Barriers toward Getting Booster Dose of COVID-19 Vaccination among Turkmen people: A Content Analysis Study

doi:10.21203/rs.3.rs-2229579/v1

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Research Article

Barriers toward Getting Booster Dose of COVID-19 Vaccination among Turkmen people: A Content Analysis Study

https://doi.org/10.21203/rs.3.rs-2229579/v1

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Background

Vaccine hesitancy is a global concern. This study was performed to understand what prevents Turkmen people from getting their third or higher COVID-19 vaccine doses.

Methods

In a qualitative content analysis study, 35 Turkmen residents of Gonbad-e Kavous city in the north of Iran who had not gotten their third or higher doses of the COVID-19 vaccine were put through semi-structured phone interviews during August and September of 2022.

Results

Analysis results determined that the following 5 category are preventing people from getting their COVID-19 vaccine booster shots: 1. Unawareness of the dangers, 2. inaccurate rumors and beliefs, 3. Negative COVID-19 vaccine experiences, 4. Vaccine effectiveness, and 5. Personal freedoms.

Conclussion:

Based on our results, interventions from multiple channels which raise awareness about the dangers of COVID-19 and the importance of booster vaccine shots are crucial. To increase the public acceptance of booster shots, healthcare policymakers must take action to raise the public's trust in vaccines and provide documented and scientific responses to the public's inaccurate rumors and beliefs.

Vaccine hesitancy

COVID-19

Barriers

Turkmen people

Until September 18th, 2022, COVID-19 cases in Iran reached 7245822 and the death toll reached 144301. Also, 65061152 first doses of vaccine, 60858455 second doses, and 31126000 third and higher doses were injected(1). Different studies indicate that vaccine effectiveness decreases over time and booster shots are required (2–5).

Several foreign and domestic vaccines were offered to the public as COVID-19 vaccination began. Sinopharm, AstraZeneca, Bharat Biotech, and Sputnik V were the foreign vaccines offered to the public as first and second doses. COVIran Barekat vaccine was the primary domestic vaccine on offer. Lately, Sputnik V, AstraZeneca, and Bharat Biotech vaccines are no longer used due to different reasons, but domestic vaccines such as Soberana (PastoCoVac), Soberana plus (PastoCoVac), SpikoGen®, and COVIran Barekat replaced them. Currently, these vaccines along with the Sinopharm vaccine are offered to the general public.

Vaccine Hesitancy is one of the biggest challenges of general global health right now. WHO's strategic advisory group of Experts has defined Vaccine hesitancy as a delay in acceptance or refusal of vaccination despite the availability of vaccination services, which can be different based on where, when, and how it happens. This problem has been confirmed by different studies and is different for every vaccine (6–8). Vaccine hesitancy is causing increasing worries across the world (9). In 2019 WHO identified it as one of the 10th biggest threats to global health(9, 10).

According to The ministry of healthcare, public acceptance of third and higher COVID-19 doses has significantly decreased compared to the acceptance of the first two doses (1). This disinclination has not been studied in Iran, but studies performed across the world suggest different reasons for it. For example, a study performed in Poland indicated that experiencing vaccine side effects and fear are the two primary reasons why COVID-19 booster shots are not popular (11). A study performed by Yadete et al, in the United States of America indicated that 38 percent of people are hesitant toward COVID-19 vaccine booster shots, and the primary reason for that is mistrust of vaccines(12).

Significant studies have been performed on vaccine hesitancy in Iran, but they focus on the first dose of the vaccine(13, 14). There have been no domestic studies on the low acceptance of booster shots. Identifying the causes of booster shots' low acceptance rate can be helpful in planning necessary interventions and healthcare services. Cultural and tribal factors can be responsible for shaping beliefs about healthcare. Turkmen are an important minority in the north of Iran, they mostly live in the Golestan province and Gonbad-e Kavous is its most important Turkmen city. Experts report a very low acceptance of third or higher COVID-19 vaccine doses among Turkmen residents of Gonbad-e Kavous. Therefore our researchers resolved to use a qualitative content analysis study to identify the obstacles to booster shot injections among Turkmen residents of Gonbad-e Kavous and use their acquired knowledge, technical understandings, and experiences about vaccination to help healthcare policymakers control the COVID-19 disease. This study was designed and performed to understand what prevents booster shot injections among Turkmen residents of Gonbad-e Kavous.

