Reentry and COVID-19: An Examination of the Vaccine Beliefs and Behaviors of Black Adults in an Urban Community

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This study employs the Health Belief and Social Ecological models as theoretical frameworks to investigate the experiences of incarceration and reentry that Black individuals perceive as influencing their health beliefs and behaviors regarding the uptake of the COVID-19 vaccine. Gaining this understanding can offer valuable insights for developing and implementing effective policy and practice strategies. Methods : Between 2021 and 2022, twelve semi-structured interviews were conducted with formerly incarcerated Black adults in the South Central region of the United States utilizing an interpretive phenomenological analysis (IPA) design. An interview guide, informed by theoretical frameworks, was employed to facilitate each interview, which was audio recorded and professionally transcribed. Data analysis adhered to the established procedures involved in IPA. Results : Participants' health status, race, and religious or spiritual beliefs significantly influenced their perceptions of susceptibility to COVID-19 infection and mortality. Participants' health and medical history, social networks, and experiences with incarceration shaped their views on the severity of the illness. Underlying health issues and job status were seen as enablers of vaccine acceptance, while a lack of reliable information, challenging community conditions, and mild symptoms of COVID-19 served as barriers. Though personal, relational, and economic factors acted as prompts for vaccination, participants showed strong self-efficacy regarding vaccine uptake. Therefore, personal, sociocultural, socioeconomic, structural, and systemic elements play a vital role in shaping the beliefs and actions of formerly incarcerated Black individuals regarding COVID-19 vaccination. Conclusions : To enhance vaccine uptake, it is imperative to implement multilevel, culturally informed, and community-engaged health promotion and prevention strategies involving individuals with lived experience. COVID-19 Vaccine Uptake Incarceration Reentry African American/Black Adults Structural Racism Interpretive Phenomenological Analysis Qualitative Methodology Background Racial disparities in COVID-19 infections and fatalities within the United States (U.S.) have been firmly established since March 2020. Black individuals remained at the forefront of this health crisis, as their probabilities of infection (1.1 times), hospitalization (2.1 times), and fatality (1.6 times) exceeded those of non-Hispanic Whites ( 1 ). The phenomenon of mass incarceration exacerbates the adverse impact of COVID-19 on the Black community, given that Black individuals constitute 14% of the U.S. population yet represent 35% of the total jail and prison population. During the pandemic’s peak, correctional facilities encountered significantly elevated rates of infection and mortality (approximately 5 times) in comparison to the general population and other congregate settings, such as nursing homes ( 2 , 3 ). As of May 9, 2023, there were 645,762 documented cases of COVID-19 and 2,934 fatalities among people incarcerated in prisons, alongside 246,541 cases and 293 deaths among correctional staff ( 4 ). To mitigate the transmission of COVID-19 within correctional facilities, numerous jurisdictions enhanced the implementation of early release for individuals charged with non-violent offenses ( 5 – 7 ). While early release strategies are essential for mitigating the spread of COVID-19 within correctional facilities, they simultaneously create a public health crisis for Black communities due to the dynamic of carceral-community epidemiology ( 5 , 8 – 10 ). That is, correctional facilities function as incubators for COVID-19 and other infectious diseases, exacerbated by the congregate living conditions, overcrowding, unsanitary environments, and the pre-existing poor health conditions of people who are incarcerated, coupled with limited COVID-19 mitigation strategies ( 2 , 6 , 7 , 11 , 12 ). Furthermore, the communities to which Black individuals return following incarceration are burdened by COVID-19 and other health inequities resulting from over-policing, elevated poverty and incarceration rates, and restricted access to healthcare ( 13 , 14 ). Particularly, over-policing significantly contributes to racial disparities in COVID-19 cases and mortality rates, as it creates a cycle of incarceration ( 6 , 9 , 10 ). For instance, in Chicago, 17% of all COVID-19 cases in neighborhoods primarily inhabited by Black and/or non-White Hispanic residents were associated with jail cycling in March 2020, compared to merely 6% of cases in predominantly White neighborhoods (Reinhart & Chen, 2021). Moreover, jail cycling accounted for 21% of the racial disparities in COVID-19 cases across neighborhoods in Chicago. Consequently, the COVID-19 pandemic and the persistent epidemic of mass incarceration are epidemiologically intertwined, with mass incarceration functioning as a mechanism of structural and systemic racism, thereby exacerbating the racial disparities linked to COVID-19 ( 10 , 15 , 16 ). Increasing vaccine uptake among Black individuals, both currently incarcerated and formerly incarcerated, is therefore critical to addressing racial disparities in COVID-19 cases and fatalities. However, studies indicate that medical and governmental mistrust, lack of confidence in vaccine effectiveness, limited access to healthcare, health effects associated with vaccine uptake, scarce trusted information concerning vaccine safety and efficacy, and a low perceived risk of COVID-19 infection are predictors of vaccine hesitancy within this community ( 17 – 24 ). Vaccine hesitancy among Black individuals is rooted in historical and contemporary structural and systemic racism and discrimination ( 8 , 9 , 13 , 25 – 27 ). Despite these challenges, research demonstrates that culturally grounded interventions, spirituality, and community engagement effectively enhance vaccine uptake among Black individuals ( 17 , 24 , 28 – 31 ). While improving vaccine uptake represents a crucial step toward ameliorating racial disparities in COVID-19 cases and mortality rates among Black individuals, knowledge regarding the factors that influence vaccine uptake among those who are incarcerated or have been formerly incarcerated remains limited ( 12 ). This understanding is vital for reducing and eventually eradicating COVID-19 and associated health inequities. Furthermore, it can inform research, policy development, and practice in effectively formulating and implementing strategies tailored to their specific sociocultural and contextual needs. This study, therefore, aimed to enhance the understanding of the incarceration and reentry experiences Black individuals perceive as influencing their health beliefs and behaviors related to COVID-19 vaccine uptake. This research originated from a collaboration with a reentry program affiliated with a local health department in the South Central region of the U.S., prompted by the number of participants opting not to receive vaccination. The health belief model (HBM) guided this study because it includes six health determinants (i.e., perceived susceptibility, severity, benefits, and barriers, cues to action, and self-efficacy) that suggest a person’s belief in the threat of COVID-19 infection and death, alongside their belief in the effectiveness of the vaccine, influences their decision to vaccinate ( 32 ). Additionally, the Social Ecological Model (SEM) served as a guiding framework for this study, as it sought to identify the multilevel factors (including individual, social, institutional, community, and policy) that shape their vaccine-related beliefs and behaviors ( 33 ). Consequently, the research question includes: How do the lived experiences of Black adults in reentry influence their health beliefs and behaviors regarding the COVID-19 vaccine? Methods This study utilized an Interpretive Phenomenological Analysis (IPA) design to qualitatively describe and interpret Black adults' personal and collective experiences concerning incarceration and reentry, specifically how these experiences informed their health beliefs and behaviors regarding the COVID-19 vaccine (34). This study is grounded in constructivism, which acknowledges that knowledge is socially constructed, recognizes the existence of multiple realities, and emphasizes the significance of context, while perceiving research participants as active contributors to the knowledge creation process (35,36). All procedures associated with this study were approved by the internal review board (IRB) committee of the sponsoring university and the local health department, and each participant consented to participate. Sampling and Recruitment Purposive sampling was employed to recruit potential participants (37). To qualify, prospective participants were required to (a) self-identify as African American/Black, (b) be 18 years of age or older, and (c) have been released from a jail or prison setting during or after March 2020, as well as (d) have been offered a COVID-19 vaccine upon their release into the reentry program. In collaboration with the director, instructors, and case managers of the reentry program, recruitment activities included posting flyers at the program site, distributing flyers via email to the organization's listservs, gaining direct referrals from the program’s director, instructors, and case managers, and conducting both in-person and virtual group presentations. Interview Guide The Health Belief and Social-Ecological Models informed the formulation of the semi-structured interview guide to identify multilevel determinants of vaccine beliefs and behaviors among Black adults in reentry. The interview guide examined participants' (a) personal and familial backgrounds, (b) incarceration and reentry experiences, and (c) beliefs