COVID-19 Vaccine Acceptance among People who Smoke in Rural Southwest Georgia: Perspectives and Influencing Factors

Abstract

Background:

The COVID-19 vaccine is a critical tool in reducing COVID-19 related morbidity and mortality. Unfortunately, vaccine hesitancy is an ongoing public health challenge, especially in certain geographic areas and sub-populations. This study assessed factors associated with COVID-19 vaccine uptake and hesitancy among individuals who smoke in rural communities in southwest Georgia, one of the first COVID-19 “hot spots” in the U.S.

Methods:

We conducted qualitative interviews (n=23) using a semi-structured interview guide, informed by the Integrated Behavioral Model (IBM), that assessed vaccine-related behavior, intention to be vaccinated, perceived risk, social norms, attitudes, and environmental barriers and facilitators influencing vaccine hesitance and uptake.

Results:

Participants were 46 years old on average (SD=9.9; range: 25–63), 82.6% female, 60.9% Black, and 43.5% with an annual income <$25,000. Slightly over half (56.5%) had received at least one dose of the vaccine, 17.4% planned to, and 26.1% were unsure or did not plan to. Generally, participants acknowledged that those who smoke were at risk for worse COVID-19 related outcomes. Positive attitudes toward vaccination included reduced stress or concern about contracting and/or spreading the virus, less worry about becoming severely ill and/or dying from the virus, and reduced stress about socializing and inviting people over. Negative attitudes commonly focused on the speed of vaccine development and unknown long-term side effects, but also included distrust of government, fear of getting the virus from the vaccine, fear of needles, conspiracy theories, and dislike of mandates. Normative influences, most often from family members, were especially salient in the decision to get the vaccine, as was “doing research.”

Conclusions:

Current results uncovered several salient factors aligning with IBM that should be considered when addressing vaccine uptake and hesitancy among priority populations, particularly those in rural areas who smoke, and improving vaccination outreach efforts.

INTRODUCTION

COVID-19 was a leading cause of morbidity and mortality in Georgia and the US (Shiels et al., 2022). The introduction of COVID-19 vaccines was a major turning point in the pandemic. Despite strong evidence indicating the effectiveness of vaccines in protecting against severe disease, hospitalization, and death (Liu et al., 2021), COVID-19 vaccine hesitancy is disproportionately high among groups with greater prevalence of severe outcomes, including those who smoke, women, African Americans, people living in rural areas, and those of lower socio-economic status (Krebs et al., 2021; Kricorian et al., 2022; Malik et al., 2020; Moore et al., 2021). Thus, assessing and intervening on determinants of vaccine uptake and hesitancy are ongoing public health priorities (Chevallier et al., 2021; Malik et al., 2020).

Reasons for hesitancy may be specific to or vary in salience by sub-populations. For example, a recent review of qualitative studies on vaccine hesitancy among racial and ethnic minority populations identified three main themes, including institutional mistrust, lack of confidence in the vaccine and development process, and lack of reliable information or messengers (Hess et al., 2022; Shearn & Krockow, 2023). Studies among rural residents show vaccine hesitancy is associated with safety concerns, perceived lack of necessity (Kohut et al., 2023; Patterson et al., 2022), and concern about infringement on personal liberties (Patterson et al., 2022). Studies by Bogart et al. (2021), Kricorian et al. (2022), and Reichelt et al. (2023) highlight how healthcare mistrust differed between rural and urban communities during COVID-19. In rural areas, mistrust was largely driven by limited healthcare access, political beliefs, and misinformation, while urban mistrust, particularly among Black Americans, was more likely to be rooted in systemic racism and historical injustices. Trusted local figures may help address rural skepticism, whereas urban communities would benefit from longer term strategies that confront structural inequities, in addition to the engagement of trusted leaders. Effective public health responses must tailor trust-building efforts to each community’s unique context.

Research on vaccine hesitancy among people who smoke has documented relatively high levels of concern, particularly about the speed of development, possible long-term side effects, general mistrust in vaccines, and a preference for natural immunity (Cruvinel et al., 2022; Jackson et al., 2021; Krebs et al., 2021). Several studies suggest that people who smoke are at significant risk for poor outcomes as a result of COVID-19 infection (Alqahtani et al., 2020; Baker et al., 2022; Benowitz et al., 2022; Reddy et al., 2021; Zhang et al., 2021), therefore vaccination could be a critical prevention tool for this population.

