In the United States, Black communities exhibit the highest levels of medical mistrust, largely due to historical and contemporary marginalization exacerbated by ongoing structural racism. The COVID-19 pandemic highlighted the devastating repercussions of such racism, given inequities in prevention and treatment. For example, Black individuals experienced COVID-19 mortality at a rate 3.6 times higher than their white counterparts.

This study investigates the mediating effect of medical mistrust between participants' health beliefs and vaccine uptake among predominantly Black residents in New Jersey and Illinois, who are medically and socially vulnerable to COVID-19. The data used in this analysis was collected as part of two randomized controlled trials (R01MD010629 and U01AI169469) to test adaptive interventions aimed at increasing COVID-19 testing in historically disinvested and predominately Black communities. The research project implemented community-based participatory principles throughout all phases. We applied a social determinants of health framework, incorporating Bogart's multi-level (e.g., individual, structural) understanding of medical mistrust, along with the Health Belief Model (HBM), to guide a cross-sectional examination of baseline data gathered from 1,159 individuals. Control variables included demographics (e.g., gender, age, race, religion), structural factors (e.g., income, marital status, education), HBM domains (e.g., perceived threat, perceived benefits, perceived barriers), and a Medical Mistrust variable (e.g., Kalichman COVID-19 Assessment). The outcome variable was self-reported COVID-19 vaccination status (yes or no).

Our results confirmed a negative relationship between high levels of medical mistrust and vaccine uptake. Specifically, the SEM analysis revealed that marital status and religious affiliation influenced the strength of the paths differently, while race, income level, and gender showed no significant effects. The analysis underscores the importance of adopting an intersectional approach to understanding and addressing vaccine uptake in medically and socially marginalized populations. Our paper offers a comprehensive perspective on the complexities surrounding vaccine acceptance among largely Black communities.