Abstract
BACKGROUND: Negative attitudes toward vaccines and suboptimal vaccination rates among African American and Black (Black) Americans have been well documented, due to a history of medical racism and human rights violations in the United States. However, digital health interventions (DHI) have been shown to address racial disparities in several health outcomes, such as cardiovascular disease, HIV, and maternal health. The Tough Talks COVID (TT-C) study was a randomized controlled trial of a DHI designed to empower Black young adults in the United States South to make informed, autonomous decisions about COVID-19 vaccine uptake by addressing structural barriers and misinformation about vaccines. OBJECTIVE: Our objective was to identify subgroups of Black young adults with various vaccine attitudes at baseline and determine the subgroups for which the TT-C DHI was most impactful. METHODS: Black young adults aged 18-29 years in Alabama, Georgia, and North Carolina who were unvaccinated or insufficiently vaccinated against COVID-19 completed three online surveys over three months (N=360). Latent profile analysis was used to identify subgroups based on general vaccine attitudes at baseline, including hesitancy, confidence, knowledge, conspiracy beliefs, and mistrust. Logistic regression was used to examine the associations between latent profiles and vaccine uptake, and linear regression was used to examine changes in vaccine attitudes at three months post-randomization. Modification of the TT-C DHI's effects was assessed by latent profiles. RESULTS: Three latent profiles emerged: vaccine-receptive (n=124), vaccine-neutral (n=155), and vaccine-resistant (n=81). Political affiliation, income, social support, and recent flu vaccination differed significantly between the three subgroups (P<.05). Vaccine uptake was not significantly different by subgroup, and the TTC-DHI did not have differing effects on uptake across subgroups. However, the DHI had the strongest effect-with statistically significant measures of association (P<.05) and interaction P values (P<.10)-among the baseline vaccine-resistant and vaccine-neutral subgroups compared to the vaccine-receptive subgroups at three months in improving vaccine hesitancy, confidence, and conspiracy beliefs at three months: vaccine-resistant difference: -0.40 (-0.76 to -0.37), 0.39 (0.02 to 0.75), and -0.47 (-0.86 to -0.09); vaccine neutral difference: -0.36 (-0.52 to -0.19), 0.35 (0.18 to 0.51), and -0.24 (-0.44 to -0.03). The DHI had no effects on these outcomes among the vaccine-receptive subgroup. CONCLUSIONS: Our findings revealed subgroups of Black young adults in the United States South with different vaccination attitudes, for which the TT-C intervention had differing effects. Black young adults who are vaccine-resistant or vaccine-neutral may experience larger gains from a digital vaccine intervention. Future work aimed at improving vaccination outcomes could target these populations to maximize resource efficiency and drive the greatest improvements in vaccine outcomes.