The current study used a qualitative approach to better understand COVID-19 vaccine uptake and hesitancy among rural residents who smoke, in southwest county that was particularly impacted early in the pandemic (spring of 2020), making national news and experiencing high mortality rates, particularly among Black residents (Chastain et al., 2022; Racine et al., 2022; Shah et al., 2020). This study was guided by the Integrated Behavioral Model (IBM) which aligns conceptually with WHO’s widely used 3Cs (confidence, complacency and convenience) (MacDonald, 2015; SAGE Working Group) and the expanded 5Cs (confidence, constraints, complacency, calculation, and collective responsibility) models of vaccine hesitancy (Betsch et al., 2018), and CDC’s Behavioral and Social Determinants of Vaccination Framework (Health et al., 2021). IBM hypothesizes specific associations among constructs, explicitly includes normative influences on behavior, and has a large evidence base documenting its utility for a range of health behaviors (Alber et al., 2021; Cohen & Head, 2014; Rodriguez et al., 2020). While IBM has been used to examine vaccine hesitancy related to COVID-19 in several quantitative studies (Hagger & Hamilton, 2022; Romate et al., 2022; Wicaksana et al., 2023), very few qualitative studies have used IBM to provide a theory-based understanding of COVID-19 vaccine uptake and hesitancy in specific contexts. Using a robust behavioral science framework and qualitative methods is critical to enhance our understanding of the drivers of vaccination behaviors across populations and contexts. Current findings contribute specifically to the knowledge base on COVID-19 vaccine uptake and hesitancy among smokers, particularly those living in rural areas, and have implications for theory-based efforts to increase vaccination rates in these communities.

METHODS

Study Participants

We conducted qualitative interviews with people who smoke (N=23) in southwest Georgia, to assess their willingness to receive the COVID-19 vaccine and factors associated with their attitudes towards vaccination. Participants were recruited from April 2021 to October 2021 through a Community Advisory Board (CAB) and other community partners, by distributing fliers, and Facebook ads targeting southwest Georgia. Eligibility criteria included: 18 years of age and older, smoked at least one cigarette in the past 30 days, spoke and understood English, and lived in rural southwest Georgia. Findings on the influence of COVID-19 on smoking behavior are reported elsewhere (Kegler et al., 2023).

Data Collection Procedures

Participants were screened for eligibility and then consented verbally. The interviews were conducted via telephone by four master’s level research staff experienced in qualitative data collection. Interviews were audio recorded and professionally transcribed. Interviews took an average of 32 minutes, and participants received a $40 gift card for their participation. The Emory University Institutional Review Board approved this research.

The research team developed the IBM-informed qualitative interview guide, which assessed: knowledge; COVID-19 vaccination history; perceived risks, benefits, and social norms; intention to get vaccinated; and environmental constraints/barriers.

Closed-ended survey questions were also administered to assess demographics, key smoking-related characteristics, and COVID-19 vaccination status. We classified each participant by their county of residence based on the National Center for Health Statistics urban-rural continuum designation (1= large central metro, 2=large fringe metro, 3=medium metro, 4=small metro, 5=micropolitan, 6=noncore) (Ingram & Franco, 2014).

Data Analysis

The codebook was developed by interviewers familiar with the major topics covered in the interview guide. After coding three transcripts collaboratively and refining the codebook to enhance understanding and consistent coding, two coders coded each additional transcript independently, with discrepancies resolved through consensus. NVivo 12 was used for data management, retrieval, and analysis. Reports were generated for each major code (e.g., positive attitudes). One analyst then identified themes within each broad topic and placed them in a matrix with specific themes on the Y-axis, participant IDs on the X-axis, and the cells indicating whether the theme was present for any given participant. Themes were reviewed and confirmed against the code-specific reports by a second analyst, and against the full vaccine-related segment of the transcripts by a third analyst. Matrices were used to identify a particular theme’s strength, to look for patterns by vaccination status, and also allowed for an audit trail that strengthens the trustworthiness of the findings (Miles et al., 2014). Survey-based items were summarized using descriptive analysis conducted in SPSS.

