key: cord-0928530-jfq5dw7v
authors: Eissa, Azza; Lofters, Aisha; Akor, Nancy; Prescod, Cheryl; Nnorom, Onye
title: Increasing SARS-CoV-2 vaccination rates among Black people in Canada
date: 2021-08-09
journal: CMAJ
DOI: 10.1503/cmaj.210949
sha: 514a738e651b3d37daf6ed94ddaf0428781815bf
doc_id: 928530
cord_uid: jfq5dw7v

nan

I n June 2020, Public Health Ontario started collecting data on race of patients with COVID-19, after months of community advocacy. It soon became apparent that Black people were disproportionately infected with SARS-CoV-2 in the province. According to the first data released by the Toronto Public Health Unit, people of African and Caribbean descent accounted for 21% of patients with COVID-19 in Toronto, despite representing only 9% of the city's population. 1 From January to May 2020, rates of SARS-CoV-2 infections, hospitalizations, admissions to the intensive care unit and deaths were about 3, 4, 4 and 2 times higher in Ontario's most ethnic neighbourhoods, respectively. 2 The rate of COVID-19 among Black people in Toronto jumped from 741 cases to 1311 cases per 100 000 from March to April 2021. 1 Despite being among those hardest hit by the pandemic, only 56.6% of Black Canadians reported willingness to receive the SARS-CoV-2 vaccine, compared with 76.9% in the popu lation overall, 3 according to a Statistics Canada report from March 2021. The World Health Organization defines vaccine hesitancy as a "delay in acceptance or refusal of vaccines despite availability of vaccination services." 4 Thus, before labelling patients and communities as vaccine-hesitant or lacking in health literacy, we must ensure adequate access to vaccination services and address the systemic racism that underpins many social inequities faced by Black communities in Canada. In a pandemic that has disproportionately burdened Black people, the SARS-CoV-2 vaccine rollout offers an opportunity to rebuild trust and accountability, and to correct the long-standing health inequities experienced by Black communities. We discuss what clinicians can do to help achieve higher rates of SARS-CoV-2 vaccination among Black Canadians.

Although no evidence has shown vaccine hesitancy for routine childhood vaccines among Black populations in Canada, a 2012 study found that Black Ontarians were the group least likely to receive influenza vaccines compared with other racialized groups. 5 The TAIBU Community Health Centre, which serves predominantly Black populations, developed a model to address this issue. Using a continuous quality improvement initiative that centred on respecting Black perspectives to build vaccine confidence, the centre increased influenza vaccine rates among the people it served from 8% in 2013 to 53% in 2018. 6 Providers at TAIBU employed an "Afrocentric" health promotion approach, anchored in values of cooperation and collective input. 7, 8 The term "Afrocentric" applies to people of African and Caribbean descent, meaning that providers centred this community in their work. They listened and spoke with patients respectfully, acknowledged concerns based on values and beliefs, and identified barriers to vaccination. Barriers were then addressed by providing culturally relevant and specific resources and posters on the flu vaccine, improving accessibility through expanding clinic hours, using a patient reminder calling system and informing patients that providers had been immunized themselves. We suggest that clinicians incorporate such an Afrocentric approach to increase acceptance and uptake of the SARS-CoV-2 vaccine among Black Canadians.

An Afrocentric approach, which also acknowledges that health care experiences of Black people are affected by historical and present-day anti-Black racism, 9, 10 can be combined with communication frameworks to counsel vaccine-hesitant patients. For example, the LEAPS of care model could be used by providers, as follows: listen and learn about the patient's lived experience; engage and empower patients by respecting their own self-determination and perspectives; ask and acknowledge patients' fears and concerns, which includes asking about previous health care encounters during which they may have experienced racism; paraphrase and provide vaccination information and educational handouts, and administer the vaccine if consent is obtained; and support and spark future patient engagement and community partnerships as needed. When providing information, clinicians may boost vaccine confidence among Black Canadians by citing data on the number of Black patients who received the vaccine and highlighting the contributions of Black scientists, as Dr. Anthony Fauci did by commenting that the Moderna vaccine "was developed by an African American woman (Dr. Kizzmekia Corbett)." 11 Endorsement of vaccines by physicians and nurses is one of the strongest factors in influencing vaccine decisions for all patients. 11 Clear, consistent and accessible information about vaccine efficacy, contraindications, adverse effects and the time needed for protection (with multiple doses) is crucial to building vaccine confidence. Emphasizing the importance of population-wide coverage to protect the community may also help to increase vaccine acceptance.