regarding COVID-19 and associated health behaviors, including COVID-19 knowledge, perceived susceptibility, severity, and benefits, barriers, cues to action, and self-efficacy. Probes were also developed to explore how personal and social-structural factors influence their beliefs and behaviors, and each participant was asked to describe what successful reentry means to them and to offer recommendations for reentry programs. Data Collection Procedures Individual interviews (n=12) were conducted with Black adults in reentry between March 2021 and August 2022. Each interview lasted approximately 60 minutes and adhered to the semi-structured guide. Interviews were conducted using Zoom and in person in a private room at the reentry program. Each interview was audio recorded and transcribed professionally, and participants received an incentive of $40 for their participation. Analysis To facilitate analysis and interpretation, we uploaded each transcribed audio file into the software Dedoose and adhered to the established procedures involved in IPA (34). Initially, we engaged in a comprehensive reading and rereading of each transcript while simultaneously listening to the corresponding audio recording and developing exploratory notes on initial semantic content and the language utilized, thereby refamiliarizing ourselves with narratives provided by each participant. Subsequently, we individually coded each transcript in Dedoose, focusing on the key determinants influencing beliefs and behaviors regarding the COVID-19 vaccine. Following this, we constructed a list of experiential themes pertinent to the research question derived from each transcript. In the next phase, we refined this thematic list by clustering the themes based on similarities. We then developed a table of Personal Experiential Themes (PETs), designating each cluster and incorporating verbatim excerpts from the transcripts. Finally, we generated Group Experiential Themes (GET) by conducting a cross-case analysis, actively searching for convergences and divergences among the identified PETs (34,38). We employed peer debriefing, memoing, and audit trail strategies to ensure credibility, transferability, dependability, and confirmability (37) . Researcher’s Positionality Our positionalities shaped this study (39,40). The first author is a Black cisgender man and a faculty member in social work, who investigates racism-related and healing-centered determinants of health among Black youth and adults with incarceration histories. Although he has never been incarcerated, he believes that mass incarceration constitutes a significant determinant of health within Black communities. The second author is a Black male pursuing a Ph.D. His professional experiences as a licensed clinical social worker focused on reducing health disparities among underserved populations influenced his engagement with this study. The third author, a White female with a Ph.D. and a master's in social work, aligns this research with her scholarly interest in the mechanisms of structural racism. The fourth author is a South Asian cisgender female and Ph.D. student. Her experiences as a school social worker providing underserved youth and families access to healthcare have significantly shaped her interest in this work. The fifth author is an East Asian woman currently enrolled as a Ph.D. social work student, possessing a doctorate in public health and expertise in the health belief model. The sixth author is a queer Chicanx woman and an abolitionist social worker, actively working as a participatory dense organizer. She maintains that the abolition of the prison industrial complex represents the most secure path to liberation and justice for Black and Brown communities. This seventh author is a Black public health social work faculty member who investigates health disparities among marginalized communities, particularly African-American men and women, through an intersectional lens that integrates spirituality, mental health, and social networks. While we acknowledge our status as outsiders, having never been incarcerated, our lived experiences as racially and ethnically minoritized individuals raised in historically marginalized communities affected by racism-related determinants of health provide us with a crucial perspective. This perspective remained central to our attention throughout this study concerning the experiences that shape health beliefs and behaviors surrounding COVID-19 among Black adults in reentry. Results A total of 12 individuals identifying as Black and engaged in reentry participated in the study (see Table 1). The average age of the participants was 52 (n=10), with approximately 60% identifying as single (n=7). Furthermore, 33% of the participants obtained a high school diploma, 17% earned a college degree, and 42% accumulated some college credits without attaining a degree. Regarding housing arrangements, 43% reported residing with family or friends, 33% lived independently, and 25% were classified as unhoused. Nine of the 12 individuals experienced multiple incarcerations. Concerning COVID-19, all 12 participants confirmed they had undergone testing for COVID-19 before enrolling in the study, and ninety-two percent reported being fully vaccinated (receiving two shots). One participant additionally indicated receiving a booster shot (totaling three shots). All participant names have been represented with pseudonyms. Table 1. Participant Demographic Characteristics (N = 12) Characteristics Frequency (no.) % of Participants Gender Male 8 67% Female 4 33% Age 40 - 49 5 42% 50 - 59 5 42% 60 - 69 2 16% Marital Status Married 1 8% Single 7 59% Divorced 3 25% Widowed 1 8% Education Less than a high school diploma 1 8% High school diploma 4 33% Some college, no degree 5 42% College degree 2 17% Housing Lives alone 4 33% Lives with family or friends 5 43% Unhoused 3 25% No. of Incarcerations 1 - 3 9 75% 4 - 6 2 17% 7 - 9 1 8% COVID Test Yes 8 67% No 4 33% COVID Vaccine (2 shots) Yes 11 92% No 1 8% *INSERT TABLE 1* The findings illustrate how individual motivators, alongside interpersonal, institutional, community, and policy-level factors, converge to affect vaccine uptake among Black adults in reentry. Participants’ perceptions of susceptibility to, as well as the severity of, COVID-19 were significantly intertwined with their health status, racial identity, religious beliefs, and experiences of incarceration. Racial disparities in COVID-19 infections and mortality rates, in conjunction with the stringent conditions encountered in correctional facilities, also influenced the participants' vaccine beliefs and behaviors. Furthermore, restricted access to reliable information, economic conditions within the community, and inconsistent messages from religious leaders constituted significant barriers. The results are systematically presented and analyzed in relation to the six constructs of the Health Belief Model (HBM). Perceived Susceptibility : Risk of COVID-19 Infection and Death The beliefs held by participants concerning their health status, racial group identity, and religion/spirituality significantly influenced their perceptions regarding the risk of contracting COVID-19. For instance, some participants stated: “I never contracted it before, and I never will…I’ve never been sick before in my life” (Participant 07), and “I felt like I would dodge it if I stayed prayed up and believed in the hands of a higher power” (Participant 06). Identifying as Black and having experienced incarceration led many individuals to perceive themselves as highly susceptible to contracting COVID-19, particularly in light of the racial disparities in COVID-19 infections and fatalities among Black individuals, as well as the vulnerabilities associated with living in congregate settings. One participant remarked, “Seeing the rate was so high for Black people, I was like, man, I see nothing wrong with me. I can never get that. But when it starts getting close to home, it makes you realize it’s different” (Participant 10). Another participant noted, “Being around so many people in close contact, you can get bed bugs, lice, so you could get COVID” (Participant 09). Perceived Severity: Seriousness and Consequences of Contracting COVID-19 The health status and history of participants, as well as their social networks and experiences related to incarceration, significantly influenced their perceptions regarding the seriousness of contracting COVID-19. Participants with underlying health conditions displayed an increased awareness of the potential severity of COVID-19. For example, one participant articulated, “I felt like because I was a breast cancer survivor, that will play a big role [in the severity] if I ever got COVID” (Participant 04). The loss of Black family members and friends to COVID-19 also shaped their views on the gravity of contracting the virus, even when they considered their positive health status and history as protective factors. One participant expressed, “Like I’ve had family members who passed away due to COVID-19, and I was like, ‘Okay, it’s not a joke.’ If that makes sense, it’s hitting closer to home” (Participant 12). Furthermore, participants perceived the limited mitigation strategies in correctional facilities as exacerbating the seriousness of the situation. One participant further elaborated: We never knew what was going on unless the guards would tell us, ‘Yes, that lady had COVID.’ We started asking, ‘Shouldn’t we be tested?’ They said, ‘No, there are no symptoms. You all don’t seem to be coughing or anything like that.’ Then they just went out the door. (Participant 02). Perceived Benefits: Effectiveness of the COVID-19 Vaccine Numerous participants emphasized the advantages of receiving the COVID-19 vaccine in light of their pre-existing health conditions and post-release financial necessities. One participant articulated, “I didn’t come outside until America said, ‘Go get the COVID shot.’ I didn’t take the incentive or anything. My health is something I don’t play with” (Participant 01). Another participant remarked, “I understand we are in the pandemic, but that doesn't take the fear out of my heart [about getting the shot]. But because I need employment to get my life back on track, I took the shot” (Participant 05). While many participants acknowledged the personal benefits of vaccination, some also recognized that vaccinating against COVID-19 could serve the interests of their Black families and community. One participant elucidated: I believe more than anything that it helps the community because if you get sick, you may not know for a week or two, a month or two. There’s no telling who you can infect. I’m terrified about bringing that shit home to my mom. I am not really worried about me. (Participant 07). Perceived Barriers: Internal and External Obstacles to Vaccinating Limited access to reliable COVID-19 health information, the contextual influence of the community, the experience of mild symptoms following the contraction of COVID-19, and contradictory messages from religious or spiritual leaders posed significant obstacles to vaccine uptake. In relation to COVID-19 health information, one participant remarked: The first thing on my mind is you want me to kill myself. You’re asking me to take this shot, and I don't know how it will affect me because I haven't been updated. I haven't been talked to about it. If you don't inform people or enlighten people on this thing, it’s hard for them to take your word for it. (Participant 05). Another participant noted the economic marginalization of the communities to which they were released as a significant obstacle, asserting, “Biden gets the vaccine right away, but not in lower-income and middle-income families…. It has something to do with money and where you’re from” (Participant 15). Concerning the mistrust surrounding vaccine development, one participant expressed, “I was hesitant at first about getting the vaccination because of how fast it got to the market” (Morris). Cues to Action: Factors Influencing Vaccine Uptake Participants were motivated to receive vaccinations for COVID-19 due to personal, relational, and economic considerations. One participant articulated, “My job. That’s the only reason I got the shots, man. Otherwise, I never would have gotten them” (Participant 11). Another participant remarked, “Me and my daughter, we went down there, and we signed up. I was just happy to be out having to be with my daughter, happy to be around family, people that I ain’t seen a long time” (Participant 08). The presence of an underlying health condition constituted another significant factor, as one participant noted, “Being around sick people was not something that I would be able to do – like my body can’t take that, and my mother can’t either. So, we just knew that getting a vaccine will be the way” (Participant 04). Self-Efficacy: Belief in the Ability to Vaccinate Participants exhibited a high level of confidence regarding COVID-19 vaccination, as evidenced by the fact that 11 out of the 12 were fully vaccinated. The majority of participants perceived their previous experiences with vaccine uptake as having contributed to their self-efficacy. One participant articulated, “This is not something new. We’ve got the shots over our lifetime to prevent getting diseases. Now, all of a sudden, this new virus comes out, and it’s obviously killing people. Why not get the vaccination?” (Participant 12). Historical substance use and other risk-taking behaviors also appeared to exert an influence on participants' self-efficacy with respect to vaccine uptake, as further explained by another participant: I wasn’t going to take the shot, then I thought about it. I was like, “Well, growing up, you tried all these different types of wine, you tried all these different types of gin. You were smoking weed, smoking all these different types of drugs. You didn’t know nothing about it, you just was doing it. So, why not take the shot? Something that can help you and probably protect you? (Participant 02). Discussion This Interpretative Phenomenological Analysis (IPA) study investigated the lived experiences of Black individuals during reentry, which they perceived as influencing their health beliefs and behaviors regarding the COVID-19 vaccine. The results indicate that health status, race, religion, social networks, and experiences of incarceration significantly shaped their perceptions of susceptibility to and severity of COVID-19, as well as the benefits and barriers associated with vaccination. Consequently, individual, social, institutional, community, policy, and historical factors are essential in shaping their health beliefs and behaviors. The results are consistent with the literature that underscores the influence of social, systemic, and cultural factors on the beliefs and behaviors of racially minoritized communities regarding COVID-19 and other health-related matters (9,10,13,15,16). Our findings indicate that factors, such as racial group membership, health history and status, and religion/spirituality, are pivotal in threatening uptake of the COVID-19 vaccine (17,19,20,28). Notably, religiosity and spirituality significantly affected participants’ perceived susceptibility to COVID-19 infection and mortality, as these factors seemed to provide solace to those who faced the pandemic through praying, adherence to a life of faith, and church attendance (28,29,31). Conversely, individuals with underlying health conditions or those who lost a loved one to the virus reported an increased perception of severity, which instigated a desire to safeguard both themselves and others. These insights illuminate the intricate interplay of individual and interpersonal influences on attitudes and behaviors related to vaccination, especially among those recently released from a correctional facility. In line with prior research, our findings indicate that the conditions and infrastructure of correctional facilities compromise the health of individuals who are incarcerated, thereby increasing vulnerability to COVID-19 infection and mortality (2,3,6,7,12,24,26). Numerous participants acknowledge their elevated risk resulting from the vulnerabilities inherent to residing in a congregate environment. This situation underscores the necessity for institutional and policy-level reforms, including decarceration, data transparency, and the abolition of the cash bail system, to address the carceral-epidemiological factors that adversely influence the health-related experiences and outcomes of individuals who are incarcerated in a correctional facility (2,6,7,9,12). The reentry program served as a space for participants to access community resources and social networks that foster self-efficacy and provide information about the positive aspects of the COVID-19 vaccination. However, participants remained skeptical and apprehensive regarding the vaccine’s safety and potential side effects. Many individuals articulated their continued efforts to seek credible information about the vaccine, despite having access to existing resources. This behavior underscores the influence of interpersonal, social, political, and historical factors on vaccine acceptance (12,22,23,30). Nonetheless, the necessity for employment significantly impacted vaccine uptake for many individuals, as vaccination was often a for employment. Despite this, their hesitancy towards the vaccine can, in many respects, be attributed to the ramifications of mass incarceration, medical malpractice, and other various mechanisms of systemic racism that have engendered mistrust in medical institutions among Black individuals (17,19,21,24). These findings emphasize the critical need to thoroughly comprehend how multilevel, racism-related determinants of health contribute to and perpetuate racial inequities among Black individuals who are currently or formerly incarcerated. Specifically, timely and accurate race and ethnicity data are imperative during health crises, such as the COVID-19 pandemic, as it was not until May 2020 that it was revealed that mortality rates for Black Americans were three times higher than those of the overall population (13). Implications Our research substantiates the necessity for multilevel, culturally-informed, and community-driven strategies aimed at reducing and ultimately eliminating disparities in COVID-19 infections and fatalities among Black individuals who are currently or have been incarcerated. It is imperative that federal, state, and local policies prioritize testing and vaccinations in correctional facilities, in alignment with the recommendations set forth by the Centers for Disease Control (12). Furthermore, there is a critical need for a more proactive approach to address the social and institutional determinants that influence the health experiences and outcomes of individuals who are incarcerated, rather than solely focusing on correctional staff. It is also essential to expand decarceration policies and practices; however, these efforts must intentionally intertwine carceral and community healthcare to ensure a continuum of care and to avert public health crises within Black communities (5,14,31). Health education and strategies to enhance vaccine uptake should incorporate culturally affirming messages from trusted sources, including individuals with incarceration experiences. They must also recognize and address the historical and ongoing harms inflicted by medical and research professionals on Black individuals, especially those within correctional facilities (17,19,20,29). An additional factor to consider is the provision of financial incentives for vaccine uptake, considering that economic resources are vital for individuals currently and formerly incarcerated (2,6,7,28). Moreover, engaging individuals directly impacted by mass incarceration, celebrities, and faith-based organizations in COVID-19 promotion and prevention initiatives