Decisions about adopting novel COVID‐19 vaccines among White adults in a rural state, USA: A qualitative study

Abstract Purpose Many people, especially in rural areas of the United States, choose not to receive novel COVID‐19 vaccinations despite public health recommendations. Understanding how people describe decisions to get vaccinated or not may help to address hesitancy. Methods We conducted semistructured interviews with 17 rural inhabitants of Maine, a sparsely populated state in the northeastern US, about COVID‐19 vaccine decisions during the early rollout (March–May 2021). We used the framework method to compare responses, including between vaccine Adopters and Non‐adopters. Findings Adopters framed COVID‐19 as unequivocally dangerous, if not personally, then to other people. Describing their COVID concerns, Adopters emphasized disease morbidities. By contrast, Non‐adopters never mentioned morbidities, referencing instead mortality risk, which they perceived as minimal. Instead of risks associated with the disease, Non‐adopters emphasized risks associated with vaccination. Uncertainty about the vaccine development process, augmented by social media, bolstered concerns about the long‐term unknown risks of vaccines. Vaccine Adopters ultimately described trusting the process, while Non‐adopters expressed distrust. Conclusion Many respondents framed their COVID vaccination decision by comparing the risks between the disease and the vaccine. Associating morbidity risks with COVID‐19 diminishes the relevance of vaccine risks, whereas focusing on low perceived mortality risks heightens their relevance. Results could inform efforts to address COVID‐19 vaccine hesitancy in the rural US and elsewhere. Patient or Public Contribution Members of Maine rural communities were involved throughout the study. Leaders of community health groups provided feedback on the study design, were actively involved in recruitment, and reviewed findings after analysis. All data produced and used in this study were co‐constructed through the participation of community members with lived experience.


| INTRODUCTION
Following an uneven rollout, COVID-19 vaccinations have been made available to adults in the United States since May 2021. 1 The public health benefits of vaccination are clear: vaccinated individuals are less likely to develop serious symptoms or transmit the virus. 2 Nevertheless, 21.5% of eligible Americans still had not received any doses in July 2022. 3 While some people face barriers in accessing vaccines, 4 16% of US adults consistently report that they will 'definitely not' get vaccinated, 5 a phenomenon known as vaccine hesitancy. The proportion of rural respondents who express no intention to get vaccinated is nearly twice as high. 6 To promote vaccine adoption, particularly among rural or other medically underserved populations, we must understand vaccination decisions.
Past research on vaccine hesitancy shows that reasons to delay or reject vaccines vary by disease, 7 but lessons can be drawn. Hesitancy about MMR vaccination has been associated with a general mistrust of profit-seeking pharmaceutical corporations and the perception that exposure risk for vaccine-preventable diseases is low. 8 Similarly, research has shown that parents' hesitancy towards HPV vaccination is rooted in the belief that their child's risk of infection is low since 'good' children delay sexual activity. 9 In both cases, reasons for hesitation are based on risk perceptions: non-adopters underestimate disease exposure risk and overstate vaccine risks.
Uncertainty is known to skew risk perceptions 10 and is associated with distrust in risk-reduction efforts and avoidance of medical decision-making. [11][12][13] Given the degree of scientific uncertainty inherent in an emergent public health threat like a pandemic, distrust can be anticipated. Indeed, research on COVID vaccine adoption reports that Adopters have greater trust in the system or are persuaded by others they trust. [14][15][16] Non-adopters are exposed to more misinformation 17 which is linked to concerns vaccines were under-studied or about side effects. 18,19 Regardless of associations with trust or uncertainty, many studies have found that COVID-19 vaccination intent is shaped by personal risk and concern for others. 20 Aw 21 Contemporary research in the US reports demographic dimensions as well-Adopters tend to be older, more formally educated and more liberal. 22 Decisions to adopt or reject novel vaccines are relevant for planning successful public health responses to emerging diseases.
Understanding these decisions entails not only identifying factors but also describing how they relate to decision-making. To clarify these decisions for people in our community, we interviewed rural inhabitants of Maine to collect situated accounts of how they made decisions about adopting novel vaccines 1 year into the COVID-19 pandemic.

| Research design
Qualitative approaches permit in-depth exploration of how factors contribute to health behaviors at an individual level, as participants can construct accounts in reference to what they believe is relevant. 23 We used elements of a grounded theory (GT) approach, including flexible sampling strategies informed by ongoing data collection, and the constant comparative method to ground interpretations and findings, while recognizing that data is socially constructed. 24 Our goal was not to build an inductive theory, so we modified GT, employing the framework method to structure the analysis and facilitate constant comparison. 25 To understand the spectrum of COVID-19 vaccine Adoption/Non-adoption, we sought to interview a purposive sample of people who were and were not vaccinated until reaching thematic saturation for both groups. The study was determined by the Maine Medical Center IRB to be exempt from oversight based on minimal risk to participants.

