Vaccine Confidence in NYC: Thematic Analysis of Community Stories

1

Abstract

The vaccine community has produced extensive evidence on vaccine hesitancy, but research to understand the factors that affect public trust in vaccines and vaccine confidence among Black, Indigenous and People of Color (BIPOC) remains limited. To enrich extant literature, we present themes from 332 stories collected from predominantly BIPOC communities in New York City that explored motivators for vaccination during the COVID-19 pandemic. Stories were collected by trained community health workers from December 2021 to June 2022. The most frequently reported motivators to getting vaccinated against COVID-19 were related to preventing sickness and death from COVID-19 infection, for oneself and for others. Information from medical professionals, the news and social media, and community-based organizations contributed to decision-making about vaccines. Findings point to a strong sense of social solidarity, with the desire to protect and positively influence others, including friends, family, and the community at large, as salient motivators to vaccination. Accessible information through trusted messengers played a key role in decisions to get vaccinated. To better represent communities of color in literature, we call for more research on vaccine confidence and motivators for vaccination in BIPOC and other communities.

Background

Throughout the United States, including in New York City, Black, Indigenous and People of Color (BIPOC) bore the brunt of the morbidity and mortality resulting from COVID-19 (Kalyanaraman Marcello et al., 2020; Mude, Oguoma, Nyanhanda, Mwanri, & Njue, 2021). The arrival of effective vaccines to prevent COVID-19 infection and reduce hospitalizations and deaths was therefore widely celebrated. However, persistent disparities in vaccination rates prompted global discussion about the factors leading to low rates of vaccination in BIPOC communities (Trent, Seale, Chughtai, Salmon, & MacIntyre, 2022). Vaccine hesitancy was linked to rampant mistrust of government and the health system due to the decades of discrimination, neighborhood disinvestment, limited access to health care, health resources including culturally accessible information (Afzal et al., 2022; Rane et al., 2021). To date the perceived lack of enthusiasm for vaccination among BIPOC has dominated public and academic discourse on these disparities (Jarrett, Wilson, O’leary, Eckersberger, & Larson, 2015). Vaccine hesitancy thus stands as the dominant narrative frame about vaccination in BIPOC communities, leading to varied efforts to interpret the delay in acceptance or refusal of vaccines (McAteer, Yildirim, & Chahroudi, 2020)

First, we must acknowledge that in almost every setting, there are stakeholders who have doubts or difficulty deciding on vaccination (Jarrett, Wilson, O’leary, Eckersberger, & Larson, 2015). The reasons for this can be complex and context-specific, varying across time, place, demographics, and vaccine (Sallam, 2021). However, limiting the interpretation of individual actions and vaccine decision-making to the confines of vaccine hesitancy limits our ability to explore innovative strategies for community engagement and communication in BIPOC communities.

According to Susan Spiggle (1998) in the book “Representing Consumers” researchers often represent consumers by transforming data into a research narrative frame (Stern & Stern, 1998). To better represent the observed reality of New York City’s BIPOC communities, we have chosen to frame this article around vaccine confidence instead of vaccine hesitancy. A frame is a system of interpretation that serves as the background to a core message, setting the context for discussion, what is considered relevant information, and establishing the viewpoint from which we address a topic (Stern & Stern, 1998). Frames can make a dominant narrative seem true, natural, or inevitable, even when it is not. The CDC Vaccinate with Confidence framework defines vaccine confidence as the belief that vaccines work, are safe and are part of a trustworthy medical system (CDC, 2022). People must trust the system, including the processes and policies that lead to vaccine development, licensure, manufacturing, and recommendations for use, to feel fully confident in their decision to get vaccinated. This foundation of trust is critical and built over time (CDC, 2022). The framing around vaccine confidence influenced the sources of knowledge we considered legitimate and trustworthy and the attribution of responsibility for delays in acceptance or refusal of vaccines.

We present themes derived from stories of BIPOC New Yorkers in priority neighborhoods on why and how they made a confident, informed, autonomous decision about the COVID-19 vaccine. We share these findings as lessons to guide future community engagement efforts and to ensure that BIPOC communities are better represented in literature on decision-making practices around vaccine uptake.