can significantly contribute to building community trust, engagement, and partnership (17,28). Limitations One limitation of this study is that the sample is restricted to Black older adults in reentry within a single urban community in the South Central region of the U.S. Their perspectives regarding COVID-19 vaccinations may differ from those of Black youth and individuals residing in rural areas. Additionally, the participants were predominantly Black adults who received the vaccination. Their viewpoints may diverge from those who chose not to vaccinate. Finally, the sample represented older Black adults who served lengthy prison sentences and identified as aging out of crime. Consequently, they may display heightened concern regarding their health status and behaviors, including vaccine uptake, compared to individuals who have completed shorter sentences. Conclusions This study examined the lived experiences of Black adults in reentry concerning their health beliefs and behaviors regarding the COVID-19 vaccine. Utilizing the Health Belief and Social Ecological Models, we identified that factors such as race, religion, health status, and incarceration significantly influence concerns related to COVID-19 susceptibility and severity. The presence of underlying health conditions and economic needs impacted beliefs regarding the benefits of vaccine uptake. In contrast, the scarcity of trusted information, health-related concerns regarding vaccine uptake, and prevailing community conditions acted as impediments. Consequently, financial incentives, including employment opportunities, familial obligations, and health concerns, emerged as motivators for vaccine uptake. In light of these findings, carceral and public health prevention and promotion campaigns must become increasingly intertwined and inclusive of Black communities, particularly among individuals who have experienced incarceration. Abbreviations GET: Group Experiential Theme HBM: Health Belief Model IPA: Interpretive Phenomenological Analysis PET: Personal Experiential Themes SEM: Social Ecological Model Declarations Ethics Approval and Consent to Participate This study was approved by the Human Subjects Ethics Committee at the University of Houston (IRB ID: STUDY00002959) and the Houston Health Department. All procedures were conducted in accordance with the ethical standards of both committees and the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants. Consent for Publication Not Applicable Availability of Data and Materials No/Not Applicable (this manuscript does not report data generation or analysis) Competing Interest The authors declare that they have no competing interests. Funding Research reported in this publication was supported by the University of Houston New Faculty Research Program under award number 000181669. This content is solely the responsibility of the authors and does not represent the official views of the University of Houston. Authors’ Contributions C.L. contributed to the study conception and design. C.L., M.B., and M.R. performed material preparation and data collection, and C.L., M.B., M.R., P.K., R.B., and Y.M. performed formal analysis. C.L. wrote the first draft of the manuscript, and all authors reviewed, edited, and commented on previous versions. All authors read and approved the final manuscript. Acknowledgements Not Applicable References CDC. 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Brain Behav Immun - Health. 2021 Aug 1;15:100277. Restrepo N, Krouse HJ. COVID-19 Disparities and Vaccine Hesitancy in Black Americans: What Ethical Lessons Can Be Learned? Otolaryngol Neck Surg. 2022 Jun 1;166(6):1147–60. Willis DE, Andersen JA, Bryant-Moore K, Selig JP, Long CR, Felix HC, et al. COVID-19 vaccine hesitancy: Race/ethnicity, trust, and fear. Clin Transl Sci. 2021;14(6):2200–7. Liu YE, Oto J, Will J, LeBoa C, Doyle A, Rens N, et al. Factors associated with COVID-19 vaccine acceptance and hesitancy among residents of Northern California jails. Prev Med Rep. 2022 Jun 1;27:101771. Batelaan K. ‘It’s not the science we distrust; it’s the scientists’: Reframing the anti-vaccination movement within Black communities. Glob Public Health. 2022 Jun 3;17(6):1099–112. Wilson Y. Is Trust Enough? Anti-Black Racism and the Perception of Black Vaccine “Hesitancy.” Hastings Cent Rep. 2022;52(S1):S12–7. Muhammad KG. The condemnation of blackness: race, crime, and the making of modern urban America, with a new preface [Internet]. Cambridge, Massachusetts: Harvard University Press; 2019 [cited 2024 Jul 23]. 380 p. Available from: http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&db=nlabk&AN=2157763 Adeagbo M, Olukotun M, Musa S, Alaazi D, Allen U, Renzaho AMN, et al. Improving COVID-19 Vaccine Uptake among Black Populations: A Systematic Review of Strategies. Int J Environ Res Public Health. 2022 Jan;19(19):11971. Hawkins D, Simon-Roberts S. Music Videos as Health Promotion: Juvenile’s “Vax That Thang Up” and the Promotion of the COVID-19 Vaccine in the Black Community. Am Behav Sci. 2023 Jan 11;00027642221145027. Padamsee TJ, Bond RM, Dixon GN, Hovick SR, Na K, Nisbet EC, et al. Changes in COVID-19 Vaccine Hesitancy Among Black and White Individuals in the US. JAMA Netw Open. 2022 Jan 21;5(1):e2144470. Walsh F. Loss and Resilience in the Time of COVID-19: Meaning Making, Hope, and Transcendence. Fam Process. 2020;59(3):898–911. Champion, V. L., & Skinner, C. S. (2008). The health belief model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior and health education: Theory, research, and practice (4th ed., pp. 45–65). Jossey-Bass/Wiley. Stokols D. Translating Social Ecological Theory into Guidelines for Community Health Promotion. Am J Health Promot. 1996 Mar 1;10(4):282–98. Smith JA, Flowers P, Larkin M. Interpretative Phenomenological Analysis: Theory, Method and Research. Second edition. Thousand Oaks: SAGE Publications Ltd; 2022. 240 p. Berger PL, Luckmann T. The Social Construction of Reality: A Treatise in the Sociology of Knowledge. New York: Anchor; 1967. 219 p. Lock A, Strong T. Social Constructionism: Sources and Stirrings in Theory and Practice. Cambridge University Press; 2010. 403 p. Creswell JW, Poth CN. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE Publications; 2016. 489 p. Charmaz K. Constructing Grounded Theory. Second edition. London ; Thousand Oaks, Calif: SAGE Publications Ltd; 2014. 416 p. Parson L. Considering Positionality: The Ethics of Conducting Research with Marginalized Groups. In: Strunk KK, Locke LA, editors. Research Methods for Social Justice and Equity in Education [Internet]. Cham: Springer International Publishing; 2019 [cited 2022 Dec 7]. p. 15–32. Available from: https://doi.org/10.1007/978-3-030-05900-2_2 Milner HR, Singer JN, Parks L, Murray I, Lane-Bonds D. Positionality as a Data Point in Race Research. Qual Inq. 2024 Sep 25;10778004241269916. Additional Declarations No competing interests reported. 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Black individuals remained at the forefront of this health crisis, as their probabilities of infection (1.1 times), hospitalization (2.1 times), and fatality (1.6 times) exceeded those of non-Hispanic Whites (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The phenomenon of mass incarceration exacerbates the adverse impact of COVID-19 on the Black community, given that Black individuals constitute 14% of the U.S. population yet represent 35% of the total jail and prison population. During the pandemic\u0026rsquo;s peak, correctional facilities encountered significantly elevated rates of infection and mortality (approximately 5 times) in comparison to the general population and other congregate settings, such as nursing homes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). As of May 9, 2023, there were 645,762 documented cases of COVID-19 and 2,934 fatalities among people incarcerated in prisons, alongside 246,541 cases and 293 deaths among correctional staff (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). To mitigate the transmission of COVID-19 within correctional facilities, numerous jurisdictions enhanced the implementation of early release for individuals charged with non-violent offenses (\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhile early release strategies are essential for mitigating the spread of COVID-19 within correctional facilities, they simultaneously create a public health crisis for Black communities due to the dynamic of carceral-community epidemiology (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). That is, correctional facilities function as incubators for COVID-19 and other infectious diseases, exacerbated by the congregate living conditions, overcrowding, unsanitary environments, and the pre-existing poor health conditions of people who are incarcerated, coupled with limited COVID-19 mitigation strategies (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Furthermore, the communities to which Black individuals return following incarceration are burdened by COVID-19 and other health inequities resulting from over-policing, elevated poverty and incarceration rates, and restricted access to healthcare (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Particularly, over-policing significantly contributes to racial disparities in COVID-19 cases and mortality rates, as it creates a cycle of incarceration (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). For instance, in Chicago, 17% of all COVID-19 cases in neighborhoods primarily inhabited by Black and/or non-White Hispanic residents were associated with jail cycling in March 2020, compared to merely 6% of cases in predominantly White neighborhoods (Reinhart \u0026amp; Chen, 2021). Moreover, jail cycling accounted for 21% of the racial disparities in COVID-19 cases across neighborhoods in Chicago. Consequently, the COVID-19 pandemic and the persistent epidemic of mass incarceration are epidemiologically intertwined, with mass incarceration