Assessment of COVID-19 Vaccine Hesitancy and Its Socio-Demographic Predictors in Rural Communities: A Mixed-Methods Study

Background: COVID-19 vaccine hesitancy represents a critical barrier to achieving herd immunity, particularly in rural communities where vaccination rates remain lower than urban areas. Understanding the determinants of vaccine hesitancy in these underserved populations is essential for developing targeted interventions. Methods: A sequential explanatory mixed-methods design was employed in four rural communities. The quantitative phase involved a cross-sectional survey of 486 adults aged 18-75 years assessing vaccine hesitancy using the validated Vaccine Hesitancy Scale, socio-demographic characteristics, and vaccination status. The qualitative phase comprised 24 in-depth interviews and 3 focus group discussions with purposively selected participants to explore barriers and facilitators to vaccine acceptance. Logistic regression identified independent predictors of hesitancy, while thematic analysis examined qualitative data. Results: Overall vaccine hesitancy prevalence was 41.8% (203/486; 95% CI: 37.4-46.3%), with 18.3% refusing vaccination and 23.5% expressing initial hesitancy. Mean age was 44.6 ± 14.2 years, with 52.5% female participants. Among hesitant individuals, mean Vaccine Hesitancy Scale score was 3.42 ± 0.86 (scale 1-5, higher indicating greater hesitancy). Independent predictors of vaccine hesitancy included age <40 years (aOR = 2.34; 95% CI: 1.48-3.70; p < 0.001), no formal education (aOR = 3.18; 95% CI: 1.86-5.43; p < 0.001), lack of health insurance (aOR = 1.89; 95% CI: 1.22-2.93; p = 0.004), and misinformation exposure (aOR = 4.26; 95% CI: 2.78-6.53; p < 0.001). Qualitative analysis revealed five major themes: safety concerns (cited by 87.5% of hesitant participants), mistrust in government and pharmaceutical companies (79.2%), and misinformation from social media (71.4%), religious beliefs (41.7%), and access barriers (54.2%). Facilitating factors included healthcare provider recommendations, community leader endorsements, and family influence. Conclusion: COVID-19 vaccine hesitancy is alarmingly high in rural communities, driven by multifaceted socio-demographic, informational, and trust-related factors. Targeted interventions leveraging trusted messengers, addressing misinformation, improving health literacy, and enhancing vaccine accessibility are urgently needed to increase vaccine acceptance in rural populations.