Using the Social-Ecological Model to Assess Vaccine Hesitancy and Refusal in a Highly Religious Lower-Middle-Income Country.

(1) Background: The aim of this study was to understand the factors associated with vaccine hesitancy and refusal in Indonesia using the Social-Ecological Model (SEM). (2) Methods: Data on demographics, religiosity, family dynamics, and perceptions of public health efforts were collected through an online survey and compared to the rates of vaccine hesitancy and refusal. (3) Results: Income and sex were significantly associated with vaccine hesitancy. Based on a vaccine passport policy to enter public spaces, people who felt inhibited to enter public spaces or perceived privacy threats were twice as likely to exhibit vaccine hesitancy. Participants who believed that religious groups had a difficult time getting vaccinated were nearly twice as likely to exhibit vaccine hesitancy and three times more likely to exhibit vaccine refusal. However, participants who believed in a higher religious power were 58% less likely to exhibit vaccine hesitancy. Religious leaders significantly influenced participants to make the decision regarding vaccination. Individuals with vaccine refusal were more than twice as likely to share information with others without fact-checking. Notably, structural barriers such as distance and transportation were most strongly associated with vaccine hesitancy and refusal. (4) Conclusion: Cultural factors play a significant role in vaccine hesitancy and refusal. The SEM can be used to propose multi-level interventions with collaboration and communication among stakeholders to improve community health.