Vaccine hesitancy and factors related to vaccine hesitancy in COVID vaccination among a tribal community of Meghalaya: A mixed methods study

doi:10.21203/rs.3.rs-2615756/v1

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Vaccine hesitancy and factors related to vaccine hesitancy in COVID vaccination among a tribal community of Meghalaya: A mixed methods study

https://doi.org/10.21203/rs.3.rs-2615756/v1

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published 11 Jul, 2023

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Background

Vaccine hesitancy should be dealt as an important issue as it carries both individual and community level risks; however, it lacks proper assessment in particular among the indigenous tribal population.

Methods

A community based sequential explanatory mixed methods study was conducted among 238 eligible individuals in Ri-Bhoi district, Meghalaya. The quantitative part involved a cross-sectional study to determine the proportion of vaccine hesitancy and the qualitative part comprised of in-depth interviews among the eligible residents and key informant interview among the health workers providing the vaccination services, to explore the facilitators and barriers of vaccine uptake.

Results

A total of 113 [47.5% (95% CI: 41.0%-54.0%)] participants were found to be hesitant to vaccination, among which 16.8% (95% CI: 12.4%-22.3%) were initially hesitant and 30.7% (95% CI: 24.9%-37.0%) had vaccine refusal. The themes generated through qualitative interviews were individual related, disease related, vaccine related, healthcare system and provider related and socio-cultural and religious. The main barriers for likelihood of action were perceived susceptibility and perceived severity under the individual perception along with ambiguity aversion, scepticism about the efficacy, mistrust, concerns on side effects, rumours and socio-cultural and religious misbeliefs.

Conclusion and recommendations

Vaccine hesitancy is found to be considerably higher and it depends on complacency towards the vaccine, confidence on its safety, perceived susceptibility to the disease and perceived severity to the disease coupled with modifying factors for cues for action. Healthcare workers should better communicate to improve the uptake of vaccine by reducing the barriers on the vaccine acceptance.

vaccine hesitancy

vaccine refusal

in-depth interview

key informant interview

COVID vaccination

Having produced a remarkable decline in the incidence of diseases that have long plagued humankind, vaccines are considered one of the greatest medical innovations of all time. From the inception of vaccination, there has been skepticism towards the vaccination, though there is no outright antagonism.¹ There was an increased public demand for COVID-19 vaccine initially due to concerns on scarcity; but vaccine hesitancy became a problem as supply met the demand and indeed has become a defining theme of the pandemic.

Vaccine hesitancy is defined as the delay in acceptance or refusal of a safer vaccine in spite the availability of services for vaccination.² Vaccine hesitancy and refusal should be dealt as an important issue as it carries both individual and community level risks. World Health Organization has announced vaccine hesitancy as one of the top ten threats to global health in 2019.³ Vaccine hesitancy is a complex phenomenon that varies across the place, time and type of vaccines. As on June 28, 2021, the percentage of people who were administered at least one dose and fully vaccinated with COVID vaccine were 27% and 5% respectively⁴ and as of June 17, 2022, the percentage of people who were administered at least one dose and fully vaccinated with COVID vaccine were 73% and 65% respectively.⁵ With regards to the Northeastern states of India, except for Sikkim, the percentage of individuals who are fully vaccinated is well below the national average; for instance 32% in Meghalaya, 33% in Nagaland and 39% in Manipur; with Meghalaya reporting the lowest coverage rate in India.⁵ This could be well compared with the coverage rates of immunization of children, in which the districts in tribal areas showed 56% coverage, which is lower when compared to the national average. The vaccination coverage remained lowest among the north eastern states of Nagaland (35.7%) and Arunachal Pradesh (38.2%).⁶

The challenges for successful vaccination could be addressed under four dimensions namely, development and production, allocation, affordability and deployment. These four dimensions of the global vaccination challenge are closely related, and the development and production steps have important implications for pricing, allocation, and public confidence.

Published research carried out largely in high-income countries have stated concerns about the safety of vaccines against COVID-19, including the rapid pace of vaccine development, as one of the primary reasons for hesitancy,⁷ but data from low- and middle-income countries (LMICs) have been limited.

The issue of vaccine hesitancy could be a potential marker for the decreased coverage rates of vaccines in our country, in particular the North-eastern states, since the tribal population are the vulnerable subset of people in a resource limited country like India. Several factors have been said to influence vaccine hesitancy, including socio-cultural context, religious beliefs, misinformation spread through social media, historical influences and mistrust, beliefs and attitudes about vaccines, and specific characteristics of the vaccines. Moreover, according to the WHO SAGE working model, targeting the under vaccinated and unvaccinated population directly along with increasing the knowledge and awareness on vaccination coupled with improved accessibility had proved to the most effective strategies in causing psychological shift to overcome vaccine hesitancy.⁸ Hence our study was planned to determine the extent of hesitancy and the reasons for the same toward the COVID vaccination among the tribal community of Meghalaya; where no proper assessment is not available till date.

