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ORIGINAL ARTICLE
Year : 2022  |  Volume : 66  |  Issue : 2  |  Page : 147-151  

Perceptions on COVID-19 Vaccination among People Aged more than 50 years in Urban Field Practice Area of Department of Community Medicine in a Tertiary Care Teaching Hospital, Hyderabad: A Reflection from Focus Group Discussions


Assistant Professor, Department of Community Medicine, ESIC Medical College, Hyderabad, Telangana, India

Date of Submission01-Sep-2021
Date of Decision18-Nov-2021
Date of Acceptance22-Dec-2021
Date of Web Publication12-Jul-2022

Correspondence Address:
S Suthanthira Kannan
Department of Community Medicine, ESIC Medical College, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.ijph_1737_21

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   Abstract 


Background: Despite several efforts to limit the viral transmission, the COVID-19 vaccine has been the only “the ray of hope” to end the pandemic. However, vaccine hesitancy could reduce coverage and hinder herd immunity. People's intention to get vaccinated can be shaped by several factors, including risk perception which, in turn, is influenced by effect. The need to acquaint oneself to the beliefs, concerns, and circumstances of one's own population in the community becomes important for successful implementation of the program. Therefore, the present study was conducted to gain insights into perceptions of vaccination. Objectives: The objective is to understand the felicitating factors and hindering factors for acceptance of vaccines by the population among people aged 50 years in urban field practice area of the Department of Community Medicine in a Tertiary care teaching hospital, Hyderabad. Subjects and Methods: Data were extracted from audio recording of five focus group discussions that were conducted in the urban field practice care of a tertiary care teaching hospital in Hyderabad through open-ended questions. Categories, subcategories, and themes were created by deductive approach. Results: The motivating factors for vaccine acceptance were found to be fear of getting disease, wanting to return normalcy, and trust in treating doctors, whereas, barriers were fear of death due to vaccine, opacity in vaccine details, anxiety, and misinterpretation of adverse events. Conclusion: Having a clear understanding about the belief system of the target population could help in designing the guidelines for vaccination program to escalate the immunization and increase the acceptance.

Keywords: COVID-19 vaccination, focus groups discussions, Hyderabad, qualitative study


How to cite this article:
Rajeshwari S, Kannan S S, Shahnoor H, Katkuri S. Perceptions on COVID-19 Vaccination among People Aged more than 50 years in Urban Field Practice Area of Department of Community Medicine in a Tertiary Care Teaching Hospital, Hyderabad: A Reflection from Focus Group Discussions. Indian J Public Health 2022;66:147-51

How to cite this URL:
Rajeshwari S, Kannan S S, Shahnoor H, Katkuri S. Perceptions on COVID-19 Vaccination among People Aged more than 50 years in Urban Field Practice Area of Department of Community Medicine in a Tertiary Care Teaching Hospital, Hyderabad: A Reflection from Focus Group Discussions. Indian J Public Health [serial online] 2022 [cited 2022 Aug 18];66:147-51. Available from: https://www.ijph.in/text.asp?2022/66/2/147/350655




   Introduction Top


Vaccination is regarded as one of the most important public health measures to combat both communicable and noncommunicable diseases. However, over the years vaccine hesitancy has become a growing focus of concern and attention. Vaccine hesitancy is defined as delay in acceptance or refusal of vaccines despite the availability of vaccination services. Vaccine hesitancy is a continuous sequence of behaviors between full acceptance and complete refusal which is influenced by factors such as complacency, convince, and confidence.[1]

In India COVID-19 vaccination started on January 16, 2021, as of May 05, 2021, India had administered 160,494,198 doses including 1st and 2nd dose of currently approved COVID-19 vaccine, i.e., Covishield and Covaxin.[2] A significant proportion of India population experienced vaccine hesitancy for the new COVID-19 vaccination which posed danger to individuals and their community as exposure to this contagious disease pathogen placed the person at risk and favored the spread of the disease, which in turn lead to creation of new virulent mutants leading to subsequent new wave of infection in the community. Hence, this study was planned to address this important concern in the current COVID 19 crisis, exploring this aspect of vaccination will definitely help our policymakers to undertake appropriate measures to improve vaccine acceptance, coverage and achieve the desired national targets.

