Exploring the Continuum of Vaccine Hesitancy Between African American and White Adults: Results of a Qualitative Study.

Vaccine delay and refusal present very real threats to public health. Since even a slight reduction in vaccination rates could produce major consequences as herd immunity is eroded, it is imperative to understand the factors that contribute to decision-making about vaccines. Recent scholarship on the concept of "vaccine hesitancy" emphasizes that vaccine behaviors and beliefs tend to fall along a continuum from refusal to acceptance. Most research on hesitancy has focused on parental decision-making about childhood vaccines, but could be extended to explore decision-making related to adult immunization against seasonal influenza. In particular, vaccine hesitancy could be a useful approach to understand the persistence of racial/ethnic disparities between African American and White adults. This study relied on a thematic content analysis of qualitative data, including 12 semi-structured interviews, 9 focus groups (N=90), and 16 in-depth interviews, for a total sample of 118 (N=118) African American and White adults. All data were transcribed and analyzed with Atlas.ti. A coding scheme combining both inductive and deductive codes was utilized to identify themes related to vaccine hesitancy. The study found a continuum of vaccine behavior from never-takers, sometimes-takers, and always-takers, with significant differences between African Americans and Whites.  We compared our findings to the Three Cs: Complacency, Convenience, and Confidence framework. Complacency contributed to low vaccine acceptance with both races.  Among sometimes-takers and always-takers, convenience was often cited as a reason for their behavior, while never-takers of both races were more likely to describe other reasons for non-vaccination, with convenience only a secondary explanation.  However, for African Americans, cost was a barrier.  There were racial differences in trust and confidence that impacted the decision-making process. The framework, though not a natural fit for the data, does provide some insight into the differential sources of hesitancy between these two populations. Complacency and confidence clearly impact vaccine behavior, often more profoundly than convenience, which can contribute either negatively or positively to vaccine acceptance. The Three Cs framework is a useful, but limited tool to understanding racial disparities. Understanding the distinctions in those cultural factors that drive lower vaccine confidence and greater hesitancy among African Americans could lead to more effective communication strategies as well as changes in the delivery of vaccines to increase convenience and passive acceptance.