What matters to us: Bridging research and accurate information through dialogue (BRAID) to build community trust and cultivate vaccine confidence

Highlights

• •Historical and present healthcare experiences drove COVID-19 vaccine distrust.
• •Rapidly evolving and unclear COVID-19 information eroded vaccine confidence.
• •The BRAID model connected community and scientific experts for open conversations.
• •BRAID empowered participants with timely information to share downstream.
• •Community experts shared strategies for improving community trust in the health system and to encourage vaccine uptake.

Abstract

Despite higher rates of SARS-CoV-2 infections and mortality, vaccine uptake in Black and Latinx populations remained disproportionately low, including in the Bronx, New York. In response, we used the Bridging Research, Accurate Information, and Dialogue (BRAID) model to elicit community members’ COViD-19 vaccine-related perspectives and informational needs and inform strategies to improve vaccine acceptance.

We conducted a longitudinal qualitative study over 13 months (May 2021-June 2022), with 25 community experts from the Bronx including community health workers, and representatives from community-based organizations. Each expert participated in 1–5 of the 12 conversation circles conducted via Zoom. Clinicians and scientists, attended circles to provide additional information in content areas identified by the experts. Inductive thematic analysis was used to analyze the conversations.

Five overarching themes, related to trust, emerged: (1) disparate and unjust treatment from institutions; (2) the impact of rapidly changing COVID messages in the lay press (a different story every day); (3) influencers of vaccine intention; (4) strategies to build community trust; and (5) what matters to community experts [us].

Our findings highlighted the influence of factors, such as health communication, on trust (or lack thereof) and vaccine intention. They also reinforce that creating safe spaces for dialogue and listening and responding to community concerns in real time are effective trust-building strategies. The BRAID model fostered open discussion about the factors that influence vaccine uptake and empowered participants to share accurate information with their community. Our experience suggests that the model can be adapted to address many public health issues.

1. Introduction

Disparities in COVID-19 vaccine uptake have persisted in many communities of color, such as the Bronx, New York, where over 80% of the population is Black and Latino. (NYC Department of Health and Mental Hygiene and Vaccine, 2022, Quick, 2021) Disparate COVID-19 vaccine uptake was evident over the course of the vaccine roll-out in early 2021. (NYC Department of Health and Mental Hygiene and Vaccine, 2022, The New York Times, 2021, Renelus et al., 2021, The New York Times, 2021) Despite high COVID-19 morbidity and mortality rates, (Tai et al., 2021, Kalyanaraman Marcello et al., 2020) only a small percentage of Bronx residents had received at least one dose of the vaccine at the start of the present study (May 2021), making it one of the lowest vaccination rates in New York City. (NYC Department of Health and Mental Hygiene and Vaccine, 2022, The New York Times, 2021, Hygiene 0000, Hygiene NYCDoHM, 2021) While various initiatives, incentives, and mandates may have since increased (first dose) vaccine uptake for communities of color in the US (Padamsee et al., 2022), emerging evidence indicates persistent racial and ethnic disparities for COVID-19 boosters (Gaffney et al., 2022) and pediatric vaccinations (Alfieri et al., 2021). This evidence underscores the need for sustainable strategies that address the underlying drivers of vaccine confidence.

Studies indicate Black and Latinx populations are less likely to trust vaccine safety and effectiveness of vaccines or believe that vaccine distribution is fair—top predictors of vaccine intention. (Crouse Quinn et al., 2017, Quinn et al., 2017, Dudley et al., 2021, Balasuriya et al., 2021) Historical distrust in healthcare systems and the continued legacy of medical injustice and racial and ethnic discrimination have contributed to COVID-19 vaccine distrust. (Balasuriya et al., 2021, Corbie-Smith, 2021, Bajaj and Stanford, 2021, Presser, 1969) Institutional distrust is more prevalent among racial and ethnic minority populations, especially Black Americans who report experiencing racism and bias regularly in healthcare and other settings. (Bajaj and Stanford, 2021, Best et al., 2021, Armstrong et al., 2007)Glaring racial and ethnic disparities in healthcare delivery and outcomes offer more evidence of disparate treatment as well as the perceptions of an unjust and untrustworthy health system. (Corbie-Smith, 2021, Institute of Medicine Committee, 2002).