A community based sequential explanatory mixed methods study was conducted among the individuals aged 18 years and above in the rural field practice area of NEIGRIHMS, Ri-Bhoi district (Vaccination coverage rate before commencing the study was 30%), after obtaining approval from the institute ethics committee. The rural field practice area of NEIGRIHMS caters to the population of around 20000 in the villages around the health centre. The study was conducted from November 2021 to January 2022. The quantitative part involved a cross-sectional study among the individuals aged 18 years and above residing in the village under the field practice area to determine the proportion of vaccine hesitancy. The qualitative part comprised of in-depth interview among the eligible residents of the village and key informant interview among the health workers providing the vaccination services in the rural health centre of NEIGRIHMS.

Quantitative (Cross-sectional Survey)

Sample size and sampling

Based on the proportion of individuals with vaccine hesitancy as 29%,⁹ with a relative precision of 20% at 95% confidence level, the sample size was estimated to be 235 using nMaster 2.0. A line-listing of adults (aged 18 years and above) was done and the individuals were chosen using simple random sampling until the sample size was reached.

Data Collection Procedure

The principal investigator along with a senior resident posted in the rural health centre was involved in the data collection. The eligible individuals were explained about the purpose of the study and the procedure involved before the administration of the questionnaire. Individuals were also assured regarding the confidentiality of the information, and data collection was started after obtaining informed consent. Information on socio-demographic variables was collected using a semi-structured questionnaire. The questionnaire also included individual’s perception toward COVID vaccine, hindrance related to access to point of delivery for vaccine, members involved in motivation for accepting vaccination after initial hesitation, and various reasons for vaccine hesitancy.

Qualitative (In-depth Interview And Key Informant Interview)

Data collection procedure

Seven in-depth interviews were conducted among the individuals at the place of their convenience using an interview guide. Individuals who were fully hesitant/ vaccine refusal (three individuals), partially/initially hesitant (three individuals) and non-hesitant (one individual) were selected for the interview. Individual with vaccine refusal was explored more on barrier factors, and individuals who accepted after initial hesitancy was interviewed to explore the reason for accepting the vaccination even after initial hesitancy. Individual who got vaccinated without any hesitation was interviewed to find the facilitating factors in the campaign. Two key informant face-to-face interviews were conducted with the vocal and willing health care workers who were selected purposively. Participants were interviewed regarding their perception on hesitancy toward the COVID vaccine and asked to give suggestions and solutions to improve the vaccine acceptance.

The interviewer was the principal investigator or co-investigator (senior resident) who was formally trained in qualitative research and also had previous experience in qualitative research. The interview started after obtaining consent and explaining the purpose and motive of the study. The privacy of the information was ensured by conducting the interview in an isolated room without the presence of any non-participants. Participants were ensured confidentiality of the information obtained through the interview. All the interviews were audio-recorded with consent with each interview lasting for 15–30 minutes. Field notes were taken during the interview. At the end of the interview, a summary was presented to the individuals for validation of the data collected. Transcription was done verbatim within two days of data collection to prevent the loss of information.

Statistical analysis

Quantitative

Data entry and analysis was done using SPSS V21 for Windows. The prevalence of vaccine hesitancy will be summarized as proportion with 95% confidence interval.

Qualitative

Collected data was transcribed verbatim followed by translation and back translation. Participant's statements were taken as a unit of analysis. Descriptive manual content analysis was used to derive the categories and codes and themes was generated using thematic analysis. Study was reported in accordance to the consolidated criteria for reporting qualitative research (COREQ).¹⁰

Ethics Statement

The study was conducted after obtaining approval from institute ethics committee (NEIGR/IEC/M15/F10/2021) and informed consent from the study participants.

Quantitative

A total of 238 eligible participants were interviewed of which 113 [47.5% (95% CI: 41.0%-54.0%)] participants were found to be hesitant to vaccination, among which 40 participants [16.8% (95% CI: 12.4%-22.3%) were initially hesitant and 73 [30.7% (95% CI: 24.9%-37.0%) were having vaccine refusal. (Fig. 1)

Qualitative

A total of seven in-depth interviews (one- non-hesitant, three- initially hesitant and three- vaccine refusal) and two key informant interviews (One ANM and one medical officer) were conducted. Table 1 shows the characteristics of the participants of in-depth interview.

