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10/19/2021
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Chapter Two: Review of literature

Introduction

The section presents the literature review section, which analyses and assesses current

and definite literature on vaccine hesitancy (VH) in the United States of America (USA).

Notably, it attempts to verify VH evident among African American community. To conduct an

in-depth analysis, the section surveys and criticizes literature related to VH in the USA among

the African American community and elaborates the connection of the section to the PICOT

question. In preparing for the DVN project, it is essential to use evidence-based data when

recommending changes to existing practice (Quinn et al., 2019). The following chapter attempts

to actualize such an outcome by highlighting patients' comprehension of COVID-19 and how it

impacts vaccination compliance to attain patient safety. Bunch (2021) explains that most patients

seek professional input once they associate a condition with its risks on quality of life and overall

well-being. It is the same ideology expressed in the Health Belief Model (HBM) in which the

same source ties the perceived risk of a condition to increased willingness to seek treatment.

Therefore, the literature review will explore the application of the model to VH evident among

African American community. All-inclusive, the section examines multiple strategies and

objectives that indicate the necessity of the change proposed in the project.

Moreover, it offers an understanding of questions tied to the appraisal of existing

evidence-based research. Finally, it recommends means by which the target audience may

understand its relevance to clinical practice. Thus, the literature used in this section was selected

based on the evidence and relevance to the study topic. 

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Search Strategy/Rationale for Research / Systematic review

A systematic review defines the extent to which vaccination hesitancy is rampant among

African American communities and establishes whether education on vaccination's risks and

benefits will increase the population of African Americans in Metropolitan cities being

vaccinated within the next eight months. Credible databases were accessed to locate valid and

credible peer-reviewed sources that informed the study topic and PICOT question. A search was

done on Cochrane Database of Systemic Reviews, PubMed, Wilkes University library, Google

Chrome PUB MED, Google Scholar, and Center for Disease Control and Prevention (CDC). The

search aimed to identify studies conducted between 2015 and 2021 on vaccination hesitancy

among African Americans. A search on the selected primary databases generated ten articles.

The articles were searched using free-text terms and indexes connected to vaccination hesitancy

in African American communities. Out of the ten sources generated, only five were used in this

section; the other five were eliminated based on repetition. Thus the selected seven sources were

the most adequate for use in the literature review section. 

Critique and Synthesis of Research Findings /Discussion

COVID-19 significantly distressed the African American community in the USA, which

manifested in considerable virus severity and higher fatalities. While a COVID-19 vaccine can

vastly decrease this adverse condition, increased individuals from the African American

communities are not getting the vaccine (Momplaisir et al., 2021). The authors claim that

vaccination hesitancy is a crucial reason why the increased population of this ethnic group

continues to lead a life of distress compared to other ethnic groups. In a bid to explain the stated

observation, Momplaisir et al. (2021) conducted focus group studies in which they evaluated the

attitudes, concepts, and perceptions of the racial group in the COVID-19 vaccine. The study was
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done in barbershops and salons in African American communities. The findings revealed that

VH is driven by a lack of trust in its medical establishment, the presence of political climate

advocating for racial injustice, the absence of data on the vaccine's immediate and long-term

efficacy, and uncertainty on how fast the vaccine was developed (Momplaisir et al., 2021). The

listed observation answers the research question. It indicates a lack of education on the benefits

of the COVID-19 vaccine in the investigated study area, adversely impacting the percentage of

the population seeking vaccination. It further implies that if the ethnic group was educated on the

benefits and risks of the vaccine, it increased the likelihood of individuals getting vaccinated.

Nonetheless, despite being an informative source, a fundamental limitation to the study

was using a small study sample which increases the margin of errors. In addition, the authors

failed to incorporate behavior change in the survey, indicating potential results inefficiencies.

However, other than the two shortcomings, the source was credible and rich in context hence its

inclusion. 

