Socio-economic determinants and reasons for persistent vaccine hesitancy: A mixed-methods study in the predominantly vaccinated population of Chikkaballapur, Karnataka, India

In low- and middle-income countries (LMICs), despite the availability of effective vaccines, challenges persist in achieving adequate vaccination rates due to inequitable access and vaccine hesitancy. The objective of this study was to explore the demand and supply-side determinants of vaccine hesitancy in a high COVID-19 vaccination coverage district and contribute to the limited evidence on predictors of persistent hesitancy, particularly in rural India. On the demand side, using the 5Cs framework, we explore socio-economic and behavioral characteristics and self-reported reasons for hesitancy on the basis of a quantitative survey across 1469 households in Chikkaballapur district. On the supply side, we qualitatively assess health system challenges in tackling vaccine hesitancy through key informant interviews with various stakeholders involved in the planning and execution of the COVID-19 vaccination program. The quantitative survey reveals that socioeconomic factors like education and employment positively affect intent for future vaccine uptake and fear of injections was a primary reason for hesitancy in unvaccinated (unvaccinated) individuals. Other reasons included lack of confidence in the vaccine and its effects, complacency about severity of COVID-19, longer travel time and higher costs associated with vaccines, and weaker perception of having received accurate information about the vaccines. We find that belief in the government, social workers, community health workers, and religious and community leaders as trusted sources of information positively influences both likelihood of being unvaccinated as well as acceptance of future vaccines. Our qualitative interviews explored through KIIs with medical practitioners and local health officials found socioeconomic characteristics, misinformation, fear of mandatory immunization, adverse health effects and distance from nearest vaccination center to be the primary determinants of vaccine hesitancy in the district. Our findings have important policy implications in addressing health inequities, particularly in rural regions of LMICs, and can help inform vaccine campaigns in the future.