Black patients experiencing vaccine distrust

The LEAPS of care framework can help address concerns about the COVID-19 vaccine among Black patients experiencing hesitancy

The LEAPS of care framework is an Afrocentric counselling approach that can be used to address distrust around the COVID-19 vaccine experienced by some Black patients, considering the broader context of historical and current anti-Black racism. This framework is one of many approaches that have been made available to meet the diverse needs of this community and to address hesitancy where it exists.

Black people have been disproportionately impacted by the COVID-19 pandemic. During the first wave of the pandemic, 21 per cent of reported COVID-19 cases in Toronto occurred among Black people, who make up only nine per cent of the city’s overall population. Rates of COVID-19 infections, hospitalizations, ICU admissions and deaths have consistently been higher among Black community members in Ontario.

Despite being among those most affected by the pandemic, only 56.4 per cent of Black Canadians reported being willing to receive a COVID-19 vaccine compared to 76.9 per cent of the population overall. This puts them at a greater risk of experiencing the health impacts of COVID-19.

There are many reasons why patients, including Black patients, may refuse the vaccine or delay getting vaccinated. Misinformation, health literacy gaps, complacency and challenges with access can all contribute to COVID-19 vaccine hesitancy.

A major barrier for some Black patients experiencing vaccine hesitancy can be distrust in the medical system due to historical and ongoing racism. For instance, the unethical Tuskegee Syphilis Study in Alabama from 1932 to 1972 run by the United States Public Health Service deceived Black men about the purpose of the study and withheld information about treatment options, leading to many deaths. Although the Tuskegee experiment is one that is well documented and cited, there are historic, anecdotal examples of mistreatment of Canadian Black communities that contribute to distrust.

In 2017, the United Nations reported numerous examples of mistreatment of Black Canadians within and outside of health care, leading them to express their concern for the human rights of Black Canadians, including institutional racism in the health-care system. Systemic racism in the policies, procedures and structures that govern our health-care system continues to affect Black people.

Lived experiences of anti-Black racism in health care, such as the negative attitudes displayed by some health-care workers during patient encounters, can also play a major role in distrust in the medical system. Harmful stereotypes about Black people, including the beliefs that they are prone to genetic disease, are of lower intelligence and have a different pain threshold, contribute to these racist attitudes.

The racism experienced by Black patients has been amplified during the COVID-19 pandemic, leading to more stigma and distrust toward the health-care system. While vaccine distrust is prevalent among some Black patients, not all Black patients experience distrust, and many non-Black patients also distrust COVID-19 vaccines.

Physician support for the COVID-19 vaccine can help influence patients who are hesitant to take the vaccine. To build trust and confidence in the vaccine, physicians should consider and acknowledge that Black people are subject to ongoing external pressures related to historical and current experiences of anti-Black racism. By approaching the conversation around COVID-19 vaccines in a culturally sensitive way with Black patients who are experiencing hesitancy, physicians can empower patients to engage in discussions about their vaccine-related concerns.

Acknowledging racism is key to having respectful and honest discussions with Black patients experiencing vaccine distrust. Validating the experiences and the historical reasons why some Black people may be hesitant establishes common ground and ensures that enough information is available, so that proactive counselling can take place.

The LEAPS of care framework is a counselling approach that is centered around values of cooperation and collective input. This framework can help physicians address COVID-19 vaccine distrust with Black patients who are experiencing hesitancy in an open and empathetic way that respects patients’ values and perspectives.

By considering the broader context and influence of distrust in the health-care system and anti-Black racism, the framework can allow for building therapeutic alliances and trust by acknowledging patients’ lived experiences of racism in health care. This approach can also be modified for other groups and individuals experiencing hesitancy around COVID-19 vaccines.