Significant predictors of vaccine acceptance among healthcare workers in the South Bronx, NY, included low confidence in the science behind vaccines and concern about how quickly they were developed. (Ciardi et al.,) Vaccine literacy was significantly associated with increased vaccine confidence. Structural barriers, including limited access to appointments as well as culturally and linguistically appropriate COVID-19 vaccine information, influenced community attitudes and reduced vaccine confidence. (Strully et al., 2021, Carson et al., 2021) Additionally, information overload and mis/dis -information spread through digital and physical environments during the pandemic, defined by the World Health Organization as an “infodemic”, called for the need for reliable sources and timely delivery of accurate information to the public. (Organization, 2019) Building trust in the safety of the vaccine and in institutions involved in vaccine development and distribution is therefore crucial.

The BRAID Model is an intervention developed in 2020, by author (D.G.) and researchers at the Albert Einstein College of Medicine (AECOM) to address the drivers of disparate uptake of and distrust related to the COVID-19 vaccine. Informed by several evidence-based approaches, including motivational interviewing (Miller and Rose, 2009, Miller and Rollnick, 2012), and well as other community engagement approaches. (Chabra, 2018, Joosten et al., 2015, Rapkin et al., 2017) BRAID was designed to foster trust between healthcare systems, and community members who are “experts” in what matters most to their community. (Fig. 1) BRAID provides space for bilateral, dynamic dialogues (“conversation circles”) with community experts and researchers that elicit community perspectives, concerns, and questions related to a variety of public health topics, such as COVID-19 vaccines. Based on community expert input, clinical, scientific, and public health experts (subject matter experts) are invited to join the circles to learn about what matters to the community and share accurate health information tailored to community concerns. Circles re-convene over time, with the goals of (1) building trust between community and subject matter experts, (2) addressing emerging health information needs in real-time, and (3) collaborating with community experts to co-produce health messages that are acceptable to the community.

Fig. 1.

The BRAID (Bridging Research, Accurate Information and Dialogue) Model.

For this study we used BRAID conversation circles with a combination of community experts, including several community health workers (CHWs), to elicit and address community concerns related to COVID-19 vaccination. By leveraging the expertise of community experts and subject matter experts, the BRAID Model offers a promising approach to build trust and increase vaccine confidence in communities of color, ultimately contributing to more equitable vaccine uptake and better health outcomes.

2. Materials and methods

The BRAID intervention and study were funded by the Centers for Disease Control and Prevention Foundation and the New York City Community Engagement Alliance. The present community-engaged, longitudinal qualitative study used data collected from BRAID conversation circles about COVID-19 vaccination. Participants completed an oral informed consent prior to participating in the study and were compensated $20/hour for their time and community expertise. Procedures were in compliance with the AECOM Institutional Review Board. Consolidated Criteria for Reporting Qualitative Research guidelines are used to report data (Hsieh and Shannon, 2005).

3. Study design

We engaged two community-based organizations (CBOs), Bronx Health Reach (Institute for Family Health affiliate) and Mosholu Montefiore Community Center, as research partners to help recruit community experts to participate in a series of BRAID conversation circles. Community experts first participated in a BRAID orientation circle followed by a series of up to four follow-up circles. Conversation circles of 2–8 participants were spaced 1–4 weeks apart and were facilitated by the study PI (D.G., a community researcher and internist) and co-facilitated by Einstein and Montefiore researchers, including (C.H-S.) and a CBO leader (M.B-Z.). For follow-up circles, groups with fewer than 4 participants were combined. At the conclusion of each circle, perceptions and COVID-19 vaccine questions that had emerged during the conversation were summarized by the study team. Community experts then prioritized content areas they wanted to explore in more depth. Clinical and scientific experts were invited to follow-up circles to provide additional information in these areas.

3.1. Participants

The study sample includes members of the Bronx community, such as community health workers (CHW) and members of a community youth group. Participants with the potential to serve as community experts due to their social connections and established trustworthiness were recruited via CBO outreach emails and events. Eligibility included age ≥ 18, live and/or work in the Bronx and English speaking. Community experts were grouped to participate in circles, based on commonalities such as age or other distinctive features that may present unique perspectives (i.e., community health workers, youth group leaders).