The present study was conducted with the objective of understanding the Perceptions on COVID-19 vaccination among people aged more than 50 years, before it is initiated in the second phase of COVID-19 vaccination program in the urban field practice area of the Department of Community Medicine in a Tertiary care teaching hospital, Hyderabad.


   Subjects and Methods Top


After obtaining the Institutional Ethics Committee approval, the study was conducted in urban field practice area of ESIC MC, Sanath Nagar Hyderabad. Focus Group Discussions (FGDs) were conducted among five different groups involving a total of 39 people aged more than 50 years. The study was conducted between 1st and 27th February 2021.

Research team and reflexivity

The research team involved a facilitator, notetaker, and a recorder. The facilitator was MD in community medicine (first author, SR), trained in Qualitative research and mixed-method research methodology. Other researchers were taught by the facilitator on the areas of note-taking, recording, transcription and coding for the purpose of the study.

Study design

Grounded theory approach was used to understand the perceptions of the study participants on COVID-19 vaccination.

Participant selection

Participants were selected based on purposive sampling. They were approached face to face with the help of the field workers (Accredited Social Health Activist or Auxiliary Nurse Midwife) catering to the area and whoever were consented to participate were included in the FGD, they were all informed about the study objectives and assured about the confidentiality. The FGDs were done at a place convenient to participants and researchers such as Urban Primary Health Center, Basti clinics, temple in the Urban field practice area. Each FGD had 6–12 participants seated facing each other, along with the facilitator and note-taker. The study was done before the introduction of the COVID-19 vaccines for elderly age group in India as part of second phase of COVID-19 vaccination. Before the beginning of the study, a question guide was prepared by authors after through literature review and brainstorming and pilot tested in another group to ensure that objectives of the study were met.

FGDs were conducted in Telugu and Hindi, lasting for about 45–60 min. Audio recordings of the FGDs were taken, field notes were taken during and after the FGD. FGDs were continued until no new information was obtained from the discussion and saturation level was obtained after 5 FGDs.

Data analysis

The audio recordings from Hindi and Telugu were transcribed and translated into English. The transcripts were coded by two coders (HS and KS), they were further analyzed by first author (SR) manually by inductive approach.[3] The themes were identified from the codes and categories after coding the transcripts.

The findings were summarized to the participants in the group to establish member check and found relevant to their expressions. Field notes during and after the FGD were written and any striking impressions from the facilitator was documented to account for any bias. The study was scrutinized using consolidated criteria for reporting qualitative study[4] and found to be compliant with the guidelines except for the disclosure of participating subject identity.

The script was written, reviewed, and revised by other authors. Finally, the script was prepared for publication.


   Results Top


Demographic characteristics of the subjects

A total of 39 elderly participated in 5 FGDs in Urban field practice area of ESIC hospital. They were in the age group of 50–70 years. 25 women and 14 men participants. All the 25 women were homemakers. Out of 14 men, 3 men were involved in manual labor, carpenter, and businessman, remaining of them had retired from work and were staying at home.

After coding the transcripts, two major themes were identified, motivating factors for vaccination and barriers for vaccination uptake. Under the themes, subthemes were identified as follows. This is depicted in [Figure 1] and [Figure 2].
Figure 1: Motivating factors for vaccine acceptance.

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Figure 2: Barriers for vaccine acceptance – (The responses are based on ascending order of responses).

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Motivators for vaccination

Fear of COVID-19 disease

In general, all participants expressed their fear for the disease but few elderly thought vaccine might prevent them from getting infection they also thought that with vaccination, infection reduces or they will not get infected “With vaccine, corona will reduce madam, even if it comes it will be less” said a 65-year old woman. “If we take the vaccine, we will survive” said another woman confidently.

