In the proposed study, the investigators will conduct qualitative interviews and focus groups with Black, Hispanic, and medically underserved communities, living in the rural south and will provide a quantitative survey (mixed methods) to identify reasons for vaccine hesitancy, including any structural barriers experienced by this population. The investigators will assess what vaccination messaging was received by trusted individuals and how this messaging may have impacted vaccination behavior. This mixed methods study design will allow for a comprehensive picture of vaccine equity and hesitancy for this population. The quantitative survey provides a focused and concrete uncovering of the issues and relationships and the qualitative design allows for a detailed, contextualized insight into lived experiences. Coupled together, this mixed methods design will provide a rich depiction of the underlying drivers of vaccine hesitancy, structural barriers to vaccination, and messaging that impacted uptake for medically underserved and rural populations.

Objective 1: To identify reasons for vaccine hesitancy, structural barriers to vaccination, vaccine messaging received, and vaccination behavior among medically underserved and vulnerable populations living in the rural south.

Objective 2: To assess vaccine messaging from trusted individuals (e.g., clergy/church leaders, community health workers, and community leaders) who serve medically underserved and vulnerable populations living in the rural south.

Objective 3: To identify best vaccine confidence and uptake strategies to improve vaccine acceptance, confidence, and trust among medically underserved and vulnerable populations living in the rural south.

Hypotheses:

H1a. It is hypothesized that top reasons for vaccine hesitancy may include access to care issues (such as transportation, long wait times, no available appointments, not sure where to go, no internet, and language barriers), safety and efficacy concerns, distrust in government and health organizations, as well as lack of information and/or misinformation.

H1b. It is hypothesized that structural barriers to vaccination may include geographic barriers, access to information, clinic/outlet location or trusted points of access, internet access, immigrant status, language, transportation, among others.

H1c. It is hypothesized that vaccine messaging received from trusted individuals in the communities (i.e., faith-based leaders, community health workers, and community leaders) will have impacted confidence and uptake more so than other vaccine messaging efforts.

H2. It is hypothesized that the vaccine messaging from trusted individuals will be mixed with some messaging based on science and some based on anecdotal evidence. It is not well-known what messages are being delivered around vaccination from trusted individuals who serve our priority population and thus, we can only hypothesize that the messaging will vary.

H3. It is hypothesized that the most effective strategies to boost vaccine confidence and uptake for vaccine hesitant, medically underserved, and vulnerable populations living in the rural south will include culturally tailored messaging from engagement with trusted individuals.

Inclusion Criteria: All English or Spanish speaking adults 18 years or older. -

Exclusion Criteria: Anyone over 18 years of age who does not speak English or Spanish or anyone under 18 years of age.

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Eastern North Carolina (ENC) is a largely rural, poor, and underserved region of the state with 1 in 5 adults living below the poverty level, and nearly half living in a community designated as rural. Health in ENC is significantly poorer than health in the rest of NC, and health in the ENC-29 counties is poorest of all. Of the 40 counties in NC that are most economically distressed, 19 (48%) are in the ENC-29-county sub- region. Residents of ENC experience a high burden of health disparities driven by limited access to healthcare and inequitable distribution of social determinants of health.

Deidentified data can be shared upon reasonable request.