This is an Explorative qualitative study performed during August and September of 2022 on 35 Turkmen residents of Gonbad-e Kavous who had not received their third or higher COVID-19 vaccine doses. Sampling was done in a purposive way with utmost diversity. People who had received their first and second doses of vaccine but not the higher ones were chosen using the public vaccination system and interviewed through calls. The interviewer, a Turkmen resident of Gonbad-e Kavous who worked at the city's healthcare center, asked the participants why they hadn't received their booster shots yet, after introducing himself and clarifying his goals. The participants were also asked to talk about their vaccination experiences and why they stopped it. The next questions were based on the participants' previous answers and the interview guide. The interviews were all recorded, carefully written down, prepared, organized, reported, and studied. Our diverse participants included members of both sexes with different ages and educational backgrounds so they would be as close to our target population as possible. In the end, the participants' demographic characteristics were recorded in a separate table.

Qualitative analysis methods were used to analyze data. First, the recorded conversations were written down, and then they were closely studied to extract their common and general messages. Then the interviews were organized through open codification. The MAXQDA10 text organizing software managed the extracted codes. Repeated studies on the extracted codes helped organize them and find their differences and similarities. Finally, they were analyzed. After each interview, the text of the interview was analyzed through content analysis methods. First, units of meaning were identified in the text of each interview (Our study's analysis units). Then these units of meaning, sentences that had the same general meaning, were summarized without losing their meanings. The summarized units of meaning were labeled with codes. Different codes were compared based on their similarities and differences and then organized into different levels.

The average of the participants' age was 43.11 ± 16.51 with an age range of 21–81. Nineteen participants were women (53.4 percent). 26 participants were married (74.3 percent). 14 participants had education beyond diplomas (40 percent), 10 participants had not achieved their diplomas (28.6 percent), 6 participants had Diplomas (17.1 percent), and 5 participants were uneducated (14.3 percent). Most of the participants had been injected with Sinopharm vaccines (77.1 percent) (Table 1).

Table 1

Study participant profile
Participant ID number	Age (years)	Gender	Marital status	Education	Occupation	Vaccine Brand
1	60	Female	Widow	Illiterate	House keeper	Sinopharm
2	28	Male	Married	University degree	Teacher	Sinopharm
3	34	Male	Married	University degree	Teacher	Sinopharm
4	46	Male	Married	High school diploma	Driver	Sinopharm
5	28	Male	Single	University degree	Skilled worker	Sinopharm
6	80	Male	Married	Illiterate	Unemployed	Sinopharm
7	47	Male	Married	University degree	Employer	AstraZeneca
8	45	Male	Married	High school diploma	Football coach	Sinopharm
9	28	Female	Married	Primary school	House keeper	Sinopharm
10	26	Female	Married	University degree	Employer	Sinopharm
11	42	Female	Single	University degree	House keeper	Sinopharm
12	38	Female	Married	University degree	Retailer	Sinopharm
13	42	Female	Married	Primary school	House keeper	Sinopharm
14	39	Male	Married	University degree	Teacher	Sinopharm
15	21	Female	Married	High school diploma	House keeper	AstraZeneca
16	23	Female	Single	High school diploma	student	Sinopharm
17	38	Male	Single	Secondary school	Driver	Sinopharm
18	26	Male	Married	University degree	Skilled worker	AstraZeneca
19	30	Female	Single	University degree	House keeper	Sinopharm
20	50	Female	Married	Primary school	House keeper	AstraZeneca
21	50	Male	Married	Secondary school	Retailer	AstraZeneca
22	40	Female	Married	High school dropout	House keeper	Sinopharm
23	49	Male	Married	Secondary school	Mullah	Sinopharm
24	65	Male	Married	Secondary school	Driver	Sputnik V
25	43	Female	Married	Primary school	House keeper	Sinopharm
26	21	Female	Single	High school diploma	Student	AstraZeneca
27	74	Female	Widow	Illiterate	House keeper	Sinopharm
28	58	Female	Married	University degree	Teacher	Sinopharm
29	33	Female	Married	Secondary school	House keeper	Sinopharm
30	62	Female	Married	University degree	Teacher	Sinopharm
31	45	Male	Married	University degree	Farmer	Sinopharm
32	81	Male	Married	Illiterate	Unemployed	Sinopharm
33	63	Female	Widow	Illiterate	House keeper	Sinopharm
34	30	Male	Married	High school diploma	Photographer	Sputnik V
35	24	Female	Married	University degree	House keeper	Sinopharm

