Vaccine Hesitancy Among Caregivers in North East Nigeria: A Theoretical Model of Decision-Making Processes and the Role of Community Influencers

Vaccine hesitancy has emerged as a critical barrier to achieving optimal immunisation coverage in north-eastern Nigeria, where historical vaccination boycotts, misinformation networks, and distrust of government health services intersect with ongoing conflict. Despite the recognised importance of this phenomenon, a comprehensive theoretical model grounded in empirical evidence from this context is absent. This study employs grounded theory methodology to develop a contextualised explanatory theory of vaccine hesitancy decision-making among caregivers in Yobe, Borno, and Gombe states. Theoretical sampling yielded 68 in-depth interviews with hesitant and accepting caregivers, 18 interviews with community and religious influencers, and 14 healthcare provider perspectives. Data were analysed using constant comparative analysis and the three-stage coding procedures of constructivist grounded theory. The resultant substantive theory, conceptualised as Navigating Legitimacy, proposes that caregivers in this context make vaccination decisions through a legitimacy appraisal process evaluating government trustworthiness, community consensus, religious authority endorsement, and perceived vaccine risk narratives disseminated via social networks. Uncertainty management through influential intermediaries emerged as the core category. Religious scholars who publicly endorsed vaccination were the most powerful legitimacy anchors, while social media rumour networks were identified as the primary source of vaccine safety misinformation. The theory challenges individualistic health belief models by centring collective legitimacy appraisal as the dominant mechanism. It provides a novel theoretical contribution with direct implications for community engagement strategies in vaccine communication programmes. Keywords: vaccine hesitancy, grounded theory, North East Nigeria, community influencers, immunisation.