Trust

They trusted the health care providers and believed that it was for their wellbeing and of the community that vaccination was promoted. All the participants together said in chorus “Doctors are saying vaccine is good, you are giving it to us because it is good know? Otherwise why will you give us? They expressed their need to hear few reassuring words of motivation by their treating doctors “if my treating doctor tells nothing will happen with vaccine, we will take the injection” said a 70-year-old gentleman. “We should be informed what happens if we take the vaccine. We want to know!” said another woman aged 65 years with authority expressing their obligation to know about the vaccine. They also wanted to know about vaccination and its effect on health especially if there were any other comorbidities, like in the quote “We have all problems and diseases, should we take the injection after they are all controlled or can we take it directly? We need certain information on this.”

Returning to normalcy

Our elderly expressed their wish to see all things becoming normal. “If we take injection, we can again start to live normally, without these masks” said a participant. Another woman said, If I take the vaccine, my fear about going out will go. Then I can go out to nearby temple to pray.”

Suggestions

When asked about how to improve the acceptance of vaccination among the elderly in the community, they said, “If vaccine is given to big people like political leaders, doctors or anyone well known in front of us, like it is done in election campaign right in front us and instead of just showing it on TV or media, then people will trust and have faith in the vaccine. We will think when they only can take why don't we also take… their word of mouth will spread and all will want vaccines” they also told that “Government should regulate private hospitals for the minimum cost of vaccine and restrict private hospitals from charging extravagantly on hospitalisation due to vaccine.

Barriers for vaccination

The factors for influencing vaccine acceptance and hesitancy are described under.

Fear

We found that myths and misconceptions regarding the safety of the vaccine to be a major barrier to its acceptance among our participants. Fear of some adverse event or death happening because of the jab was expressed my majority like “We cannot tolerate, we are old age people, we worry if something might happen, we get scared. Because of this we back off from taking injection.” said one elderly and another said “We are getting scared of dying with vaccine side effect”. There was a lot of speculation regarding their age and tolerability for vaccine. One gentle man also said “If vaccine is taken it will cause infertility”.

Ignorance

The ignorance about the disease as reducing in aggregate numbers was found to be an inhibiting factor for vaccination uptake as told by a participant that “Corona is over. There is only little left and it is also reducing.”

Anxiety

“We cannot go alone to hospital, our children have to go to their duties, they have to pay their children school fees and have other responsibilities, we don't want to trouble them, if anything happens to us, our children should not have the difficulties, that is the fear we have” said an elderly woman who was worried about the burden her children might have to face as she anticipated hospitalization as a result of vaccination. Another woman who was 59 years old said, “Something we do for the pain and other problems we have now, and spending life somehow, but if this gets worse with vaccine, then who will look after us? We are scared if we die” who did not want any additional problems which would add on to her already existing health issues. “Death is anyways inevitable, it has to come, but instead of living 4 days we will die early in 2 days because of injection” said another participant who didn't want to take any risk with life. To add to this, another participant expressed doubts regarding vaccination, “If something happens because of injection? why spoil life unnecessarily, instead of taking the injection, I would rather stay at home, that would be better.” The trust and willingness that was there many years ago when small pox vaccine was given is not there today as told by a 68-year-old lady “When we were small we were given small pox vaccine, that time no fear was there, we used to demand for vaccine to be given for our children also, now we are scared because of corona, even if one speaks the other person gets infection, death scares.”

Frustration

Resentment toward private hospitals was expressed in terms of overcharging. It was evident in phrases told by most of our participants “In private hospitals, they will give injection, if something happens, they will ask us to wait for some time and then wait more… and charge more”. A 70-year-old man expressed his disappointment with not being able to get proper and required information regarding vaccination. He said, “Even if we go to doctors they only write, they won't tell anything, whether we take or not take the injection with our existing problems?” Fear of death because of vaccination was strongly imprinted in the minds of the elderly participants as a woman said, “They are saying after vaccination you will get power to fight the virus. We should survive first after taking the vaccine for that isn't it?

In one of the FGDs, A thought of not trusting any of the measures was told, instead only believing divine in a statement, “we did everything what government asked us to do., we used masks, sanitizers, distancing, masks, nothing was effective and now vaccine will also not work. It is only increasing. Now we are leaving all that god only will take care of us.”