Table 2

Categories extracted from qualitative data
Category	Subcategory	Description
Unawareness of the dangers	Believing Corona is not as dangerous anymore	People don't believe they are in as much danger as before and think Corona has weakened.
Inaccurate rumors and beliefs	Rumors about vaccination being deadly	Rumors are circulating the society about vaccines being deadly
Negative COVID-19 vaccine experiences	Experiencing extreme side effects caused by the first two doses	Experiencing side effects caused by the first two doses of vaccine causes fear and lack of enthusiasm about vaccination
Vaccine's function	Uncertainty about the effectiveness of vaccines Mistrust of the vaccine production procedure Numerous injections Changing the vaccine brand for the third dose	The vaccine does not prevent death or Corona and its injection doesn't make any difference. Vaccine production happened so fast that they couldn't have had time for clinical tests Vaccination every 4–6 months makes people suspect its effectiveness and lose interest Changing the vaccine brand for the third dose makes people lose their trust in the vaccine
Personal freedoms	Lack of social restrictions and mandatory vaccination laws	The lack of social restrictions and mandatory vaccination laws has lowered vaccination rates

Our findings indicated that there are 5 main levels of reasons why our participants had not received their 3rd or higher vaccine doses. These levels are:

1) Unawareness of the dangers

2) Inaccurate rumors and beliefs

3) Negative COVID-19 vaccine experiences

4) Vaccine effectiveness

5) Personal freedoms

Unawareness of the dangers

One of the extracted levels is Unawareness of the dangers of COVID-19. Some participants believed that the COVID-19 virus has weakened and it is not as dangerous as it used to be. Therefore they see no reason to get their booster shots. The opinion of one of the participants regarding this matter:

"We have no intention to get our third and fourth vaccine doses. It has been so long since our second dose. We were some of the first people to get the second dose last summer. We are not going to get the other doses. There is no Corona anymore, our lives are not in danger. We are very healthy."

*Is that why you haven't received the third and fourth vaccine doses?

" As I said, there's no problem anymore. Our lives are back to normal; we have no more problems. We don't see a need for it anymore. Right now it seems like the storm has passed us. Things are back to normal." (Participant #2).

Another participant said:

"We were very enthusiastic about the first and second doses. Back then the disease was very dangerous. Right now the situation has improved, thank goodness. Things are safe and sound. The new variance was not very intense either, it was a simple cold, and running nose, …. The situation in our village is okay right now, thank goodness. I don't know about the city. It's not like it used to be. Back then, one side of the cemetery got filled in a really short time. It's not like that anymore, Thank goodness." (Participant#14).

Inaccurate rumors and beliefs

Inaccurate rumors and beliefs formed another one of the extracted levels. Many participants believed vaccination causes death. For example:

" A young boy lost his life when he got vaccinated. He died two days after vaccination. He was my son's friend. He didn't continue his vaccination because of that. Neither did I." (Participant #1)

Another one of the participants said:

"To be honest, I'm scared to have the third dose. My cousin died because of this, last week."

*After he had his vaccine injected?

"Yes. The poor soul had it injected. He died last week. Because of that, I'm literally scared to go near vaccines. Our entire neighborhood is talking about how he died because of the Corona vaccine. His wife is crying out loud, begging people not to get vaccinated. It's so unfortunate. His time was up right? He didn't even have any other diseases. He was a healthy boy. Very healthy. He was an employee. A rental driver. He would leave for work early in the morning and come back late at night. He left three kids behind." (Participant #14)

Participant #18 said:

"We're not getting it for now. Three of my neighbors got the vaccine and died. I'm not doing it yet."

