“If You are Going to Step on This Campus, You Have to Get Vaccinated”: A Qualitative Understanding of COVID-19 Vaccine Hesitancy Among Black Emerging Adults Returning to College Campuses

Abstract

For the academic year 2021–2022, many American colleges mandated the COVID-19 vaccine for students to return to campus. However, when academic leaders put these mandates into effect, they may have failed to consider the emotional impact on vaccine hesitant students, especially students who have been historically marginalized or underrepresented such as Black emerging adults. This qualitative study explored how vaccine hesitant Black emerging adults describe and understand their return to academia and, how the historical mistreatment of Black Americans influenced their feelings and decision-making process around the vaccine mandates. The researcher conducted semi-structured interviews with 14 respondents, ages 18–25. The following themes were identified using thematic analysis: “…The Black Experience”: Historical Racism and Medical Misrepresentation; Personal and External Reasons for Vaccine Hesitancy; Factors Impacting the Final Decision to get Vaccinated; Experiencing Varied Emotions about being Vaccinated. Findings demonstrate that the historical mistreatment of Black individuals shaped respondents’ experience and informed their hesitancy about being vaccinated. Further, while all respondents ultimately complied with the vaccine mandate and were able to return to campus, overall feelings post vaccination varied. Implications for future research, higher education, and clinical practice are discussed.

Since March 2020, the novel coronavirus (COVID-19) has killed more Americans than any other public health crisis (McKeever, 2021), with death rates accentuating existing racial health disparities within the United States (Tavernise & Goodnough, 2021; The New York Times, 2021). Recent evidence indicates that in 1 year COVID-19 killed one in 555 Black Americans compared to one in 665 White Americans (APM Research Lab Staff, 2021). For most Black Americans, the COVID-19 pandemic amplified the historical truth about public health crises: Black Americans experience them at disproportionate levels (Krishnan et al., 2020). Past research from the 1918 flu pandemic reveals lower infection rates among Black Americans, which White health officials at the time attributed to racial immunity, though the likely antecedent was segregation serving as a form of quarantine (Krishnan et al., 2020). Reasons remain unclear as to why Black Americans had lower influenza morbidity rates. However, what is clear is when Black Americans got the flu, they were denied access to institutional healthcare (Krishnan et al., 2020) and died at higher rates (Brooks, 2020). With this type of historical mistreatment embedded and woven into the fabric of our history and culture, some Black Americans rightfully hold feelings of distrust and hesitancy towards government officials and the healthcare system (Goldstein & Sedacca, 2021; Quinn & Andrasik, 2021).

Systemic failure to address longstanding issues has influenced how Black Americans feel about the American healthcare system and the government’s handling of COVID-19 (Krishnan et al., 2020). By the fall of 2021, the climate of the COVID-19 pandemic was at a place where three vaccines were available, with varied dosing options (Goldstein & Sedacca, 2021). By September 2021, vaccine uptake had been moderately well received by the American public with 207.16 million people vaccinated, accounting for just over 65% of the total population (Our World in Data, 2022). However, in the Black community, overall trust towards the vaccine was still met with a high degree of skepticism (Goldstein & Sedacca, 2021). As of December 2021, the race and ethnicity of all vaccinated Americans had only been partially accounted for, as restrictive state guidelines limited the recording of this data (Centers for Disease Control and Prevention, 2022) to 70% of the total vaccinated population (Ndugga et al., 2021). Of this percentage, 10% of the individuals identified themselves as Black (Ndugga et al., 2021). In the United States, Black Americans account for 13.6% of the total population (United States Census Bureau, 2021).

To better understand vaccine hesitancy, research must expand its reach beyond adult populations to include individuals at different developmental stages, one subset being Black emerging adults (EAs) at the college level. For the 2021-2022 school year 1000 U.S. colleges mandated the vaccine (Best Colleges, 2021), however, a dearth of literature exists on whether mandates have impacted Black emerging adults and their college experience. Black emerging adults represent the next generation of leaders and activists who will continue to fight for the freedoms and rights of minority groups. The purpose of this study is to understand Black emerging adults’ reasons for vaccine hesitancy and allow them to voice how and why they decided to take the vaccine in order to return to their college campus. Findings have the potential to inform clinical practice for therapists working with Black EAs and college leaders as they attempt to implement COVID-19 policies and maintain student enrollment amid this ongoing pandemic.

Historical Perspective

Historical trauma theory is a framework that assists in understanding how “collective trauma experienced by one generation can negatively impact the wellbeing of future generations” (Conching & Thayer, 2019, p. 74). Collective trauma creates physiological and psychological wounding which travels through time via trauma narratives, imparting present generations with their ancestors’ experience (Mohatt et al., 2014). The field of epigenetics confirms that prolonged exposure to trauma and adversity can increase risk of disease and fundamentally alter biological functioning. Meaning, individuals subjected to long-term trauma may experience altered gene expression and changes to their DNA, eventually impacting their overall biology and health (Conching & Thayer, 2019). For Black communities, long-term trauma is seen in the form of subjugation, discrimination, and abuse (Quinn & Andrasik, 2021). Moving to present day, and in an attempt to deeply understand the complexity of vaccine hesitancy for Black EAs, it is of critical importance to consider the role that history plays. Systemically, Black individuals have often faced complete disregard by larger social systems (Quinn & Andrasik, 2021). Consequentially, this generation of Black emerging adults is layered with knowledge surrounding historical mistreatment of their community, especially within the medical field. This is significant and in accordance with historical trauma theory, which posits that individuals make decisions that are influenced by experiences from the past (Pihama et al., 2014).

