Associations Between Healthcare Discrimination, Medical Mistrust, and COVID-19 Vaccine Uptake Among Young Black Adults in the Southern United States

Racial inequities related to COVID-19 exposure, morbidity, mortality, and access to care in the United States (U.S.) are notable, and COVID-19 vaccine uptake is lower among Black Americans than White Americans. Yet, mechanisms linking healthcare experiences to COVID-19 vaccination behavior among young adults are not well characterized. We analyzed cross-sectional data collected between March and June 2023 from 360 Black young adults (ages 18-29) enrolled in a digital health trial in Georgia, Alabama, and North Carolina (NCT05490329). Discrimination in medical settings and group-based medical mistrust were assessed. COVID-19 vaccination was measured as ever receiving at least one dose. Correlations and a mediation model (PROCESS Model 4; 5,000 bootstrap resamples) tested whether medical mistrust statistically mediated the association between discrimination in medical settings and COVID-19 vaccination, adjusting for age, sex at birth, state, insurance, education, and perceived COVID-19 risk. In mediation analyses, discrimination in medical settings had a significant total effect on COVID-19 vaccination (B=-0.44, SE=0.13, p<.001) and was associated with higher mistrust (B=0.42, SE=0.04, p<.001); higher medical mistrust was associated with lower likelihood of COVID-19 vaccination (B=-0.65, SE=0.24, p=.006). The indirect effect was significant (B=-0.28, SE=0.12, 95% CI [-0.557, - 0.081]). Findings suggest that discriminatory healthcare encounters may reduce COVID-19 vaccination uptake partly through elevated medical mistrust, highlighting the need for trust-building, non-stigmatizing strategies to improve vaccination among Black young adults in the U.S. South.