RESULTS

Study Participants

All participants (N=23) were residents of southwest Georgia. Average participant age was 46 years (SD=9.9; range: 25 to 63) (Table 1). The majority were female (82.6%), identified as Black (60.9%), and were employed full or part-time (60.9%). Among the sample, 43.5% reported an annual household income of less than $25,000, and 52.2% reported some college or other post-secondary education. The majority reported smoking daily (73.9%). Slightly over half of participants had received at least one dose of the COVID-19 vaccine (56.5%), 17.4% were planning to get the vaccine, and 26.1% were either unsure or did not plan to get vaccinated. Table 2 describes each participant, including rurality of county of residence, political affiliation, vaccine status, race, gender, age, and education level ordered by vaccination status.

Table 1.

Demographic Characteristics of Study Participants

Demographic Characteristic	N or Mean	% or SD
Gender, N, %
Male	4	17.4
Female	19	82.6
Age, Mean (SD)	46	(9.9)
Marital Status, N, %
Married/living with someone	10	43.5
Divorced/separated	3	13.0
Single	10	43.5
Race, N, %
White	7	30.4
Black/African American	14	60.9
Asian/Pacific Islander/Native Hawaiian	1	4.3
Multi-Racial/Mixed	1	4.3
Education, N, %
High school graduate or GED	11	47.8
Some college	6	26.1
College graduate or higher	6	26.1
Employment, N, %
Full or part-time	14	60.9
Homemaker	2	8.7
Retired	1	4.3
Unable to work or disabled	6	26.1
Annual Household Income, N, %
Less than $25,000	10	43.5
$25,000 to $50,000	9	39.1
$50,000 or more	2	8.7
Smoking Status, N, %
Everyday	17	73.9
Some days	6	26.1
Everyday Smokers
No. of cigarettes per day, Mean (SD)	12.6	(6.1)
Past-year Quit Attempts, Mean (SD)	1.84	(1.9)
Vaccination Status, N, %
Vaccinated (1 or more doses)	13	56.5
Planning to be vaccinated	4	17.4
Unsure/does not plan to be vaccinated	6	26.1

Note: missing data excluded from denominators

Table 2.

Description of Study Participants Ordered by Vaccination Status (n=23, all Southwest GA)

Vaccine Status	NCHS County Code	Political Affiliation	Smoking Status	Gender	Race	Age	Education
Definitely No	6	Not engaged	Everyday	Male	Black	44	High school
Definitely No	4	Not engaged	Everyday	Female	White	46	Some college
Unsure leaning towards No	4	Prefer not to answer	Everyday	Female	White	25	Some college
Unsure leaning towards No	4	Conservative	Some days	Female	White	38	Some college
Unsure leaning towards No	5	Not engaged	Everyday	Female	White	32	High school
Unsure leaning towards No	5	Not engaged	Everyday	Female	Multi- racial	29	High school
Unsure leaning towards Yes	4	Prefer not to answer	Everyday	Male	White	52	College
Plan to	4	Liberal	Everyday	Female	Black	48	College
Plan to	4	Liberal	Everyday	Female	Black	49	High school
Plan to	5	Libertarian	Everyday	Female	White	52	High school
Yes, 1st dose received, 2nd dose scheduled	5	Liberal	Everyday	Female	Black	63	High school
Yes	4	Liberal	Some days	Female	Black	32	Some college
Yes both doses	4	Conservative	Everyday	Female	Black	60	High school
Yes both	4	Prefer not to	Some	Female	Black	*	Some
doses		answer	days				college
Yes both doses	5	Not engaged	Everyday	Female	Black	43	High school
Yes both doses	6	Libertarian	Everyday	Female	White	53	Some college
Yes both doses	4	Liberal	Everyday	Female	Black	57	College
Yes both doses	4	Liberal	Some days	Female	Black	53	College
Yes both doses	4	Liberal	Some days	Female	Black	44	College
Yes both doses	4	Liberal	Everyday	Male	Black	48	High school
Yes both doses	4	Liberal	Everyday	Male	Black	47	High school
Yes both doses and booster	5	Liberal	Some days	Female	Black	53	High school
Yes both doses	4	Liberal	Everyday	Female	AI/AN	41	College

4=Small metro, 5=micropolitan, 6=Noncore

^*=missing

Qualitative findings are organized by IBM construct (Table 4): experiential attitudes (positive and negative emotions), instrumental attitudes (positive and negative beliefs), injunctive norms (pro and anti-vaccination expectations from social network members), descriptive norms, and other factors (perceived risk).

Table 4.