Materials and Methods

The New York City Department of Health and Mental Hygiene (NYC DOHMH) formally launched the Public Health Corps, a partnership with community-based organizations (CBOs) to advance vaccine equity goals, in September 2021. Community partners were contracted to develop tailored messaging and to facilitate community conversations about COVID-19 in the 33 neighborhoods identified by the Mayor’s Taskforce on Racial Inclusion and Equity (TRIE) as priority for vaccine equity (City of New York, 2020). The Public Health Corps prioritized trauma-informed community engagement strategies and implemented storytelling, starting with telling their own vaccination stories, to build vaccine confidence in the TRIE neighborhoods.

Data Collection

Story collection was led by 34 CBOs contracted by the NYC DOHMH under the Public Health Corps Initiative as part of an ongoing evaluation to inform programming. Data was collected in two batches: one set between December 2021 and February 2022 (Winter), and another between April 2022 and June 2022 (Summer). Stories were sought from residents of the 33 TRIE neighborhoods with low vaccination uptake where CBOs had conducted outreach and education on COVID vaccines. The purpose was to accurately represent the personal journeys of New Yorkers who had been uncertain about vaccination but then decided to get vaccinated. Community members who shared their stories signed media release forms for their stories to be shared by the NYC department of health. For participants under 18 years old, parents signed the consent form, and the participant verbally agreed to the activity. Demographic information was not collected from participants. Findings from these stories were used to guide future programming and messaging by community partners.

Staff at the NYC DOHMH developed guidance for collecting stories from community members. This guidance included the objectives for this project, questions to ask community members, suggested media formats, and guidance on how to collect the information. The main question explored was, “What helped you make your decision to get vaccinated?” The Community Health Workers who led the story collection process were trained to ask follow-up questions for clarification and to capture additional information from community members.

Data Analysis

Data analysis was conducted by NYC DOHMH staff – including qualitative data analysts and program evaluators – as part of an ongoing process evaluation. Analysts conducted inductive (e.g., empirical observations from the data) and deductive (e.g., based on knowledge of vaccine confidence principles) thematic analysis to identify key themes related to vaccine confidence (e.g., motivators for getting the COVID-19 vaccine). NYC DOHMH qualitative analysts developed a codebook to organize the data (Table 1). The initial codebook development was based on themes that were derived from similar community feedback collected by the same CBOs during outreach activities, existing literature, and a general understanding of vaccine confidence and hesitancy principles (CDC, 2022). Empirical codes, which were based on emerging themes that arose from the data, were added throughout the analysis process to accurately reflect the data. Analysts responsible for coding the data performed intercoder reliability tests and attended regular coding meetings to address discrepancies, discuss emerging themes, and add empirical codes to the codebook. NVivo software was used to organize and code the data.

Table 1. Codebook used to identify key themes

Motivators	Brief definitions
Prevent COVID-19 infection, illness, and death	Getting vaccinated in order to avoid/prevent infection, sickness, or death from COVID-19. Includes general mentions of “being safe” or “staying healthy.”
Protect family members	Vaccination to avoid spreading the virus to family members, especially those who you live with or see frequently.
Protect others and the community	Vaccination to avoid spreading the virus to others in the community, which may include friends or strangers. Includes a desire to protect more vulnerable individuals.
Preexisting condition or risk factor	Understanding that there is a higher risk for sickness and death if you have a preexisting condition. Getting vaccinated due to higher risk of severe reaction to COVID-19 infection.
Experience with a previous COVID-19 infection	Getting vaccinated because you have previously gotten COVID-19 and had a bad reaction. Reference to the previous infection with COVID-19, and how bad it was, as a reason for getting the vaccine.
Anecdotes from other who had COVID	Influenced by personal stories from community members about family, friends, coworkers, etc. who were infected with COVID-19 and either got sick or passed away as a result. Does not include mentions of “people dying” on the news; only personal stories.
To set a good example for others	Getting vaccinated to influence others – including family, friends, coworkers, and neighbors – to get vaccinated, too.
To “end the pandemic”	Desire to end the pandemic, so that “things return to normal.” Belief that getting vaccinated will contribute to ending the pandemic.
Travel, restaurants, and events	Vaccination in order to be able to travel, go to restaurants and bars, or attend events. Includes other activities that require vaccination.
Job or school mandate	Getting vaccinated because of a job or school mandate or requirement.
Based on data, research, or evidence	Consideration of data, research, or evidence when choosing to get vaccinated. Includes citing research that the vaccine works or that COVID-19 is a serious health issue. Reference to specific sources, numbers, or data. Doesn’t include vague statements, like “people are dying.”
Health education from outreach	Getting vaccinated as a result of conversations with community health workers that provide information/education about COVID-19.
Advice from medical professional	Getting vaccinated as a result of advice from a doctor, nurse, or other medical professional.
Advice from friends and family	Getting vaccinated as a result of advice from family members or friends.