As an extension to medical mistrust indicated in the first selected source, the second

source further sheds light on medical distrust caused by the systematic racism system that has

seen increased VH among the African American population in the US. The second source by

Bogart et al. (2020) examined COVID-19 medical mistrust and vaccine hesitancy in a small

African American sample of persons living with HIV. The authors recorded that 97% of the

participants had a mistrust belief, which resulted in an effective COVID-19 treatment and

vaccine hesitancy. In response, the authors recommended increased public awareness on the

benefits of COVID-19 vaccines as a strategy to overcome the public mistrust observed among

the African American population. Regardless of seconding an observation noted in the first

source, the second source was also limited by using a small sample size. The authors utilized 101
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participants, which is notably a limited figure increasing low statistical power. Using a limited

sample size in the first two sources illustrates the significance of using large samples to depict

medical and vaccine mistrust among Black Americans accurately. Nevertheless, the findings of

the study hold water as they second those observed in the first study and answer the PICOT

questions. 

The third source also explores that angle of mistrust but from a lens of racial justice.

Bunch (2021) explores VH as a means of elevating racial justice in the US. The author notes that

2020 yielded two significant catastrophes in the USA; a global pandemic and racism occasioned

by police brutality on people of African American descent. The mistrust of the COVID-19

vaccine stems from a history of distrust towards pharmaceutical companies, health practitioners,

and governmental agencies' motives towards the African American community. A history

defined by a lack of transparency, no admission of uncertainties, and limited accessibility by the

Black community has seen any initiative by the three bodies interpreted as a motive for

amplifying racist deeds (Bunch, 2021; Quinn et al., 2019). The COVID-19 vaccine is being

pushed by the bodies, which explains why increased African Americans are hesitant to embrace

it for fear of being used as a racial injustice card. Racism and vaccine hesitance feed into each

other. Unless increased transparency is exercised, discussions on uncertainties and accessibility

are granted to all, and Black Americans will continue to perceive the COVID-19 vaccine as

grounds for exercising racism. Thus embracing strategies that combat racism rationales is vital in

enhancing vaccine uptake by the Black communities in the US. The third source has introduced

the theme of racism, which is why increased African Americans continuously reject healthcare

practices meant to improve quality of life and overall health. A history of racism and inadequacy
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by relevant parties to end racism justifies the link between racism and VH; nevertheless, health

providers need to embrace and execute strategies that will warrant increased vaccine uptake. 

Increased vaccine uptake will only be actualized if healthcare providers implement

strategies that encourage their intake. Khubchandani et al. (2021) conducted a comprehensive

and methodological analysis of COVID-19 vaccine hesitancy on American adult demography,

interested in understanding Americans' thoughts about getting the vaccine. The results revealed

that over 50% of the respondents were very likely to get the vaccine. However, there was an

entry on vaccine hesitance as 22% of the respondents expressed an unlikelihood of receiving the

vaccine (Khubchandani et al., 2021). The authors state the key reasons behind the hesitance were

the perceived threat of becoming infected, low income, and education levels. The fourth source

adds other entries as a reason for VH. The first three sources have already justified mistrust, and

this source introduces the discussion on the threat of becoming infected, low income, and

education levels. 

Collectively, the new direction on VH highlights a plight of low health care accessibility,

insignificant interactions with healthcare providers, expenses-related issues, negative beliefs in

medicine and public healthcare centers, low literacy indices, and common vaccine public

awareness. In addition, these areas reveal poor execution of strategies that encourage access to

healthcare services and knowledge, which notably affects the minority groups in the US. The

disparity of implementation of healthcare services defined by ethnicity is an important reason

why increased African Americans and other minority groups in the US are not embracive of the

COVID-19 vaccines. The fourth source was selected because it offers further justification to VH

other than mistrust. In addition, it used an adequate sample size which increased the precision of

the estimates and the ease of drawing a valid conclusion. Generally, it is an informative addition
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to the analysis of vaccine hesitancy that emphasizes the role of healthcare providers in

encouraging vaccine uptake. 

The fifth source emphasizes the role of the healthcare sector in vaccine hesitancy.

