Multilevel Factors Affecting COVID-19 Vaccination Among African American Communities in South Carolina

Background: Persistent health disparities has led to significant public health challenges, especially for African American (AAs) communities, and have been exacerbated by the COVID-19 pandemic. Achieving high population vaccination rates are crucial to controlling the virus’ spread. However, AAs have higher rates of COVID-19 infection and mortality than Whites, yet their vaccination rates remain relatively low. The dissertation aimed to investigate the multilevel factors and mechanisms that affect AAs’ vaccination behavior. The first objective is to assess the impact of the intrapersonal level factor (i.e., perceived barriers to vaccination) on vaccination behavior. The second objective is to investigate the impact of the interpersonal level factor (i.e., health provider’s recommendation) on vaccination behavior. The third objective is to examine the impact of the structural level factor (i.e., racial residential segregation) on vaccination rates between AAs and Whites. Methods: The dissertation employed two types of data. Studies 1 and 2 utilized data from a cross-sectional study among 2,029 AAs in South Carolina (SC) from November 2021 to September 2022. Variables such as demographic information, perceived barriers to vaccination, information seeking about COVID-19 vaccines, trust in public health agency, confidence in COVID-19 vaccines, and vaccination behavior were analyzed using descriptive statistics, correlation analysis, and structural equation modeling to investigate mediation effects. Study 3 analyzed county level data across 46 counties in SC to examine the impact of racial residential segregation (e.g., an index of dissimilarity) on vaccination disparities, employing correlation and regression analyses. Results: Findings revealed a complex interplay of factors at different levels. Study 1 demonstrated that perceived barriers are inversely related to confidence in COVID-19 vaccines, which is, in turn, negatively correlated with vaccination uptake. AAs’ confidence in COVID-19 vaccines mediated the relationship between perceived barriers and vaccination uptake. In addition, information seeking about COVID-19 vaccines moderated the relationship between perceived barriers to vaccination and confidence in COVID-19 vaccines. Study 2 showed that confidence in COVID-19 vaccines mediated the relationship between health care provider’s recommendations and AAs’ vaccination uptake. Trust in the public health agency was found to moderate the relationship between health care provider’s recommendations and confidence in vaccines, with higher trust levels strengthening the impact of provider recommendations on confidence in vaccines. For study 3, among the 46 counties analyzed, 25 were identified as least segregated, and 21 as most segregated. Findings revealed that in the most segregated counties, AAs were vaccinated at a rate 9.59% lower than Whites for at least one dose. In the least segregated counties, AAs received at least one dose at a rate 9.25% higher than Whites. A significant correlation was found between the percentage of AAs vaccinated with at least one dose and the level of residential segregation, indicating a negative association between segregation and vaccination rates among AAs. Conclusion: To enhance vaccination rates in AA communities, it is crucial to implement interventions specifically tailored to overcome the unique barriers to vaccine uptake. Health care professionals should give priority to community engagement and collaboration to facilitate the dissemination of trustworthy vaccine information, thereby boosting vaccine confidence and acceptance. In addition to emphasizing credible healthcare recommendations, there is a need to rebuild and reinforce trust in public health agencies. By adopting a dual approach that underscores both medical advisement and trust in the public health infrastructure, strategies can be more efficacious in addressing vaccine hesitancy among AAs. Furthermore, the consideration of racial residential segregation is essential in the allocation of resources for vaccination promotion. Recognizing and addressing structural factors, such as residential segregation, allows for more tailored strategies that cater to the most affected communities. This targeted approach can enhance vaccination rates among AAs populations, thereby improving the overall preparedness of the health care system for future public health challenges.