There is a long history of maltreatment and deceit of Black Americans by public health officials (Quinn & Andrasik, 2021). Two notable events occurred during the flu pandemic and syphilis outbreak. During the 1918 flu pandemic, faced with racism, Jim Crow laws, and healthcare discrimination, Black Americans were routinely denied access to hospitals and advanced medical care (Brooks, 2020). In order to stay alive, Black Americans were often left with no choice but to stay home and receive basic care from family members and other members of their community (Brooks, 2020). The Tuskegee Syphilis Experiment, which began in 1932 with a syphilis outbreak that lasted 40 years until 1972, is the longest documented case of grossly unethical abuse in a research study. During the Experiment, the United States Public Health Service (PHS) purposefully misinformed 400 syphilitic Black American male study participants and 200 uninfected men of their diagnostic status to observe the natural progression of untreated syphilis (Corbie-Smith, 1999). This violation of ethical standards led to the 1979 development of the Belmont Report (Adashi et al., 2018) and the Institutional Review Boards (IRB) (Corbie-Smith, 1999).

Past fears stemming from government and institutional abuse (Quinn & Andrasik, 2021) have inadvertently paved the road for how Black individuals may continue to navigate the COVID-19 pandemic. Presently, one of the areas of healthcare that has gained a lot of interest with vaccine availability, is the prevalence of vaccine hesitancy (Dror et al., 2020). Vaccine hesitancy is an indefinable, multifaceted construct that refers to one’s feelings of reluctancy or total denial of a vaccine despite accessibility (MacDonald & The SAGE Working Group, 2015). According to current literature, COVID-19 vaccine hesitancy within Black communities is influenced by healthcare provider stigma and prejudice, lack of accessibility to web-based registration forums, and an unfair disbursement of the vaccines at healthcare sites that are difficult for Black communities to access (Quinn & Andrasik, 2021). Initially, the Johnson & Johnson (J&J) vaccine was recommended for Black neighborhoods where vaccine pop-up clinics were common as this one-shot vaccine requires less refrigeration compared to Moderna and Pfizer (Goldstein & Sedacca, 2021). However, when the J&J vaccine was temporarily discontinued due to causing blood clots in women’s brains, suspicion and distrust among Black Americans only increased (Goldstein & Sedacca, 2021). These types of experiences and healthcare barriers only further cement existing skepticism (Quinn & Andrasik, 2021). While previous studies have looked at how Black Americans are broadly and disproportionately affected by COVID-19 (Kirksey et al., 2021; Laurencin & McClinton, 2020) it is also important to account for how the pandemic will impact Black individuals during different developmental stages, specifically emerging adulthood.

Emerging Adulthood

The theory of emerging adulthood (EA) was first proposed by Jeffrey Jensen Arnett and focuses on individuals ages 18–25. It is a life stage where one is neither an adolescent nor an adult but is culturally encouraged to explore and establish their own identity. Arnett categorized five main components of emerging adulthood: identity exploration, instability, self-focus, feeling of in between, and possibilities. The main application of this theory is for emerging adults in industrialized societies that support an extended phase of identity exploration. By the end of this stage, most individuals concede that the choices they made during this period had the most influential effect on the rest of their lives (Arnett, 2000).

When looking at the theory of emerging adulthood, it is important to consider that, for all EAs, the brain undergoes a fundamental reintegration process (Funahashi & Andreau, 2013). The prefrontal cortex (PFC) finishes myelinating at age 25; this is significant because the PFC governs logic, executive functioning, planning, and future thinking (Funahashi & Andreau, 2013), so a delay in maturation impacts how all EAs make decisions about their future. Another significant neurodevelopmental change occurs in the striatum, which regulates impulse control, decision-making, and reward perception (Peters & Crone, 2017). Functionally, there is increased striatal activity during emerging adulthood (Peters & Crone, 2017), and thus decision-making processes are impacted by the neurodevelopmental changes occurring during this phase. While different arenas, like college campuses, offer ceaseless opportunities for all EAs to make decisions about their future, policymakers at the college level must also account for how the neurodevelopmental changes occurring at this time may impact these decisions.

EAs seek autonomy in their decision making and strive to find their place in society (Arnett, 2007). Commonly, their efforts to educate themselves on various topics are progressive and so seeking information on this public health crisis and vaccine development is no different (Barello et al., 2020). While the stage of emerging adulthood is about making autonomous decisions, vaccine mandates limit an independent way of thinking, which significantly compromises a neurodevelopmental norm. For young Black Americans, the already difficult nature of emerging adulthood is punctuated by the added weight of current and historical racism that members of their community have faced.

One way that Black EAs come to understand the history of racism is through parental colloquy. An important role of minoritized parents is to assist their children in developing an understanding of their culture and a positive ethnic racial identity (Reynolds et al., 2016). However, this comes at the cost of sharing the risks associated with being a minority individual in this country (Hurd et al., 2014). For minoritized groups, parental socialization may contain memories and embedded ideologies about past traumatic events, therefore impacting what is remembered and how it is recalled (Mohatt et al., 2014). Consequently, Black EAs carry the burden of knowledge that discrimination exists at the educational, environmental, and professional levels (Hurd et al., 2014). Thus, the complexity of navigating emerging adulthood may feel more complicated than the experiences of their non-minority counterparts (Syed & Mitchell, 2013). Literature suggests that in totality these experiences may be further impacting the degrees of psychosocial distress that Black EAs are facing during this developmental stage (Hurd et al., 2014). Considering these factors, it becomes clear why the decision-making process surrounding vaccine mandates may have been profoundly overwhelming.

What We Know about COVID-19 Vaccine Hesitancy and the Black Emerging Adult Population at the College Level

During COVID-19 many American colleges required the COVID-19 vaccine to return to campus (Best Colleges, 2021). While there were procedures in place to prevent the further spread of COVID-19 on university campuses (Paltiel & Schwartz, 2021), academic leaders may have failed to consider whether and why Black EAs on their campuses may have been vaccine hesitant and what that meant for their educational and psychosocial outcomes. According to Hanson (2021), it is projected that 17.5 million EAs were enrolled for the 2021-2022 school year at undergraduate universities, 9.6% of whom identify as Black. At the time of this research, for American universities requiring students to get vaccinated prior to arriving on campus for the fall 2021 semester, the only viable option to decline the vaccine was a religious or medical exemption (Paltiel & Schwartz, 2021). Just as one may not have opted out because of a personal stance, the right to choose, free will, or the right to self-determination, Black EAs could not use historical mistreatment as reasoning for not complying with university vaccine requirements.