functioning as a mechanism of structural and systemic racism, thereby exacerbating the racial disparities linked to COVID-19 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIncreasing vaccine uptake among Black individuals, both currently incarcerated and formerly incarcerated, is therefore critical to addressing racial disparities in COVID-19 cases and fatalities. However, studies indicate that medical and governmental mistrust, lack of confidence in vaccine effectiveness, limited access to healthcare, health effects associated with vaccine uptake, scarce trusted information concerning vaccine safety and efficacy, and a low perceived risk of COVID-19 infection are predictors of vaccine hesitancy within this community (\u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). Vaccine hesitancy among Black individuals is rooted in historical and contemporary structural and systemic racism and discrimination (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan additionalcitationids=\"CR26\" citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Despite these challenges, research demonstrates that culturally grounded interventions, spirituality, and community engagement effectively enhance vaccine uptake among Black individuals (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29 CR30\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). While improving vaccine uptake represents a crucial step toward ameliorating racial disparities in COVID-19 cases and mortality rates among Black individuals, knowledge regarding the factors that influence vaccine uptake among those who are incarcerated or have been formerly incarcerated remains limited (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This understanding is vital for reducing and eventually eradicating COVID-19 and associated health inequities. Furthermore, it can inform research, policy development, and practice in effectively formulating and implementing strategies tailored to their specific sociocultural and contextual needs.\u003c/p\u003e \u003cp\u003eThis study, therefore, aimed to enhance the understanding of the incarceration and reentry experiences Black individuals perceive as influencing their health beliefs and behaviors related to COVID-19 vaccine uptake. This research originated from a collaboration with a reentry program affiliated with a local health department in the South Central region of the U.S., prompted by the number of participants opting not to receive vaccination. The health belief model (HBM) guided this study because it includes six health determinants (i.e., perceived susceptibility, severity, benefits, and barriers, cues to action, and self-efficacy) that suggest a person\u0026rsquo;s belief in the threat of COVID-19 infection and death, alongside their belief in the effectiveness of the vaccine, influences their decision to vaccinate (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Additionally, the Social Ecological Model (SEM) served as a guiding framework for this study, as it sought to identify the multilevel factors (including individual, social, institutional, community, and policy) that shape their vaccine-related beliefs and behaviors (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Consequently, the research question includes: How do the lived experiences of Black adults in reentry influence their health beliefs and behaviors regarding the COVID-19 vaccine?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis study utilized an Interpretive Phenomenological Analysis (IPA) design to qualitatively describe and interpret Black adults\u0026apos; personal and collective experiences concerning incarceration and reentry, specifically how these experiences informed their health beliefs and behaviors regarding the COVID-19 vaccine (34). This study is grounded in constructivism, which acknowledges that knowledge is socially constructed, recognizes the existence of multiple realities, and emphasizes the significance of context, while perceiving research participants as active contributors to the knowledge creation process (35,36). All procedures associated with this study were approved by the internal review board (IRB) committee of the sponsoring university and the local health department, and each participant consented to participate.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and Recruitment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePurposive sampling was employed to recruit potential participants (37). To qualify, prospective participants were required to (a) self-identify as African American/Black, (b) be 18 years of age or older, and (c) have been released from a jail or prison setting during or after March 2020, as well as (d) have been offered a COVID-19 vaccine upon their release into the reentry program. In collaboration with the director, instructors, and case managers of the reentry program, recruitment activities included posting flyers at the program site, distributing flyers via email to the organization\u0026apos;s listservs, gaining direct referrals from the program\u0026rsquo;s director, instructors, and case managers, and conducting both in-person and virtual group presentations. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInterview Guide\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Health Belief and Social-Ecological Models informed the formulation of the semi-structured interview guide to identify multilevel determinants of vaccine beliefs and behaviors among Black adults in reentry. The interview guide examined participants\u0026apos; (a) personal and familial backgrounds, (b) incarceration and reentry experiences, and (c) beliefs regarding COVID-19 and associated health behaviors, including COVID-19 knowledge, perceived susceptibility, severity, and benefits, barriers, cues to action, and self-efficacy. Probes were also developed to explore how personal and social-structural factors influence their beliefs and behaviors, and each participant was asked to describe what successful reentry means to them and to offer recommendations for reentry programs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection Procedures\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIndividual interviews (n=12) were conducted with Black adults in reentry between March 2021 and August 2022. Each interview lasted approximately 60 minutes and adhered to the semi-structured guide. Interviews were conducted using Zoom and in person in a private room at the reentry program. Each interview was audio recorded and transcribed professionally, and participants received an incentive of $40 for their participation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAnalysis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo facilitate analysis and interpretation, we uploaded each transcribed audio file into the software Dedoose and adhered to the established procedures involved in IPA (34). Initially, we engaged in a comprehensive reading and rereading of each transcript while simultaneously listening to the corresponding audio recording and developing exploratory notes on initial semantic content and the language utilized, thereby refamiliarizing ourselves with narratives provided by each participant. Subsequently, we individually coded each transcript in Dedoose, focusing on the key determinants influencing beliefs and behaviors regarding the COVID-19 vaccine. Following this, we constructed a list of experiential themes pertinent to the research question derived from each transcript. In the next phase, we refined this thematic list by clustering the themes based on similarities. We then developed a table of Personal Experiential Themes (PETs), designating each cluster and incorporating verbatim excerpts from the transcripts. Finally, we generated Group Experiential Themes (GET) by conducting a cross-case analysis, actively searching for convergences and divergences among the identified PETs (34,38). We employed peer debriefing, memoing, and audit trail strategies to ensure credibility, transferability, dependability, and confirmability (37)\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResearcher\u0026rsquo;s Positionality\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur positionalities shaped this study (39,40). The first author is a Black cisgender man and a faculty member in social work, who investigates racism-related and healing-centered determinants of health among Black youth and adults with incarceration histories. Although he has never been incarcerated, he believes that mass incarceration constitutes a significant determinant of health within Black communities. The second author is a Black male pursuing a Ph.D. His professional experiences as a licensed clinical social worker focused on reducing health disparities among underserved populations influenced his engagement with this study. The third author, a White female with a Ph.D. and a master\u0026apos;s in social work, aligns this research with her scholarly interest in the mechanisms of structural racism. The fourth author is a South Asian cisgender female and Ph.D. student. Her experiences as a school social worker providing underserved youth and families access to healthcare have significantly shaped her interest in this work. The fifth author is an East Asian woman currently enrolled as a Ph.D. social work student, possessing a doctorate in public health and expertise in the health belief model. The sixth author is a queer Chicanx woman and an abolitionist social worker, actively working as a participatory dense organizer. She maintains that the abolition of the prison industrial complex represents the most secure path to liberation and justice for Black and Brown communities. This seventh author is a Black public health social work faculty member who investigates health disparities among marginalized communities, particularly African-American men and women, through an intersectional lens that integrates spirituality, mental health, and social networks. While we acknowledge our status as outsiders, having never been incarcerated, our lived experiences as racially and ethnically minoritized individuals raised in historically marginalized communities affected by racism-related determinants of health provide us with a crucial perspective. This perspective remained central to our attention throughout this study concerning the experiences that shape health beliefs and behaviors surrounding COVID-19 among Black adults in reentry.