Rungkitwattanakul et al. (2021) assessed vaccine hesitancy and willingness among patients at a

dialysis hospital, which caters to principally the African American community. The first two

sources advocate for public awareness and education on the importance and risks of COVID-19

vaccines as a means of overcoming VH. However, Rungkitwattanakul et al. (2021) note that

there has been an increase in public awareness programs, but still, a significant number of

Americans are unwilling to engage in the vaccination program. The authors investigated

COVID-19 vaccine hesitancy in which they recorded a high vaccine unacceptance and

unwillingness. The two were attributed to mistrust and inadequate data regarding safety and

vaccine efficiency rates (Rungkitwattanakul et al., 2021). The healthcare sector is responsible for

providing the public with adequate data on the efficacy and safety of the vaccine. When such

data is not availed, it increases uncertainty and mistrust, which results in increased VH. The

sector is failing as even with increased mass education on the benefits of the vaccine, limited

data is provided to back its safety and efficacy, which is one of the strategies of encouraging

increased vaccination. The absence of critical data of COVID-19 vaccine combined with a poor

implementation of strategies to promote vaccine intake and racism has seen increased African

Americans refrain from being vaccinated. 

Conclusion of the Literature Review Findings

Overall, the section elucidates various issues, which are vital while studying VH among

the African American community living in the USA. The analysis has listed mistrust, racism,

lack of income and education, and poor health care strategies that encourage vaccine uptake as
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critical reasons for VH. All studies are recent and conducted by credible authors who discussed

each point raised in detail. Generally, the input from the selected studies was insightful and will

facilitate studying the VH disparities among the African American Community in the USA's

Northern Metropolitan city. Nevertheless, a key shortcoming to the selected sources was a

limiting study sample size and lack of incorporating possible behavior change metrics to gauge

vaccine hesitancy among Black Americans. Future studies need to consider national sample sizes

to facilitate generalizing results when investigating vaccine hesitancy among African Americans

and incorporate possible behavioral changes.

 
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References

Bogart, L. M., Ojikutu, B. O., Tyagi, K., Klein, D. J., Mutchler, M. G., Dong, L., ... & Kellman,

S. (2021). COVID-19 related medical mistrust, health impacts, and potential vaccine

hesitancy among Black Americans living with HIV. Journal of Acquired Immune

Deficiency Syndromes (1999), 86(2), 200.

https://doi.org/10.1097/QAI.0000000000002570

Bunch, L. (2021). A tale of two crises: Addressing Covid-19 vaccine hesitancy as promoting

racial justice. In HEC Forum 33(1), 143-154. https://doi.org/10.1007/s10730-021-09440-

Khubchandani, J., Sharma, S., Price, J. H., Wiblishauser, M. J., Sharma, M., & Webb, F. J.

(2021). COVID-19 vaccination hesitancy in the United States: A rapid national

assessment. Journal of Community Health, 46(2), 270-277.

https://doi.org/10.1007/s10900-020-00958-x

Momplaisir, F., Haynes, N., Nkwihoreze, H., Nelson, M., Werner, R. M., & Jemmott, J. (2021).

Understanding drivers of COVID-19 vaccine hesitancy among Blacks. Clinical

Infectious Diseases: An Official Publication of the Infectious Diseases Society of

America. https://doi.org/10.1093/cid/ciab102 

Quinn, S. C., Jamison, A. M., An, J., Hancock, G. R., & Freimuth, V. S. (2019). Measuring

vaccine hesitancy, confidence, trust and Flu vaccine uptake: results of a national survey

of White and African American adults. Vaccine, 37(9), 1168-1173.

https://doi.org/10.1016/j.vaccine.2019.01.033

Rungkitwattanakul, D., Yabusaki, A., Singh, D., Lawson, P., Nwaogwugwu, U., Iheagwara, O.

S., & Mere, C. (2021). COVID‐19 vaccine hesitancy among African American
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hemodialysis patients: A single‐center experience. In Hemodialysis International.

International Symposium on Home Hemodialysis. Wiley-Blackwell.

https://doi.org/10.1111/hdi.12922