3.2. Data collection

Over a 13-month period (May 2021–June 2022), we held 12 BRAID Conversation Circles. A semi-structured interview guide, developed based on literature review, and piloted with community experts, was used to elicit community perspectives around COVID-19 vaccinations. The guide consisted of guiding open-ended questions and prompts which were allowed for flexibility based on the group discussion. Researchers revised the guide in an iterative fashion throughout the data collection phase based on new information (variants, boosters) and information gaps identified. Circles were conducted and recorded using a secure video conferencing platform (Zoom) due to COVID-19 restrictions. Conversations ranged from 60 to 90 min. Transcripts from the videotaped recordings were de-identified.

3.3. Data analyses

Inductive thematic qualitative analysis was used to assess data from the Conversation Circles. (Braun and Clarke, 2006) A team of four coders, Y.Y, C.S.-H., R.L., J.C., three public health researchers and an undergraduate student independently reviewed the 12 transcripts to identify emerging themes that aided in creating a codebook. Three of the 12 transcripts were then independently coded and used to revise the codebook through an iterative process. Utilizing the revised codebook, the team met weekly between August 2021 to August 2022 and applied codes to all transcripts using Dedoose qualitative analysis software. (Version, 2021) Memos were maintained to track emerging themes and code applications were discussed until consensus in themes was reached among all investigators (Y.Y, C.S.-H., R.L, J.C., D.G.). Descriptive statistics were conducted using SPSS.

4. Results

Twenty-five of thirty eligible participants consented to participate in at least one of the 12 BRAID conversation circles Eighteen (68%) attended at least one follow-up conversation circle (Table 1). The mean (SD) number of conversation circle sessions attended per participant was 2.32 SD= (1.22) Participants ranged in age from 18 to 64, and more than half were under 35 years of age. Slightly more men (56%) than women participated, and most (96%) self-identified as Black/African (n = 15) American or Latinx (n = 9). More than half reported having received at least one dose of the COVID-19 vaccine at the start of the BRAID circle series.

Table 1.

Demographic Characteristics, Vaccination Status, and Session Attendance for BRAID Participants.

Participant characteristics	Total (%) (n = 25)
Age category (y)
< 20	7 (28)
20–34	7 (28)
35–54	4(16)
>55	4(16)
Undisclosed	3 (12)
Gender
Female	11(44)
Male	14(56)
Race/Ethnicity
African American/Black	15(60)
Hispanic/Latinxa	9(36)
Other	1(4)
Vaccinated before first circleb
Yes	15(60)
No	10(40)
Number of BRAID Sessions Attended
1–2	9(36)
3–5	16(64)
Residence
Bronx	22(88)
Other NYc	3(12)
Occupation
Undergraduate Student	7 (28)
Community Health Worker/Navigator	5 (20)
Youth Group Leader	2 (8)
Customer Service	3 (12)
Otherd	4 (16)
Unknown	4 (16)

^aThree participants in the Hispanic/Latinx category also identified as African American/Black race. None of the other participants in the Hispanic/Latinx identified a race.

^bBased on self-report of having received at least one dose of the COVID-19 vaccination at time of orientation circle.

^cOther NY includes 1 resident of Yonkers, NY; 1 Brooklyn, NYC; 1 Manhattan, NYC.

^dOther includes playwright; stay-at-home-parent, retired.

Three Montefiore infectious disease specialists and a public health researcher from the Borough President’s office with expertise in local COVID-19 data were invited and attended 4 of the follow-up circles to provide accurate information that addressed questions raised by the participants during prior circles.

Findings are summarized into 5 key themes and subthemes that emerged during the BRAID circles. Table 2 includes the themes and subthemes along with their illustrative quotes.

Table 2.

BRAID-Conversation Circle Themes, Subthemes, and Illustrative Quotes on COVID-19 Vaccines.