| Recruitment
The research team collaborated with community partners-Healthy We also permitted recruitment through other contacts and in surrounding counties. Some people approached for recruitment declined participation, citing fears about expressing their reasons for not vaccinating. Our strategies allowed us to involve four Nonadopters. We continued recruitment through May 2021 in an effort to recruit more Non-adopters, but we were unable to reach saturation with that group. We ended recruitment because evolving information about vaccines were changing the context of adoption.

| Analytical approach
To organize and analyze our qualitative data, we used the framework method. 25 The method utilizes a spreadsheet or 'framework' wherein analytical units (e.g., individual participants or groups) occupy rows, while categories of information or themes occupy columns. Categorical responses are compared across the framework to identify patterns. Our approach was deductive/inductive and reiterative. MK, LS and JP developed an initial framework with categories deduced from research aims and based on the guide: COVID-19 concern, reported vaccination status, vaccination intention, reasons for vaccination, vaccination concerns and evaluating information sources. Analysts independently coded transcripts, then met to discuss and revise the framework, adding several inductively derived categories: perceived COVID-19 danger to self and others, weighing risks, trust in authorities and comments on vaccine development. All transcripts were separately coded and entered into the framework table by two analysts, who checked one another's interpretations. Disagreements were discussed until consensus.
Based on prominence in the interviews, relatedness to other themes and its relevance to past vaccine research, we focused this analysis on how individuals judged the comparative risks over COVID-19 and novel vaccines.

| RESULTS
Seventeen people participated. All were White and living in rural counties; the majority were female, college-educated and politically Comparing Adopters and Non-adopters, several patterns emerge. All participants older than 60 were vaccine Adopters.
All Adopters in our sample had at least some college education, whereas Non-adopters did not. Finally, though most participants identified as politically Independent, all Democrats in our sample were Adopters.

| Weighing risks
Most respondents framed their decisions by comparing the perceived risks of COVID-19 and vaccines (see Table 2). For example, one Resolute Non-adopter used a metaphor of sky-diving to convey his risk calculation for vaccination:

| Perceived risks of COVID-19
All Adopters agreed COVID-19 was harmful to health, if not personally, then to the community ( Table 2). Many Adopters referenced morbidity risks, emphasizing the possibility of severe acute symptoms from COVID-19 and long-term impacts on health, including long COVID and hospitalization. Most Early Adopters were in high-risk groups, including four participants older than 60 and several others with comorbidities. Some Adopters identifying themselves as 'low risk' for COVID severity downplayed personal health risks but instead referenced the psychological harm of being responsible for infecting others: Seeing firsthand how it impacts a community, that was enough to want to get the COVID vaccine, because I don't want to be the person responsible for spreading it to others, or possibly causing them to die. I mean I just would never be able to live with myself after that. (Ashley) Non-adopters never referred to morbidity risks of SARS-CoV-2 infection. On the contrary, Tammy drew an analogy from her actual T A B L E 2 Quotes on weighing risks and COVID concerns.

Pseudonym Weighing Risks COVID Concern Type of Concern
Patricia "I'm certainly concerned and trying to be careful." General John "…I definitely don't want to be on a respirator."

Morbidity
Chris "…unless there was […] like 75% morbidity rate for people who actually got the vaccine as opposed to not getting the vaccine, it was irrelevant." "I was concerned enough to get vaccinated when I could."

General Morbidity
Sarah "[the vaccine] just kind of puts you down and out for a day, which is much better than the alternative-getting COVID, so…" "…I'm very careful like if I go into the grocery store, I always wear my mask, always wash my hands.

General
Mary "…when you compare that to the secondary effects of COVID for those people who survive it, I would not want to be in their place."

Morbidity
Rebecca "…the risks associated with the vaccine are minimal compared to the risks of getting COVID…" "…I have asthma and I would be in a in a pickle and probably hurting…"

Morbidity
Debbie "COVID is like the flu on steroids to me…" Morbidity Ashley "…I don't want to be the person responsible for spreading it to others, or possibly causing them to die…"