Source of hesitancy

All our participants said that TV, radio newspaper, and neighbors were their major source of information. They expressed anguish over the Television media “In news they are telling that people are dying because of taking injection, I have friends in Town X, they have taken injection and died even though he was young and healthy.” Another participant said, “TV also not giving proper information. They are only telling it can be taken but are not answering any of our concerns like if it can be taken with other diseases being present?” Resistance for vaccination was also because they believed that the vaccine was still under research and has not yet proven to be safe. “I still feel vaccine is under trial that is why not given to everyone” said another elderly.


   Discussion Top


Vaccination is considered to be one of the greatest achievements of public health. Lack of confidence in vaccines is now considered a threat to success of vaccination program. Vaccine hesitancy is believed to be responsible for decreasing vaccine coverage and increase risk of disease outbreak and epidemics.

In our study, we were able to address both motivating factors and barriers to the COVID 19 vaccine. One of the motivating factors from our study was fear of disease. This was similar to the study conducted by Manthiram et al.[5] where the found out that fear of disease is a major driver for vaccination. Szmyd et al.[6] in their study also reiterated the same finding as fear of catching COVID 19 to be a motivating factor.

The second major motivator of vaccine acceptance was trusting local general practitioners and government health systems that deliver vaccines. Our participants believed that reliable information from local doctors and accessible immunization services foster trust. Several studies have demonstrated that a medical professional recommendation to vaccinate has positively correlated with uptake of vaccination in our study too, the participants voiced high confidence in doctor's recommendation.[1] According to the study by Lazarus et al.,[7] in the countries with high levels of social trust on national governments, for example, China, South Korea, Singapore, the approval rate of the COVID-19 vaccine exceeded 80%.

Although many subjects may repeat the critical information they received from the media, these claims rarely originate from the subject de novo. These vaccine myths could be easily removed by the influencer group which consists of highly acclaimed social group such as doctors, TV actors, politicians, local political leader. Misinformation spread through multiple channels could have a considerable effect on the acceptance of a COVID-19 vaccine.[8] Positive reinforcement of the value and safety of immunization from these community members makes immunization a social norm. This finding is recommended by Agarwal et al.,[9] Healthcare workers and other health actors have a crucial role in improving confidence towards childhood vaccination by communicating accurate information about risks and benefits of vaccines to parents.

In our study, we found that participants felt there was an opacity in vaccine details as many opined that vaccines ware still under trial. Thiagarajan et al.,[10] also depicted the same finding mentioning that hurried approval of the vaccine threatens to undermine domestic trust. In the study by Feleszko et al.,[11] 17% of participants could have been convinced with the presentation of the results of scientific research on vaccine safety, 11% would vaccinate themselves to enter foreign countries which would require that, and 10% would take a vaccine if there would be a high fine.

The main barrier found in our study was the concern over adverse effect following vaccination misinterpreted to cause death was an important finding as also expressed by researchers Evedube[12] misinterpretation of AEFI is associated with a complete refusal to all vaccinations and Rief.[13]

The aggregated cumulative number of cases reported on various platforms was giving a perception of the number of cases as reducing and elderly participants no longer see the need for COVID-19 vaccine as preventive measure. This creates a sense of ignorance among the public. Research by El Elimat[14] state about people perceiving the existence of conspiracy around the Covid 19 pandemic which questions trustworthiness about the benefits of the vaccine.

It is very important in COVID 19 crisis that the benefits of the vaccination need to be communicated to balance out the more readily available information about the risk and adverse effects from the media. Strategic placement of key information in physical and virtual places where people spend time can help to spread the words beyond scientific journals.

Last but not the least, the media should be more responsible and selective in their reporting of adverse event. The strength of the study is a qualitative study with over 5 FGDs which allows the crossing of the data. Compared to the existing literature on vaccine hesitancy our study is the first of its kind in this age group where we are able to address both the motivating factors toward arrival of new vaccine and barriers which can be removed at the grass-root level by just priming the target group.