Table 1

Characteristics of the study participants (in-depth interview)
Participants characteristics (In-depth interview)
P₁: Female aged 28 years with education till high school level and a home maker (Initially hesitant) P₂: 22 year old male who was a graduate student (Vaccine refusal) P₃: 58 year old illiterate female and a homemaker (Initially hesitant) P₄: Graduate female aged 27 years who was a homemaker (Initially hesitant) P₅: 21 year old illiterate pregnant female (Vaccine refusal) P₆: 25 year old female with higher secondary level of education (Non-hesitant) P₇: 52 year old illiterate female (Vaccine refusal)

Based on the thematic analysis using inductive approach, the following themes were generated from the interviews based on the health belief model conceptual framework (Fig. 2)

Individual related

Disease related

Vaccine related

Healthcare system and provider related

Socio-cultural and religious

Theme 1: Individual Related Factors

Lack of awareness and negative attitude

There was lack of awareness and negative attitude among most of the respondents, in particular among the responders without formal education

“Government say common cold, Coryza as COVID and so they take medicine from market” (ANM)

A 28 year old female who was initially hesitant was of the opinion that “There were many people who scared me who said that the vaccine is meant to kill a person so that he will not live long, its meant to reduce the population but later …………, I realized that I need to take the vaccine in order to protect myself since everyone was taking it.”

Health Consciousness

“I’m just you know a little want to take every precaution so that none of us catch it.” (A 25 year old non-hesitant female with higher secondary level of education)

Theme 2: Disease Related Factors

Some individuals were with a belief that the disease just mimics common cold and it is not severe.

The medical officer said that a patient was of the opinion that “I will probably wait. Is the cure worse than the actual virus itself? I might be a little concerned that if it is rushed that there may be some long-term side effects.”

“We heard here and there when they made announcements in the village. They said the disease spreads from one person to another.” - A 25 year old non-hesitant female replied when asked about the facilitating factor for taking the vaccine without any hesitancy.

Theme 3: Vaccine Related Factors

Skepticism about efficacy and fear of side effects

Majority of the individuals had vaccine related mistrust in its efficacy and were concerned about the side effects.

“I thought I will take it later because I’m breastfeeding but they assured us that even if I’m breastfeeding, it is still okay to get vaccinated. There is no harm to the baby so that is why I agree to take the vaccine.” (A 28 year old female who was initially hesitant)

“They are some people who were complaining that after giving the injection, they start getting sick and chills. (After a pause) Moreover we do not know what we carry in our body, ……. I have asked the Anganwadi worker whether they test before giving the vaccine, she said no.” (A graduate female aged 27 years who was initially hesitant)

“……..people were scared of the side effects” (ANM)

“Scared because I am pregnant” (21 year old pregnant female with Vaccine refusal)

Theme 4: Healthcare System And Provider Related Factors

“Because they said you just get the vaccine (not that you are not sick), so I was hesitant but when I understood it properly then I went to get vaccinated.” (A 58 year old illiterate female)

An initially resistant 27 year old female said that “Initially, I did not believe that it is for the COVID-19 disease. It was my little brother who told me even if people were saying whatever I took the vaccine.”

“I thought I will take it later because I’m breastfeeding but they assured us that even if I’m breastfeeding, it is still ok to get vaccinated. There is no harm to the baby so that is why I agree to take the vaccine.” (A 28 year old female who was initially hesitant)

Theme 5: Socio-cultural And Religious Related Factors

The religious beliefs were highly prevalent among those who refused taking the vaccine.

A 52 year old female refused taking vaccine saying that “I Believe in God. If God wants me to die, it’s okay.”

Similarly, a 22-year-old replied that “In God we trust”

Globally, even though majority of the population accept the vaccination, a considerable proportion of individuals refuse to some vaccines but accept to others whereas some delay vaccination or even accept to take the vaccines without surety. Hence, vaccine hesitancy could be defined on a continuum from those who accept the vaccine without any doubts to those who completely refuse taking the vaccines and the hesitant individuals are the heterogenous group of individuals between the two extremes. This mandates the assessment of individuals preference for COVID-19 vaccine acceptance which could remain a key for formulation of strategies for addressing the problems due to hesitancy and refusal. Furthermore, since there is dearth for data on the level of hesitancy in this part of the country, our study could well be a preliminary step to know the individuals’ concerns, preferences and willingness for COVID-19 vaccine.

Our study results show that vaccine hesitancy was present among 47.5% (95% CI: 41.0%-54.0%) participants, among which 16.8% (95% CI: 12.4%-22.3%) were initially hesitant and 30.7% (95% CI: 24.9%-37.0%) were having vaccine refusal. A nationwide study by Chandani S et al,¹¹ on vaccine hesitancy for COVID-19 had concluded that vaccine hesitancy was present among 37% participants, which is considerably lower than our study results. Previous studies by Chowdhury SR et al⁹ and Umakanthan S et al,¹² had reported the hesitancy to be 29% and 12% respectively. Our study results could be well compared with the immunization status of children 12–23 months old (routine immunization), where only 63.8% of children were fully vaccinated according to NFHS-5 reports.¹³ This clearly shows that the issue of vaccine hesitancy/refusal is already rooted deep in this part of the country and hence not surprising. A study by Danabal KGM et al¹⁴ in Tamil Nadu had shown similar prevalence of vaccine hesitancy and refusal as 40.7% and 19.5%, respectively.

