1. Introduction

2. Factors Influencing Vaccine Hesitancy in Visible Minority Populations

2.1. The safety and efficacy of the COVID-19 vaccine

Analyses identified concerns around the safety and efficacy of the COVID-19 vaccine as the most frequently appearing reason in the literature for COVID-19 vaccine hesitancy. The themes from the literature that were classified within this factor were safety, vaccine effectiveness, short-term and long-term side effects, fear of needles, and the number of injections. With respect to side effects, people of Muslim religion expressed COVID-19 vaccine hesitancy because of concerns related to how the side effects associated with the COVID-19 vaccine may interfere with the Festival of Ramadan ^[5]. In a study involving Black and Latinx long-term care staff, both ethnicities reported the possibility of developing side effects because of vaccination as their primary reason for being vaccine-hesitant ^[6]. In a UK-based study involving ethnic minorities, the most common reasons for hesitancy included side effects and long-term health effects, particularly among Black respondents ^[7]. Short-term side effects of concern that were commonly reported varied from prolonged injection site pain across people of African American descent ^[8]. On the other hand, more long-term health concerns were centered around fertility issues for women, specifically in the Arab female population ^[9].

In a study involving Black persons living with HIV, half of the participants perceived the COVID-19 vaccine as harmful and were worried about the safety of the vaccine ^[10]. Similar findings were obtained in Filipino populations, where nearly half were opposed to receiving the vaccine due to safety concerns ^[11]. Apprehension towards the safety of the COVID-19 vaccine differed across race and ethnicity, with most Black participants (66%) citing this as a reason for refusing the vaccine, followed by Hispanics (47%) and others (14%) ^[12]. Shifting to Indigenous populations in Canada, vaccine hesitancy remains a significant challenge compared to other populations within Canada ^[13]. Fear and concerns around the safety of the COVID-19 vaccines arise from medical experimentations that took place using Indigenous peoples to test the safety and effectiveness of vaccines ^[13][14]. Kreps et al. found that women and Black respondents were less likely to report willingness to take the vaccine especially due to concerns surrounding vaccine efficacy and the possibility of severe vaccine adverse effects ^[15].

The frequency of injections and vaccine schedules influenced the decision-making of certain visible minorities. Female respondents were more likely than male participants to report a higher willingness to vaccinate if the vaccine involved fewer injections ^[16]. On a similar note, a study conducted in the USA indicated that among racial and ethnic groups, non-Hispanic Blacks were least likely to vaccinate due the perception of the complicated vaccine schedule ^[17]. Several reasons underly how the frequency of injections/vaccine schedules impact vaccine hesitancy. Respondents preferred fewer doses, partly because fewer visits to immunization sites save transportation and time costs ^[18]. For those who fear needles, as the number of injections required increased, the chances of receiving vaccinations voluntarily decreased ^[18].

2.2. Mistrust

The mistrust was identified as the second most-frequent factor appearing in the literature regarding COVID-19 vaccine hesitancy in visible minority populations. The themes linked to this factor include pharmaceutical/government medical mistrust, racism, underrepresentation in medical clinical research, and biased non-diverse healthcare providers. Mistrust was used as a broad term to explain three types of mistrust: medical mistrust, government mistrust, and pharmaceutical mistrust. According to Thompson et al., the Middle East and North Africa (MENA) populations in the USA are underrepresented in health inequity because the US government does not recognize them as a minority group that is distinct from the white ethnicity ^[19]. This minority group experiences healthcare barriers due to medical mistrust and discrimination ^[19]. The participants in the Bogart et al. study showed high rates of COVID-19 mistrust and hesitancy related to future vaccines ^[10]. Nearly all (97%) Black participants validated one mistrust belief, with the most being mistrust due to the government withholding of information concerning COVID-19 ^[10]. This mistrust of Black Americans can be directly linked to events in the course of medical history in the United States, such as the Tuskegee study ^[20]. Another study by Laurencin et al. elaborates how Black ethnicity has been affected by mass incarceration, poverty, and limited healthcare access ^[21]. These factors are linked to racism and segregation that has been part of the Black community for decades, which has created increased numbers in COVID-19 vaccine hesitancy today ^[21]. Another example of racism’s impact on COVID-19 vaccine hesitancy is that due to racism, non-Hispanic Blacks were least likely to get a COVID-19 vaccine ^[17].

The lack of visible minority representation in the medical profession has a profound impact on COVID-19 vaccine hesitancy. For example, Black men are less represented in the medical profession: while they comprise about 13% of the US population, they only comprise 4% of US doctors, and less than 7% of the US medical students ^[21]. Vulnerable populations have a difficult time trusting the medical profession; this can be mitigated if the healthcare providers come from their own communities ^[22]. Laurencin et al. show an increase in the number of black men in the healthcare profession would increase the trust in the Black community on matters concerning COVID-19 vaccination ^[21]. Further trust can be earned if there is an adequate representation of racial minority groups in vaccine trials ^[23].