Themes by Major Integrative Behavioral Model Constructs

Construct	Positive/Supportive of Vaccination	Negative/Against Vaccination
Attitudes- Experiential (feelings about the vaccine)	Reduced stress about contacting/spreading the virus Less worry about becoming severely ill and/or dying from the virus Reduced stress about socializing and inviting people over	Uncertainty and concern about speed of vaccine development Uncertainty and concern about long- term side effects Distrust of government and its leaders Fear of getting the virus from the vaccine Fear of needles Fears and concerns stemming from conspiracy theories (e.g., implants for tracking) Dislike of mandates
Attitudes- Instrumental (beliefs about vaccine outcomes)	Decreased chance of getting the virus Decreased severity of the virus if infected Contribute to slowing the spread of the virus Reduce hospitalizations and increase capacity of health care system to address other needs	Vaccine was ineffective Vaccine was not necessary due to good health or preventive behaviors Vaccine made people sick (e.g., short-term side effects)
Norms- Injunctive (behavioral expectations from social networks)	Family members modeled getting the vaccine Family members persuaded Family members combined persuasion with sharing their own experience The need to protect older or younger family member Friends encouraged vaccine with persuasive arguments Doctor encouraged the vaccine President of the U.S. modeled getting the vaccine	Family members discouraged vaccination by sharing beliefs (see above) Friends discouraged them by sharing beliefs (see above)
Norms- Descriptive (observed behavior of various groups)	Older people with underlying health conditions Black/African American community Workers mandated to get the vaccine People who worked with children prior to children being eligible	Young people Very religious people Black/African American community People not mandated to get the vaccine Some medical personnel
Environmental Barriers and Facilitators	Ease of access to the vaccine, doctor’s offices and drive-thru locations	Insurance card required Too expensive Lack of transportation Difficult for homebound persons

Experiential Attitudes (feelings about the vaccine)

Positive Feelings about the Vaccine.

We asked participants about the good things that did or could result from the vaccine. Less stress about contracting the disease was a strong theme, reported by half of the participants. Participants spoke about it in terms of less worry about becoming severely ill or even dying: “I got a chance of living, or there’s a chance of dying, so I would want to take the vaccine […] I don’t have to worry about, you know, I’ve got it, so that’s a good thing about the vaccination” (Black/female/60/fully vaccinated). Participants also spoke about reduced stress associated with potentially spreading the virus, often in the context of spreading the virus to family members: “Less stress about COVID itself. Being one of the participants to try to help slow the spread. But not having it feel that I’m going to go out to the store somewhere and bring it back to my mama” (Black/female/57/fully vaccinated). Relatedly, many participants talked about how vaccination would reduce stress related to socializing and inviting people over to their homes. One said, “First of all, I’ve gone to relax a little bit more about it; I don’t fear it, I was freaking out, […]I can see more people. I don’t freak out if somebody comes in my house, like I was before, I didn’t want nobody coming inside the house” (Black/female/53/fully vaccinated).

Negative Feelings about the Vaccine.

Participants were asked about any downsides of getting the vaccine, those who had gotten the vaccine were asked if they were ever hesitant about getting it; and those not planning to get it were asked what made them unsure or unwilling. Many participants who expressed uncertainty about the vaccine focused on the speed of development and possible long-term side effects: “Just because they came out with it so quickly, and I don’t understand how they were able to just come up with something just so quickly[…] I just don’t feel like there’s been enough research done on it to feel safe enough about getting it” (White/female/32/unsure leaning towards no).

Others had stronger views on the possible side effects, “Sometimes seeing the negativity that’s on TV, you know, with the concerns and just seeing that some people have taken the vaccine and may have had side effects that were deadly. So seeing those things, sometimes it doesn’t make it easier” (Black/female/48/planning to get vaccine). A couple of participants were against mandates: “It was my choice but I would leave a job if they tried to push me to do anything like that. That is somebody’s right, not somebody can just tell them it’s mandatory. People have to have the right to choose” (AI/AN/female/41/vaccinated).

Instrumental Attitudes (beliefs about vaccine outcomes) Positive Beliefs about Vaccine Outcomes.

Instrumental attitudes covered the same general topics as those categorized as experiential attitudes, but views were framed as opinions or facts rather than emotion-based (e.g., fear, stress). For example, some participants shared how getting the vaccine would decrease chances of getting the virus and/or decrease its severity, as opposed to personal fear of the sickness: “The main thing is that [if] you do contract the COVID-19, obviously, you know, not to get as sick, that’s one good thing” (White/female/38/unsure). Similarly, a few spoke about how obtaining the vaccine would contribute to slowing the spread of COVID-19 and/or reduce hospitalizations and increase capacity to address other health issues: “I would also say it was hospitals were getting full; there was nowhere close around that you could go, for sick people” (Black/female/57/fully vaccinated).