While an abundance of research is available on the historical and racial mistreatment of Black Americans (Corbie-Smith, 1999; Jones & Saines, 2019; Quinn & Andrasik, 2021) and vaccine hesitancy for the general public (Dror et al., 2020; Machingaidze & Wiysogne, 2021), no current literature specifically focuses on Black emerging adults and their reasoning for potentially being vaccine hesitant. Further, no research has examined Black EAs on American college campuses. Current available literature is limited to research conducted in 2021 where dozens of interviews with Black New Yorkers ages 18–44 revealed that only 28% of this group was vaccinated, with their hesitancies being rooted in numerous justifications but mainly in government mistrust (Goldstein & Sedacca, 2021). Due to the newness of this topic, major gaps in the literature exist. Much of the current available literature for college campuses is pro-vaccine (Barello et al., 2020; Lucia et al., 2020) and focuses on camaraderie towards social responsibility to help combat the pandemic (Barello et al., 2020), therefore failing to highlight the perceptions and experiences of those who hold vaccine hesitancy. One notable article that addresses the Black community, historical racism, and vaccine hesitancy recommends that healthcare providers listen to the voices of those who have been marginalized and abused by our political and healthcare systems (Quinn & Andrasik, 2021); however, this article does not focus on the emerging adult group.

Research focused on vaccine uptake in American universities is available through three different studies (Lucia et al., 2020; Silva et al., 2021; Synnott, 2021). Within the literature for the emerging adult developmental stage, vaccine reluctancy is difficult to contextualize. Due to inconsistencies between the data sets, claiming to fully understand the perceptions of vaccine hesitant college populations would be over speculative. Furthermore, there is a lack of specific demographic data available on the student participants. Out of all three studies, only one study gathered demographic information, which in this case identified 84% of student respondents as White, limiting the perspective of Black and other minority populations (Silva et al., 2021). Within this study, only 14% believe that the vaccine should not be mandated (Silva et al., 2021). Another study shows that even medical students voiced significant vaccine hesitancy despite feeling that it was necessary to develop a vaccine to combat COVID-19 (Lucia et al., 2020).

Previous literature exposes fundamental racial inequalities and cracks in our political and healthcare system both historically and presently. However, no current literature considers the experience of Black students.

Research Questions

To address this gap, the following questions were developed to guide this research: How do Black emerging adults who are vaccine hesitant describe and understand their return to a university that requires the COVID-19 vaccine? How did the history of racism within the healthcare system shape their perceptions about the COVID-19 vaccine? What are the factors that shaped their decision to ultimately get vaccinated?

Methods

Respondents

The sample consisted of 14 respondents all of whom identified as Black and were between the ages of 18 and 25 years old (M = 22.35 years). Two respondents were 19 years old, one respondent was 20 years old, six were 22 years old, two were 24 years old, and three were 25 years old. Respondents identified as nonbinary (n = 1), female (n = 11), male (n = 1), and unidentified (n = 1). Respondents attended a 4-year undergraduate program (n = 9), master’s program (n = 2), doctorate program (n = 1), and community college (n = 2). All respondents resided and were attending college in the United States at the time of this study. Of these respondents, two were freshmen, four were juniors, four were seniors, two were graduate students, one was a doctoral student, and one was post-masters completing prerequisites for a doctoral program.

Procedure

Respondents were recruited using purposive sampling. This recruitment style was selected because it assists in identifying individuals who share specific traits, have knowledge of the phenomenon being studied, and are best suited to answer the research questions (Rai & Thapa, 2015). The researcher prepared a recruitment flyer and sent it to colleges on the east coast who mandated that students get the COVID-19 vaccine in order to return to campus. The researcher emailed the flyer to the following departments: Psychology, Social Work, and African Studies. Since these departments are involved in allied healthcare the researcher hoped that they may see the importance of this research, understand the concerns for social justice, and be inclined to share the flyer. Finally, the researcher messaged the flyer to the colleges’ Black Student Union clubs via Instagram and created a Facebook ad that included the flyer and eligibility criteria. Inclusion criteria included: (a) between the ages of 18–25 years old, (b) identify as Black American, (c) attended a college for the 2021/2022 school year, (d) their college required the COVID-19 vaccine in order to return to campus, and (e) upon hearing about the requirement, experienced vaccine hesitancy. All respondents were prescreened to confirm they met the eligibility criteria.

Respondents were recruited based on their enrollment status for the 2021/2022 school year and if their school required them to receive the COVID-19 vaccine in order to return to campus. While 19 respondents were screened, only 14 were determined eligible for this study. Prior to the start of this study, all protocols were approved by the Institutional Review Board (IRB) of a large university located in the northeast.

Data Collection

Each interview began with the researcher reviewing the consent form, obtaining verbal consent, and gathering respondents’ demographic information (e.g., age, name of their university, current grade, and if their classes were in person, virtual, or hybrid). Data was then collected using semi-structured interview questions (see Figure 1; Padgett, 2017). The researcher hoped to capture the respondents' feelings and perceptions about their college’s vaccine requirement, their reasons for vaccine hesitancy, their experiences on their college campus since the start of the pandemic, and how the history of racism in healthcare has shaped the ways they have navigated the pandemic and vaccine requirement. Interviews took place between January and February 2022 and were conducted via HIPAA-compliant Zoom. All interviews were audio recorded and ranged in time between 45 minutes to 1 hour for each interview. Upon completion of the interview, all respondents received a $25 Amazon gift card which was delivered electronically.