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 12 individuals identifying as Black and engaged in reentry participated in the study (see Table 1). The average age of the participants was 52 (n=10), with approximately 60% identifying as single (n=7). Furthermore, 33% of the participants obtained a high school diploma, 17% earned a college degree, and 42% accumulated some college credits without attaining a degree. Regarding housing arrangements, 43% reported residing with family or friends, 33% lived independently, and 25% were classified as unhoused. Nine of the 12 individuals experienced multiple incarcerations. Concerning COVID-19, all 12 participants confirmed they had undergone testing for COVID-19 before enrolling in the study, and ninety-two percent reported being fully vaccinated (receiving two shots). One participant additionally indicated receiving a booster shot (totaling three shots). All participant names have been represented with pseudonyms.\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003eParticipant Demographic Characteristics (N = 12)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\" style=\"width: 441px;\"\u003e\n \u003cp\u003eCharacteristics\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003eFrequency\u003c/p\u003e\n \u003cp\u003e(no.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 91px;\"\u003e\n \u003cp\u003e% of Participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eGender\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Male\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;40 - 49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;50 - 59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;60 - 69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e16%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eMarital Status\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e59%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Divorced\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Widowed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eEducation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Less than a high school diploma\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;High school diploma\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Some college, no degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e42%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;College degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eHousing\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Lives alone\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Lives with family or friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e43%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Unhoused\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eNo. of Incarcerations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;1 - 3\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e75%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;4 - 6\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;7 - 9\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eCOVID Test\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e33%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003eCOVID Vaccine (2 shots)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e92%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 441px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 91px;\"\u003e\n \u003cp\u003e8%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*INSERT TABLE 1*\u003c/p\u003e\n\u003cp\u003eThe findings illustrate how individual motivators, alongside interpersonal, institutional, community, and policy-level factors, converge to affect vaccine uptake among Black adults in reentry. Participants\u0026rsquo; perceptions of susceptibility to, as well as the severity of, COVID-19 were significantly intertwined with their health status, racial identity, religious beliefs, and experiences of incarceration. Racial disparities in COVID-19 infections and mortality rates, in conjunction with the stringent conditions encountered in correctional facilities, also influenced the participants\u0026apos; vaccine beliefs and behaviors. Furthermore, restricted access to reliable information, economic conditions within the community, and inconsistent messages from religious leaders constituted significant barriers. The results are systematically presented and analyzed in relation to the six constructs of the Health Belief Model (HBM).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Susceptibility\u003c/strong\u003e: \u003cstrong\u003eRisk of COVID-19 Infection and Death\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe beliefs held by participants concerning their health status, racial group identity, and religion/spirituality significantly influenced their perceptions regarding the risk of contracting COVID-19. For instance, some participants stated: \u0026ldquo;I never contracted it before, and I never will\u0026hellip;I\u0026rsquo;ve never been sick before in my life\u0026rdquo; (Participant 07), and \u0026ldquo;I felt like I would dodge it if I stayed prayed up and believed in the hands of a higher power\u0026rdquo;\u0026nbsp;(Participant 06). Identifying as Black and having experienced incarceration led many individuals to perceive themselves as highly susceptible to contracting COVID-19, particularly in light of the racial disparities in COVID-19 infections and fatalities among Black individuals, as well as the vulnerabilities associated with living in congregate settings. One participant remarked, \u0026ldquo;Seeing the rate was so high for Black people, I was like, man, I see nothing wrong with me. I can never get that. But when it starts getting close to home, it makes you realize it\u0026rsquo;s different\u0026rdquo; (Participant 10). Another participant noted, \u0026ldquo;Being around so many people in close contact, you can get bed bugs, lice, so you could get COVID\u0026rdquo; (Participant 09).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Severity: Seriousness and Consequences of Contracting COVID-19\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe health status and history of participants, as well as their social networks and experiences related to incarceration, significantly influenced their perceptions regarding the seriousness of contracting COVID-19. Participants with underlying health conditions displayed an increased awareness of the potential severity of COVID-19. For example, one participant articulated, \u0026ldquo;I felt like because I was a breast cancer survivor, that will play a big role [in the severity] if I ever got COVID\u0026rdquo; (Participant 04). The loss of Black family members and friends to COVID-19 also shaped their views on the gravity of contracting the virus, even when they considered their positive health status and history as protective factors. One participant expressed, \u0026ldquo;Like I\u0026rsquo;ve had family members who passed away due to COVID-19, and I was like, \u0026lsquo;Okay, it\u0026rsquo;s not a joke.\u0026rsquo; If that makes sense, it\u0026rsquo;s hitting closer to home\u0026rdquo; (Participant 12). Furthermore, participants perceived the limited mitigation strategies in correctional facilities as exacerbating the seriousness of the situation. One participant further elaborated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe never knew what was going on unless the guards would tell us, \u0026lsquo;Yes, that lady had COVID.\u0026rsquo; We started asking, \u0026lsquo;Shouldn\u0026rsquo;t we be tested?\u0026rsquo; They said, \u0026lsquo;No, there are no symptoms. You all don\u0026rsquo;t seem to be coughing or anything like that.\u0026rsquo; Then they just went out the door. (Participant 02).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Benefits: Effectiveness of the COVID-19 Vaccine\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNumerous participants emphasized the advantages of receiving the COVID-19 vaccine in light of their pre-existing health conditions and post-release financial necessities. One participant articulated, \u0026ldquo;I didn\u0026rsquo;t come outside until America said, \u0026lsquo;Go get the COVID shot.\u0026rsquo; I didn\u0026rsquo;t take the incentive or anything. My health is something I don\u0026rsquo;t play with\u0026rdquo; (Participant 01). Another participant remarked, \u0026ldquo;I understand we are in the pandemic, but that doesn\u0026apos;t take the fear out of my heart [about getting the shot]. But because I need employment to get my life back on track, I took the shot\u0026rdquo; (Participant 05). While many participants acknowledged the personal benefits of vaccination, some also recognized that vaccinating against COVID-19 could serve the interests of their Black families and community. One participant elucidated:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI believe more than anything that it helps the community because if you get sick, you may not know for a week or two, a month or two. There\u0026rsquo;s no telling who you can infect. I\u0026rsquo;m terrified about bringing that shit home to my mom. I am not really worried about me. (Participant 07).