This article for developing awareness surrounding racial and ethnic disparities in care was funded by GSK.
Dr Folasade May is contracted by GSK and is compensated for the development of this article.

Minority populations face numerous barriers to accessing equitable healthcare including vaccinations. Racial and ethnic disparities in vaccine uptake have been extensively documented. Issues including historical context, availability of healthcare, current barriers faced by underserved or underrepresented populations, and potential measures to improve adult vaccination in these populations are discussed.

Despite increased awareness, racial inequities still exist in our healthcare system. This leads to a variety of barriers to healthcare faced by our underserved and underrepresented communities. One particularly clear example of the effect of racial inequities on healthcare outcomes is adult vaccination uptake. By examining the individual and structural causes of this issue, we can chart a path towards equitable solutions.

Adult vaccination rates are currently below national standards, and the problem is even more evident when looking at data in African American and Latinx populations. For example, in the 2017-2018 flu season, adult influenza vaccination coverage was 49.3% for White adults compared to only 39.0% for African American and 37.5% for Latinx adults. The disparity is even greater when considering herpes zoster vaccination rates. The most recent data from 2020 show 33.4% of White older adults (≥50 years of age) received the recommended varicella zoster vaccination, compared with only 17.4% of older African American adults and 15.6% of older Latinx adults. Based on these data, it is evident that barriers to receiving preventive care exist in these communities.

When considering these barriers, I like to classify them into four levels: policy, healthcare system, provider, and individual patient. I strongly feel that a multifactorial approach is needed to address inequities at each level. Beginning at the policy level, some improvements have been recently achieved. For example, the Affordable Care Act delivered healthcare access to more of the population and allowed adults up to age 26 to stay on their parents’ health plan. The legislation also reduced or eliminated cost sharing for preventive services such as vaccinations. If we turn to barriers at the level of healthcare systems, I have observed that vaccine administration tends to be opportunistic rather than programmatic. This means providers may discuss vaccinations during a particular encounter and patients may receive the recommended vaccination at that visit, but there oftentimes are no routine systematic measures in place for accountability of vaccination uptake. With the availability of Immunization Information Systems, also known as vaccine registries, and widespread use of electronic health records, we can potentially identify unvaccinated individuals and intervene appropriately. However, integration and interconnection of these modalities will require additional intervention at the policy level.

Next, let us consider inequality at the provider and individual patient levels. Studies show mistrust between minorities and the medical community exists and is more pronounced in African American, Latinx, and Asian populations. African Americans often report discrimination when going to see a doctor or visiting a health clinic, which can lead to avoidance of seeking healthcare for themselves or family members in the future. While it is common to suppose that minority populations mistrust the medical establishment because of historical wrongs inflicted on their communities such as the Tuskegee experiments or HeLa Cell controversies, I find that my patients’ mistrust typically stems from their own negative experiences within the healthcare system. In other words, racial wrongdoings are not simply a historical problem, but can also appear contemporarily with ongoing consequences. For example, in one study, African American women reported feeling that their providers spoke about them instead of speaking to them. They desired a more comprehensive, honest, and open discussion with their providers to generate a better feeling of health autonomy and empowerment. Additionally, language barriers have potentiated disparities in vaccine uptake. When considering influenza vaccination in Latinx populations, patients who preferred communicating in English had higher vaccination rates than those who preferred communicating in Spanish. Furthermore, when considering prevalence of vaccine hesitancy in Pacific Islander groups, multivariate analyses demonstrate significant associations with socioeconomic status, gender, education, employment, and income. Vaccine-hesitant individuals tended to be younger adults with less formal education and lower household incomes.

To help mitigate this problem, we need to take a multifaceted approach. It is the provider’s responsibility to present accurate vaccination information to all patients without bias using plain, linguistically and culturally appropriate language. This can lead to increased knowledge, confidence, and stronger vaccine acceptance amongst the general population. Healthcare providers can directly impact vaccine uptake by countering misinformation around vaccines during patient encounters. Healthcare systems can work towards diversifying their workforce to increase vaccine acceptance across diverse communities. Targeted community outreach to specific faith-based and other community organizations may offer further improvements in vaccine acceptance in minority communities. In underserved communities, healthcare resources tend to be limited. The availability of vaccinations in nontraditional settings such as workplaces, pharmacies, and schools has been shown to improve availability to larger portions of the population. Retail pharmacies are an important setting through which access to vaccines has been greatly expanded.

Important groundwork has been established to help address the issue of racial and ethnic disparities surrounding vaccine uptake. Continued collective efforts between lawmakers, health systems, providers, and their patients are the key to help remove barriers and eliminate racial inequities and biases within the healthcare system.