Participant #21 believed:

"As you know people are saying vaccines kill people. So I thought I shouldn't dig my own grave with my own hands and didn't continue with the vaccination. I told myself we won't get Corona and fortunately we're still healthy. But when we got vaccinated we got sick. Even though we were completely healthy before the vaccine, we got sick after we had it."

Another rumor says that vaccination makes other diseases and physical issues get worse and more intense. One of the participants said:

"They say vaccines reveal any diseases you might have in your body. And I got scared. I had already had two doses." (Participant #13).

Negative COVID-19 vaccine experiences

Negative COVID-19 vaccine experiences, especially negative experiences caused by the second dose, are major obstacles on the way to full vaccination and were repeated by our participants numerous times. Negative severe side effects caused by previous doses created mistrust and fear of vaccination among our participants and prevented their full vaccination. One participant said:

"I have migraines, which get really bad sometimes. Before vaccination, it used to get bad once every two or three weeks, but after I got vaccinated it gets bad every day or every other day. I don't have other specific reasons." (Participant #3)

Another participant said:

"My family and I are always in pain and fatigued. Four members of our family were ready for vaccination and we had two doses. My family is fatigued like me too. I personally always have a fatigued and hurting body. My wife also has pains which won't go away."

*Did all this start after you get vaccinated?

"Yes, it started after the second dose. The first dose didn't have any side effects. But the second dose caused fatigue, muscular pains, and overall pains. We took multivitamins effervescent tablets. The symptoms would go away periodically but they would always come back. That's why we didn't continue with the rest of the doses. We didn't want any more problems." (Participant #22)

Observing intense side effects on acquaintances is a sublevel of this level, which was mentioned by many of our participants. One participant said:

"Well, I had the first and second doses. I was waiting to go get the third dose when my neighbor took their third dose. There was another disease going around back then too, the Omicron. After getting the third dose, they started experiencing shortness of breath. I was afraid it would happen to me too so I didn't continue with the vaccination. We were cleared for our third dose almost at the same time. My neighbor took it first and all of that happened which scared me. I had already had the first and second doses but I didn't go for the third and fourth. I was scared. That's why I didn't continue." (Participant #9)

Vaccine effectiveness

Vaccine effectiveness was another level extracted in this study. Four of this level's sublevels were: uncertainties about the effectiveness of vaccines, mistrust of the vaccine production procedure, numerous injections, changing the vaccine brand for the third dose.

Some of our participants believed that vaccine injection does nothing to prevent death or Corona. One participant said:

"Injecting it or not doesn't matter. Vaccinated people die too. The ones who didn't get vaccinated are living normal lives. Some people didn't even have the first and second doses. I believe people can't say they're completely safe since they've gotten vaccinated. Even vaccinated people die. You're not safe after getting vaccinated. (Participant #5)

Another participant said:

"I got Corona after having the first and second doses. They didn't have any effects. I got the virus again after getting two shots of the vaccine. That was the second time. First I got it after the first dose and then again I got it after the second dose." (Participant #7)

People mistrusted the high speed of vaccine production. People had negative opinions about how fast vaccines are being produced. One of the participants said:

"In my opinion, vaccines should be thoroughly tested first. Then they should inject it into people. They haven't tested these vaccines, have they? They made a vaccine in a short time and are forcing people to have it injected. But it's not a vaccine that has been tested and experienced for a long time. I think the Corona vaccine isn't like that. That's my opinion though. Am I right? They haven't tested it." (Participant #30)

Multiple injections every few months were another reason people didn't want the third and fourth doses. One of the participants said:

"They say you have to keep getting more and more doses every some time. Like after a few months you'll have to take the third, fourth, fifth, and even sixth dose. They say that's what it's going to be like. And they say it's harmful." (Participant #4)

Another participant said:

"They say it loses its effectiveness over time and you have to keep taking it. For example, we would have to get vaccinated every month. They say that has side effects. That's why I'm not continuing with it." (Participant #16)

Changing the vaccine brand for the third dose was Another sublevel mentioned by a few participants. Participant #24 said:

"When we went to have our third dose, they didn't have our vaccine anymore. They said we should take another brand. But we didn't. I said if they have Sputnik V we'll have it, we don't want the other brands. And we didn't continue with our vaccination after that."