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerceived Barriers: Internal and External Obstacles to Vaccinating\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLimited access to reliable COVID-19 health information, the contextual influence of the community, the experience of mild symptoms following the contraction of COVID-19, and contradictory messages from religious or spiritual leaders posed significant obstacles to vaccine uptake. In relation to COVID-19 health information, one participant remarked:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first thing on my mind is you want me to kill myself. You\u0026rsquo;re asking me to take this shot, and I don\u0026apos;t know how it will affect me because I haven\u0026apos;t been updated. I haven\u0026apos;t been talked to about it. If you don\u0026apos;t inform people or enlighten people on this thing, it\u0026rsquo;s hard for them to take your word for it. (Participant 05).\u003c/p\u003e\n\u003cp\u003eAnother participant noted the economic marginalization of the communities to which they were released as a significant obstacle, asserting, \u0026ldquo;Biden gets the vaccine right away, but not in lower-income and middle-income families\u0026hellip;. It has something to do with money and where you\u0026rsquo;re from\u0026rdquo; (Participant 15). Concerning the mistrust surrounding vaccine development, one participant expressed, \u0026ldquo;I was hesitant at first about getting the vaccination because of how fast it got to the market\u0026rdquo; (Morris).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCues to Action: Factors Influencing Vaccine Uptake\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were motivated to receive vaccinations for COVID-19 due to personal, relational, and economic considerations. One participant articulated, \u0026ldquo;My job. That\u0026rsquo;s the only reason I got the shots, man. Otherwise, I never would have gotten them\u0026rdquo; (Participant 11). Another participant remarked, \u0026ldquo;Me and my daughter, we went down there, and we signed up. I was just happy to be out having to be with my daughter, happy to be around family, people that I ain\u0026rsquo;t seen a long time\u0026rdquo; (Participant 08). The presence of an underlying health condition constituted another significant factor, as one participant noted, \u0026ldquo;Being around sick people was not something that I would be able to do \u0026ndash; like my body can\u0026rsquo;t take that, and my mother can\u0026rsquo;t either. So, we just knew that getting a vaccine will be the way\u0026rdquo; (Participant 04).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSelf-Efficacy: Belief in the Ability to Vaccinate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants exhibited a high level of confidence regarding COVID-19 vaccination, as evidenced by the fact that 11 out of the 12 were fully vaccinated. The majority of participants perceived their previous experiences with vaccine uptake as having contributed to their self-efficacy. One participant articulated, \u0026ldquo;This is not something new. We\u0026rsquo;ve got the shots over our lifetime to prevent getting diseases. Now, all of a sudden, this new virus comes out, and it\u0026rsquo;s obviously killing people. Why not get the vaccination?\u0026rdquo; (Participant 12). Historical substance use and other risk-taking behaviors also appeared to exert an influence on participants\u0026apos; self-efficacy with respect to vaccine uptake, as further explained by another participant: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eI wasn\u0026rsquo;t going to take the shot, then I thought about it. I was like, \u0026ldquo;Well, growing up, you tried all these different types of wine, you tried all these different types of gin. You were smoking weed, smoking all these different types of drugs. You didn\u0026rsquo;t know nothing about it, you just was doing it. So, why not take the shot? Something that can help you and probably protect you? (Participant 02).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis Interpretative Phenomenological Analysis (IPA) study investigated the lived experiences of Black individuals during reentry, which they perceived as influencing their health beliefs and behaviors regarding the COVID-19 vaccine. The results indicate that health status, race, religion, social networks, and experiences of incarceration significantly shaped their perceptions of susceptibility to and severity of COVID-19, as well as the benefits and barriers associated with vaccination. Consequently, individual, social, institutional, community, policy, and historical factors are essential in shaping their health beliefs and behaviors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results are consistent with the literature that underscores the influence of social, systemic, and cultural factors on the beliefs and behaviors of racially minoritized communities regarding COVID-19 and other health-related matters (9,10,13,15,16).\u0026nbsp;Our findings indicate that\u0026nbsp;factors, such as\u0026nbsp;racial group membership, health history and status, and religion/spirituality, are pivotal in threatening uptake of the COVID-19 vaccine (17,19,20,28). Notably, religiosity and spirituality significantly affected participants\u0026rsquo; perceived susceptibility to COVID-19 infection and mortality, as these factors seemed to provide solace to those who faced the pandemic through praying, adherence to a life of faith, and church attendance (28,29,31). Conversely, individuals with underlying health conditions or those who lost a loved one to the virus reported an increased perception of severity, which instigated a desire to safeguard both themselves and others. These insights illuminate the intricate interplay of individual and interpersonal influences on attitudes and behaviors related to vaccination, especially among those recently released from a correctional facility.\u003c/p\u003e\n\u003cp\u003eIn line with prior research, our findings indicate that the conditions and infrastructure of correctional facilities compromise the health of individuals who are incarcerated, thereby increasing vulnerability to COVID-19 infection and mortality (2,3,6,7,12,24,26). Numerous participants acknowledge their elevated risk resulting from the vulnerabilities inherent to residing in a congregate environment. This situation underscores the necessity for institutional and policy-level reforms, including decarceration, data transparency, and the abolition of the cash bail system, to address the carceral-epidemiological factors that adversely influence the health-related experiences and outcomes of individuals who are incarcerated in a correctional facility (2,6,7,9,12).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;The reentry program served as a space for participants to access community resources and social networks that foster self-efficacy and provide information about the positive aspects of the COVID-19 vaccination. However, participants remained skeptical and apprehensive regarding the vaccine\u0026rsquo;s safety and potential side effects. Many individuals articulated their continued efforts to seek credible information about the vaccine, despite having access to existing resources. This behavior underscores the influence of interpersonal, social, political, and historical factors on vaccine acceptance (12,22,23,30). Nonetheless, the necessity for employment significantly impacted vaccine uptake for many individuals, as vaccination was often a for employment. Despite this, their hesitancy towards the vaccine can, in many respects, be attributed to the ramifications of mass incarceration, medical malpractice, and other various mechanisms of systemic racism that have engendered mistrust in medical institutions among Black individuals (17,19,21,24). These findings emphasize the critical need to thoroughly comprehend how multilevel, racism-related determinants of health contribute to and perpetuate racial inequities among Black individuals who are currently or formerly incarcerated. Specifically, timely and accurate race and ethnicity data are imperative during health crises, such as the COVID-19 pandemic, as it was not until May 2020 that it was revealed that mortality rates for Black Americans were three times higher than those of the overall population (13). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur research substantiates the necessity for multilevel, culturally-informed, and community-driven strategies aimed at reducing and ultimately eliminating disparities in COVID-19 infections and fatalities among Black individuals who are currently or have been incarcerated. It is imperative that federal, state, and local policies prioritize testing and vaccinations in correctional facilities, in alignment with the recommendations set forth by the Centers for Disease Control (12). Furthermore, there is a critical need for a more proactive approach to address the social and institutional determinants that influence the health experiences and outcomes of individuals who are incarcerated, rather than solely focusing on correctional staff. It is also essential to expand decarceration policies and practices; however, these efforts must intentionally intertwine carceral and community healthcare to ensure a continuum of care and to avert public health crises within Black communities (5,14,31). Health education and strategies to enhance vaccine uptake should incorporate culturally affirming messages from trusted sources, including individuals with incarceration experiences. They must also recognize and address the historical and ongoing harms inflicted by medical and research professionals on Black individuals, especially those within correctional facilities (17,19,20,29). An additional factor to consider is the provision of financial incentives for vaccine uptake, considering that economic resources are vital for individuals currently and formerly incarcerated (2,6,7,28). Moreover, engaging individuals directly impacted by mass incarceration, celebrities, and faith-based organizations in COVID-19 promotion and prevention initiatives can significantly contribute to building community trust, engagement, and partnership (17,28).