Negative Beliefs about Vaccine Outcomes.

Negative instrumental (as opposed to more emotion-based) attitudes included believing the vaccine was ineffective, it had negative side effects, it transmitted COVID-19, that it was not needed, and conspiracy beliefs about the purpose of the vaccine. More than half of participants noted adverse side effects as a barrier to being vaccinated. Participants reported learning of side effects from various sources, including individuals that were already vaccinated, the news media, and social media: “I know people that have taken the vaccine and the only thing I can hear from those people are: ‘After I got this first shot. And then after the second shot I was sicker than after I got the first shot.’ So basically, I don’t see no good side effects to that” (Black/male/44/definitely not getting vaccine). A few participants stated they didn’t need the vaccine due to protective behaviors (e.g., limiting social activities) or because of a history of good health: “Because I don’t hardly ever get sick, so I don’t see the point in it, to be perfectly honest.” (Multi-racial/female/29/unsure leaning toward no).

Injunctive Norms (behavioral expectations from social networks) Pro-Vaccine Expectations from Social Network Members.

When participants were asked to think about who encouraged them to get the vaccine, the majority reported family members. Family members encouraged through modeling the behavior which allowed participants to observe the relatively mild side effects: “My mom, from her actually getting the vaccine and seeing her, about the only thing that she’s had is some soreness in her arm at the injection site, she’s had some soreness” (White/male/52/unsure leaning toward no). Family members also used persuasive tactics, arguing that the vaccine was needed due to an underlying health condition or because the participant smoked, for example: “My mother and my nieces have all been encouraging me, and my daughter, she’s been encouraging me lately to go get it. […] They’re telling me that because I do smoke cigarettes, that it would be in my best interest to get the vaccination to help prevent me from getting COVID, and it would keep me safer in the long run” (White female/52/plans to get vaccine.) Other family members shared their own experience combined with persuasive tactics: “My cousin, she got it first, she let me know that she didn’t get sick. She told me, you know, you want to live a long time for your kids and we had an emotional session over the phone. And I said, ‘Yes ma’am,’ and I made my appointment the following day” (Black/female/32/fully vaccinated).

Protecting family members was another theme related to norms, either protecting an older family member or protecting oneself from younger members of the family who were not yet vaccinated. A participant explained, “I provide care for my elderly mother, and when she decided first that she was tired of stressing about the COVID, and that she wanted to take the vaccine. And so with me being her caregiver, I qualified to take it too. And, of course, if she was willing to take it, I humbled myself and took it too, for her sake more than mine” (Black/female/57/vaccinated).

Friends and doctors were also viewed as encouraging the vaccine, for example: “For my doctor to tell me, okay, this vaccine is better for you, […] Because he told me to do the research myself first and then come to him with any concerns and questions” (White/female/52/plans to get vaccine). Another shared, “My race, it was hitting us pretty hard. So, we [co-workers, my husband, my siblings, my friends] had these conversations about that, and how we need to do anything we can to protect ourselves” (Black/female/53/vaccinated).

Anti-Vaccine Expectations from Social Network Members.

When asked about social influences that discouraged vaccination, participants most commonly reported that family members discouraged them. Although less common, friends were also described as discouraging the vaccine. Almost half stated that no one personally discouraged them from getting vaccinated. One participant shared that she didn’t know anyone who had gotten the vaccine and that, “My fiancé, sister-in-law, mother-in-law, father-in-law, grandparents [are against it] … They’re just skeptical about the vaccine. They don’t know what it is” (White/female/25/unsure leaning toward no). When asked about what his friends were saying, one participant who had decided not to get the vaccine responded, “What’s the point in getting it, if you can catch the virus anyway? It defeats the purpose.” (Black/male/44/definitely not getting vaccine). Another person who had gotten vaccinated, described how his friends discouraged him through conspiracy theories: “A couple of people were just saying they didn’t want the government marking them and all that. It’s a government thing and all of us are going to fall sick and the government is going to know where you at and all that craziness” (Black/male/47/vaccinated).

