BACKGROUND: The Coronavirus Infectious Disease 2019 (COVID-19) pandemic has continuously affected human life with several devastating effects. Currently, there are effective vaccines to protect people from COVID-19 and the World Health Organization (WHO) has highlighted strategies to influence COVID-19 vaccine uptake in hard-to-reach communities in Ghana. However, prior studies on COVID-19 vaccine acceptability in Ghana are online surveys targeting the literates and those in urban areas, leaving residents in far-flung communities. We assessed knowledge, attitude and acceptability of COVID-19 vaccine among residents in rural communities in Ghana. METHODS: This study was a community-based cross-sectional study and was conducted at three selected regions in Ghana (Northern, Ashanti and Western North) from May to November, 2021. This study included residents 15-81 years, living in the selected rural communities for more than 1 year. Study participants were recruited and questionnaires administered to collect data on knowledge, attitude and acceptance of the COVID-19 vaccine. Statistical analyses were performed using Statistical Package for Social Science (SPSS) version 26.0 and GraphPad Prism Version 8.0 software. RESULTS: Of the 764 participants included in this study, more than half had inadequate knowledge (55.0%), poor attitudes (59.4%) and bad perception about COVID-19 vaccine (55.4%). The acceptability of COVID-19 vaccine in this study was 41.9%. The acceptability of COVID-19 vaccine in Ashanti, Northern and Western North regions were 32.5%, 26.2% and 29.6% respectively. In a multivariate logistic regression analysis, receiving recent or previous vaccine such as HBV vaccine [aOR = 1.57, 95% CI (1.23-3.29), p = 0.002], having good attitude towards COVID-19 vaccine [aOR = 61.47, 95% CI (29.55-127.86), p < 0.0001] and having good perception about the COVID-19 vaccine [aOR = 3.87, 95% CI (1.40-10.72), p < 0.0001] were independently associated with higher odds of accepting COVID-19 vaccine. CONCLUSION: More than half of residents in Ghanaian rural communities have inadequate knowledge, poor attitudes and bad perception about COVID-19 vaccine. The acceptability of COVID-19 vaccine is generally low among rural residents in Ashanti, Northern and Western North regions of Ghana. Residents living in hard-to-reach communities must be educated about the benefits of COVID-19 vaccine to achieve effective vaccination program.