Current Theme/subtheme	Quotes
Theme 1: Disparate and Unjust Treatment from Institutions
Subtheme 1a: Historic Structural Racism	“I know for the African American community there's a lot of historical mistrust in the medical community…things like Tuskegee…where African American groups was experimented [on], not given a lot of rights and say…in their health care.” “I was thinking about historically, how the government has not treated black people appropriately in the health field so that added to my anxiety about being vaccinated…” “…because of the way the world has been moving, considering…human rights for black people and other marginalized identities, it’s been difficult for me to fully trust the health system in the US.”
Subtheme 1b: Being Part of the Experiment	“There’s a long history of vaccines or medications being trialed on communities of color before being trialed on other communities, so I was very nervous” “ I mean I honestly do feel like it’s one big experiment, we don't know what this thing is doing, we don't know, you know, what is going to do to a lot of people years down the line. We are the experiment.” “..[my daughter’s] like oh no, not my child…. He’s not going to be a guinea pig …for science”
Subtheme 1c: Transactional Healthcare Experience: “They're always trying to sell you something”	“I can't trust health professionals because they’re always trying to sell you something” “I'm like 23 years old, I can’t remember [a] time [when] I spoke to a doctor for more than 5 min. It’s just kind of like a transaction, like “Oh,.., you should try X, Y and Z. I hope you feel better, take care.” “…I mean we’ve heard about the doctors, they get kickbacks and stuff from pushing things and maybe people feel… like Oh, you know there's gonna be some type of benefit for them to tell me to go get it [the vaccine]…”
Subtheme 1d: Hierarchical and Disrespectful Power Dynamics	“… health practitioners …they give me this information about my health, and I can't even read it. It's like not even English” “there are some professionals that may come into spaces feeling, as if Oh, I have my knowledge, because I have my experience, and if you don’t agree with me, or you don’t want to listen to what I have to say, then you're wrong” “I feel like they [health system] are trying to work with governments instead of you know, making this [the vaccine] between [health care providers] people and your community so that’s why I feel like people are not trusting the medical field.”
Theme 2: “A Different story every day”	“I want to understand … the COVID vaccine, because everybody is scared you know maybe, [it’s] affecting people….what you have is …..[a] different story everyday.” “I think that you’re going to have the backlash …like… with the J&J, it’s hard to build that trust back again once you done, you know, once you cheated…,. they’re gonna have a hard time getting people to put the face mask back on.” See Fig. 2.
Subtheme 3: Influencers of Vaccine Intention
Subtheme 3a: Families as influencers	“Me] and my mom, we talked about it. We said we were going to do it together. My grandma got it and she’s fine. …My brother got it and its just me and my mom. So, we just going to get a date and just get it.” “I [made] the appointment, but when I came back and told my father, he said that he doesn't think it’s safe, because people were saying that you might be safe now, but 2 to 5 years from … now, you might have some problem because of you took the vaccines” “….. I was one of those people that was kind of hesitant to get the vaccine early on…One of the reasons that I did go ahead and get it was that my son is off to college and [his school is] requiring students be fully vaccinated. … he’s very excited to go and we wanted to support him in that decision. So, we decided as a family we would get it…”
Subtheme 3b: COVID-19 Disparities Fueling Suspicion	“We lost a couple of family members to COVID, so I know that [my Mom] was real skeptical about how the shot was gonna affect her and if she would be okay afterwards.” “My biggest concern … was if we get the vaccine, but yet people are still getting sick …still dying what is it really out here doing.” “people who are richer or more well off will get the Pfizer… compared to low-income communities, especially Black communities, will get like the ‘Moderna’ or like a very… cheap considered vaccines”.
Theme 4: Strategies to Build Community Trust
Subtheme 4a: Creating Access to Relatable Empathetic Experts	“I feel that’s the best way to go about doing it, you know someone who’s willing to answer these questions, no matter how absurd it may be, I think it’s important to have someone to be able to …someone who is willing to. …as well as someone who speaks English. that sounds like a very common thing…” “I feel like the communication between communities and Health Care Providers should be more casual and personable because… they’re the ones who like we interacted with the most, they see our bodies, and like really get to know us on a personal level so that that feeling should be translated into the way we communicate as well” “Health practitioners… it’s just hard to converse with them… I have people in my life, who have a lot of natural health remedies and… experience… that showcases to me that they’re more informed in health than I am, and they seem more personable… I can still feel their intensity of trying to make sure that I'm doing okay. See that's cool.”
Subtheme 4b: BRAID as a Strategy	“it’s just different when you're not talking to someone directly. With this conversation that we’re having right here… It just feels a lot more personable, not something like a million views that I don't know who wrote it or who’s behind it, or who's promoting [it]…” “…if I had more experiences like this in the past with my experiences with health care providers, I feel like that would have boosted my confidence and getting the vaccine.” “I’m so happy to be in a conversation like this because straight from my heart I can say whatever I want to say, for real.” “I love it when Health Care Providers are able to talk to patients as equals and I definitely sense that I’ve been getting that through this whole research Community conversation.” “It feels like Christmas… I am getting so many questions answered and information I can share with others.” “…Now that I have access to this information, I’ll be able to share what I learned with people that I know from school or…my family so like …a ripple effect of the right information being shared”
Subtheme 4c: Trusted Messengers sharing authentic experiences	“maybe health care workers like nurses from New York City… maybe they could share their experiences with Covid … and how it affected them…it’s one thing for a government official …or people who make the vaccine to come and speak to us, and it's one thing [coming] from a nurse from the Bronx [to] talk about their experience with the vaccine.” “I use a few faith leaders, that I knew [were] very influential in the community, so we have… them… get the vaccine. …and they [tell the community] I got mine, so you need to get yours….…So every week…after the Friday service, they will collect 50 or 60 people on the list, they would give me [the] okay, these people want to do the vaccines now and they will send it to me and I [would] schedule them.” “that’s what I’ve been telling them. Come out and tell your Community I did my vaccines… I took my shot, you need to take yours too. No, we need to use them as a bridge for the CDC and the Community.”
Theme 5: What Matters to Community Experts [Us]
Subtheme 5a: Facilitating equitable access to information	“Something that I value is spreading factual information and I feel [the lack of factual information] … prevented not only my friends from getting vaccinated but also it like delayed the time that I needed to take the vaccine…” “We are around people that don’t have no information, they don’t have no healthcare, they have immigration issues and public charges, so they [are] scared to go see doctors and stuff. So, the information we bring to them, that’s what they know.” “to inform the… African immigrant community [with] the right information …because lives are at stake, so you know we can't afford to live…life, based on conspiracy theories, we have to have the correct information. So that’s why …I try to participate [in] these forums, these workshops. Get the correct information and get the right resources for our community.”
Subtheme 5b: Filling gaps in understanding of science	“I guess, I would need more information, and this is exactly why I joined this group, but maybe there's some information that I don’t know, you know, to make me feel more secure.” “I don't want to lose my trust in science and research, you know, that’s why, you know, I’m trying to get whatever I can get out. You know, because, from the beginning, I been telling these people that this, I believe in research, and I believe in what people are telling me. And so far, it’s, it’s not leaning on the wrong way.” “…it doesn't really prevent you from getting COVID… it’s supposed to make the symptoms like less, or is that not right?”

