The Role of Primary Care Providers in Promoting COVID-19 Vaccination Equity

There is an urgent need to improve the acceptability of COVID-19 vaccination among people of color in the United States, and primary care providers may be part of the answer. Black and brown people are disproportionately likely to be essential workers, live in environments that do not permit social distancing, and lack access to health care–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 people 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 health care institutions, is often referred to as “medical mistrust.” While the Tuskegee syphilis experiments of the mid-20^th century are frequently cited in this context, racism in health care is decidedly not a thing of the past.  As Jessica Jaiswal 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 have long been deceived, harmed, and neglected by the systems that produced and are delivering it. 

Findings from our research with Black women who have been involved in the criminal legal system may help inform vaccination efforts. Black people are disproportionately burdened by the criminal legal system in the U.S. We examined trust in healthcare systems and primary care providers among 193 Black women in Oakland, CA who had Medicaid, a primary care provider they could identify by name and a history of incarceration. 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 to facilitating vaccine acceptance. Indeed, some primary care providers have been frustrated by their lack of inclusion in the national vaccination effort.

Efforts such as mass vaccination sites and pharmacy-based vaccination are a welcome and overdue public health response to the pandemic. However, to reach the groups most vulnerable to COVID-19, alternative strategies are needed, 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 piece was originally published by the Center for Primary Care at Harvard Medical School.