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne limitation of this study is that the sample is restricted to Black older adults in reentry within a single urban community in the South Central region of the U.S. Their perspectives regarding COVID-19 vaccinations may differ from those of Black youth and individuals residing in rural areas. Additionally, the participants were predominantly Black adults who received the vaccination. Their viewpoints may diverge from those who chose not to vaccinate. Finally, the sample represented older Black adults who served lengthy prison sentences and identified as aging out of crime. Consequently, they may display heightened concern regarding their health status and behaviors, including vaccine uptake, compared to individuals who have completed shorter sentences.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study examined the lived experiences of Black adults in reentry concerning their health beliefs and behaviors regarding the COVID-19 vaccine. Utilizing the Health Belief and Social Ecological Models, we identified that factors such as race, religion, health status, and incarceration significantly influence concerns related to COVID-19 susceptibility and severity. The presence of underlying health conditions and economic needs impacted beliefs regarding the benefits of vaccine uptake. In contrast, the scarcity of trusted information, health-related concerns regarding vaccine uptake, and prevailing community conditions acted as impediments. Consequently, financial incentives, including employment opportunities, familial obligations, and health concerns, emerged as motivators for vaccine uptake. In light of these findings, carceral and public health prevention and promotion campaigns must become increasingly intertwined and inclusive of Black communities, particularly among individuals who have experienced incarceration.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eGET: Group Experiential Theme\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHBM: Health Belief Model\u003c/p\u003e\n\u003cp\u003eIPA: Interpretive Phenomenological Analysis\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePET: Personal Experiential Themes\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSEM: Social Ecological Model\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Human Subjects Ethics Committee at the University of Houston (IRB ID: STUDY00002959) and the Houston Health Department. All procedures were conducted in accordance with the ethical standards of both committees and the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo/Not Applicable (this manuscript does not report data generation or analysis)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch reported in this publication was supported by the University of Houston New Faculty Research Program under award number 000181669. This content is solely the responsibility of the authors and does not represent the official views of the University of Houston. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC.L. contributed to the study conception and design. C.L., M.B., and M.R. performed material preparation and data collection, and C.L., M.B., M.R., P.K., R.B., and Y.M. performed formal analysis. C.L. wrote the first draft of the manuscript, and all authors reviewed, edited, and commented on previous versions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCDC. Centers for Disease Control and Prevention. 2020 [cited 2023 Jan 20]. Cases, Data, and Surveillance. 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Interpretative Phenomenological Analysis: Theory, Method and Research. Second edition. Thousand Oaks: SAGE Publications Ltd; 2022. 240 p. \u003c/li\u003e\n\u003cli\u003eBerger PL, Luckmann T. The Social Construction of Reality: A Treatise in the Sociology of Knowledge. New York: Anchor; 1967. 219 p. \u003c/li\u003e\n\u003cli\u003eLock A, Strong T. Social Constructionism: Sources and Stirrings in Theory and Practice. Cambridge University Press; 2010. 403 p. \u003c/li\u003e\n\u003cli\u003eCreswell JW, Poth CN. Qualitative Inquiry and Research Design: Choosing Among Five Approaches. SAGE Publications; 2016. 489 p. \u003c/li\u003e\n\u003cli\u003eCharmaz K. Constructing Grounded Theory. Second edition. London ; Thousand Oaks, Calif: SAGE Publications Ltd; 2014. 416 p. \u003c/li\u003e\n\u003cli\u003eParson L. Considering Positionality: The Ethics of Conducting Research with Marginalized Groups. In: Strunk KK, Locke LA, editors. Research Methods for Social Justice and Equity in Education [Internet]. Cham: Springer International Publishing; 2019 [cited 2022 Dec 7]. p. 15\u0026ndash;32. Available from: https://doi.org/10.1007/978-3-030-05900-2_2\u003c/li\u003e\n\u003cli\u003eMilner HR, Singer JN, Parks L, Murray I, Lane-Bonds D. Positionality as a Data Point in Race Research. Qual Inq. 2024 Sep 25;10778004241269916. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, Vaccine Uptake, Incarceration, Reentry, African American/Black Adults, Structural Racism, Interpretive Phenomenological Analysis, Qualitative Methodology","lastPublishedDoi":"10.21203/rs.3.rs-6597424/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6597424/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: In light of the elevated risk of COVID-19 infection and mortality rates among Black individuals who are currently or have previously experienced incarceration, it is concerning to note that vaccination rates within this demographic remain significantly low. This study employs the Health Belief and Social Ecological models as theoretical frameworks to investigate the experiences of incarceration and reentry that Black individuals perceive as influencing their health beliefs and behaviors regarding the uptake of the COVID-19 vaccine. Gaining this understanding can offer valuable insights for developing and implementing effective policy and practice strategies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Between 2021 and 2022, twelve semi-structured interviews were conducted with formerly incarcerated Black adults in the South Central region of the United States utilizing an interpretive phenomenological analysis (IPA) design. An interview guide, informed by theoretical frameworks, was employed to facilitate each interview, which was audio recorded and professionally transcribed. Data analysis adhered to the established procedures involved in IPA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Participants' health status, race, and religious or spiritual beliefs significantly influenced their perceptions of susceptibility to COVID-19 infection and mortality. Participants' health and medical history, social networks, and experiences with incarceration shaped their views on the severity of the illness. Underlying health issues and job status were seen as enablers of vaccine acceptance, while a lack of reliable information, challenging community conditions, and mild symptoms of COVID-19 served as barriers. Though personal, relational, and economic factors acted as prompts for vaccination, participants showed strong self-efficacy regarding vaccine uptake. Therefore, personal, sociocultural, socioeconomic, structural, and systemic elements play a vital role in shaping the beliefs and actions of formerly incarcerated Black individuals regarding COVID-19 vaccination.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: To enhance vaccine uptake, it is imperative to implement multilevel, culturally informed, and community-engaged health promotion and prevention strategies involving individuals with lived experience.\u003c/p\u003e","manuscriptTitle":"Reentry and COVID-19: An Examination of the Vaccine Beliefs and Behaviors of Black Adults in an Urban Community","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-13 12:37:40","doi":"10.21203/rs.3.rs-6597424/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-22T05:42:43+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-30T08:30:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T03:33:25+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T20:49:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198454875510509995404545593867320704334","date":"2026-04-20T01:50:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97275972089302923642155345034945428771","date":"2026-04-19T20:08:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-19T01:42:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"209373866982467273670769372586114616817","date":"2026-04-18T01:09:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"264464287629070703580712904868437369237","date":"2026-04-17T16:03:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T15:43:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T14:21:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-02T02:06:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"237211978282773602039706016107236063140","date":"2025-06-21T04:16:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217117392470814057920572216185368496023","date":"2025-06-20T17:14:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201240054497029766041204732812555873287","date":"2025-06-18T16:52:31+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-11T17:44:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-10T05:20:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-21T11:57:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-20T19:59:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-20T19:58:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1c1851cd-adf2-457b-8dbe-76475f0d5828","owner":[],"postedDate":"June 13th, 2025","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-22T05:42:43+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-05-22T05:54:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-13 12:37:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6597424","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6597424","identity":"rs-6597424","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}