“In the beginning, I said I wouldn't get it.”: Hesitant adoption of the COVID-19 vaccine in remote Alaska between November 2020 and 2021

Achieving sufficient COVID-19 vaccination coverage has been hindered in many areas by vaccine hesitancy. Many studies based on large survey samples have characterized vaccine refusal, but there are fewer in-depth qualitative studies that explore hesitant adoption: the middle-ground between vaccine acceptance and refusal, and how individuals may move across this continuum depending on their lived experience. For this paper, we use the narratives of 25 adults living in off-road, predominately Alaska Native communities to describe the complex decision-making processes undertaken by ‘hesitant adopters’, defined in our study as those who completed their initial COVID-19 series despite reporting hesitancy. Interviewees' stories help illustrate how hesitant adopters' decision-making processes involved making sense of information through interactions with trusted individuals, lived experiences, observations, emotions, and personal motivations. For the majority of these hesitant adopters' (n = 20, 80%) interpersonal interactions were key in helping to make the decision to get vaccinated. Over half of the interviewees (n = 14, 56%) described how conversations with individuals they trusted, including healthcare providers, family, friends, and interactions through their professional network made them feel safe. One third of the hesitant adopters (n = 7, 28%) attributed their decision to get vaccinated based on the influence of Alaska Native Elders including their knowledge, personal experiences, as well as being motivated by the desire to protect them. Independent research was also important to about a quarter of hesitant adopters (n = 6, 24%), and for these interviewees it was the process of gathering information on their own and learning from others, especially healthcare providers who could answer their questions and alleviate their concerns. This paper illustrates the temporality of vaccine decision-making: vaccine acceptance for those who are hesitant may be an ongoing process that is influenced by personal experience, relationships, and context. •Understanding hesitant adoption provides insights into increasing vaccine acceptance•In remote Alaska, Elders may influence the decisions community members make•Images and conversations reinforced narratives of safety and efficacy•Agency in information-seeking increased vaccine confidence