Results

A total of 332 stories were collected and analyzed by qualitative specialists at the NYC DOHMH. Various media formats were used to submit stories, including audio, video, text, and photos (Table 2). Most stories were collected in English, with a subset in Spanish, and one story in French (Table 3). Although all five boroughs were represented, almost 80% of stories came from Brooklyn and the Bronx (Table 4). Participant demographic information was not collected, but the age range or respondents included teenagers, adults, and elderly.

Table 2. Summary of media formats used for story collection

File type	Winter	Summer	TOTAL
Audio	4	6	10
Video	52	51	103
Text	76	86	162
Photo	37	20	57
TOTAL	169	163	332

Table 3. Language breakdown

Language	Winter	Summer	TOTAL
English	147	140	287
Spanish	21	23	44
French	1	0	1
TOTAL	169	163	332

Table 4. Distribution of stories across the five NYC boroughs

Borough	Winter	Summer	Total	Percent
Manhattan	12	18	30	9%
Brooklyn	68	48	116	35%
Bronx	80	67	147	44%
Queens	9	24	33	10%
Staten Island	0	6	6	2%
TOTAL	169	163	332	100%

Common Motivators

The most frequently reported motivators for getting vaccinated against COVID-19 were related to preventing sickness and death from COVID-19 infection, for self and others. Community members were driven by a desire to protect others and to have a positive impact in their communities. Thematic frequency is outlined below (Table 5), along with summaries and informative quotes to illustrate what vaccine confidence looks like from community members directly (Table 6).

Table 5. Additional informative quotes from community members, organized by theme