It is important that clinicians not only communicate information about the vaccine itself, but also support patients in navigating a complex system. Conflicting messaging about SARS-CoV-2 variants, vaccine safety, adverse events, priority groups and vaccination sites (e.g., information on vaccination websites not aligning with government messaging) has been detrimental to building trust in vaccines. Confidence in the vaccines will not improve if Black communities are told that they are at high risk and should continue to socially distance, while they are also excluded from vaccine priority lists or are not provided greater access to vaccines. Providers should offer accurate, current information to high-risk Black patients about how to access vaccines, given the difficulties in keeping up with changing preregistration criteria at different sites. Black-led health care partnerships play a pivotal role in bridging this gap. For instance, the Black Creek Community Health Centre (located in northwest Toronto, a hard-hit hotspot area) used trained community ambassadors and coordinated a series of lowbarrier vaccine clinics during evenings and weekends to accommodate essential workers, which resulted in a successful surge in vaccine uptake, from 5.5% in April 2021 to 56.3% in May 2021. 1 Community health centres (e.g.,TAIBU and Black Creek), Blackled organizations (e.g., Black Health Alliance, Black Scientists' Task Force on Vaccine Equity, Black Physicians' Association of Ontario, Health Association of African Canadians) and many Black health leaders in Nova Scotia and other provinces have been combatting vaccine distrust in Black communities by organizing town hall meetings, advocating for race-based data collection and creating sharable resources that dispel misinformation. Clinicians should be aware of this work and these resources. More remains to be done in the careful collection of data to inform evolving solutions to the COVID-19 crisis for Black communities. We cannot merely present alarming epidemiologic data without action. 12, 13 Qualitative data on Black peoples' lived experiences of racism during the pandemic are needed to support endeavours toward dismantling barriers and improving the experiences, access and outcomes in health care for Black people in Canada.

Toronto: City of Toronto

Toronto: Public Health Ontario

COVID-19 vaccine willingness among Canadian population groups. Ottawa: Statistics Canada

Social determinants and inequities in health for Black Canadians: a snapshot. Ottawa: Government of Canada

Influenza vaccination coverage across ethnic groups in Canada

Use of a quality improvement strategy to increase flu immunization rates among racialized groups

Family Medicine forum

An Afrocentric approach to building cultural relevance in social work research

Mental health for youth: applying an African-centered approach

Addressing vaccine hesitancy in BIPOC communitiestoward trustworthiness, partnership, and reciprocity

Beyond Tuskegee -vaccine distrust and everyday racism

Planning for a COVID-19 vaccination program

governance, access, and protection (EGAP): a data governance framework for health data collected from Black communities in Ontario. Blackhealthequity.ca

The COVID-19 vaccines rush: participatory community engagement matters more than ever

The authors thank Sané Dube at Gattuso Centre for Social Medicine at University Health Network for editing assistance on a previous draft of this manuscript.

Contributors: Azza Eissa, Aisha Lofters and Onye Nnorom contributed to the conception and design of the work. Nancy Akor and Cheryl Prescod provided insights on how Black-led community partnerships at the TAIBU and Black Creek Community Health Centers, respectively, used Afrocentric health promotion approaches and existing trusted relationships to increase vaccination rates in the Black communities they serve. Azza Eissa drafted the manuscript. All authors reviewed the manuscript critically for important intellectual content, gave final approval of the version to be published and agreed to be accountable for all aspects of the work.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: https://creativecommons.org/licenses/by-nc-nd/4.0/