4.1. Theme 1: Disparate and unjust treatment from institutions

Participants provided insight into how distrust of the healthcare system and the science behind the vaccine stemmed from historical structural racism as well as contemporary healthcare experiences that were perceived as transactional or hierarchical.

4.1.1. Subtheme 1a: Historic structural racism

Knowledge of historical racial injustices added to participants’ vaccine concerns.

“I was thinking about historically how the government has not treated Black people appropriately in the health field so that added to my anxiety about being vaccinated”.

4.1.2. Subtheme 1b: Being Part of the Experiment.

“…We are the experiment.”.

The legacy of historical structural racism in Black communities and of being “experimented on” contributed to distrust of the vaccine.

“There's a long history of vaccines or medications being trialed on communities of color before being trialed on other communities, so I was very nervous”.

4.1.3. Subtheme 1c: Transactional Healthcare Experiences: “They’re Always Trying to Sell You Something”.

Participants' personal experience of healthcare delivery including communication styles used by healthcare providers and the rapid pace of office visits contributed to their distrust of providers and the care delivered by them.

“I'm like 23 years old, I can’t remember [a] time [when] I spoke to a doctor for more than 5 min. It’s just kind of like a transaction…”.

4.1.4. Subtheme 1d: hierarchical and disrespectful power dynamics

Community members shared how health professionals often communicated and behaved in ways that conveyed elitism and disinterest in partnering with patients, including sharing health information that was confusing and not tailored to their level of health literacy, as well as encounters with health care providers who were perceived as disrespectful.

“…there are some professionals that may come into spaces feeling, as if ‘Oh, I have my knowledge, because I have my experience, and if you don't agree with me, or you don't want to listen to what I have to say, then you're wrong’”

4.2. Theme 2: A different story every day

“I want to understand … the COVID vaccine, because everybody is scared you know maybe, [it’s] affecting people… what you have is …[a] different story every day.”.

Rapidly changing and confusing information shared by the scientific community and media outlets added to participants’ mistrust of the vaccine and healthcare messages. Fig. 2 maps evolving perspectives of BRAID participants captured from conversation circles within a month of the media event together with data pulled from the NYC.gov COVID-19 dashboards on the day of the media story.

