Approximately 75–90% of the population needs to be immunized to reach population immunity; however, a substantial proportion of the global population is still hesitant to receive the COVID-19 vaccine [9,10]. Quantitative approaches have been used by various studies focused on examining COVID-19 vaccine attitudes and behaviors [11–13]. However, studies using qualitative approaches to understanding hesitancy towards the COVID-19 vaccine are still emerging and have focused on racial or ethnic or specific national populations [14,15]. This is the first qualitative study to analyze COVID-19 vaccine hesitancy among a broad general population in the US. The Increasing Vaccination Model (IVM) illustrates the role individuals’ thoughts Int. J. Environ. Res. Public Health 2021, 18, 8690. https://doi.org/10.3390/ijerph18168690 https://www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2021, 18, 8690 2 of 9 and feelings play in shaping vaccine motivation and vaccination behaviors [16]. In order to fill this gap in knowledge about COVID-19 vaccine hesitancy, we conducted a qualitative study that leverages the IVM to examine the thoughts and feelings of participants who are hesitant about the COVID-19 vaccines. 2. Materials and Methods 2.1. Study Design and Sample This study used a qualitative descriptive design [17]. This methodology focuses on summarizing respondent experiences and perceptions while also emphasizing the meanings attributed to their experiences [18,19]. Data were collected using an online survey with broad, open-ended questions to explore attitudes and lived experience related to the COVID-19 vaccine. Respondents were recruited from six primary care clinics located in different towns throughout the state of Arkansas between 30 October 2020 and 16 January 2021. Recruitment e-mails describing the study’s purpose and inclusion criteria were sent to 6092 e-mail addresses. A total of 876 responses to the survey were collected. Of those, 809 met the inclusion criteria; however, 21 provided no data past the eligibility screener, and an additional 34 duplicate records were removed. A total of 754 were determined to be non-duplicates who took part in the survey. Research Electronic Data Capture (REDCap) was used to capture participant responses. REDCap is a widely used web-based software for working with survey data [20]. Inclusion criteria included being an adult (age ≥ 18) and living, working, and/or receiving health care in the state of Arkansas. Respondents reviewed study and consent information at the beginning of the online survey, and consent was documented in REDCap. A $20.00 gift card was provided as a participant incentive. Survey responses were stripped of identifying information prior to analysis. The study was approved by the Institutional Review Board at the University of Arkansas for Medical Sciences (UAMS) (IRB#261226). In addition to the qualitative responses, questions from the Behavioral Risk Factor Surveillance System (BRFSS) were used to capture demographic information, including age, sex, income, race, and education [21]. Two vaccine attitude measures were used to assess general trust in vaccines [22] and vaccine hesitancy [23] specifically related to the COVID-19 vaccine. General vaccine trust was assessed by asking, “Overall how much do you trust vaccines?” Respondents could answer with “not at all”, “very little”, “somewhat”, “to a great extent”, and “completely”. Those who answered “to a great extent” or “completely” were coded as 1 to indicate a high level of trust. The other responses were coded as 0 to indicate lower levels of trust. COVID-19 vaccine hesitancy was measured by asking, “If a vaccine for COVID-19 were available today, what is the likelihood that you would get vaccinated?” Those who selected “unlikely” or “very unlikely” were coded as hesitant towards a COVID-19 vaccine. The survey questionnaire is included in Supplementary File 1. 2.2. Analytic Strategy Demographic and vaccine attitude data were analyzed in order to document frequencies, percentages, and standard deviations. The IVM was used as an analytical framework to analyze the domain of participants’ “thoughts and feelings” related to the COVID-19 vaccination. The codebook was developed by the first author in collaboration with a second researcher on the qualitative analysis team using an iterative process grounded in a consensus model. The codebook was revised three times, and all open-ended responses were reviewed by two additional qualitative researchers. Analysis summaries and all coded segments were critically reviewed by the research team to ensure data, as well as illustrative excerpts from coded data, were extracted and categorized within the relevant thematic domain. Quotes were collated, and statements which best reflected emergent themes were chosen by consensus among the research team [24] and followed standard qualitative research practices that ensured coherence and data saturation [25]. The research team reviewed the data, codebook, and excerpts to ensure analytic rigor and reliability. All Int. J. Environ. Res. Public Health 2021, 18, 8690 3 of 9 responses were coded using MAXQDA, a qualitative data analysis tool developed and supported by VERBI software [26]. Any divergence in the interpretation of coded segments was discussed by the research team and resolved with team-