Figure 1.

Interview questions.

Data Analysis

The six phases of thematic analysis were used to code and closely examine the data and identify broader themes and patterns. This type of analysis is inductive, flexible, and promoted identification (Braun & Clarke, 2006) of reasons why respondents experienced vaccine hesitancy. Saturation occurs when the data that has been collected and analyzed does not yield any new codes or themes. Initially, the researcher interviewed 12 respondents. When no new codes or themes emerged from these interviews, the researcher believed to have accomplished or closely accomplished saturation. At this point, two additional interviews were conducted to ensure that no new themes materialized, and it was then determined that no further data needed to be collected (Saunders et al., 2018). (a) All audio recordings were transcribed verbatim by the researcher, read through to increase familiarity with the data, and then entered into MAXQDA2022, a software program designed to organize and analyze qualitative data. (b) During this initial read through, the researcher closely reviewed all transcripts and identified initial codes by remaining open to all possible theoretical directions suggested by the data. Analysis questions were not used by the researcher to guide the identification of codes. Initial codes were refined by examining for similarities or differences and merging similar codes. The focus of the coding was to pinpoint and develop the most salient categories in the total data. A list of 57 initial broad codes was established. Using MAXQDA2022, a code heading was established for each initial code and then coded material was organized underneath that heading. (c) The initial code set was collated with supporting data from the interviews and these codes were reviewed across all interviews to identify patterns. The code set was then organized into four preliminary themes: historical medical mistreatment of Black communities, reasons for vaccine hesitancy, making the decision to get vaccinated, and reaction to being vaccinated. (d) Over 3 months, the coded interview text and how it related to each of these initial themes was reviewed and refined to confirm that the themes formulated a clear pattern that was in alignment with the total data collected. This was to ensure that each theme had an adequate amount of data to support it. At this time, it was identified that reasons for vaccine hesitancy fell into two sub-themes: personal and external reasons for vaccine hesitancy. (e) The researcher then began to formulate how these themes could create a larger narrative and began to name and define the themes. The final codes and themes were organized in MAXQDA. Data extracts were also selected that highlighted the feature of the themes. (f) Then the final report was developed (Braun & Clarke, 2006).

Throughout the analysis, the researcher integrated numerous practices to promote methodological rigor and trustworthiness. A detailed audit trail was kept throughout the research process to reflect the steps that were taken to ensure that the findings were based on respondents’ responses and not the researcher’s biases. Peer debriefing was conducted with two unbiased, independent colleagues to enhance research validity. During these debriefings, the coded themes were checked to ensure trustworthiness of the coding and negative case analysis also assisted to re-evaluate the initial codes and themes and any data that contradicted it. The use of memoing served as an instrument for the researcher to reflect on the raw data, examine and challenge research biases and assumptions, and explain the research phenomena. Finally, the researcher engaged in member checking to confirm the accuracy of the respondents’ experiences; in total, 50% of respondents participated in member checking. Five respondents agreed with the accuracy of the themes (Padgett, 2017), however, two respondents had some objections. One respondent thought that themes two and four were not direct to the research topic. The researcher offered to send a summary of these two themes, however, did not hear back from the respondent. The researcher then reviewed this respondent’s transcript and confirmed that their data did in fact fall into themes two and four. This respondents’ reason for vaccine hesitancy fell into the external reasons and they reported feeling good about their decision to be vaccinated. Despite not hearing back from this respondent, the respondent’s objections did not have to do with the accuracy or trustworthiness of the data, which is the purpose of member checking. The second respondent did not agree with theme one, however, after communicating with this respondent and providing a description of theme one this respondent was then in agreement. Based on the member check, the data was still reliable and as a result, the researcher decided to stick with her original viewpoint and identified themes (Padgett, 2017).

It should also be noted that I, the researcher, identify as a White female. I am a psychotherapist and specialize in treating emerging adults. During the pandemic, I became immersed in how every aspect of COVID-19, including the vaccine mandates, created hardship for this demographic. As I assisted my clients, who were grappling with the decision-making process around the vaccine, I considered the necessity of research on this topic, especially for people of color. Because my racial background differed from the respondents, I contemplated how comfortable respondents might be talking about such a vulnerable topic. I ultimately decided that this research was vitally important and that I held a moral responsibility to elevate the voices of those who have been marginalized. In preparation for the interviews and with the goal of creating a foundational understanding, I delved into the available literature that focused on the historical medical mistreatment of Black communities. Then, I constructed questions that were in accordance with my objectives as a researcher. The main purpose of the interviews was to understand the respondents’ reasons for vaccine hesitancy and what impact historical medical mistreatment of Black communities had on their decision-making process. I made every effort to remove any of my own biases or assumptions when formulating the interview questions, however, also recognize that my own understanding, and lack thereof, influenced which questions I chose to ask. The interview process was both humbling and inspiring. The respondents were wonderful to work with and their stories filled me with a deep sense of purpose and honor. After the interviews, my goal was to ensure that the respondents’ stories were adequately represented in this research. Reflexivity served as a helpful tool throughout the research process, which included memoing and reflecting on my own thoughts and feelings that arose during and after the interviews. The final analysis was developed without personal biases and only accounts for the perspective of the respondents. I recognize my privilege and position as a researcher and as a White individual, especially working with respondents who share the effects of historical racism, marginalization, and systemic abuse.

Results

The researcher identified four themes that captured the experience of vaccine hesitant Black emerging adults as they navigated their college’s vaccine mandate: (a) “…The Black Experience”: Historical Racism and Medical Misrepresentation (b) Personal and External Reasons for Vaccine Hesitancy (c) Factors Impacting the Final Decision to get Vaccinated (d) Experiencing Varied Emotions about being Vaccinated. Respondents’ confidentiality was ensured by using numbers and not including demographic information on their colleges.