Theme	Manhattan	Brooklyn	Queens	Bronx	Staten Island
Prevent COVID-19 infection, sickness, and death	“He felt that the virus was a threat to people everywhere, and vaccines offered a chance to protect himself.” (Story from Alliance for Positive Change)	“The COVID-19 vaccination was comforting in a sense that I felt somewhat protected to a degree that I have a fighting chance against the virus.” (Story from Caribbean Women’s Health Association)	“I didn’t want to die, I didn’t want to be hospitalized.” (Story from Relume Foundation Inc)	“The vaccine made me feel safer. I know now that if I get COVID-19, my body will be able to fight it. I won’t have to worry about being hospitalized, and most importantly, my daughter won’t be left alone.” (Story from Bronx Works)	“I decided to take the vaccine as a way to protect myself and others from COVID. In case I contract it again, I hope I wouldn’t fall into fatality.” (Story from Community Health Action of Staten Island (CHASI))
Previous infection andanecdotes from others who got COVID	“I did get Covid in March 2020 when New York was the epicenter. I was very sick and I was very afraid. After I got Covid and then the vaccine I felt protected. I knew if I were to get it again it would be less hurtful.” (Story from SMART)	“I contracted COVID, and I was really sick. So what motivated me to get the vaccine is to improve my quality of life and to prevent any future harm to others, spread it to others.” (Story from Church Avenue Merchant Block Association (CAMBA Inc.))	“I have family and friends I have witnessed having COVID, and it’s serious.” (Story from Epicenter)	“The decision that led me to get vaccinated was because my husband was hospitalized for three months on oxygen. And seeing so many people hospitalized.” (Story from Transnational Villages Network)	n/a
Preexisting condition or risk factor	“She is a chronic cigarette smoker and reports having other habits that she calls an unhealthy lifestyle, so she recognized complications from COVID-19 could be serious for her.” (Story from Alliance for Positive Change)	“I have asthma and COPD, so I needed that booster.” (Story from CABS Home Attendant Services Incorporated)	“I don’t want to get in trouble. I’m diabetic and I must take care of myself!” (Story from Epicenter)	“I live in the Bronx, I am 15 years old, and I got my vaccine because my parents decided that I would need it due to me having asthma.” (Story from Neighborhood Initiatives Development Corp. (NIDC))	“Truthfully, I feel like if my family wasn’t vaccinated my mom may have not survived when she had COVID, she was having a very hard time breathing because she also has asthma.” (Story from Community Health Action of Staten Island (CHASI))
Protect others andthe community	“After seeing the millions of people die, bodies in the street, that visual alone, I don’t understand why people don’t think that is real. That’s real. Protect yourself and your neighbors. Save yourself and save another life.” (Story from SMART)	“I wanted to keep myself safe for my family since I am my mother’s only child. And I also wanted to protect myself and my New York City community, because we all need to protect each other. That’s what New Yorkers do.” (Story from Neighborhood Housing Services of Brooklyn)	“Since I am very young, most likely getting COVID would only get me very sick rather than kill me. Getting vaccinated was a way to protect the elderly, immunodeficient, and those who are unable to get the vaccine.” (Story from Relume Foundation Inc.)	“A person close to my sister died because they didn’t want to get vaccinated, because of their beliefs, their doubt. And if they had gotten the vaccine, they would be alive. I think yes, it’s a personal decision, but also, it involves all of our risk, because you and me are in the same society.” (Word of Life International)	“I think that everyone is entitled to their own choice to get vaccinated, but I personally think it’s a good move to be vaccinated, not only to work but also for the health’s sake of you, your family & those around you.” (Story from Community Health Action of Staten Island (CHASI))
Protect family members	“It’s just preparing you and the person that you’re with. Like, if I was with my sister and I was outside and I had been vaccinated, also it’s protecting her because I’m with her and she’s with me, like, it’s protecting in between both of us.” (Story from SMART)	“Everybody in our whole entire family got vaccinated and boosted. We didn’t play, because we’re a very tight family and we like to visit each other.” (Story from CABS Home Attendant Services Incorporated)	“The ultimate factor that influenced my decision to get vaccinated was my family. While in Rockaway, I frequently see my grand- parents. Before we were all vaccinated, there was an overwhelming s anxiety when someone sniffled.” (Story from RISE Rockaway)	“I live with my family, and I wanted to keep all of us safe. It’s highly important for people to get the vaccine because it’ll keep others safe.” (Story from Neighborhood Initiatives Development Corp. (NIDC))	n/a
Travel, events, and putting an end to the pandemic	“After seeing the number of people being affected by this virus, physically or mentally, I wanted it to be gone. I got vaccinated to save lives, my older family members, my friends, myself, even people on the street.” (Story from SMART)	“I wanted to get it so that I could do things like my get driver’s permit and take driving lessons, go to the movies, etc.” (Story from Arab-American Family Support Center)	“I’m grateful for the vaccine. I live abroad much of the year and do a great deal of flying, so prior to the vaccine this travel was very anxiety-inducing.” (Story from RISE Rockaway)	“I hope that everyone can get the vaccine and be able to go out and have fun without worrying about getting sick I would like to go out with my friends without worrying about a mask or being sick after.” (Story from Neighborhood Initiatives Development Corp. (NIDC))	“I feel like because I am only 16, I can express that the vaccine has helped myself and my friends be able to live life again. The worry of being so trapped from hanging out, knowing you took the steps to protect others, is gone.” (Story from Community Health Action of Staten Island (CHASI))
Trust in science, data, research, or evidence	“Team provided them information regarding the FDA-approved vaccines and facts showing the vaccines were safe… They have both received their first shots, influenced by the sense of safety, and the monetary incentive offered by the city.” (Story from Alliance for Positive Change)	“What helped me make the decision to get vaccinated was researching the information and work put into creating the vaccine.” (Story from Brooklyn Community Services)	“I always knew I would get the COVID-19 vaccine as soon as it became available. I had been reading about the progress that was being made with the vaccine and I completely trusted the process and that when it was approved it would be safe to take.” (Story from RISE Rockaway)	“Growing up in the US, I never saw polio… Seeing it up front made me understand the importance of vaccination. So, when COVID vaccines came around, I thought: there’s an end to this human suffering.” (Story from Sauti Yetu)	“At lunch I was speaking to my friends and asked if they are doing it and was told no. My reply was, you fear what? Did you not get vaccinated from birth on; it’s the same thing! Did you ever take over the counter meds because most are not FDA approved.” (Story from Community Health Action of Staten Island (CHASI))
Advice from doctors, friends, and family	“Eventually, friends convinced me that vaccination was the better route to take. One friend said: We are all going to die sooner or later, and you stand a better chance getting the vaccine than getting COVID again.” (Story from SMART)	“My mother was very adamant that I know that vaccinating [my son] was not just about his health but also about protecting her. She is the reason I educated myself about the vaccine studies for my kids. My son has now returned to in person learning at school.” (Story from Holy Tabernacle)	“As of then I was pregnant, and the doctor said I had to get vaccinated because most of her patients had COVID during their delivery.” (Story from Epicenter)	“I just waited for the doctor’s decision, for her to tell me: ‘you’re ready for the vaccine now.’ For my health, that’s what I can say. And it was positive.” (Story from Transnational Villages Network)	n/a

