“In the beginning, I said I wouldn’t get it.”: In-depth Qualitative Interviews to Understand Vaccine Hesitancy, Acceptance, and Decision-Making in Remote Alaska between November 2020 and July 2021

Abstract Background Despite leading national rates early in the pandemic, COVID-19 vaccine coverage in Alaska currently ranks 26th nationwide. Prevailing literature primarily reports urban or aggregated data. Here instead, we further characterize the complex decision-making around the COVID-19 vaccine based on in-depth interviews with Alaskans living off the road system. Methods We conducted 38 semi-structured in-depth interviews by phone with remote Alaska residents. Interviewees were survey respondents who had self-selected for a follow-up interview, and were predominately Indigenous, female, with post-secondary education. Interviews occurred in February and July 2021, after emergency use COVID-19 vaccine approval. Results Of 38 interviewees, 16 (42%) were “low intention” or “deliberating” vaccine acceptance based on their survey responses. Of these, 13 (81% of low-intention/deliberating) got vaccinated between the survey and follow-up interview timeframes. Vaccinated interviewees were motivated by individual-level perceptions of benefits (n = 18, 82%), protecting others (n = 6, 27%), and current or potential requirements (n = 7, 32%). Over half (n = 22, 58%) had vaccine-related concerns, including 13 (46%) of those vaccinated. Concerns primarily pertained to safety (n = 18, 47%), especially potential side effects (n = 11, 29%). Interviewees reported using multiple sources to make their decision, including media (n = 18, 49%) and interpersonal interactions (n = 16, 42%). Confidence among vaccinated/high-intention interviewees was attributed to trusting the source and/or information (n = 14, 44%), learning from others (n = 9, 28%), and personal experiences (n = 8, 25%). Scientific knowledge does not appear to have been a dominant factor for decision-making. Unvaccinated/low-intention interviewees (n = 5) desired more time and information. Conclusions This paper illustrates how vaccine hesitancy and acceptance are dynamic decisions that are influenced by complex processes involving knowledge circulation and reception. These results show that even those who respond that they will “definitely not” get vaccinated may change their minds at some future point. Further, vaccinated individuals may still have vaccine-related concerns. These findings indicate that building vaccine confidence involves a combination of consistent messages disseminated through a variety of media, as well as interpersonal interactions and observations. Trusting the source and/or understanding the information, as well as having a sense of agency appears to be important to interviewee decision-making, regardless of vaccination status and intention.