Personal freedoms

Personal freedoms were another level extracted in this study. Since vaccination is not mandatory and social restrictions on unvaccinated people have been lifted has caused people to be less enthusiastic about their remaining vaccine doses. One participant said:

"As long as it is not mandatory, I won't have it. I believe they should make people have their vaccination cards when going around. If vaccination cards are necessary, people will get vaccinated." (Participant #16)

Vaccine hesitancy is a massive health challenge. Recently, this challenge has grown bigger due to the COVID-19 pandemic, its vaccination, and multiple vaccine doses. This study aimed at identifying obstacles that prevent third and fourth COVID-19 vaccine dose injections among Turkmen residents of Gonbad-e Kavous city. In the end, 5 main levels were extracted which will be discussed below:

Unawareness of the dangers

One of the main reasons why booster COVID-19 vaccine shots were not accepted by the public was the public's unawareness of the dangers of COVID-19. The majority of our participants believed that the disease has gotten weak and we are not faced with a severe and deadly virus anymore. This is true to some extent, and the mortality rates of the previous months indicate that the disease has gotten weaker. This can be due to widespread public vaccination. In the summer of 2021, people were very enthusiastic about the first and second vaccine doses since the Delta variant was taking numerous lives. That enthusiasm led to widespread vaccination which strengthened the public's immunity levels against the disease. According to healthcare guidelines about understood threats, when people consider themselves vulnerable to a disease that is very severe and deadly, they will take preventative measures against it(15). In the case of COVID-19, which had a high spreading rate and was severe and deadly, the death of acquaintances forced people to personally seek vaccination and preventative measures. The results of Denis et al's study indicated that unawareness of the dangers of the disease resulted in low vaccination rates among British healthcare workers (16). Therefore it seems like people believe the disease has gotten weaker and they see no reason to get vaccinated. The results of Rzymski et al's study in Poland indicated that people who were hesitant about getting their booster shots did not believe it was necessary(11). The results of the study performed by Wang et al and Harapan et al indicated that vaccination rates among people who were aware of possible dangers were twice the vaccination rates of the unaware(17, 18) .

Inaccurate Rumors and beliefs

Negative rumors and stories were mentioned by a significant number of our participants and are primary obstacles against vaccination. The most important rumor said people die after the third dose. This is an inaccurate rumor which is circulating among Turkmen residents of the city and will soon turn into an inaccurate belief that will prevent vaccine injection. Healthcare policymakers must use intervening methods through different channels to regain the public trust and correct this rumor. Inaccurate information about health threats is a massive threat to the public's health itself (19). This pandemic came with enormous quantities of fake news about the characteristics of the disease, its nature and spreading, preventative measures, and remedies which lowered the public's trust in healthcare authorities(20, 21). Fake news includes a wide variety of misleading, purposefully included or excluded, accidental or false, and altered information. Fake news is a mixture of incorrect information and lies (22). WHO announced that healthcare systems are not facing a pandemic, but an infodemic (23).

Studies indicate that fake news and rumors have negative effects on public vaccination acceptance and those who are capable of recognizing the inaccurate information are more likely to accept vaccination (24–26). Therefore the public must be educated about the COVID-19 vaccine so they can recognize inaccurate information about it. Healthcare media should provide scientific and persuasive responses to inaccurate information to raise public awareness.

Negative COVID-19 vaccine experiences

Another important factor identified in our study was negative experiences caused by first and second vaccine doses. Severe side effects caused by the previous two doses caused vaccine hesitancy. Fear of short-term side effects caused by COVID-19 vaccines has been confirmed in many studies (13, 27, 28). In Rzymski et al, negative side effects of the previous dose were the biggest reason people didn't want the booster shot(11). It must always be remembered that these vaccines have side effects and that's in their nature. Healthcare authorities should provide educational content about these side effects and their treatments. That would help people gain an understanding of vaccination and its side effects and put their fears aside.