Community Mortality
Jennifer "… other than immediately dying the minute they stick it in my arm, I'm probably better off than without it." "I was really doing okay until they announced the high risk blood type. "…since it's so new, I needed to know more about it.
[…] that it had gone through established trials and that those trials were not somehow rushed." Rebecca "I am not one who believes that news is fake so I trust the institution of journalism, or at least the sources that I look to." "Initially I was concerned with the speed with which they were being rolled out, but I have been following enough to say, 'I'm comfortable with it…'" Debbie "…it's out of my hands. I'm just gonna have to trust that they're doing it right…" "It was a concern for me, I always wonder if they go through all the right steps…" "…this is a non-approved med that hasn't gone through rigorous and years' worth of testing, but to kind of read that this is a non-approved med, was like, 'Oh crap, they don't know. They don't really know.'" Melissa "…I guess I trust scientists…" Hannah "I trust that the providers aren't going to give us a vaccine that hasn't been properly studied…" "One of the biggest things was thinking that it wasn't studied or the vaccine was rushed to be put together…" Angela "I mean, it was very quickly done, but, I mean, we have to trust the science on that." "I'm certainly not anti-vaccine, [ By contrast, for Non-adopters like Samantha, known issues like blood clots were not evidence the system was working, but instead evidence other harms were possible. While some referenced known risks like anaphylaxis or blood clots, all 4 Non-adopters emphasized possibilities of the unknown, longer-term side effects (see Table 3).
By contrast, only half of the Adopters mentioned other unknown risks, mostly around women's fertility. Despite hearing these side effects, Adopter's comments suggested a lack of concern.
Several Non-adopters (David, Tammy (10) commented on this timeline without prompting (see Table 4). This And that makes me very, very uncomfortable that we have so many people pushing this on us. (Tammy, Non-adopter) The profit motives of pharmaceutical companies were also cause for distrust: …they haven't studied it. They're more worried about, 'Well, hey, let's get this out. Let's get some money. Let's do this'. I think the safety is a little bit of a concern, but I think it's a very small percentage when compared to how much medical stocks have raised. (Jacob) Jennifer (Adopter) echoed this concern, alluding to the ongoing opioid epidemic: We can't even develop non-addictive pain medicine, but we could come up with three vaccines for a pandemic? In contrast, Tammy cited changing recommendations as a reason to distrust the vaccine, which in turn convinced her to distrust doctors recommending the vaccine (see Table 4).

| Whom to trust?
The clearest division between Adopters and Non-adopters was trust in relevant authorities (see Table 4). Nearly every Adopter (10/13) justified vaccination decisions by declaring trust in science. Jennifer, Ashley and Emily used the language of faith to describe their trust in science despite doubts (see Table 4 for supporting quotes). In contrast, no Non-adopters described trusting scientific or medical authorities. Instead, they sometimes suggested trusting these authorities would lead to harm, comparing people who trust the vaccine with experimental animals.
Adopters also expressed trust in medical providers. Several described overcoming initial concerns after consulting with providers.
By contrast, Non-adopters never described physicians as trustworthy, though Jacob said he planned to discuss it with his doctor during his next visit. Mostly Non-adopters said they trusted friends and/or family: Trust is built or eroded through cumulative experience. At the time of data collection, several pharmaceutical companies, including one involved with vaccines, were successfully avoiding lawsuits for products causing harm. 37 Many drug developers are alleged to have misled authorities and doctors about the addictiveness of opioids. 38 People have good reasons to be skeptical, 39 and so it is remarkable that so many people in rural Maine and elsewhere have chosen to adopt COVID-19 vaccination. They have made that choice, by their own accounts, because they trust scientific and medical authorities. Without that trust, people rely on their own 'research' or rely on friends, family, co-workers and others they trust.
To ensure that more people vaccinate in the future, public health messages aimed to influence vaccine decisions could be coupled with efforts to make the process of drug and vaccine development more trustworthy. 40

| Limitations
Our qualitative approach does not allow us to make claims about how common the various motivations are in the population, both because of our sample (purposive and nonrepresentative) and our method of semistructured interviewing, which privileges the discovery and exploration of novel themes over the ability to quantify specific content. 41 As we did not reach saturation for Non-adopters, additional concerns are possible. Nevertheless, as noted above, previous work on vaccine hesitancy suggests our Non-adopters were not anomalous. Because recruitment was based on connections to community health groups, our sample may not represent community members who are unengaged with health care. Finally, the COVID-19 pandemic has continued to evolve since the completion of interviews, including the Delta and Omicron wave, with increasing breakthrough cases and recommendations for additional booster vaccinations, thus all results should be understood in a temporal context.

| CONCLUSION
Many respondents framed COVID vaccination decisions around comparing risks between the disease and the vaccine. Associating greater risk with COVID-19 diminishes the relevance of risks from vaccines, whereas skepticism about risks from COVID-19 heightens their relevance. Our novel findings on how people think differently about COVID-19 morbidity risk as opposed to mortality risk could be explored in other contexts around the world. These insights could be used to address vaccine hesitancy in the future.