Household and Community Clustering of Concurrent Vaccine Hesitancy in China: Multicenter Survey

Abstract Background Vaccine hesitancy remains a persistent global challenge, especially in the context of major public health emergencies. While individual-level factors have been widely studied, whether and how household and community contexts shape hesitancy clustering has received little attention. Objective This study aimed to assess household- and community-level clustering of COVID-19 booster vaccine hesitancy (CBVH), identify key associated factors, and explore potential intervention targets. Methods In March 2023, a household-based cross-sectional survey was conducted among Chinese adults across 4 provinces. Concurrent CBVH was defined as hesitancy reported for both current and future booster intentions within the same survey. The analytical samples included 5462 participants for current CBVH, 5437 for future CBVH, and 5407 for concurrent CBVH. Three-level logistic regression models were used to quantify variance attributable to individual, household, and community levels and to identify associated factors. Network analysis was also used to examine interrelationships among key factors and identify central intervention targets. Results Among 5407 participants, 1461 (27.0%) exhibited concurrent CBVH. The unweighted prevalence of current and future CBVH was 28.4% (1553/5462) and 30.1% (1636/5437), respectively. The corresponding poststratified prevalence estimates were 30.88% and 32.55%, respectively. In the null model, the combined household- and community-level intraclass correlation coefficients were 77.73% (95% CI 72.40%‐82.29%) and 78.84% (95% CI 73.57%‐83.30%), respectively. Prior COVID-19 vaccination, self-efficacy, perceived benefits, trust in vaccine developers, and knowledge of the vaccine were associated with lower CBVH, while perceived barriers, perceived severity, household income, chronic disease, history of allergies, and living in the eastern region were associated with higher hesitancy. Network analysis revealed that self-efficacy and prior COVID-19 vaccination had the strongest associations with CBVH. Perceived barriers and trust in vaccine developers formed the strongest association among nodes. The current and future CBVH networks showed similar configurations. Conclusions The substantial household and community clustering highlights the need for group interventions. Household-centered vaccine education, community-based vaccine counseling services, and transparent vaccine communication may help reduce vaccine hesitancy and strengthen preparedness for future infectious disease outbreaks.