2.3. Socioeconomic Characteristics 

The themes from the literature categorized in this factor include gender, age, education, income, occupation, location, and having children. Several studies have investigated how themes influence an individual getting a COVID-19 vaccine. Women in the USA were more likely to refuse the vaccine because they tend to practice preventive behaviors and avoid risky behaviors, e.g., wearing face masks to prevent COVID-19 infections ^[24]. In the USA, support towards vaccination for COVID-19 increased with age across Black Americans and other populations ^[25]. Education plays a significant role; in a Canadian study, learned individuals with less than a high school education showed lower adjusted odds of wanting to vaccinate themselves against COVID-19 ^[26]. Furthermore, Black Americans with lower educational attainment are more hesitant to accept a COVID-19 vaccine ^[25]. A study conducted in Latin America and the Caribbean disclosed similar findings but added that lower education influences vaccine hesitancy due to the general distrust in vaccines and the robustness of conspiracy beliefs across individuals with lower education levels ^[27]. In terms of occupation, essential Canadian non-healthcare workers were shown to have lower odds of intending to receive the COVID-19 vaccine when it is available ^[26]. In the USA, research by Allen et al. found that ethnic minorities such as Chinese, Black, Latina, and others were less likely to report the intention to vaccinate with lower levels of income ^[23]. Similar findings by Nikolovski et al. and Khubchandani et al. were observed in African American individuals located in the USA ^[8][24]. In an Ohio-based Amish population, one reason for vaccine refusal was that those who had children believed that if they gave their children shots, it would imply that they were not putting their faith in God to look after their children ^[28]; hence families with children were more likely to refuse COVID-19 vaccination ^[28].

2.4. Vaccine Development

Vaccine development was the fourth most common factor in the literature influencing COVID-19 vaccine hesitancy in visible minority populations. Themes that fell under this factor included the place of manufacturing for the vaccine, cost of the vaccine, the vaccine’s novelty, frequency of injections associated, short duration of development, and the duration of immunity. As for the place of vaccine manufacturing, in a study by Gramacho et al., one factor that has a higher chance of increased vaccine uptake was the concerns on where the vaccine was manufactured and developed ^[29]. Respondents from a study conducted by Kreps et al. were less likely to choose vaccines developed outside of the United States, particularly from China, the associated vaccines manufactured outside the USA with a lower probability of choosing the vaccine ^[30]. In addition, rushed vaccines developed under a presidential administration with less transparency to the consumers were a recipe for suspicion, regardless of ethnic background ^[31]. COVID-19′s novel vaccination technologies, utilizing the messenger RNA and adenoviral transgene delivery, not previously used in the general population, were associated with the generation of many questions that would need answers to help clear the uncertainty among the people ^[22]. In terms of the cost of the vaccine, the COVID-19 vaccine price being high in the market may deter a substantial share of the at-risk people, especially those earning low incomes, from getting vaccinated against COVID-19 ^[32]. Furthermore, another study by Gatwood et al. suggested that Hispanics, in comparison to Whites and Blacks, had a higher agreement with the statement “New vaccines carry more risks than older vaccines” ^[25]. A study by Green et al. showed that Arab respondents felt that childhood vaccines differ from the COVID-19 vaccines because childhood vaccines have been well-integrated into the healthcare system, whereas COVID-19 are very new ^[9]. A study conducted in the USA indicated that among racial and ethnic groups, non-Hispanic Blacks were least likely to vaccinate due to lack of confidence in the vaccine ^[17]. When it comes to the short duration of vaccine development, according to Thompson et al., vaccine uptake rejection among Black participants compared with the overall mean rejection was flagged as one of the reasons why the Black ethnicity was hesitant to get the COVID-19 vaccine ^[19]. According to a study by Khubchandani et al., high vaccine hesitancy could be linked by a response from the participants in a Kaiser Family Foundation (KFF) poll where a majority (62%) believed that sociopolitical factors and pressures lead to a rushed approval for the COVID vaccine ^[24]. Finally, the duration of immunity that the COVID-19 vaccine would provide plays a role in influencing vaccine uptake. A study involving Black and Latinx participants revealed that among several factors that would matter in their vaccination decisions was how long protection from the vaccine lasts, with nearly 68% of participants supporting that ^[33]. Similarly, a longer duration of immunity of 5 years in comparison to 1 year was associated with higher support towards receiving the COVID-19 vaccine ^[15].

3. Conclusion

Knowing how different factors influence COVID-19 vaccine hesitancy in visible minority populations is essential for developing customized strategies for improving vaccination rates in different minority populations. While the identified factors for COVID-19 vaccine hesitancy in visible minority populations are presented as distinct factors, each factor does not impact vaccine hesitancy in isolation. Understanding the relationships among the identified factors and understanding how the factors impact each visible minority group are essential to improving the health of visible minority groups while helping the global population reach COVID-19 herd immunity thresholds.