With regards to factors contributing to vaccine hesitancy, most of the factors are well defined by various studies conducted elsewhere.^15,16 The conceptual framework for the factors associated with vaccine hesitancy was developed using health belief model, in our study.¹⁷ Health belief model is one of the commonly used frameworks for the prediction of human behavior and it is independently employed by various researchers to predict the intention to vaccinate.^18,19 At the individual level, the factors were built upon the perceived susceptibility and perceived severity with lack of awareness and negative attitude serving as a major barrier among the majority, in particular among the responders without formal education. A study by Chandani S et al¹¹ had also shown that the hesitancy was greater among those respondents who did not perceive the COVID as a severe and a serious disease. Even during the Measles and Rubella drive, the lack of awareness and mistrust were the important barriers.²⁰ Similarly, along the lack of awareness, health consciousness, skepticism about the efficacy and the fear of safety and mistrust on the vaccine and the delivery system were acting as major factors in the perceived benefits and perceived barriers; which eventually determined the acceptance of the vaccine. Similarly, the available literature also shows that the panic driven side-effects following vaccination, lack of proper information on the safety and effectiveness of the drug and co-morbidities were identified as the most common reason for vaccine acceptance.^12,21 One interesting finding in a study by Umakanthan S et al¹² is that spread of rumours through social media was one of the reasons contributing to the vaccination denial. Not surprisingly, false information/rumours and religious beliefs negatively impacted vaccine acceptance among our study respondents. Societal disagreements as an important predictor of hesitancy have been established in various other studies.^22,23 The results of a study by Mello MM et al had highlighted that the respondents who were adherent to COVID-19 preventive and safety measures strictly were found to have a higher uptake of vaccine, which is also similar to our study findings.²⁴ The involvement of community level personnel, health care workers and the political commitment when it acts in unison could well be helpful in the development of positive attitude in vaccine acceptance.

Adopting a mixed methods approach added strength to our study by making it possible to explore the barriers and facilitators of vaccine uptake both individual perspective and the healthcare worker perspective; not forgetting the fact that all the stakeholders could not be involved in the interview; which could have added more robustness to our results. Additionally, the study was conducted in a community setting which added further strength to the validity of our study findings. Nevertheless, our study findings could well have some programmatic implications. The primary care physicians; as always believed remain as a source of trusted information and they are the primary source of overcoming the fear due to the vaccine related problems and hence they are burdened with the duty of counseling the hesitant individuals in improving the confidence and hence vaccine acceptance. This is well supported by similar literatures addressing vaccine hesitancy.^25,26 Moreover, a safe system should be created for concerns regarding the vaccine through effective communication which could improve the individual’s confidence.

Hence it could be concluded that the vaccine hesitancy depends on complacency towards the vaccine (efficacy, safety), confidence on its safety, perceived susceptibility to the disease and perceived severity to the disease coupled with modifying factors like age, gender, literacy level, occupation, socio-cultural factors, religious beliefs and accessibility. The primary care physicians and other healthcare workers has the duty of counselling the hesitant individuals and in creating safe system for increasing the confidence for accepting the vaccine. Furthermore, larger community based studies would add more robustness for making better policy decisions.

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No competing interests reported.

Download PDF

Journal Publication

published 11 Jul, 2023

Read the published version in Journal of Patient Experience →

Version 1

posted

You are reading this latest preprint version

Vaccine hesitancy and factors related to vaccine hesitancy in COVID vaccination among a tribal community of Meghalaya: A mixed methods study

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Results

Conclusion and recommendations

Figures

Introduction

Materials And Methods

Quantitative (Cross-sectional Survey)

Sample size and sampling

Data Collection Procedure

Qualitative (In-depth Interview And Key Informant Interview)

Data collection procedure

Statistical analysis

Quantitative

Qualitative

Ethics Statement

Results

Quantitative

Qualitative

Theme 1: Individual Related Factors

Lack of awareness and negative attitude

Health Consciousness

Theme 2: Disease Related Factors

Theme 3: Vaccine Related Factors

Skepticism about efficacy and fear of side effects

Theme 4: Healthcare System And Provider Related Factors

Theme 5: Socio-cultural And Religious Related Factors

Discussion

References

Additional Declarations

Status:

Journal Publication

Version 1