Table 6. Common motivators for getting vaccinated against COVID-19

Theme	Motivators	Count
Protecting self and others (Section 3.2)	Prevent COVID-19 infection, illness, and death	181
	Protect family members	111
	Protect others and the community	89
	Preexisting condition or risk factor	45
	Experience with a previous COVID-19 infection	30
	Anecdotes from other who had COVID	28
Influencing others (Section 3.3)	To set a good example for others	29
Ending the pandemic (Section 3.4)	To “end the pandemic”	38
	Travel, restaurants, events, etc.	26
	Job or school mandate	25
Trusted, accurate, and accessible information (Section 3.5)	Based on data, research, or evidence	25
	Health education from outreach	25
	Advice from medical professional	19
	Advice from friends and family	18

Protecting Self and Others

Preventing COVID-19 infection, illness, and death was the most frequently mentioned motivator for getting vaccinated. Fear of sickness and death was often mentioned alongside negative experiences with previous infections and anecdotes from others who have severe COVID-19 illness. Additionally, those who were more likely to be exposed to COVID-19, including essential workers, mentioned their interaction with others as a reason for heightened protection.

Community members were also motivated by the desire to protect family members, loved ones, and others in the community. Many participants reported getting vaccinated so that their grandparent, mother, father, or child would not get sick. Some also mentioned that vaccination is a way to protect others in the community, even strangers, from getting COVID-19. Participants that self-identified as low risk stated that they got vaccinated to protect those who may be more vulnerable to getting sick.

”[I got vaccinated] because, once I understood the remarkable research that led to this vaccine, I was convinced it was safe and key to ending the pandemic. I wanted to keep myself safe for my family since I am my mother’s only child. And I also wanted to protect myself and my New York City community, because we all need to protect each other. That’s what New Yorkers do.” (Story from Neighborhood Housing Services of Brooklyn; Brooklyn)

Whether by protecting self, family, or others, the theme of preexisting conditions and risk factors arose frequently among community members. Many mentioned that they got vaccinated either because they were more likely to experience serious illness from COVID-19 or because they had family members at elevated risk.

Influencing Others

Another key motivator to vaccination was the opportunity to set a positive example for family, friends, and the broader community. By getting vaccinated, people hoped they might positively influence others to get vaccinated, as well. Likewise, data revealed that anecdotes and advice from friends and family were also strong drivers for getting vaccinated, which aligns with the sentiment that one might get vaccinated, share their story, and influence another to do the same.

