Medical Trustworthiness and COVID-19: Examining Health Beliefs and Vaccine Uptake in Disinvested Black Communities

In the United States, Black communities exhibit high levels of medical mistrust, largely due to historical and contemporary marginalization exacerbated by structural racism. The COVID-19 pandemic highlighted the devastating repercussions of such racism, given inequities in prevention and treatment. For example, Black individuals experienced disproportionate mortality. This study investigates the mediating effect of medical mistrust between participants’ health beliefs and vaccine uptake among predominantly Black residents in New Jersey and Illinois, who are medically and socially vulnerable to COVID-19. Data for this analysis were collected as part of two randomized controlled trials (R01MD010629 and U01AI169469) testing adaptive interventions to increase COVID-19 testing in historically disinvested and predominantly Black communities. The research project implemented community-based participatory principles throughout all phases.

A social determinants of health framework, integrating Bogart’s multi-level model of medical mistrust and the Health Belief Model (HBM), to guide a cross-sectional analysis of baseline data from 1,159 participants. Control variables included demographics (e.g., age, gender, race, religion), structural factors (e.g., income, education, marital status), HBM constructs (e.g., perceived threat, benefits, barriers), and medical mistrust (Kalichman COVID-19 scale). The outcome variable was self-reported COVID-19 vaccination status (yes/no). Descriptive statistics and data screening were conducted in SPSS v29. Logistic regression, structural equation modeling (SEM), and moderation analyses were performed in R (Mountain Hydrangea) using the Lavaan package.

Out of 1,159 participants, 973 were complete cases. Most identified as Black (77%) and male (49%), with a mean age of 43 years. About 70% reported an annual income below $20,000, and 42% were unvaccinated. Data met assumptions for normality and multicollinearity.

SEM results showed that fear of COVID-19 (β = 0.11, p < .001) and self-efficacy (β = 0.02, p = .001) were positively associated with medical mistrust. In turn, medical mistrust significantly decreased the odds of vaccine uptake (β = -0.30, p < .001). Model fit was strong (RMSEA = 0.04, SRMR = 0.06, CFI = 0.98). Moderation analysis revealed that marital status and religious affiliation influenced the strength of associations. Among participants who were not never married, fear of COVID-19 had a stronger effect on mistrust (β = 0.18, p = .001), and mistrust significantly reduced vaccination likelihood (β = -0.35, p < .001). For never-married individuals, self-efficacy was a stronger predictor of medical mistrust (β = 0.03, p < .001).

Among Christians, fear and self-efficacy did not significantly impact mistrust, but mistrust still predicted lower vaccine uptake (β = -0.34, p < .001). Among non-Christians, both fear (β = 0.19, p < .001) and self-efficacy (β = 0.02, p = .001) were significant predictors of mistrust, which also reduced vaccine uptake (β = -0.21, p = .001).

Medical mistrust mediates the link between health beliefs and vaccine behavior, particularly among socially vulnerable Black populations. Intersectional factors like marital status and religious affiliation influence these pathways. Trust-building strategies tailored to relationship status and faith context—especially through family- and faith-based channels—are critical for increasing vaccine equity. Future efforts must address structural racism and community trust to improve public health outcomes.