Fig. 2.

A different story everyday: Influence of rapidly changing media stories and COVID tracking data* on BRAID community dialogues. Evolving attitudes and perspectives of BRAID community participants over time were mapped to a COVID-19 media story and data timeline. Data was pulled from the NYC.gov COVID-19 dashboards on the day of the media story. Quotes were captured from conversation circles that occurred within a month of the media event.

*Data from ¹NYC.gov COVID Dashboards; ^aCNBC 4/13/21; ^bCNN 4/13/21; ^cCNN 5/20/21; ^dWSJ 4/27/21; ^eCNBC 5/13/2021; ^fNPR 5/14/21; ^gABCNews 6/8/21; ^hNYT 6/23/21; ⁱCNBC 6/27/21; ^jNY1 News 10/13/21; ^k,lCDC News Release 10/21/21; ^mFDA 11/19/21; ⁿFirst 2021, Fully 2021 12/1/21; ^oForbes 1/10/22; ^pCNBC 4/20/22; ^qNYT 6/21/22; ^rNYT 6/20/22.

4.3. Theme 3: Influencers of vaccine intention

BRAID participants shared that family influenced vaccine intentions. Severe illness and death related to COVID-19 contributed to reduced confidence in the vaccine.

4.4. Subtheme 3a: Families as influencers

Families could have a positive or negative influence on vaccine decisions. One mother successfully utilized, “mom guilt” and “emotional blackmail” to influence her son to get vaccinated.

In contrast, a young woman struggled with her decision to get vaccinated because of her father’s concerns about the long-term safety of the vaccines. Camaraderie (making the decision to do it together) was also a positive influencer supporting behavior change.

4.5. Subtheme 3b: COVID-19 disparities Fueling Suspicion

Many BRAID participants shared personal and family experiences of loss due to the pandemic, “COVID was just terrible, I mean I lost a lot of people…” Surprisingly, participants shared that deaths of loved ones did not motivate their communities to get the vaccine and, in some cases, increased vaccine mistrust “We lost a couple family members to COVID, so I know that she [my Mom] was real skeptical about how the shot was gonna affect her and if she would be okay afterwards.” Some participants also expressed concerns about inequitable and unethical vaccine distribution “people who are richer or more well off will get the Pfizer…” compared to “low-income…especially Black communities will get like the ‘Moderna’ or like a very…cheap considered vaccines.”.

4.6. Theme 4: Strategies to build community trust

Participants shared strategies they believed could repair mistrust and nurture future trust. Specifically, they described BRAID circles and trusted messengers outside the health system as effective conduits for building community and individual trust of clinicians, the health system, and the vaccine.

4.7. Subtheme 4a: Creating access to Relatable Empathetic experts

Participants suggested forums with healthcare experts to answer questions would be an effective strategy to increase vaccine confidence. “I feel that's the best way to go about doing it, you know someone who’s willing to answer these questions, no matter how absurd…”.

4.8. Subtheme 4b: BRAID as a Strategy.

The experience of participating in BRAID circles and hearing health information in the safe spaces that were created was described as more personal and trustworthy in comparison to vaccine information received from anonymous sources through social media, “ … if I had more experiences like this in the past with my experiences with health care providers, I feel like that would have boosted my confidence and getting the vaccine.”.

Participants reported feeling respected and free to express their true concerns and opinions at the circles. “I’m so happy to be in a conversation like this because straight from my heart I can say whatever I want to say, for real.”.

Community experts also expressed feeling empowered to take action for themselves and their communities. “I am going to share this through my social media.”.

4.9. Subtheme 4c: Trusted messengers sharing authentic experiences

Multiple participants emphasized the power of authentic stories shared by trusted messengers as an effective vaccine promotion strategy. A CHW explained how by convincing one Muslim faith leader to share his vaccine experience he was able to get most of the mosque’s members vaccinated. “I use a few faith leaders, that I knew [were] very influential in the community, so we have…them…get the vaccine…and they [tell the community] I got mine, so you need to get yours.” Another CHW explained how he plans to use this strategy for Christian leaders and the potential broader impact if implemented with all faith leaders, “that’s what I’ve been telling them… we need to use them as a bridge for the CDC and the Community.”.