“I knew I had to do my part. I knew this isn’t just about me but about the entire world who does not need to suffer anymore. I decided to get vaccinated because I couldn’t risk anyone’s lives, at work or at home and I knew that getting the vaccine would enable my loved ones to follow in my footsteps.” (Story from Arab-American Family Support Center; Brooklyn)

“My wife was scared to get the vaccine because of what she was hearing, but I convinced her to take it. And when I took the vaccine and didn’t have any side effects, she decided to get vaccinated…I will continue to encourage other people to be vaccinated and to take precautionary measures to battle this virus.” (Story from Caribbean Women’s Health Association; Brooklyn)

Children and teenagers frequently reported “setting a good example for friends” as a motivator. The social aspect of getting the vaccine was more apparent among younger age groups. Young children also noted that their vaccination status may influence parents to allow their kids to get vaccinated as well.

Ending the Pandemic

Although less common than other motivators, some New Yorkers were driven by a desire to end the pandemic and “return to normal.” Some expressed the belief that if more people were vaccinated, then COVID-19 cases would decrease, and schools and businesses could reopen to pre-pandemic levels. These community members were motivated to “do their part” to help end the pandemic, highlighting a sense of collective action and community-oriented decision making.

Others were motivated to get vaccinated to end the pandemic’s restrictions to daily living. Resuming travel, going to bars and restaurants, and attending social gatherings were cited as specific motivators to vaccination. For example, one teen reported that attending her senior prom had motivated her to get the COVID-19 vaccine.

“The vaccine and booster shot allowed me to maintain my employment, travel, and interact socially and I’m very content with that.” (Brooklyn Community Services; Brooklyn)

In some cases, participants stated that although they were nervous about the vaccine, they got vaccinated because they were required to for a job or for school. Although mandates were not always viewed as positive motivators, many reported that they were nevertheless glad they got vaccinated in the end.

Trusted, Accurate, and Accessible Information

Information from medical professionals, the news and social media, and community-based outreach contributed to decision-making about vaccines. Several community members referred to outreach from CBOs as a supportive factor to getting vaccinated, due to provision of accurate information, one-on-one conversations, and assistance scheduling appointments. Health education from CBO outreach was often considered alongside with other sources, including advice from medical professionals, friends, family, personal research, or the news.

“I told others in my community not to listen to the conspiracy theories, but rather listen to the experts, ask questions, and make an informed decision.” (Story from Sauti Yetu Center for African Women and Families; Bronx)

Finding trusted and accurate information was often mentioned as a challenge for community members, or a reason for initial hesitancy to get vaccinated. Many reported that they were initially anxious about getting the vaccine but changed their mind after receiving advice from a medical professional, family member, or friend. Trusting the information source – whether due to perceived expertise, earned respect, or participant belief that the source cares for their well-being – was a consistent and pervasive theme related to vaccine confidence, especially in under-resourced neighborhoods where there may be historical mistrust of the government and health system.

Recommendations from BIPOC Residents and Youth

To address health inequities, community engagement strategies and story collection activities prioritized specific groups and communities, including BIPOC, immigrant populations, young children, and the elderly. Motivators varied between priority populations, although a desire to protect family and others was consistent across all groups.

BIPOC residents reported that addressing trauma, mistrust of the government, lack of resources, and language barriers were essential to fostering vaccine confidence.

• Mistrust of the government: “He considers himself very skeptical of the government in general, as well as physicians. As a Black man, he felt it was important that white people got the shots first, for him to feel safe taking them.” (Story from Alliance for Positive Change; Manhattan)

• History of unethical medical practices: “Initially, I was hesitant to get vaccinated because I felt that the government would use Black people for studies based on past government actions, such as the Alabama incident where people were purposefully given syphilis. But after speaking to other friends and family who got vaccinated, I changed my mind.” (Story from United Sikhs; Queens)

• Language barriers: “I knew COVID-19 was a reality, but words cannot describe the pain that I endured [when I got infected]. I was gasping for breath. On my way to recovery, I agreed to be interviewed in the Hausa language to get the community informed about the virus. People across the world got my message. I heard from people who listened to my story on social media. They were convinced and followed the medical guidelines to protect themselves and their families.” (Story from Alliance for Positive Change; Bronx)

Recent approval of pediatric vaccines has made children a priority population for targeted outreach. Children are often considered more vulnerable than adults, and many parents are anxious about vaccinating their children, especially those with preexisting conditions (e.g., asthma).

