Ever since the COVID-19 vaccines have become available, there have also been many myths and misinformation spreading about them. Countries all over the world are fighting the misinformation campaign targeting COVID-19 vaccines and the fight is likely to continue throughout the pandemic. Given the irrefutable benefit of the vaccination in ending the pandemic, it is imperative to increase their uptake and acceptance in communities.
The WHO has listed vaccine hesitancy in the top 10 threats to global health. It is defined as ‘delay in acceptance or refusal of vaccines despite their availability’ (World Health Organization, 2019). It is a key hindrance in achieving optimal vaccination coverage among populations around the globe. In the first few weeks of vaccine roll-out, media reports indicated vaccine hesitancy among healthcare workers in states such as Tamil Nadu and Punjab. Several state-level and regional surveys have since corroborated these anecdotal reports (Jayadevan et al. 2021).
The Delhi-NCR Coronavirus Telephone Survey-round 4 (DCVTS-4), administered between December 23, 2020, and January 4, 2021, provides some evidence of vaccine hesitancy. The survey, conducted by the NCAER National Data Innovation Centre, re-contacted randomly selected households who were reached out in the earlier rounds of DCVTS from Delhi-NCR — this included Delhi as well as rural and urban areas from selected districts of Haryana, Rajasthan and Uttar Pradesh. The findings showed that about 20 per cent respondents were certain about not taking the vaccine, with significant rural (22.4 per cent) and urban (17.5 per cent) differences being observed. An additional 4 per cent mentioned that they will not take it as they were already infected. Another 15 per cent were unsure about taking the vaccine. Combining all these three categories, vaccine hesitancy was found to be quite high (39 per cent) . The top three reasons for this hesitancy included “I plan to wait and see if it is safe and may get it later”, “I think other people need it more than I do right now”, and “I am concerned about possible side effects of a COVID-19 vaccine”. Further, state level hesitancy was found to be between 24% (Uttarakhand, Madhya Pradesh)- 34% (Haryana) in the states of AIF’s interest for the intervention.
Identifying lack of awareness, access and affordability as immediate impediments to vaccinating the vulnerable, AIF is forging strategic partnerships with key stakeholders, devising national awareness drives and behavior change campaigns under The First Million program. Its immediate focus includes facilitating registrations, securing priority vaccination slots for the vulnerable population and resolving multiple access issues through personalized support. Besides that, vaccine hesitancy will be tackled through a communication campaign.
In this context, discussions were conducted telephonically with 25 NGOs across 5 states- MP, Maharashtra, Haryana, Uttarakhand and Rajasthan, to understand the prevalent barriers and misconceptions regarding COVID 19 vaccines among the vulnerable communities that these NGOs serve.
Almost all of the NGOs catered largely to rural areas, and half of them additionally catered to urban areas as well. Most of the NGO personnel reported that the communities do not take COVID-19 as seriously as they should- they do not follow safety behaviors like wearing masks or social distancing, especially during large gatherings or when COVID infection numbers are low and they are not under surveillance. While all NGO personnel reported that the communities they work with have heard about COVID-19 vaccines, majority had observed hesitancy associated with getting vaccinated, mostly in rural areas.
The most prominent reasons that emerged for vaccine hesitancy across states were as follows-
- Fear of fever/ illness post vaccination
- Fear of sterility/ impotency
- The fact that vaccinated people were also getting infected
- Fear of death due to vaccine (mainly from across Madhya Pradesh and pockets of Maharashtra)
Among the vaccine eager population across the 5 states, barriers that came up were non-availability of vaccines, inability to register on COWIN app and not being able to afford days off from work to go for vaccination and associated sick days.
Majority of the NGOs reported that there were specific groups of people who were hesitant about vaccination- mainly men from the Muslim community and women in general.