“…The Black Experience”: Historical Racism and Medical Misrepresentation

In discussing potential reasoning for vaccine hesitancy, respondents shared how the history of medical mistreatment of Black Americans played a significant role in their current perspective. Respondents explained how history, racism, and medical inequality impact how they move about in the world. “The Black Experience” is woven into every fabric of their being: how they interact with others, how they carry themselves, and how they navigate structural systems such as education and healthcare. R14 (a 20-year-old female) captured what nearly all respondents affirmed about racism:

It’s just kind of built into you. Well, at least for me and my family, it’s just built in and ingrained into you as a Black American. Most, a lot of the systems that are built in this country don’t look out for us, period. Yeah, that’s all it comes down to. There hasn’t been a lot of support for us in the past.

Respondents stated that historically and presently, the Black community has been viewed and treated as less than human. Events such as the Tuskegee Experiment and the Black Lives Matter movement were referenced as backdrops describing how the physical body of Black Americans has been and continues to be discounted. Understandably, this type of treatment has influenced feelings of distrust and fear for Black Americans when it comes to navigating structural systems. R1 (a 24-year-old female) describes the historical dehumanization of Black Americans:

There is a history of distrust, rightfully so, in the Black community, especially Black Americans, just because of the way that experimentation has gone on without our consent, that we were dehumanized continually because of the history of how Black Americans ended up in this space, in this country. And so, when you’re not seen as human, it’s very easy to be disregarded when it comes to your physical body.

When reflecting on the impenetrable design of present systems and how they are still set to work against Black Americans, R2 (a 19-year-old female) discussed the inevitability of being overcome by the continuous cycle of social oppression:

In every system, it feels like there’s a flaw that has been so well covered up or so well designed to benefit the majority that it's not even a flaw anymore. It’s just the way it is. It would take overthrowing the government to break the essential cycle in the system. When you’re born the minority, it’s going to catch you at some point. The fact that you’re Black or the fact that you’re a minority will catch you at some point in your life.

Furthering her feelings, R2 explained how the vaccine connected back to her family and race:

I don’t even know if they’re [vaccines] scholarly approved, but I heard in my family and stuff, we’re a Black family and it affected us poorly compared to other groups and other ethnicities in the nation and across the world, so I was scared about that.

Similarly, R1 stated:

If you could walk a mile in a Black individual’s shoes, you would understand absolutely, why they are afraid of this vaccine, and why they are afraid to believe that medical information is given to them at face value.

Over half of the respondents discussed the medical field and how healthcare professionals historically and currently view and treat Black individuals differently. R16 (a 22-year-old female) explained, “The past is what makes us hesitant of trusting the medical system, because you don’t know. They did a lot of things to hurt us, so you don’t know if it’s still happening. Well, it is still happening.” R1, echoing the same feelings as R16, said, “Understanding and being in that space and understanding how few Black individuals are reflected in medical advice, makes me leery of that advice if it can’t reflect the nuances that are The Black Experience.”

Respondents provided personal and general accounts of medical mistreatment against the Black community. When it comes to pain management, R1 explained, “There’s still a level of error where doctors believe we don’t perceive pain in the same way, or we don’t experience things in the same way that a human being does.” Childbirth and family planning were discussed by six of the 14 respondents. R2, voiced her personal fear, “Black women are more likely to die at childbirth than other groups for the same reasons. At some point it could catch me. It could catch up to me.” R10 (a 24-year-old female) summarized these nuances, “If racism is going on in the world, then the medical field didn’t escape those narratives, those mindsets.”

Despite these experiences, education was viewed as a means to escape the story that history has written about Black Americans. R19 (a 22-year-old female) explained, “Getting my degree is one of the gateways out of that…. Education is very important to me and getting this degree will be the next step to catapult me away from the situation I’m in right now.” R15 (a 25-year-old female) felt similarly and reflected:

I’ve worked hard for the things that my ancestors have fought for. Yeah. We have activists that were fighting just for us to go to college and to receive a higher education. And it’s like you’re saying, ‘If you don’t get the vaccine, you can’t achieve that higher education,’ which doesn’t help with the upper mobility in our community.”

The historical narrative of Black Americans has reverberated through time and infiltrated respondents’ experiences within the healthcare and education spheres. For respondents, racism is imprinted and embedded into their identity impacting their daily lived experience.

Personal and External Reasons for COVID-19 Vaccine Hesitancy

While all respondents did eventually get the COVID-19 vaccine and were able to return to their campuses, reasons for vaccine hesitancy fell into two main categories: personal and external reasons for vaccine hesitancy.

Personal Reasons for Vaccine Hesitancy

Nine respondents voiced hesitancy rooted in body autonomy or, as R8 (a 25-year-old male) stated, “my body, my choice.” R15 affirmed similar thoughts as she reflected, “I don’t know what I’m injecting in my body…And I don’t want to be injecting something in my body and then I end up spreading it to my community.” When considering the effects on their physical body, respondents also voiced hesitancy rooted in fear of side effects like death and impacts on future reproductive health and preexisting health issues.

For example, both male and female respondents voiced concern over contemplating how the vaccine could impact their ability to procreate. As R1, explained:

I was so scared of the reproductive... health situation that came with them not really knowing what was going on at the beginning of this vaccination, why people were having spontaneous evacuations of pregnancy or what the birth effects would be beyond this vaccination. But as a young adult who hopes to have a family in the future, that was important to me.

Media sources and conversations with peers and families fueled the wide spread of information. As R8 reflected, “I’m going to listen to people that are saying things that the vaccine is deadly, or someone saying that someone died from it. So, it’s through all that news and what other people are saying.” R2 recounted her fear of dying after hearing media coverage about one of the vaccines in particular:

I’m not getting Johnson & Johnson. I don’t want to die. I don’t want a blood clot or whatever it causes. I don’t want it. I don’t want that for me or my family. It was a simple, no go. I don’t want any part of it.