For children and teenagers, motivators to vaccination included protecting their friends, setting a good example for others, and attending activities, school, and events. Some stories from youth also directly addressed fears and concerns about pain from getting the shot.

• Protecting others: “The vaccination doesn’t hurt that much, it only hurts a little bit…. I got vaccinated because I needed to protect my family and myself, and it wasn’t just about me, it was about others too.” (Story from Relume Foundation Inc; Brooklyn)

• Breathe in and breathe out: “I would just breathe in and breathe out during the shot, so they aren’t scared. It is really quick, and you get it out of the way.” (Story from Sisterhood Mobilized for AIDS Research and Treatment (SMART), Manhattan)

• Setting a good example: “My experience can convince other parents to get their child to get the vaccine. Please get your child vaccinated!” (Story from Bangladeshi American Community Development and Youth Services; Brooklyn)

Impact of Community Engagement

Community engagement strategies fostered vaccine confidence by engendering collective responsibility and action within communities; providing community members with accurate and easy-to-understand information; and using knowledge of contextual factors (through understanding of community needs and beliefs) to build trust with community members and address individual barriers. Community members cited trust in information from CBOs and an openness to their advice.

“Roman (not real name) received his first shot in November after participating in a conversation group during Alliance’s Thanksgiving event. He expressed his concerns about how the vaccine might affect his health and current medical treatments. Alliance’s VEPE team sat with the individual and went through the vaccine facts and encouraged him to speak with his doctor. He stated he already talked to his doctor, and he highly recommended the vaccine, but he was still hesitant until he spoke with Alliance’s team. He then requested assistance in scheduling his vaccine appointment. Alliance’s VEPE team scheduled the appointment and did a follow up call to remind him about it.” (Story from Alliance for Positive Change, Manhattan)

Our research revealed that context and personal circumstances impacted decisions to get vaccinated, based on living situations, personal health, past experiences, and beliefs. Extensive community engagement allowed for individualized outreach as community health workers were able to address barriers to vaccination through open communication, acknowledgment of cultural and social norms, and trust between peers.

Discussion

We explored themes from stories gathered from BIPOC community members who decided to get vaccinated to explore their motivations. Common motivators for getting vaccinated against COVID-19 included the desire to protect self and others; positively influence others’ decisions; and end the pandemic. Information received from a variety of sources, including medical professionals, media, friends, family, and community-based organizations, facilitated vaccine decision-making by informing individual confidence in the vaccine.

Social solidarity emerged as a common thread across leading motivators. The strong desire to protect one’s own health and the community appeared to be as important as the trust in the health product. This desire played a strong role in the vaccine decision process (Larson, Cooper, Eskola, Katz, & Ratzan, 2011). Other studies have found that social solidarity, a collective consciousness to help reduce public health risk leading to collective actions by society, is vital during a pandemic (Mishra & Rath, 2020). Enabling individuals to act on their intrinsic motivations to protect themselves and promote collective well-being could be an important facilitator of vaccine confidence. This is especially important for BIPOC communities where the lived experience and the history of abuse by the health system with the ensuing lack of trust could get in the way of social solidarity. This finding provides support for the re-orientation of community engagement efforts toward promoting social solidarity as a way to gain wider acceptance of vaccines in BIPOC communities.

