A qualitative exploration of perceptions of the COVID-19 vaccine in Malawi during the vaccine rollout phase

INTRODUCTION

Vaccination against COVID-19 is an important step towards ending the COVID-19 pandemic^[1]. To date, 2.17 million doses of COVID-19 vaccines have been administered in Malawi, and an estimated 6.0% of the total population in Malawi has been fully vaccinated^[2]. Malawi has received a total of 4,469,720 million COVID-19 vaccine doses from COVAX, African Vaccine Acquisition Trust (AVATT), bilateral and donations. The COVID-19 pandemic is the latest epidemic incident that requires us to rethink and adjust the current healthcare models without any further delays. Health can no longer be conceived only in relation to human beings; it should also be considered in global terms, as a dimension that connects humans, plants, animals, and the environment as a holistic, One Health. While many approaches grouped under the One Health can be useful for limiting the spread of new epidemics or pandemics, they face significant implementation difficulties because they require significant changes, such as attitudes, social, and ethical practices. In Malawi, many are either undecided or have refused to be vaccinated^[3]. Vaccine hesitation is a deferment in getting vaccinated or a rejection of vaccination despite the accessibility of vaccination services^[4]. There are several factors that have been reported to be associated with vaccine hesitance, such as gender (women, especially pregnant women and those in the reproductive age bracket, are more hesitant than men), age (young people are more undecided than older people)^[5,6], and educational status (lower educational level is associated with higher hesitancy)^[5,6]. Other studies have reported conspiracy theories, attitudes, and beliefs as some factors that cause hesitancy^[7-9]. The majority of the Malawian population who have been hospitalized due to COVID-19 are unvaccinated, and therefore it is important to realize the reasons to develop interventions that can be developed to increase vaccination rates. While it is imperative to unearth mental issues behind COVID-19 vaccine hesitation^[10], most of the studies conducted have been quantitative. In-depth, qualitative exploration would be beneficial to understand how these views and attitudes are developed and sustained. To our understanding, there are very few small-scale case studies published in the Daily Times and the Nation newspapers in Malawi that have focused on certain populations (healthcare workers and police) and locations.

We anticipate that reasons for vaccine hesitancy will change over time as rollout progresses. Thus, this study aimed to explore factors leading to hesitation to and/or refusal of the COVID-19 vaccination in Malawi from a group of people enrolled in a community-based project.

METHODS

This study contributes to the Zambia Malawi Collaboration (ZaMaC) component in Malawi. It is part of a capacity strengthening project with an element of implementation research. Data collection on demographic and mental issues associated with COVID-19 vaccine acceptance were collected via a survey. The Malawi vaccination rollout program was prioritized by age groups (starting with the elderly) at the time of data collection. Near the end of data collection, vaccines had been made available to younger adults over the age of 18 years.

RESULTS

DISCUSSION

This study explored opinions on the COVID-19 vaccine from a sample of the population residing in Area 18, Mitundu, and Kawale community in Central Malawi. Several aspects of the elements herding reluctance towards rejection of the vaccine emerged. These included fear over short- and long-term efficiency and efficacy of the vaccine, perceived political pressure to get vaccinated, and the vaccine is ineffective and experimental and a form of clinical trial on the population. However, some participants were motivated to get vaccinated with the desire to have things return back to “normal”.

Vaccine safety and fear of side-effects are important concerns that have been reported in previous studies as a barrier to COVID-19 vaccine uptake^[13]. However, our findings reveal that providing vaccine options may lessen the fear and increase uptake of vaccines.

The perceived political force to be vaccinated is a barrier to vaccine uptake. In some instances, respondents reported regret after receiving vaccination, which may affect uptake of second or booster doses with people choosing not to be vaccinated. Information campaigns and advocacy may be an alternative strategy and useful to allow people to raise and air out concerns. In addition, empathic and ordinance recommendation may be required to encourage change, since it has proven successful for vaccine hesitancy elsewhere^[14]. This should be explored as an alternative option in the near future.

Finally, respondents raised a concern that the COVID-19 vaccine is dangerous and experimental (trial-basis); this inference emerged as a result of balancing the risks and benefits, which has been previously reported as an important factor in changing people’s approaches towards COVID-19 vaccination^[15]. However, some may end up forming negative attitudes as propagated by some media and misinformation over the Internet^[13,15]. In addition, some respondents mentioned that they had lost faith and trust in getting any accurate information from the government. Therefore, providing clear, correct, and accurate information is important, in particular from the government and especially if passed via media.

Despite all the negative sentiments towards vaccine hesitancy, some respondents were motivated to get the vaccine with a perception that it will protect them and others as well as a way to fast-track getting things back to “normal”. This would be a good government strategy for nation-wide campaigns in the country. In line with this, people should be encouraged to follow all COVID-19 guidelines. Media, e.g., social media and radio, can also be utilized to deal with COVID-19 vaccine hesitancy^[16], dismissing mythologies about the vaccine and pursuing all the misinformation being passed around.

The factors described above raise great concern if not addressed as a whole, as described in the One Health approach^[17]. Health is important, and, given the Covid-19 pandemic, there is a lot of interaction among people, animals, plants, and the environment. For this reason, it has become apparent that one should protect the health not only of human beings but also of the whole ecosystem and its components. COVID-19 vaccines are a step closer to change the epistemological stance.

This study offers argument into COVID-19 vaccine hesitation from an extensive set of qualitative data collected from respondents in Central Malawi. Most respondents were from Kawale and Area 18 with a small population from Mitundu. We recognize some limitations in our study. The responses were all written, and hence there was no opportunity to ask participants for additional elaboration on their respondents. Hence, further exploration using focus groups and individual interviews is required to gather more extensive and in-depth responses. Nevertheless, we conducted qualitative research with 284 participants with some respondents expressing themselves at length. The data collection was carried out during the time of COVID-19 vaccine rollout with reports of vaccine stock-outs. In addition, the Government of Malawi rolled out the COVID-19 vaccine in a phased approach starting with healthcare workers and other priority groups such as immigration officers, police officers, teachers, and those with underlying condition and/or above the age of 60 years; hence, some respondents were not eligible to receive it yet due to this approach. This would have contributed to some of the responses. However, most adults had received at least one dose of the vaccine, and, towards the end of data collection, all adults above the age of 18 years were eligible for vaccination. However, further insight into COVID-19 hesitancy or refusal could be gained by conducting broader qualitative research on vaccine hesitancy.

This was an online qualitative study, and we acknowledge that our findings may not be generalizable to the wider Malawian population. The results were gathered by online survey, which might have excluded people who would have otherwise contributed to the study. In addition, our findings were generalized because the responses were written, and there was no room for further probing. However, the examples presented provide insight into the factors driving vaccine hesitancy. We believe that our study can further improve strategies to optimize vaccine coverage. There is room for further in-depth interviews and focus group discussions that would make it possible to weigh each of the dominant perceptions and provide specific approaches to overcome them.

In conclusion, this study provides understanding of COVID-19 vaccine hesitation from qualitative data collected from respondents from Central Malawi. Our study provides an understanding of how COVID-19 vaccine hesitation could be tackled. There is a need to design interventions that support individuals by ensuring the correct information is provided to allow people to make decisions. Recognizing and focusing on the barriers revealed by this study can contribute to increasing COVID-19 vaccine acceptance and uptake in Malawi and possibly elsewhere. In addition, stakeholders should map out the needs pointed out by the different respondents by community to develop a harmonized campaign to raise uptake of COVID-19 vaccines.