   Conclusion Top


At times of a pandemic like this when the only strategy to prevent mass fatalities is vaccination, every attempt to break the barriers of its acceptance is important for successful immunization coverage. Having an understanding about the believes, attitudes, needs of the target population helps in designing the guidelines, education materials accordingly that can be used and implemented before the launch of the program. This not only adds on to the success of the program but also saves the precious time in mass vaccination programs like this.

Limitations

A major limitation of the study was the fact that it was done in the field practice area of our hospital area. Moreover, there are some local factors which may not be applicable everywhere. Even with these limitations, we feel that the findings can be transferable to policy level.

Acknowledgments

The authors would like to thank medical officers of urban health centers and ASHA workers.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Butler R, MacDonald NE; SAGE Working Group on Vaccine Hesitancy. Diagnosing the determinants of vaccine hesitancy in specific subgroups: The Guide to Tailoring Immunization Programmes (TIP). Vaccine 2015;33:4176-9.  Back to cited text no. 1
    
2.
Coronavirus in India: Latest Map and Case Count. Available from: https://www.covid19india.org. [Last accessed on 2021 May 08].  Back to cited text no. 2
    
3.
Tjora A. Qualitative Research as Stepwise-Deductive Induction. London: Routledge; 2018. p. 179.  Back to cited text no. 3
    
4.
Consolidated Criteria for Reporting Qualitative Research (COREQ): A 32-Item Checklist for Interviews and Focus Groups | The EQUATOR Network. Available from: https://www.equator-network.org/reporting-guidelines/coreq/. [Last accessed on 2021 May 08].  Back to cited text no. 4
    
5.
Manthiram K, Edwards K, Hassan A. Sustaining motivation to immunize: Exchanging lessons between India and the United States. Hum Vaccin Immunother 2014;10:2930-4.  Back to cited text no. 5
    
6.
Szmyd B, Karuga FF, Bartoszek A, Staniecka K, Siwecka N, Bartoszek A, et al. Attitude and behaviors towards SARS-CoV-2 vaccination among healthcare workers: A cross-sectional study from Poland. Vaccines (Basel) 2021;9:218.  Back to cited text no. 6
    
7.
Lazarus JV, Ratzan SC, Palayew A, Gostin LO, Larson HJ, Rabin K, et al. Author correction: A global survey of potential acceptance of a COVID-19 vaccine. Nat Med 2021;27:354.  Back to cited text no. 7
    
8.
Cornwall W. Officials gird for a war on vaccine misinformation. Science 2020;369:14-5.  Back to cited text no. 8
    
9.
Agrawal A, Kolhapure S, Di Pasquale A, Rai J, Mathur A. Vaccine hesitancy as a challenge or vaccine confidence as an opportunity for childhood immunisation in India. Infect Dis Ther 2020;9:421-32.  Back to cited text no. 9
    
10.
Thiagarajan K. COVID-19: India is at centre of global vaccine manufacturing, but opacity threatens public trust. BMJ 2021;372:n196.  Back to cited text no. 10
    
11.
Feleszko W, Lewulis P, Czarnecki A, Waszkiewicz P. Flattening the curve of COVID-19 vaccine rejection – An international overview. Vaccines (Basel) 2021;9:44.  Back to cited text no. 11
    
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Dubé E, Laberge C, Guay M, Bramadat P, Roy R, Bettinger J. Vaccine hesitancy: An overview. Hum Vaccin Immunother 2013;9:1763-73.  Back to cited text no. 12
    
13.
Rief W. Fear of adverse effects and COVID-19 vaccine hesitancy: Recommendations of the treatment expectation expert group. JAMA Health Forum 2021;2:e210804.  Back to cited text no. 13
    
14.
El-Elimat T, AbuAlSamen MM, Almomani BA, Al-Sawalha NA, Alali FQ. Acceptance and attitudes toward COVID-19 vaccines: A cross-sectional study from Jordan. PLoS One 2021;16:e0250555.  Back to cited text no. 14
    


    Figures

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