Vaccine effectiveness

Vaccine effectiveness was another extracted level. Some participants believed vaccines are not effective and injecting them does not prevent COVID-19 infection. Some claimed to have gotten infected with the virus again after getting vaccinated which they took as the ineffectiveness of vaccines. Some believed the fact that multiple vaccine doses were required showed ineffectiveness and meant vaccination was pointless. Other studies indicated that people did not trust the effectiveness of corona vaccines(29, 30) (31, 32). The results of the study performed by Khankeh et al indicated that people did not trust the effectiveness of vaccines which decreased public enthusiasm toward vaccination(13).

People also mistrusted the fast production rates of COVID-19 vaccines. Some of our participants mentioned the fast production rates of COVID-19 vaccines and believed the researchers had no time to perform clinical tests and experiments on them. Other studies also identified this problem (14, 31–35).

Some participants mentioned that they did not continue with their vaccination because they had to change the vaccine brand they had taken for the first two doses. For example, some participants had AstraZeneca or Sputnik V vaccines for their first two doses but were recommended a different brand for their third dose. This problem has been caused by the removal of those vaccine brands from the public vaccination system and their replacement with different brands. This change might have decreased public enthusiasm toward vaccination. To regain public trust, healthcare authorities must provide scientific and persuasive proof of the effectiveness of the new brands and explain why the old ones were replaced.

Personal freedoms

Another extracted level was Personal freedoms. The lack of social restrictions on unvaccinated people and mandatory vaccination laws has reduced the public's enthusiasm toward booster shots in comparison with the first two doses. In 2021, many Iranian governmental organizations did not provide services to unvaccinated people which forced people to get vaccinated. But lately, these restrictions have been lifted and mandatory vaccination laws are no longer in place which caused some people to not continue with their vaccination. The results of the study performed by Torabi and Sotodeh on the students of Shiraz University in Iran indicated that many students got vaccinated because of public pressure and did not truly want the vaccine(36).

Study Strengths

This study enjoys a few advantages which should be mentioned. Firstly, this was a qualitative study that gave us access to the deepest beliefs of our participants. Secondly, the interviews were performed through phone calls which results in better, more honest answers compared to face-to-face interviews. Thirdly, our participants had already received two doses of vaccines but had not continued with their vaccination which helped us find out why public enthusiasm toward vaccination decreases after the second dose. All this helped us provide healthcare policymakers with clear insights.

Study Limitations

The qualitative nature of the study limited the possibility of generalization of the results. Social pressures and orientations might have affected the data collected by our team. To minimize this problem our interviewer explained the goals of our study before beginning the interview and assured the participants of their anonymity. The third limitation was the fact that this study was performed on Turkmen citizens. Other groups of people might have different opinions and beliefs.

The results of this study indicated 5 kind of barriers that prevent third and higher COVID-19 vaccine injections among Turkmen citizens: unawareness of the dangers, inaccurate rumors and beliefs ,negative COVID-19 vaccine experiences, vaccine effectiveness, personal freedoms

Interventions through educational channels are necessary to increase public awareness about the dangers of COVID-19, stop the inaccurate rumors about vaccination, increase awareness about vaccine side effects, regain the trust of Turkmen citizens, and increase their enthusiasm toward COVID-19 booster shots. Performing similar studies on other groups in other regions of our country can better help identify the obstacles against COVID-19 vaccination and provide healthcare authorities with proper guidelines they can use to design interventions and increase enthusiasm toward COVID-19 vaccine booster shots.

Acknowledgements

The authors appreciate all the participants who took part in the study.

Authors’ contributions

MG took part in acquisition of data, analysis and interpretation,, and gave final approval of the version to be published. AC participated in study design, data interpretation, preparing of draft and its review.

Funding

This research was funded by the Golestan University of Medical Sciences with project number 48-113177.

Availability of data and materials

The datasets used and/or analyzed during the current study are all available from the corresponding author on reasonable request.

Ethics approval and consent to participate

This study was approved by the Golestan medical university's technology and research group's moral committee and given the following identity code: IR.GOLESTAN.REC.1401.272

Consent for publication

Not required

Competing interests

All authors declare that there are no competing interests.