4.10. Theme 5: What matters to community experts [US]

In the beginning of each conversation circle, participants shared their reasons for joining the session which included wanting to gain accurate information and dispel misinformation for themselves, their families, and their communities.

4.11. Subtheme 5a: Facilitating equitable access to information

“Something that I value is spreading factual information and I feel [the lack of factual information] … prevented not only my friends from getting vaccinated but also it like delayed the time that I needed to take the vaccine…”

Participants valued being able to facilitate the flow of information from knowledgeable health experts to the marginalized communities they serve.

“We are around people that don’t have no information, they don't have no healthcare, they have immigration issues and public charges, so they scared to go see doctors and stuff. So, the information we bring to them that's what they know.”

4.12. Subtheme 5b: Filling gaps in understanding of science

Many participants also requested information that would help them, and their communities make informed vaccination decisions.

“I guess, I would need more information, and this is exactly why I joined this group, but maybe there's some information that I don't know, you know, to make me feel more secure.”.

4.13. Discussion

We explored Bronx community members’ COVID-19 vaccine attitudes, beliefs, and their perceptions of participation in BRAID Circles. Researchers identified 5 overarching themes related to trust, including historical atrocities and mistreatment of communities of color, which fueled distrust for the government, health systems, and vaccines, and effective strategies to build and repair trust. Participants’ experiences with healthcare providers were characterized as “transactional” and they perceived the healthcare system as prioritizing other interests over their communities’ interests.

Rapidly changing vaccine guidelines and media messages caused confusion and eroded trust in the vaccine. Most participants reported experiencing severe illness and deaths either themselves or within their families and social networks. This trauma, together with an awareness of the overwhelming historical racism in medicine, added to their questioning of the vaccine and the motives of those promoting it. We observed participants weighing the pros and cons of evidence of vaccine efficacy and safety. Our findings align with those of Corbie-Smith, (2021) who described how adverse and traumatic experiences increase the length of time individuals require to deliberate before getting the vaccine. (Corbie-Smith, 2021)Additionally, families were powerful influencers of vaccine intention in both directions.

We learned about what mattered to our participants including the ability to have their and their community’s concerns addressed during the BRAID circles. Participants felt heard, respected, and that their concerns were prioritized; many noted that the BRAID circles were their first positive experience communicating with healthcare professionals. These findings align with those of Balasuriya et al. (2021) who highlight the significance of listening and responding to community concerns as a vital first step to improving COVID-19 vaccine acceptance (Balasuriya et al., 2021).

The BRAID model aims to build trust and empower local trusted messengers to share accurate vaccine information through their networks. It aligns with Wilkins’ (2018) community engagement principles for building trusting partnerships. (Wilkins, 2018) BRAID participants, as community experts, shared effective strategies to foster trust between communities and the health system to encourage vaccine uptake.

5. Limitations and strengths

Results and conclusions are limited by several factors. Due to pandemic precautions, Zoom was used for all conversation circles. While this may limit trust and relationship building, it increased access and ease of participation for the community and clinical/scientific experts. Social desirability may have influenced participants’ responses. However, participants noted that they felt free to express their true feelings and ideas. Our study included mostly Black and Latinx participants, most of whom lived in the Bronx, NY. This may make our findings less generalizable for other populations. However, our study focused on a community where marked disparities in COVID-19 vaccine uptake existed. The study was conducted in English, which may present limited perspectives to English-speaking members of the Bronx community.

6. Conclusions

Community experts reported that participating in BRAID increased their trust in the vaccine and the scientists who created and endorsed it. It also empowered them as trusted community messengers of accurate vaccine information. Their insight helped us understand beliefs and attitudes related to COVID-19 vaccine confidence in the Bronx. It is noteworthy that by the conclusion of our conversation circle series, all participants shared that they and some of their previously unvaccinated family members had obtained the vaccine. This included individuals who had previously expressed strong objections to the vaccine. While a variety of factors (incentives, mandates, and changes in infection rates) likely contributed to this behavior change, multiple participants directly attributed their participation in BRAID as the deciding factor that moved them and their families toward vaccination.

The BRAID model can also be easily adopted to explore and impact drivers of other disparate health conditions. Findings from this study have many important implications. At the individual provider level, we hope that insight gained encourages providers to reflect on their own practices and open spaces for honest dialogue. At the health system level, our findings can inform effective trust-building strategies for medical centers in underserved communities.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.