For nine of the respondents, personal feelings such as fear, anxiety, confusion, lack of safety, feeling forced, and feeling like a “lab rat” influenced vaccine hesitancy. As R18 (a 19-year-old female) described, “they [school] just want to put things in us so they can have us as a lab rat, like someone they tested it on and get data from us and up their numbers in the vaccine.” R17 (22-year-old nonbinary) voiced an undercurrent of emotion stating, “It just made me anxious, I just was like, what is going to happen?”

For respondents, their hesitancy reflects their overall feelings about the vaccine and concerns about their physical wellbeing. Additionally, the widespread mix of conflicting information through media sources and conversations with their families impacted their understanding of the vaccine.

External Reasons for Vaccine Hesitancy

External reasons for vaccine hesitancy were rooted in thoughts and feelings about school mandates, the government, and the science behind the vaccine. Some respondents discussed how the college mandate itself increased hesitancy. R15 recalled her university declaring, “If you are going to step on this campus, you have to get vaccinated.” And for R8, the language used in university correspondences fueled his hesitancy, “the mandatory thing actually made me feel much more hesitant than I actually was before about the vaccine. It made me feel really, really suspicious.” R14 explained that the mandate limited her ability to choose, stating “I was mad because it wasn’t the fact of getting the vaccine. It’s the fact that they just told us that we had to get it. And I felt like that was kind of a violation of our rights.”

The government’s involvement in creating, dispersing, and encouraging vaccine uptake fueled hesitancy in 10 of the respondents. As stated by R14, “I just didn’t want it because I just didn’t trust it. And I think just being a Black American, we don’t really have a lot of trust in our government in the first place. Well, I don’t.”

Finally, for 11 of the respondents, the science behind and limited access to information about the vaccine fueled their hesitancy. R3 (a 22-year-old female) explained, “There’s no information about the research that went into it. How many groups of people did they test it on? Did they even test it on people? What was the process? That information wasn’t necessarily known publicly.” The speed of creating the vaccine furthered hesitancy in respondents too. As stated by R8, “It was just distrust for me, and just that it was so fast when it first came out. That was very scary.”

Respondents’ vaccine hesitancy was impacted by larger social systems. An important source of their vaccine hesitancy was the erosion of the belief that their schools, the government, or those creating the vaccine were looking out for their wellbeing.

Factors Impacting the Final Decision to get Vaccinated

While all respondents spoke about their college’s COVID-19 vaccine requirement, several respondents shared a number of factors that ultimately shaped their final decision to get vaccinated. For example, some respondents felt that the wellbeing of their family influenced their decision-making process. R11 (a 25-year-old female) worried about bringing COVID-19 home to her family, especially her grandfather who was high risk if he contracted COVID-19 and who had not yet gotten the vaccine:

I didn’t want to bring COVID to my family, and I wanted to be able to see my family. I think that was the biggest thing that was really swaying my decision. I knew that my grandpa, who hasn’t gotten the vaccine, he’s at risk. I was like, ‘Well, I don’t want to give him COVID, so let me go get the vaccine to decrease my chances of getting COVID and bringing it home or something.’

R1 felt similar when discussing concerns about her mother who suffers from end-stage kidney failure, stating, “biggest motivator became wanting my mother to remain safe… I was like, ‘I am afraid of what I don't know, and of being deceived, but I am more afraid of the harm that I could cause the people around me.’”

Other respondents shared that conversations with family members impacted their decision-making process. R17 had conversations with his younger brother who strongly encouraged him to get the vaccine:

My little brother was very like, ‘you need to get this vaccine, this is why.’ He was the one putting all our family on, giving our family the facts, he scheduled our appointments. And I’m really close with my little brother, so I was like, ‘okay, I trust him.’

Respondents shared a desire for life to ‘get back to normal’. R17 stated, “I think just a big thing was the hope that it would help things go back to...normal or be enjoyable again.” Similarly, R2 discussed numerous aspects of being an emerging adult that have been compromised due to COVID-19. She voiced a desire for life to feel like a pre-COVID world and believed that by getting the vaccine she would be closer to that and stated, “I’d rather just take the risk and get the vaccine if it means that I can be in person, if I can be in a new area and see new people. That was definitely the full weight of the decision.”

Collectively, responses revealed that nearly half of the respondents complied and received the COVID-19 vaccine only because of their school’s requirement. Though thoughts and feelings varied, what is evident is that they did not take the decision-making process lightly. The comments of two respondents capture these dynamics: R10 (a 24-year-old female) discussed waiting until the last minute to get the vaccine:

I was always on my calendar backtracking to see when I have to get it… I really did do it at the very last minute, and actually I came in a little bit late back to school, because I had to wait on a second dose.

R14 discussed her anger about having to get the vaccine:

The only reason I got it was because they [university] said that we had to have it, and I was just mad that whole day… I was mad that I had to get a shot that I really didn’t know what was going into my body and how this was going to affect me… That’s the only reason I got it. Literally. If I wasn’t doing so well with school or really didn’t care about my school, I would not have got it.

For respondents, the reasons to accept the vaccine varied. The decision-making process was not easy, but ultimately, their family’s wellbeing, their hope to get back to a pre-COVID norm and return to school encouraged them to receive the vaccine.

Experiencing Varied Emotions about being Vaccinated

Responses from respondents on how they felt after being vaccinated varied. For eight of the respondents, they felt good about their decision. R11 stated, “I stand by my decision to get the vaccines.” Similarly, R3 and R8 affirmed their decision by reflecting on how it will protect them from COVID-19 and future variants. R8 stated, “I do feel great about the decision because I feel like I have taken the right step in the fight against COVID.” And, as R10 stated, getting the vaccine has been a good decision because “at the end of the day, it’s almost working out because just about anything else you’re doing in life, you’re going to have to need it.” For these respondents, they had arrived on the other side of this process with a shift in perspective. They accepted the choice that they made and felt a sense of reprieve from the decision-making process.