Our work suggests that, while not a leading motivator in and of itself, access to trusted, accurate, and accessible information plays a key role in vaccine decision-making by improving confidence in the vaccine and health systems at large. Health information, in turn, may facilitate decisions to get vaccinated by removing barriers, thereby enabling individuals to act on their intrinsic motivations to protect self and promote collective well-being. These results align with other findings that demonstrate that confidence in vaccination programs relies on availability of accessible messaging (Harrison & Wu, 2020). Findings also indicate that multicomponent and dialogue-based interventions tailored to the audience are effective in building vaccine confidence (Chou & Budenz, 2020). Targeted and tailored public health education that emphasize vaccine safety while simultaneously incorporating the motivation to protect self and others may be more effective in fostering vaccine confidence in BIPOC communities (Gerretsen et al., 2021). Stories and testimonials about vaccine experiences can help foster vaccine confidence by deepening the understanding of public health messaging while addressing community needs and beliefs. This approach can help build trust with community members.

How we make sense of and develop narratives around the failures and successes of community engagement efforts in BIPOC communities matter. Do we develop community engagement approaches based primarily on hesitance and personal responsibility? Or do we explore the motivations of those who seek options to best protect their loved ones, community, and livelihoods? Will our accounts fixate on the mistrust and misinformation in minoritized or marginalized communities, or would we focus our gaze on the persisting social, economic, and biomedical tragedies that make mistrust the default? This narrative work presents a useful framing for conversations about BIPOC communities who may want more information about COVID-19 vaccines before deciding. Vaccine confidence may also be the better indicator of how trustworthy BIPOC communities think the health systems are rather than vaccine hesitancy which tends to focus on the individual responsibility when there is low vaccination uptake.

We call for a re-imagination of the vaccine hesitancy framing in public health and the re-orientation of community engagement efforts toward the drivers of vaccine confidence and the centering of the voices and motivators in BIPOC communities. The concept of public health and its programs must be broader than the how to develop and market vaccines but also in developing relationships with underserved communities to know their stories and their preferences. The practice and policy actions to actualize these changes can be guided by these findings on vaccine confidence and motivators. Community engagement strategies that foster collective responsibility and action within communities; provide community members with accurate and easy-to-understand information; and use contextual knowledge may be more effective in building trust with BIPOC communities.

Strengths and Limitations

The strength of this paper lies in the methodology. The positive framing of the questions, the informal story telling format of data collection instead of formal interviews increased the number of study participants. Having trusted community members who live and work in the neighborhoods lead the data collection process also increased community participation and trust. Another strength is the large number of stories collected from several neighborhoods which provides more representative data from a cross section of BIPOC New Yorkers. This study also encountered some limitations, including the lack of demographic information that could have allowed for comparison between groups. There were also language limitations that could have introduced some bias. In some cases, stories were collected in indigenous languages and translated into English or Spanish by CHWs on the spot. These limitations are not expected to significantly compromise the validity of the findings.

Conclusion

The vaccine community has produced rigorous evidence on vaccine hesitancy but there is paucity of equally rigorous research to understand the factors that affect vaccine confidence. The themes emerging from the stories from BIPOC communities in NYC point to a strong sense of social solidarity. For those who decided to get vaccinated, the desire to protect self and others, to help end the pandemic and to influence others appeared stronger than concerns about vaccine safety. Accessible information through trusted messengers played a key role in decisions to get vaccinated. To better represent communities of color in literature, we call for more research on vaccine confidence and motivators for vaccination in said communities. Public health authorities all over the world are searching for effective strategies to increase vaccine acceptance and build vaccine confidence; this article presents new options in investigating the levers of vaccine confidence. Exploring individual motivators could more effectively inform vaccine equity efforts and other preventive health programs. It could also be used to guide community engagement for vaccine and other health decision-making.

Authors’ Contributions

OI, MK, DB: Investigation and data collection.

ZS, CG: Formal analysis

OI, ZS, MK: Writing

OI, ZS, MK, CG, DB: Review and editing.

All authors approved the final version.

Acknowledgments

We acknowledge the Public Health Corps Partners and the Community Based organizations funded through the Vaccine Equity Partner Engagement Project for leading the community engagement and story collection.

Disclosure statement

The authors report that there are no relevant competing interests to declare.

Additional information

Funding

This work was supported by the Centers for Disease Control under the 2021 CDC 2103 Supplement 3 Grant