Background: Rural Appalachian communities experience significant health inequities and are particularly vulnerable to COVID-19 morbidity and mortality, yet uptake of the COVID-19 vaccine has been low. In the partner counties for this study, average adult vaccination rates are more than 24 percentage points lower than the national average. Despite the widespread availability of COVID-19 vaccine, hesitancy persists, indicating a need for multilevel interventions to address the low uptake rates.

Objectives: Our objectives were twofold: 1) Understand the facilitators and barriers to COVID-19 vaccination uptake in a 15-county target region in Appalachian Kentucky; and 2) Identify potential acceptable and feasible multilevel interventions to increase COVID-19 vaccination rates in each county.

Methods: To inform the development of multi-level county-specific interventions, interviews were conducted with community leaders and stakeholders across study counties. We used grounded theory to identify perceived barriers and facilitators for COVID-19 vaccination uptake, as well as to identify potential interventions. A minimum of two members of the research team coded each interview transcript, with regular team meeting intervals to discuss preliminary findings and achieve consensus on emerging themes.

Results: Twenty key stakeholders participated in interviews. One prominent theme was distrust of federal government as a barrier to COVID-19 vaccination, with changing guidance from CDC repeatedly pointed to as an example. “It’s just this mindset in Eastern Kentucky...it goes back to coal operators and the government and just this very distrustful mindset that is just generational.” Concerns about vaccine safety were also a barrier. Facilitators of COVID-19 vaccination included fear of the consequences of COVID-19 for themselves or another family member as well as the encouragement of local health care providers to vaccinate. “We had five and six people’s names on a funeral home board in a week here that had died of covid.” Trusted messengers for health communication varied by county and ranged from health care providers to librarians. Home visits as a modality of vaccination was commonly viewed as a potentially successful intervention strategy.

Conclusions: Our findings reflect that importance of gaining community input and trust on the development of interventions to address COVID-19 vaccine hesitancy in this health disparity population. Multilevel interventions will be tailored to each county based on these findings.

Public Health Implications: These findings help inform potential community-engaged approaches to improving COVID-19 vaccination rates among counties with historically low uptake in a highly vulnerable region of the U.S. Findings may be transferable to similar settings.