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Background Interventions for increasing the uptake of COVID-19 vaccination among Black young adults are central to ending the pandemic. Black young adults experience harms from structural forces, such as racism and stigma, that reduce receptivity to traditional public health messaging due to skepticism and distrust. As such, Black young adults continue to represent a priority population on which to focus efforts for promoting COVID-19 vaccine uptake. Objective In aims 1 and 2, the Tough Talks digital health intervention for HIV disclosure will be adapted to address COVID-19 vaccine hesitancy and tailored to the experiences of Black young adults in the southern United States (Tough Talks for COVID-19). In aim 3, the newly adapted Tough Talks for COVID-19 digital health intervention will be tested across the following three southern states: Alabama, Georgia, and North Carolina. Methods Our innovative digital health intervention study will include qualitative and quantitative assessments. A unique combination of methodological techniques, including web-based surveys, choose-your-own-adventures, digital storytelling, user acceptability testing, and community-based participatory approaches, will culminate in a 2-arm hybrid type 1 effectiveness implementation randomized controlled trial, wherein participants will be randomized to the Tough Talks for COVID-19 intervention arm or a standard-of-care control condition (N=360). Logistic regression will be used to determine the effect of the treatment arm on the probability of vaccination uptake (primary COVID-19 vaccine series or recommended boosters). Concurrently, the inner and outer contexts of implementation will be ascertained and catalogued to inform future scale-up. Florida State University’s institutional review board approved the study (STUDY00003617). Results Our study was funded at the end of April 2021. Aim 1 data collection concluded in early 2022. The entire study is expected to conclude in January 2025. Conclusions If effective, our digital health intervention will be poised for broad, rapid dissemination to reduce COVID-19 mortality among unvaccinated Black young adults in the southern United States. Our findings will have the potential to inform efforts that seek to address medical mistrust through participatory approaches. The lessons learned from the conduct of our study could be instrumental in improving health care engagement among Black young adults for several critical areas that disproportionately harm this community, such as tobacco control and diabetes prevention. Trial Registration ClinicalTrials.gov NCT05490329; https://clinicaltrials.gov/ct2/show/NCT05490329 International Registered Report Identifier (IRRID) DERR1-10.2196/41240

Interactive stories are a relatively newer form of storytelling with great potential to correct misinformation while increasing self-efficacy, which is crucial to vaccine acceptance. To address COVID-19 vaccine hesitancy and medical mistrust in young Black adults (BYA), we sought to adapt a pre-existing application ("app"; Tough Talks) designed to address HIV disclosure decision-making through choose-your-own adventure (CYOA) narratives and other activities. The adapted app (Tough Talks - COVID) uses a similar approach to situate COVID-19 vaccination decision-making within social contexts and to encourage greater deliberation about decisions. To inform content for the CYOA narratives, we conducted an online survey that was used to elicit the behavioral, cognitive, and environmental determinants influencing COVID-19 vaccine hesitancy among 150 BYA (ages 18-29) in Georgia, Alabama, and North Carolina. The survey included scenario questions that were developed with input from a youth advisory board to understand responses to peer and family influences. In two scenarios that involved discussions with family and friends about vaccination status, most respondents chose to be honest about their vaccination status. However, vaccinated individuals perceived more social pressure and stigma about not being vaccinated than unvaccinated respondents who were not as motivated by social pressure. Personal choice/agency in the face of perceived vaccine risks was a more common theme for unvaccinated respondents. Results suggest that relying on changing social norms alone may not impact barriers to vaccination in unvaccinated young adults without also addressing other barriers to vaccination such as concerns about autonomy and vaccine safety. Based on these findings, CYOA narratives in the app were adapted to include discussions with family and friends but also to touch on themes of personal choice as well as other topics that influence behaviors besides norms such as safety, side effects, and risk of COVID-19 in an evolving pandemic.

BACKGROUND Few studies have focused on attitudes towards novel coronavirus 2019 (COVID-19) vaccination among Black or African American young adults (BYA) in the Southern United States (US), despite high levels of infection in this population. OBJECTIVE To understand this gap, we conducted an online survey to explore beliefs and experiences related to COVID-19 vaccination among BYA (ages 18-29) in three southern states. METHODS We recruited 150 BYA to participate in an online survey as formative research for an intervention to address vaccine hesitancy/skepticism in Alabama, Georgia, and North Carolina between September 22, 2021, and November 18, 2021. Participants were recruited through social media ads on Facebook, Twitter, Instagram, and YouTube. Additionally, we distributed information about the survey through national organizations working with BYA, our community partners and network collaborations. We used validated measures from prior surveys on COVID-19 vaccination. RESULTS Less than half of vaccinated respondents planned to get a booster shot (47%, n=71) and 14% (n=28) had not received any doses of the COVID-19 vaccine. Half of unvaccinated respondents (50%, n=14) reported they wanted to wait longer before getting vaccinated. Motivators to get vaccinated were similar between unvaccinated and vaccinated respondents (e.g., if required, to protect the health of others); but the main motivator for those vaccinated was to protect one’s own health. Among unvaccinated individuals, reasons for not receiving the COVID-19 vaccine included concern about vaccine side effects (54%) and mistrust of vaccine safety (46%), of effectiveness (43%), and of the government’s involvement with vaccines (43%). Experiences of discrimination (40%) and mistrust of vaccines (36%) were common even among the vaccinated population. Among all respondents, those who said they would be motivated to get vaccinated if it was required for school, work, or travel, were more likely to endorse negative beliefs about vaccines compared to those motivated for other reasons. CONCLUSIONS Mistrust in COVID-19 vaccine safety and efficacy was common among this sample of BYA in the South, irrespective of vaccination status. Other motivators such as safety of family and community and vaccination requirements may be able to tip the scales towards a decision to be vaccinated among those who are initially hesitant. However, it is unclear how vaccine requirements among BYA in the South affect trust in government or healthcare in the long-term. Interventions that include young Black adults in vaccination messaging and programs may consider more proactively addressing trust and countering misinformation.

Racism in the United States has been cited as a key driver of racial health inequities. Racism as a public health crisis has been in the forefront, particularly with respect to state and municipal governments that have developed legislation, resolutions, and declarations. This policy brief includes a review of resolutions and declarations across the US related to Racism as a Public Health Crisis through the end of September 2020. There were 125 resolutions reviewed for content related to the history of racism, reference to racial health equity data, content related to action steps or implementation, and any accompanying funding or resources. We found that the majority of policies name racism as critical in addressing racial inequities in health with limited details about specific actions, funding, or resources.