaccination among marginalized populations that focus predominantly on individual-level decision-making elide critical systemic barriers to vaccination. Social/community, individual, and vaccine-specific concerns underlying VH were mitigated by trust in a personal HCP/usual-care venue, culturally tailored information addressing population-specific concerns, and altruistic motivations to protect one's family and community; nevertheless, usual sources of care were disrupted in the pandemic, more so among marginalized groups. As culturally competent professionals, social workers can contribute to addressing decisional conflict underlying vaccine hesitancy by listening to and respecting client concerns, including those based on historical and present-day racism and stigma, and empowering individuals to make informed decisions. As an equity concern, social workers have key roles to play in addressing barriers to COVID-19 vaccination through advocating and facilitating access to culturally competent healthcare and reducing logistical, technological, linguistic and financial barriers.