The framework guides you to:

  1. Listen actively to your patient and learn more about their specific vaccine concerns, fears and experiences with racism in the health-care system
  2. Engage and empower your patient by respecting their perspectives and values, including their right to choose not to get vaccinated
  3. Ask about and acknowledge your patient’s fears and concerns as well as their health-care experiences that have been impacted by historical and present-day racism
  4. Paraphrase vaccine information and provide your patient with resources once a relationship and common understanding are established
  5. Support your patient’s future engagement in health care and share available community resources that can spark your patient to connect with community partners, which can help them, their family and others in the community to access the vaccine in a more flexible, culturally-safe community setting.

Framework in practice

This video series introduces the LEAPS of care framework and how it can be applied in clinical practice. It demonstrates how to have respectful and honest conversations with Black patients who have concerns about COVID-19 vaccines.
Part 1: Introduction to LEAPS framework and clinical case
Part 1: Introduction to LEAPS framework and clinical case

Dr. Onye Nnorom introduces both the LEAPS framework and the simulated clinical case, demonstrating how it can be used in clinical practice.

Part 2: Clinical case applying the LEAPS framework
Part 2: Clinical case applying the LEAPS framework

A physician is applying the LEAPS framework in an interaction with his Black patient who is concerned about getting a COVID-19 vaccine. Note that this simulated case was filmed in late 2021 and reflects the clinical situation at that time.

Part 3: Reflection and summary of applying the framework
Part 3: Reflection and summary of applying the framework

Dr. Nnorom summarizes key reflections from the clinical case that can help when applying the framework in your own clinical practice.

Here are some considerations when applying the LEAPS of care framework with Black patients who are experiencing hesitancy.

Listen and learn

  • Maintain an open attitude to allow your patient to share their fears and concerns about the vaccine
  • Listen and learn about your patient’s lived experiences of racism in health care
  • Listen and learn about each concern and consider how it may fit within the broader context of anti-Black racism

Engage and empower

  • Empower patients by respecting their self-determination, perspectives, values and choice
  • Explore your patient’s understanding of the vaccine and inform them of the risks of not getting vaccinated

Ask and acknowledge

  • Ask for permission to share information about COVID-19 and the vaccines before doing so
  • Address each concern individually without discrediting your patient’s perspectives or experiences
  • Do not shy away from bringing up the historical mistreatment of Black people in medical research and health care
  • Ask about and acknowledge the historical and current racism experienced by your patient and/or members of their community
  • Use validating and empathetic language to keep the lines of communication open

Paraphrase and provide

  • Paraphrase the information as it relates to the patient and their specific concerns and circumstances
  • Provide quality care without judgment and give the vaccine if consent is obtained

Support and spark

  • If your patient decides against vaccination, respect their decision. You can share your concerns about remaining unvaccinated and set up a follow-up appointment to give them time to reconsider and answer any new questions that may arise
  • Support patients in accessing culturally-relevant community resources and services
  • Spark future patient engagement by providing relevant resources or offering to follow up by email on what was discussed during your appointment, with your patient’s consent

Community supports

The COVID-19 resource page helps Black patients navigate COVID-19 information, access community resources, and understand COVID-19 vaccination.

This community initiative was launched by the Black Physicians’ Association of Ontario and aims to advocate, educate and vaccinate in a culturally-safe way.

This project provides information about COVID-19 to the Black Canadian community and addresses concerns. Through community engagement, it promotes the Black Canadian community’s well-being and health.

This Scarborough Health Network initiative provides an opportunity for all Canadians to receive a one-on-one, judgment-free phone call with a physician to address any questions or concerns about the COVID-19 vaccines.

This content was developed with Black and Indigenous health leaders in Ontario: Dr. Audrey Dye (TAIBU Community Health Centre); Dr. Azza Eissa, Dr. David Esho, Dr. Dominick Shelton, and Dr. Onye Nnorom (Black Physicians’ Association of Ontario and Department of Family and Community Medicine at the University of Toronto); Dr. Chase McMurren (Indigenous Health theme lead, faculty of medicine, and Department of Family and Community Medicine at the University of Toronto); and Dr. David Burt and Nicole Welch (Black Scientists’ Task Force on Vaccine Equity).