The COVID-19 pandemic posed unprecedented challenges to global healthcare systems and communities. The rapid development and distribution of safe and effective vaccines became crucial tools in controlling the spread of the virus¹. However, vaccine hesitancy during the COVID-19 pandemic resulted in reduced vaccine uptake in certain settings. COVID-19 vaccines significantly reduced disease severity, hospitalizations, and deaths, but vaccine hesitancy remains a persistent challenge^2,3.

Vaccine hesitancy encompasses both delayed and outright refusal of vaccination that manifests differently across locations and social contexts⁴. Individuals’ motivations for vaccination, shaped by beliefs and attitudes towards health, vary widely⁵. Evaluating the risk-benefit perspective requires careful consideration of perceived risks derived from information, such as that circulating through public media and social channels, including concerns about vaccine side effects and exposure to anti-vaccination narratives⁶. Personal experiences such as financial hardship, political affiliations and having chronic medical conditions also contribute to this assessment^7,8. Importantly, vaccine hesitancy is shaped not only by individual factors but also by household dynamics and the socio-cultural context of communities^9,10. While an individual’s general opposition to vaccines may increase hesitancy towards COVID-19 vaccines specifically, new vaccines have the potential to introduce unique beliefs about hesitancy that warrant thorough investigation¹¹.

Various conceptual frameworks for identifying possible factors associated with vaccine hesitancy elucidate the diverse components influencing health behavior decision-making, including the Health Belief Model (HBM)¹², theory of planned behavior¹³, Social-Ecological Model¹⁴, 5As Framework (Access, Affordability, Awareness, Acceptance, and Activation Framework)¹⁵, COM-B Model (Capability, Opportunity, Motivation, and Behavior Model)¹⁶, Three Cs Model (Confidence, Complacency, and Convenience Model)¹⁷, and the 5 C psychological antecedents (confidence, constraints, complacency, calculation, and collective responsibility)¹⁸. These frameworks highlight the complexity of vaccine hesitancy, encompassing the interplay between psychological, social, cultural, and contextual factors^2,13,19. For instance, the socio-ecological model was used to examine factors influencing community engagement for general vaccination in India, identifying both enablers and barriers across individual, community, organizational, and policy levels. While supportive policies and social mobilization promoted community engagement, challenges such as limited formal strategies, power imbalances, and insufficient institutional support hindered progress²⁰. In Bangladesh, researchers employed the HBM, the Theory of Planned Behaviour, and the 5 C framework of psychological antecedents to examine a range of psychological factors driving COVID-19 vaccine hesitancy. Their findings revealed that the Theory of Planned Behaviour provided the highest predictive accuracy in this context¹⁸.

The HBM, a psychological framework, has been widely utilized to analyze COVID-19 vaccine hesitancy and and associated determinants^2,18. The HBM encompasses components such as the perceived severity of and susceptibility to COVID-19, perceived benefits of and barriers to receiving COVID-19 vaccines, and cues to action. These cues can include implicit or explicit incentives or situations that motivate vaccination, such as information from mass media².

Multiple factors shape individuals’ decisions to accept or refuse COVID-19 vaccination, including employment status (e.g., whether a person is employed, unemployed, or retired), religiosity, political affiliation, gender, age, education, ethnicity, and income^2,19,21. According to recent systematic reviews, primary reasons for vaccine refusal included a general opposition to vaccines, concerns about safety, the perception of COVID-19 as benign, distrust of health authorities, doubts about scientific research and vaccine efficacy, belief in pre-existing immunity, and uncertainty about the vaccine’s origin^8,22. It is important to note that behavior refers to observable actions or responses, such as deciding whether or not to get vaccinated. In contrast, attitude encompasses an individual’s internal feelings, beliefs, and evaluations regarding a subject. While attitudes can influence behavior, they do not always result in action. For instance, someone who is vaccine hesitant might still need to get vaccinated due to travel restrictions or employment requirements.

While much of the existing research on COVID-19 vaccine hesitancy has focused on high-income countries^8,19, our study shifts the focus to the Dominican Republic (DR), a middle-income nation with a Gross National Income (GNI) per capita of USD 9,710 in 2023²³. The DR’s unique sociocultural landscape is shaped by a rich blend of indigenous, African, and European influences, with spirituality and religion playing a central role in shaping societal values and healthcare practices, creating a distinctive approach to health-seeking behaviors and community support systems. Such sociocultural factors, including historical inequalities and varied access to healthcare services, are critical to understanding the context of vaccine hesitancy in the country²⁴. Additionally, previous studies have predominantly explored vaccine hesitancy in relation to individual, household, or community-level factors, but rarely all three simultaneously¹⁹. Previous research conducted in the DR which used a part of this study’s dataset focused narrowly on trust in information sources²⁵, while our study addresses this gap by exploring the association of individual, household, and community-level factors with COVID-19 vaccine hesitancy in the DR. Through this approach, we aim to enhance the understanding of COVID-19 vaccine hesitancy in the DR, broaden existing knowledge, and lay the groundwork for identifying contextually relevant factors to reduce vaccine hesitancy for future pandemics.