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Table 1. Study participant profile

Participant ID number	Age (years)	Gender	Marital status	Education	Occupation	Vaccine Brand
1	60	Female	Widow	Illiterate	House keeper	Sinopharm
2	28	Male	Married	University degree	Teacher	Sinopharm
3	34	Male	Married	University degree	Teacher	Sinopharm
4	46	Male	Married	High school diploma	Driver	Sinopharm
5	28	Male	Single	University degree	Skilled worker	Sinopharm
6	80	Male	Married	Illiterate	Unemployed	Sinopharm
7	47	Male	Married	University degree	Employer	AstraZeneca
8	45	Male	Married	High school diploma	Football coach	Sinopharm
9	28	Female	Married	Primary school	House keeper	Sinopharm
10	26	Female	Married	University degree	Employer	Sinopharm
11	42	Female	Single	University degree	House keeper	Sinopharm
12	38	Female	Married	University degree	Retailer	Sinopharm
13	42	Female	Married	Primary school	House keeper	Sinopharm
14	39	Male	Married	University degree	Teacher	Sinopharm
15	21	Female	Married	High school diploma	House keeper	AstraZeneca
16	23	Female	Single	High school diploma	student	Sinopharm
17	38	Male	Single	Secondary school	Driver	Sinopharm
18	26	Male	Married	University degree	Skilled worker	AstraZeneca
19	30	Female	Single	University degree	House keeper	Sinopharm
20	50	Female	Married	Primary school	House keeper	AstraZeneca
21	50	Male	Married	Secondary school	Retailer	AstraZeneca
22	40	Female	Married	High school dropout	House keeper	Sinopharm
23	49	Male	Married	Secondary school	Mullah	Sinopharm
24	65	Male	Married	Secondary school	Driver	Sputnik V
25	43	Female	Married	Primary school	House keeper	Sinopharm
26	21	Female	Single	High school diploma	Student	AstraZeneca
27	74	Female	Widow	Illiterate	House keeper	Sinopharm
28	58	Female	Married	University degree	Teacher	Sinopharm
29	33	Female	Married	Secondary school	House keeper	Sinopharm
30	62	Female	Married	University degree	Teacher	Sinopharm
31	45	Male	Married	University degree	Farmer	Sinopharm
32	81	Male	Married	Illiterate	Unemployed	Sinopharm
33	63	Female	Widow	Illiterate	House keeper	Sinopharm
34	30	Male	Married	High school diploma	Photographer	Sputnik V
35	24	Female	Married	University degree	House keeper	Sinopharm

Table 2: Categories extracted from qualitative data

Category	Subcategory	Description
Unawareness of the dangers	Believing Corona is not as dangerous anymore	People don't believe they are in as much danger as before and think Corona has weakened.
Inaccurate rumors and beliefs	Rumors about vaccination being deadly	Rumors are circulating the society about vaccines being deadly
Negative COVID-19 vaccine experiences	Experiencing extreme side effects caused by the first two doses	Experiencing side effects caused by the first two doses of vaccine causes fear and lack of enthusiasm about vaccination
Vaccine's function	Uncertainty about the effectiveness of vaccines Mistrust of the vaccine production procedure Numerous injections Changing the vaccine brand for the third dose	The vaccine does not prevent death or Corona and its injection doesn't make any difference. Vaccine production happened so fast that they couldn't have had time for clinical tests Vaccination every 4-6 months makes people suspect its effectiveness and lose interest Changing the vaccine brand for the third dose makes people lose their trust in the vaccine
Personal freedoms	Lack of social restrictions and mandatory vaccination laws	The lack of social restrictions and mandatory vaccination laws has lowered vaccination rates

No competing interests reported.

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Barriers toward Getting Booster Dose of COVID-19 Vaccination among Turkmen people: A Content Analysis Study

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Abstract

Background

Methods

Results

Conclussion:

Introduction

Methods

Results

Unawareness of the dangers

Inaccurate rumors and beliefs

*After he had his vaccine injected?

Negative COVID-19 vaccine experiences

*Did all this start after you get vaccinated?

Vaccine effectiveness

Personal freedoms

Discussion

Unawareness of the dangers

Inaccurate Rumors and beliefs

Negative COVID-19 vaccine experiences

Vaccine effectiveness

Personal freedoms

Study Strengths

Study Limitations

Conclusion

Declarations

References

Tables

Additional Declarations

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