While some respondents felt good about their decision, four respondents expressed mixed feelings. R2 said, “If I had to put it in percentages, I’m feeling 65% confident in that decision and 35% not confident in it.” Moreover, mixed feelings were fueled by feeling apathetic about getting it and still experiencing some hesitancy. R14 stated, “Like I said, at peace with it. Nothing I can do about it. But I don’t know if I would get another one, and I don’t know how I’m going to fight it if I’m forced to.” R6 added, “I figured that I might as well just get it, to just get it out of the way if it’s going to be required.” For these respondents, they had not arrived at a place of acceptance but instead felt like this was the concession they had to make to maintain their education.

Despite all respondents initially experiencing extensive vaccine hesitancy, only two respondents remained unhappy about being vaccinated and still had strong feelings of hesitancy and regret regarding this process. R15 expressed, “Honestly, it doesn't feel good, but I really wanted to start my masters and do my integrated marketing program…I have a scholarship to [university]. So, I was like, ‘This is a once in a lifetime thing for me.’”

Discussion

This study is one of the first to explore vaccine hesitancy in Black emerging adults who were mandated to get the COVID-19 vaccine in order to return to their college campus. The findings provide a deeper understanding of “The Black Experience,” especially for Black EAs striving to maintain independence amid a public health crisis. One factor that has further compounded the social impacts of the COVID-19 pandemic is the making of the COVID-19 vaccine and simultaneous upsurge of vaccine mandates (Dror et al., 2020), especially at the collegiate level. For Black EAs in this study, the decision to adhere to the vaccine mandate was polarizing. Respondents felt as if their options were limited to two choices: take the vaccine or forego it and risk losing everything they had accomplished regarding their education and future career. What further complicated this decision was a learned knowledge of how Black Americans have been inaccurately viewed and continue to be mistreated by our healthcare system.

This study highlights the perception of Black EAs surrounding systemic deficiencies within the educational and medical sphere. In this study, nine out of the 14 respondents questioned whether enough Black academic leaders were present during meetings where vaccine mandates were enacted and whether the consequences of mandates on Black students were specifically considered. As suggested by one respondent, those responsible for the mandates must understand and empathize with the history of medicine and the Black population. The possible lack of input from Black representatives left many respondents feeling underrepresented and contemplating leaving college for the 2021/2022 school year. However, their academic accomplishments and strong desire to earn their degree ultimately led them to comply with the mandate despite still having considerable vaccine hesitancy.

Findings from this study are congruent with literature that is available on COVID-19 vaccine hesitancy for Black individuals ages 18 to 44 (Goldstein & Sedacca, 2021). Goldstein and Sedacca (2021) assert that vaccine hesitancy is a growing public health issue for many Black adults. For respondents in this study, some reasons for vaccine hesitancy were universal, such as the timeliness to develop and potential side effects, however, many noted specific hesitancies linked directly to the Black experience. Adding to the available literature, respondents explained that it felt like certain freedoms, which have long been fought for, were being taken away by the institution of vaccine mandates. They reflected the idea that this generation of Black emerging adults feels a moral responsibility to uphold the standards of freedom fought for by their ancestors. Much of the hesitancy for this group has been fueled by historical medical experimentation, the disproportionate number of Black Americans infected with COVID-19, and vaccine campaigns targeting lower socioeconomic groups (Goldstein & Sedacca, 2021). While these reasons hold validity for the respondents, it is important to note that the accuracy of information available at the time of the college mandate was limited, especially regarding the J&J vaccine. By May 2022, scientists established a deeper understanding of the effectiveness and safety of the J&J vaccine, with the FDA suggesting that it can be given to adults 18 and older (FDA, 2022).

Despite available literature at the time, many American colleges moved beyond the initial vaccine mandate and required students to be vaccine “boosted” for the remainder of the 2022 school year (Golembeski, 2022). The time of these interviews coincided with the availability of vaccine boosters. Out of the 14 respondents, 10 referenced how the booster requirement complicated an already challenging situation. Unfortunately, academic leaders were forced to make a difficult decision in a finite amount of time (Wolf & Hodge, 2022). Now that there is a better understanding of the COVID-19 landscape, going forward academic leaders can make more informed decisions regarding vaccine mandates. As this research concluded, the country was on the precipice of another public health emergency; the outbreak of monkeypox. Findings from this research may aid academic leaders as they anticipate another public health crisis and consider the need for additional vaccine requirements.

As previous literature states, medical mistreatment is a common experience for Black Americans (Laurencin & McClinton, 2020) and fueled medical distrust amongst respondents, often due to a lack of minority representation in the sciences. According to Funk (2022, p. 5) individuals who, “fill science, technology, engineering and math classrooms and the professional ranks of these fields – do not adequately reflect the racial and ethnic diversity of the nation.” Fortunately, there is an opportunity for reformation and trust building through higher education. As explained by respondents, education can promote upward mobility and racial equality within the workforce. One field in particular that influenced decision making during the COVID-19 pandemic was the STEM field. Health-related professionals and academic leaders have an opportunity to recruit and encourage Black students to pursue these fields, ultimately increasing the number of minority individuals within the classroom and science-related careers (Syed & Mitchell, 2013).

Some of the respondents expressed that vaccine mandates created psychological distress for them. However, due to the focus of this research being on vaccine mandates, the depth of the psychological impact was not explored further. Of critical importance, is the need for ongoing research on this topic and trainings for social work and mental health clinicians who will be treating EAs at the college level and beyond. What must be considered is how the decision-making process may have fueled feelings of distrust and triggered historical trauma narratives. However, the theory of emerging adulthood does not account for the impact of mass trauma and the long-term mental health implications. Yet, drawing from this research, all respondents discussed how perpetual systemic abuse on their communities has impacted them and their trust in the medical field. The findings from this research suggest that clinicians, treating this demographic, will need a skill set that considers the psychological impact that mass trauma has on the developmental norms for all EAs.