Environmental Constraints (Barriers and Facilitators) for Vaccination.

The vast majority of participants, both vaccinated and unvaccinated, acknowledged how easy it was to get the vaccine, noting the various vaccination sites, including the doctor’s office and drive-thru locations: “I know I can get it at my primary doctor, the pharmacist I go to, I can get it there, so yes, it is very easy to do and to get” (Black/female/ 48/plans to get vaccine).

Other Factors

Perceived Risk for COVID-19 Among those who Smoke.

All participants were asked what they knew about the COVID-19 virus and smoking. The most common response, given by those vaccinated and unvaccinated, was that those who smoke were at increased risk for worse outcomes from COVID-19: “Because it’s already a problem with us smoking and then you’ve got this virus attacking the lungs as well. So, it’s like a double whammy on the lungs area, then the breathing, the whole thing” (Black/female/49/plans to get vaccine). A participant who was disinclined to get the vaccine explained: “Well, not that I know any facts, I just heard that if I smoke or get it, that it kind of takes a real harder toll on them, because it is a respiratory infection that attacks your lungs, and with smoking you’re damaging your lungs, and so you’re getting sick on top of already having weak lungs” (White/female/32/unsure/leaning towards no).

Some participants expressed a belief that those who smoke are more susceptible to getting COVID due to compromised lungs and/or immune systems. Others shared that they did not know much about COVID and smoking, and a few described that the correlation appeared to be low or nonexistent: “The only thing I’ve really heard about it related to anything was, when it first came out, it was infants and elderly, and then the duration of it, it seemed to have affected overweight people more than… had a harder time getting rid of it than anything” (White/female/46/definitely not getting vaccine). One participant recalled early reports that people who smoked may be less vulnerable. When asked what she knew about COVID-19 and smoking, she commented, “I did hear from the beginning that they did have a low correlation between people that smoked and people [non-smokers], they got coronavirus” (Black/female/57/fully vaccinated). She later noted that those who smoke were, “Not less at risk, they just wouldn’t find as many people, I guess you would say that were smokers that ended up with [COVID-19].”

A few participants shared worries and concerns about smoking and COVID related to their own health and implications for their families. As one participant explained, “I was just thinking how deadly it could be for a person as myself to smoke and who could have respiratory issues due to smoking, and so I just felt like the risk is higher, and just knowing that, that’s fearful. And knowing that, okay, this is something I really need to break this habit, because it can really be detrimental to me, because it could cost my life. And then if that happens, then I’m leaving my children and my husband, and it’s just taking my own life by doing it” (Black/female/48/plans to get vaccine).

Discussion

This qualitative study used an IBM-driven perspective to explore COVID-19 vaccine uptake and hesitancy among people who smoke, living in the primarily rural areas of southwest Georgia. While this study was not designed to produce generalizable results, the findings build on to other studies that examine rural communities, including insight into how rural populations may be influenced. Our study sample reported similar concerns about the vaccines as did participants in previous research with rural populations (Kricorian et al., 2022; Hess et al., 2022; Patterson et al., 2022; Kohut et al., 2023; King et al., 2021; Hubach et al., 2022).The main issues cited by both vaccinated and hesitant or unvaccinated participants were: concern over the speed of vaccine development and safety, concern over side effects, including long-term side effects, and lack of personal knowledge about the vaccine (e.g. its contents, how it works, how it was developed). Additionally, some participants – mostly from the hesitant or unvaccinated groups – reported significant distrust about the accuracy of the information they had received as well as distrust in the “messengers,” including government officials. A small minority also mentioned conspiracy theories as a reason to reject vaccination. Many of these same themes are seen in other populations (Krebs et al., 2021; Shearn & Krockow, 2023; King et al., 2021; Gogoi et al., 2022; McElfish et al., 2021; Latkin et al., 2022; Simione et al., 2021), underscoring some generalizability.

One key contribution of this study is the purposeful examination of normative influences, which yielded a deeper understanding of how family members, in particular, influence vaccine uptake or hesitancy. While several studies have noted the role of personal social networks, family and friends (Hess et al., 2022; Hubach et al., 2022; Robinson et al., 2022), the IBM focuses explicitly on injunctive and descriptive norms, which may be more helpful than a general “social influence” perspective. Our study documented that social norms, particularly expectations from family members, were powerful determinants, especially for vaccine uptake and hesitancy. Active encouragement from family members, as well as role modeling and a desire to protect family members from the virus, were common among vaccinated participants and discouragement from family members was mentioned by some of the unvaccinated study participants.

