This study evaluated the public trust, information sources and vaccine willingness amongst the general population of Trinidad and Tobago during the current COVID-19 pandemic. The study was conducted ten months after the start of the local epidemic at which point there was community spread in Trinidad and Tobago. As several COVID-19 vaccines have now been approved, Trinidad and Tobago, like many other countries, is preparing to vaccinate its population. The results of this study has implications for the public health and policy approach to COVID-19 in Trinidad and Tobago, particularly for the use of COVID-19 vaccines.
The results of our study showed that 62% of respondents were willing to take the COVID-19 vaccine if available and recommended and of these, only 25% strongly agreed to take the vaccine. This vaccine willingness rate is low with variable rates seen in other countries. A multi-country study examining potential COVID-19 vaccine acceptance across 19 countries, found 71.5% of respondents agreed to take the vaccine, although there was wide variation of vaccine acceptance [13]. In a recent study in the UK, 82% of respondents indicated a willingness to take the COVID-19 vaccine [14] while 64% of respondents in an early US study and 67% in a Saudi Arabian study said they would accept the vaccine [15, 16]. However, in both the US and UK studies there were differences in minority groups. In the UK, there were higher rates of COVID-19 vaccine hesitancy (defined as a delay in or refusal of vaccination despite availability of vaccination services [17]) in Black or Black British groups (72% unlikely/highly unlikely to get vaccinated) and lower rates of general vaccine uptake in Black Caribbean and Black African populations (50% vaccine uptake). In the US study, Black Americans had lower COVID-19 vaccine acceptance rates (40%). Adequate global vaccine uptake is an essential element in curbing the pandemic and the range of vaccine acceptance rates suggests that achieving herd immunity from vaccination may be challenging.
In addition to low COVID-19 vaccine willingness rates in ethnic minority groups, one US survey, conducted in September 2020, found low rates amongst health professionals as well. In that study, 63% of health professionals said they would take the vaccine [18]. Our study also found similar willingness rates amongst health care professionals with 61% stating they would take the vaccine if available and recommended (approximately 29% strongly agreeing). As COVID-19 vaccination programmes are initiated in countries, vaccination opinions may change and self-reported behaviours, willingness (or hesitancy) to receive the vaccine may not necessarily translate into actual behaviour. Therefore, alongside the technical preparations for the COVID-19 vaccine, it is also necessary to promote confidence in the vaccine through trusted institutions. We identified that higher levels of trust in the medical sector, inclusive of the Ministry of Health, were positively correlated with willingness to take the COVID-19 vaccine. This finding is consistent with studies conducted in previous health emergencies in other countries. During the H1N1 pandemic in the Netherlands, high levels of trust in the government had a positive relationship with intention to be vaccinated while during the Ebola outbreak in the Democratic Republic of the Congo, increasing trust in the government and health professionals were associated with increased acceptance of potential Ebola vaccines (1.5 times more likely to accept) [6, 19]. The multi-country study conducted on COVID-19 vaccine acceptance noted that the higher levels of vaccine acceptance were seen in Asian countries which often had greater levels of trust in governments [13]. Addressing vaccine hesitancy may involve mass education and health promotion campaigns providing populations with accurate, reliable information on the COVID-19 vaccine, using plain, non-technical language. Conducting campaigns in areas where there are high volumes of at-risk persons, such as health centers, emergency departments, pharmacies as well as private GP officers, may be beneficial. Engaging communities, co-producing information with trusted sources, allowing individuals to voice concerns and debunk myths may allow individuals to make an informed decision as well as develop vaccine delivery plans that incorporate local needs [9].
One review exploring vaccine hesitancy amongst health professionals found that vaccinated health care professionals were more likely to recommend vaccines to patients [20]. Since respondents in our study trusted health professionals as sources of information, it is necessary to build vaccine confidence in this group by addressing their own concerns and understanding what factors influence health professionals’ decision to recommend the vaccine [9, 20]. It is important to engage the various health professional associations providing necessary support to manage vaccine hesitancy as well as raise awareness of the COVID-19 vaccine both within their profession and the general population.
Supporting the national immunisation schedule and accepting the seasonal flu vaccine were other factors positively correlated with willingness to take the COVID-19 vaccine in Trinidad and Tobago. In Trinidad and Tobago vaccines are provided without direct cost in the public health system, through the Expanded Programme on Immunisation (EPI) [21]. The World Health Organization (WHO) implemented the Expanded Programme on Immunization (EPI) in 1974 with the aim of increasing immunization coverage internationally, especially among children [22]. In the Caribbean region, between 2013 and 2017, there was a general downward trend in vaccination coverage for several routine vaccines as well as a slow uptake for newer vaccines that were added to the routine schedule (eg, HPV) [23]. However, 2019 WHO and United Nations International Children’s Emergency Fund data for Trinidad and Tobago indicated a reversal of this trend with the estimated immunisation coverage above 90% for the majority of vaccines on the national immunisation schedule [24]. While this is encouraging, it should be noted that the national immunisation programme focuses on children and is often a requirement for children to be enrolled in school [25]. In our study 76% of respondents supported the national immunisation schedule suggesting that it is still necessary to improve vaccine acceptance generally. Overall, the region should critically explore the reasons contributing to decreased vaccination coverage and develop methods to build trust in the programme. This may involve implementing transparent vaccine safety monitoring systems which may alleviate concerns regarding serious adverse effects.
The study also found that increasing levels of trust in the medical sector were associated with decreasing levels of belief in misinformation as well as a greater likelihood of getting tested and sharing names of contacts. This demonstrates the importance of public trust in managing health emergencies and is consistent with results in other settings. In the early phase of the COVID-19 pandemic in the United States, one study found higher levels of trust in government sources such as the Centers for Disease and Control (70%) and lower levels of trust in social media (27% Facebook) [5]. This is important for public health communicators when deciding which media to use to share information on COVID-19 as well as ensuring that these media forms share accurate and reliable information.
Most respondents in our study believed that important things happened which the public was not aware of and that politicians usually were not forthcoming with their true motives. Therefore, on-going risk communication may be beneficial in strengthening trust in institutions generally, ensuring that populations are provided with relevant, accurate information. Our study also identified that lower levels of education and health literacy were associated with increased levels of belief in misinformation. The effect of misinformation on compliance with public health measures has been demonstrated in other studies [6, 26, 27]. Although, overall the belief in misinformation was low in this study, focusing on strengthening health literacy rates in the country, correcting misinformation, implementing targeted health promotion and health education campaigns and continuing to build trust in the medical sector may support compliance with public health measures in this pandemic and future health emergencies.
Study limitations
There are several limitations that should be acknowledged. The survey was cross-sectional in nature and therefore the results are representative of that point in time. Although the survey captured responses from all counties, some areas remained underrepresented, with the majority of participants based in Trinidad. Focused surveys may be required for the island of Tobago as well as rural areas in Trinidad. As a result of resource limitations, this study was not able to specifically focus on the growing Venezuelan migrant population in Trinidad and Tobago. As migrant groups are especially vulnerable in the pandemic, a separate study should target this sub-population.
While using the online survey format was necessary given the social distancing restrictions, the format may have limited participation from certain subsets of the population such as the elderly, those in rural areas with no internet access and those belonging to the migrant population. Using computer assisted or telephone interviews may assist with increasing participation. Although the survey attempted to provide participants with a range of responses, it would also be useful to conduct qualitative research (ensuring adherence to local restrictions) to provide a deeper understanding of the factors contributing to vaccine hesitancy.