Finally, as Arnett (2000) explains, EAs use their own discretion to make choices about their future; however, this research indicates that many of the respondents depended on the guidance of family members when faced with vaccine mandates. This finding suggests that at the height of the pandemic, Black EAs may have relied more heavily on the advice of parental figures. Looking at data comparatively, a study performed in a pre-pandemic world, it was found that “39% of African American and 41% of Latino emerging adults see their parents as more involved in their lives than they would like” (Syed & Mitchell, 2013, p. 88). Considering the barriers imposed by the pandemic, it is unclear whether the theory of emerging adulthood holds up under extenuating circumstances. Data from this research and statistics from a previous study (Syed & Mitchell, 2013) contrast with Arnett’s theory to create a unique paradox regarding the role of parental involvement in the development of personal identity for minority EAs. Further, the development of ethnic racial identity for Black emerging adults is dependent on parents fostering a present and supportive relationship with their children and educating them on the intricacies of their culture (Reynolds et al., 2016). Black communities tend to be more collectivists than White communities and families who tend to be more individualistic. Based on current research, it is unclear whether the theory of emerging adulthood considers collectivism and fully accounts for the inner workings of individuals from different racial backgrounds. Due to the extent of immigration to the United States from cultures that display collectivism, the theory of emerging adulthood may not encompass individuals from minority groups, including Black Americans (Syed & Mitchell, 2013).

Based on one of Côté’s (2014) critiques of Arnett’s work, the theory of emerging adulthood is not culturally universal, and it is unclear if EAs from minoritized groups were included in the initial group of emerging adults that Arnett based his idea on. Beyond culture, the constructs of Arnett’s theory may not account for the extremes of social circumstances that extend past day-to-day decision making (Côté, 2014). For instance, at the height of the pandemic, all respondents were faced with the unprecedented conflict of whether to accept the vaccine or not, with limited information regarding the impact of this inoculation. Their hesitancy was coupled with their understanding of how their parents and generations before them have been mistreated by larger institutions such as the government and medical professionals. Further, while all respondents in this study accepted the vaccine in order to return to their college campus, many students did not. For those who chose to forgo the vaccine based on personal choice, this may have resulted in an extended time in academia. What must be considered is the emotional, psychological, and fiscal impact that vaccine mandates created for EAs who put their academic and career goals on hold in lieu of complying with the mandate. Finally, policymakers in higher education could consider how the choice around vaccine mandates may have created a delay in maturation for EAs on their campus ultimately impacting the 4-year graduation rate.

Implications

Findings have implications for future research, theory, and policies in higher education, especially as we grow to better understand the experiences of Black emerging adults at the college level. Future research in the form of longitudinal studies could assess the long-term impact that “sheltering in place” had during the height of the pandemic and how time with family impacted key aspects of the theory of emerging adulthood. Additionally, future scholars and clinical social workers must consider how and if the deviations in independent decision making reflected in this study impact the integrity of Arnett’s theoretical framework, especially when working with minority EAs.

In the field of higher education, research needs to explore whether leaders in the STEM fields employ enough openness and mentoring to Black EAs pursuing this area of professional focus and what that relational experience is like. Collegiate internship program evaluations serve as platforms for pre-and post-surveys that assess if internships and practicums are not only rigorous but also mutually advantageous and provide enough mentoring. Additionally, academic heads could listen to the perspective of leaders from Historically Black colleges and universities (HBCU), Black churches, and Black student union clubs to understand their position on the vaccine mandates and how to address issues that respondents proposed in this research. Finally, future research could explore how growing mandates are impacting student enrollment, overall school satisfaction, and the mental well-being of college students as they navigate the ever-changing COVID-19 climate.

Limitations

This study comes with limitations. First, this study resulted in a smaller sample size compared to what is commonly seen in qualitative research, fewer respondents meant the findings were not polemical. Had the sample size been larger, additional reasoning for vaccine hesitancy may have been uncovered and contributed differently to the study’s findings. Additionally, despite nationwide recruiting, respondents were mainly female and attending universities on the east coast. If this research included a more diverse pool of respondents, the data may have yielded varied results. An additional limitation is seen in the data collection which included recruitment from specific academic settings. If respondents were recruited from different departments, such as economics or linguistics, these respondents may have a different understanding of the history of racism and medicine. While the researcher believes full saturation was achieved, it is important to note that if the sample included respondents who were less versed in racism and racist practices in the medical community, the results may have been different. Additionally, this research could be strengthened by including students from HBCUs and by interviewing academic leaders who implemented the vaccine mandates to better understand their decision-making process and consideration for students, especially Black emerging adults. Despite these limitations, this study provides essential information from a group of Black EAs and their experience with vaccine mandates and adds scholarship to the field of research.

Conclusion

This study highlights the experiences of Black emerging adults as they faced COVID-19 vaccine mandates set forth at their college campuses. The pandemic has profoundly and, in some ways, irrevocably altered every aspect of life, especially, as this research has shown, for Black emerging adults at the college level. Findings from this study provide the perceptions of some Black EAs and their reasons for vaccine hesitancy and offers academic leaders, future scholars, and clinical social workers an opportunity to help rewrite the narrative and treatment of Black individuals. An increased understanding of how vaccine mandates impacted Black emerging adults will also assist in preserving the medical and mental health of students who are enrolling in upcoming school years. A deeper consideration for the impact vaccine mandates have may allow us to support Black emerging adults who are currently struggling or who feel that their voices have been silenced.

Authur Biography

Jacqueline Soboti is a researcher and clinician who specializes in the mental health treatment of teens and emerging adults. She is a passionate advocate for this developmental stage and feels honored to support her clients and contribute to this area of research.

ORCID iD

Jacqueline Mercedes Soboti https://orcid.org/0000-0001-6791-2133