When asked about the preferred sources of information regarding COVID-19 vaccine, the following came up:
- WhatsApp/Social media messages/videos
- Health worker- ASHA/ANM/AWW
- News on the television
Local opinion leaders like Sarpanch, Wardpanch, politicians and doctors were reportedly coming forward to promote vaccination across states. However, certain religious leaders, tribal chiefs and faith healers were not only dissuading communities from getting vaccinated but were also allegedly responsible for spreading misinformation. Hence, it would be prudent to specifically include these groups in any vaccination awareness campaigns going forward.
COVID-19 Appropriate Behaviors
People in Uttarakhand, Haryana, and Maharashtra were reported to be mostly serious about following COVID-19 prevention methods like wearing masks/ maintaining social distance but there is still a long way to go especially in rural areas. As per the NGO personnel, people in urban areas take precautions as more law enforcers/ police are around and they feel they are being watched, especially when the COVID numbers are high. They had observed that people tend to throw caution to the wind once the numbers go down.
It (following precautions) is erratic here. Sometimes when the numbers peak, they are very conscious and rest of the time a bit relaxed or casual about it.”- NGO, Rohtak (Haryana)
“In rural areas these rules are followed less. Many-a-times, their masks are very dirty. If they see any stranger, only then they use masks.”– NGO, Barmer (Rajasthan)
In states like Madhya Pradesh and Rajasthan, the communities by and large, do not follow COVID-19 safety methods, like wearing masks or social distancing, especially when it is most required like while attending religious festivals or weddings, at rations shops or in public transport due to lack of awareness.
“No one follows (COVID appropriate behaviors) … Even now, some weddings have 500 guests… people still don’t wash their hands properly, they don’t even know how to properly wash their hands.”- NGO, Shivpuri (Madhya Pradesh)
“People follow these rules when there is peak of this disease. Even then, low income groups do not have the luxury of having masks, sanitizers and don’t follow (precautions) – NGO, Rajsamand
Vaccine hesitancy was reported mainly among women and elderly across both rural as well as urban areas. Many elderly people feel that they have lived their lives, and they are also more likely to fall prey to rumors, as per NGO personnel. Women, especially those who stay at home either feel that they are safe from COVID-19 and hence do not need vaccine or fear that taking the vaccine will affect their menstrual cycle/ fertility adversely. The Muslim community was also reported to be hesitant.
Both rural and urban areas in Uttarakhand will have to be focused on with an awareness programme. In urban areas, while the awareness is more, the hesitancy is also more. On the other hand, people in rural areas feel they are healthier than their urban counterparts and hence feel that vaccines are unnecessary.
“People from rural areas are ahead when it comes to taking vaccines once their doubts are cleared. In urban areas (however), the response is not very encouraging and it takes more time to convince them”- NGO, Bageshwar
“The rural community is confident about their health as they think they breathe fresh air and eat healthy, thus they will not be infected by virus and even if they do, they will naturally recover”- NGO, Dehradun
NGO personnel also expressed that vaccine hesitancy was reported particularly from the Muslim community mainly due to lack of awareness and misinformation (i.e. will not be able to have children due to vaccination).
Hesitancy was observed among both old and young people but more pronounced among the former. Tribal areas were specifically talked about as being far from the center, hence people here are less aware and more hesitant. Some backward tribes were also mentioned in this regard- Sehria tribe (Sheopur), Bheel tribe (Shahdol), etc
In terms of gender, there was no difference reported as either the whole family was getting vaccinated or no one from the family was. In general, the view was that if the heads of households/ husbands are onboard, women and children follow.
People in urban areas were thought to be more aware with easy access to health facilities than their rural counterparts.
“The whole process (of vaccination) is very long and takes around 4 to 5 hrs starting from the home, reaching block level center and waiting there for some time, getting vaccinated and going home… This is a half day process. As lot of people don’t have their own vehicle and they are dependent on others so this delays the process”- NGO, Dewas
People have heard about the COVID vaccine and majority of them are eager to get vaccinated, especially in Jaisalmer, and to some extent in Alwar, Sirohi, Pali and Karohi. This eagerness is highest among the young people, especially males.
