Spatial multilevel analysis of individual, household, and community factors associated with COVID-19 vaccine hesitancy in the Dominican Republic

Vaccine hesitancy or refusal poses a significant public health challenge resulting in the resurgence of preventable diseases and undermining the effectiveness of national and global health initiatives. This study investigates multilevel determinants of COVID-19 vaccine hesitancy in the Dominican Republic (DR) shortly after the launch of the national COVID-19 vaccination campaign in February 2021. Participants aged 18 years and older were enrolled through a national multistage cluster survey conducted from June-October 2021. The Health Belief Model guided the selection of potential factors contributing to vaccine hesitancy. Hierarchical mixed-effect logistic regression models were used to examine individual, household, and community factors associated with vaccine hesitancy. COVID-19 vaccine hesitancy was observed in 12.6% (95% CI: 11.7-13.5%) of participants (n = 5,566), with spatial variations at the cluster level. Individual factors associated with lower odds of vaccine hesitancy included older age, higher education levels, mulatto ethnicity, and perceiving vaccination as crucial for health. In contrast, factors significantly associated with hesitancy included being born in the DR and concerns about COVID-19 vaccine side effects. For factors at the household level, differential trust in health information sources significantly influenced vaccine hesitancy, with certain sources correlating with increased hesitancy and others with reduced vaccine hesitancy. Better access to healthcare, as indicated by a higher number of hospitals per population, was paradoxically associated with increased vaccine hesitancy. Future strategies to reduce vaccine hesitancy in the DR might consider these multifaceted factors.