Another notable finding is that, unlike other research (Krebs et al., 2021; Kricorian et al., 2022; Malik et al., 2020; Moore et al., 2021; Willis et al., 2021), we found there was a high level of COVID-19 vaccine acceptance among persons identifying as Black. Almost all Black participants planned to be vaccinated or were already vaccinated, while White rural residents were more likely to be against the vaccine. Perhaps this is because our participants were at higher risk of severe outcomes due to age (average of 46) and smoking status (King et al., 2021; Malik et al., 2020; Willis et al., 2021), or because they were residents of one of the early pandemic hot spots and had personal experience with the disproportionately negative outcomes by race (Chastain et al., 2022; Racine et al., 2022; Shah et al., 2020).

Environmental constraints documented in this study align with the convenience domain of the 3Cs or the constraints construct in the more recent 5Cs model (Betsch et al., 2018; SAGE Working Group). Particularly relevant to rural populations, we found that the vast majority of participants reported no structural barriers to accessing the vaccine, citing adequate geographic coverage, weekend availability, and the absence of out-of-pocket costs. As rural areas have traditionally experienced shortages in healthcare resources (Kegler et al., 2023), it is striking to find that the vaccine rollout was so effective in this area. Notably, this study was conducted at a time when the federal, state and local governments were implementing a major national rollout of the vaccine which appears to have been successful in removing logistical barriers, at least for those participating in our study. More investigation into the planning and implementation of the rollout in southwest Georgia could result in very valuable information for other rural areas that struggled with logistics and intervention delivery.

Although not an explicit domain within IBM but possibly influencing experiential attitudes or salience of the behavior, we examined risk perceptions specific to smoking, expecting this to be particularly relevant among a population of those who smoke living in an area severely impacted by the pandemic. This fits within the “complacency” domain in the 3Cs and 5Cs models, and theoretically, should have reduced complacency (Betsch et al., 2018; MacDonald, 2015; SAGE Working Group). Although participants in the study demonstrated a basic awareness of the risks associated with COVID-19 and smoking, this knowledge alone did not appear to be sufficient for some participants to overcome their hesitation to seek vaccination against COVID-19. However, findings indicated that general risk and concern about COVID-19, unrelated to smoking per se, did appear to be a major motivator for the vaccine.

Limitations

Some study limitations should be considered in interpreting results. First, our sample was drawn from an area hit hard by the pandemic with a strong public health and health care sector response (e.g., daily briefings by the local hospital, widespread availability of the vaccine); thus, current findings may differ from the experience of other rural areas within the southeast or U.S. in general. Second, findings may have been impacted by selection bias, as those with favorable views toward the vaccine or who were already vaccinated may have been more likely to participate in this type of study. A study focused solely on Black or rural people who smoke, who had not been vaccinated may have increased the salience of specific themes such as mistrust or conspiracy theories. We did, however, identify themes consistent with other studies, suggesting that persons who smoke vs. do not smoke are influenced by similar vaccination-related determinants.

Implications

Current findings reflect results from prior studies in rural populations (Hess et al., 2022; Hubach et al., 2022; King et al., 2021; Kohut et al., 2023; Kricorian et al., 2022; Patterson et al., 2022) and provide additional insights regarding the key role of social influences, information seeking and sources, and certain rural sub-groups (e.g., Black women) who may be less resistant to vaccine uptake. These advances to the literature underscore the utility of IBM in understanding influences that promote or inhibit vaccine uptake in the context of COVID-19. Injunctive norms, specific to family expectations, was particularly salient in this rural population and could be targeted through social network interventions. The crucial role of social influences, alongside the accessibility of the COVID-19 vaccine reported in this study, underscore key opportunities to leverage in socio-structural interventions to promote vaccination. Our study showed the role of distrust, suggesting a clear need to provide credible information through accessible channels (e.g., internet) regarding the risks of COVID-19 and the pros and cons of vaccination that the lay public can find, understand, and trust. Additionally, findings indicated some differences in vaccination-related attitudes and behaviors within the sample (e.g., by race and political affiliation), potentially suggesting the need for different communication and outreach strategies. Future research using the IBM could replicate the formative research described here in a range of contexts, and then develop and test interventions that target attitudes, norms (especially within family networks), and environmental conditions.