Some vaccine hesitancy among certain groups was reported from all districts but more so from Barmer and Rajsamand. There is more hesitation among the elderly and women (especially menstruating or lactating women). Rural communities were also discussed to be less aware and hence more hesitant, more specifically, SC/ ST and Muslim communities (due to rumors around death and sterility respectively as a result of vaccination).
“Urban population is more aware and eager for vaccine. Among the rural population, there is some hesitation and they are waiting others to get vaccinated (first). Those (women) who are lactating/ menstruating are hesitant (to take vaccine). They think that there may be side effect because they are weak at that time. And lactating women think that any side effect may harm their child also”. – NGO, Rajsamand
Those eager to get the vaccine face difficulties owing to unavailability of vaccines and in reaching the vaccination center.
“In many cases, people have to travel 3-5-7 km (to get vaccinated) and it is not easy… it takes a full day”- NGO, Siroli, Pali, Karoli
By and large, the people are eager to get vaccinated, and this eagerness is regardless of their age group, place of residence and gender.
“Women and men, young and old are equally eager to take vaccinations. There are very few exceptions like in case of death due to vaccination, where we intervene with support of government to educate them that there were other health issues perhaps which resulted in the death. Even rural people are now wanting to make a choice between Covishield, Covaxin and Sputnik based on their understanding… There is no difference in perception (of whether to take vaccine or not).”- NGO, Kurukshetra
The main issues that this largely vaccine-eager population was facing in getting inoculated were- vaccine unavailability, particularly for 18-45 years’ age group; and not being able to get registered online
Some hesitancy was reported from the Muslim community, mainly stemming from the fear of side effects- impotency (for men) and sterility (for women) came up in Yamunagar and Kurukshetra areas. Apart from this, convincing people from Nuh area has also been an ongoing effort for the government as well as the NGOs.
NGO personnel in the state unanimously felt that availability of vaccines and reduction of waiting time would go a long way in ensuring that the mobilization efforts do not go to waste and everyone eligible gets vaccinated.
There is vaccine hesitancy but mainly among the elderly. Women in some areas are more forthcoming, especially in Auragabad and Thane. However, it was also observed that if the head of the household was brought onboard for vaccination, the rest of the family will usually follow.
Vaccine eagerness was seen in urban areas owing to more awareness, even in low income households. However according to NGO personnel, they are unable to get vaccinated as vaccines are not available. On the other hand, rural communities are not getting vaccinated even if vaccines are available owing to misinformation like COVID is an urban disease and that they will be able to deal with it better than their urban counterparts, etc.
“In rural areas, people are not actively taking vaccine as there are rumors that the vaccine will work only for 1 year and they have to take (it) every year… (they feel) then why to take? They also think that rural people’s immunity is better than urban people.”- NGO, Aurangabad
“In Urban areas, people from slums are guided to follow the rules by the well-to-do families in building societies. In rural areas, they don’t even wear a mask.”- NGO, Thane
In Aurangabad and Nasik, NGO personnel also reported skepticism in communities with respect to the vaccine and fear of death due to vaccination:
“Some people got two doses and still they died which created fear in people but the people died due to other reasons which they don’t know.”- NGO, Nasik
NGO personnel also expressed that vaccine hesitancy was reported particularly from the Muslims, Tribal and SC/ST communities mainly due to lack of awareness. Men, mainly daily wage labourers were also reported as being more hesitant as they could not afford to fall sick and stop working.
It has emerged clearly from the research that vaccine advocacy and awareness is an urgent need of the hour. Hesitancy and misinformation associated with COVID-19 vaccines needs to be countered across rural and urban areas, but more pointedly in the former where there are lower levels of literacy and information penetration is also inadequate. Further, behaviour change communication, with community-level engagement must be done immediately to ensure that the inoculation drives are able to cover maximum number of people, especially from the most vulnerable sections.