The Lived Experiences of a COVID-19 Immunization Programme: Vaccine Hesitancy and Vaccine Refusal

"This study describes and interprets the findings to reveal the complex picture of the COVID-19 immunization program in Malaysia and uncovers its impact on vaccine hesitancy and refusal."

Despite the rapid advances in COVID-19 vaccine development and the free vaccines offered in Malaysia through the Malaysian National COVID-19 Immunization Program (NIP), the ultimate goal of breaking the coronavirus transmission chain is highly dependent on the acceptance and uptake of people towards these vaccines. Vaccine hesitancy may be due to a combination of social and behavioural factors that are described in frameworks such as the "3Cs" Behavioral Model developed by the Strategic Advisory Group of Experts (SAGE) on Immunization to highlight the role of complacency, convenience, and confidence in vaccination decisions. This study uses the 3Cs Model to capture the social and behavioural factors that determine vaccine hesitancy and vaccine uptake in Malaysia by investigating the subjective experiences of participants in that country's COVID-19 immunisation programme. The goal is to provide a fuller picture of vaccine implementation, vaccine hesitancy, and vaccine refusal so as to identify facilitating factors that could enhance vaccine acceptance and uptake.

A primer on SAGE's 3Cs model helps provide context for the study:

• Complacency refers to individual perception of risks and values of vaccines. For example, a lack of transparency in policymaking and misinformation from the media can potently induce complacency.
• Convenience is a factor in which physical barriers like availability, affordability and willingness-to-pay, geographical accessibility, ability to understand (literacy), and attractiveness of immunisation services impede the acceptance of vaccination.
• Confidence is crucial to promote engagement and trust between members of the public and the government and, subsequently, is a predeterminant of public compliance. For example, intensive coverage on the incidence of adverse reactions from COVID-19 vaccines by social media or local media may discourage people from being vaccinated.

Data collection took place in the summer of 2021, during NIP Phase 1 (priority groups: healthcare workers, senior citizens, high-risk groups with chronic diseases, and people with disabilities) and Phase 2 (adult population (citizens & non-citizens) aged 18 years and above). The qualitative study employed the hermeneutic phenomenological study design, as informed by the philosophical underpinnings of Heidegger. This approach involved inquiring into the meanings of individuals' "being-in-the-world" as they exist in their social, political, and historical settings.

Purposive sampling strategies were used to recruit 59 Malaysians with direct experiences with friends, family members, and their community who were hesitating or refusing to accept the COVID-19 vaccines. The reason for this criterion was that it was difficult to recruit participants who would proclaim themselves to be hesitating or planning to refuse the vaccine in a focus group interview (FGI). The majority of the participants had not had the COVID-19 vaccination at the point of the FGIs. Many of them reported being volunteers or leaders in churches, temples, or mosques or active in their community organisations. Several recounted their active interaction with their family and community members on the vaccines and their efforts to help elderly members register for the vaccines.

Findings from the 7 FGIs show a complex picture of interrelated factors affecting the participants' attitudes towards the COVID-19 vaccination programme and the vaccines. In recounting their families', friends', and communities' experiences, they described a range of vaccine-hesitant attitudes ranging from a lack of knowledge, complaints about inconvenience, mistrust in vaccines, and mistrust of the prevailing government and health authorities. Many participants revealed that there was a dearth of timely, official information on the effectiveness of the vaccines and that they and their community of friends and families were, therefore, affected by the preponderance of fake news or lack of information on the NIP.

Incongruence emerged as the overall thematic meaning that connected all the 3 themes and 5 sub-themes of this study. There was incongruence:

1. Between the official aims and implementation of the NIP and multiple realities and needs on the ground - Many participants questioned the slow pace of the vaccination programme, the initial limited supply of the vaccines, and the continual changes in the implementation protocols. Rural and elderly citizens had problems using the NIP's mobile application due to a lack of technological competence or access. There were accounts of missed vaccination appointments due to transport issues or fear of contamination from the big crowds at the vaccination centres.
2. Between (mis)trust in the government and the health authorities and trust in local "heroes" - A lack of transparency in disseminating information about the vaccines, their efficacy and side effects, and the progress of the NIP led to mistrust of the government's management of the NIP. Local politicians were perceived to be practising double standards in managing the COVID-19 pandemic - with ordinary citizens fined for the transgressions of the standard operating procedures while politicians seemingly escaping these regulations. On the other hand, there was trust in local vaccination heroes (local doctors, nurses, and community and village heads), as well as Instagram and YouTube local influencers. Some vaccine refusals were due to Muslims perceiving them as "not Halal" (not permitted according to Islam), whereas elderly Muslims were motivated to get vaccinated by their desire to go for their pilgrimages.
3. Between the official media and local social media in communication - When official information on the COVID-19 vaccines from the NIP was scarce and not timely, participants revealed they and their communities educated themselves on the vaccines through the spread of information to each other. In this digital age of smartphones and proliferating technologies, about 86% of the Malaysian population in 2021 were active social media users, highly engaged with consuming information and communicating with each other. In particular, there was widespread use of WhatsApp, YouTube, and Facebook to disseminate information about COVID-19 vaccination. Some participants said their families and friends who were vaccinated became champions of the vaccinations through social media, and thus, influenced their peers and families positively. On those same platforms, however, some participants recounted how community members were influenced by conspiracy theories and fake news. Yet the official governmental website and the Director-General of Health's daily briefings were perceived as "too scientific" and lacking in emotional appeal to the general population.

Returning to the 3C Model of Vaccine Hesitancy:

• Complacency was detected among the younger participants, as they perceived risks of the COVID-19 disease to be low, and vaccination was not deemed a necessary preventive action. The researchers suggest that this perception could be linked to the fact that communication on the dangers of the virus was not directed to them as a specific group. The researchers found that the attitudes of vaccine hesitancy were not fixed: There appears to be the willingness to be counselled and be provided with the correct information from trusted leaders or heroes.
• Convenience: The less digitally savvy sector of the community deemed the MySejahtera mobile application to be cumbersome to use when attempts were made to register for vaccination appointments. Participants recounted how their community and family members were affected by access issues, which would affect their attitudes and trust in the NIP.
• Confidence: Lack of trust in the effectiveness and safety of vaccines was a major determinant of vaccine hesitancy and refusal in this study.

In conclusion: "This qualitative study can provide input to policymakers and program evaluators to develop appropriate strategies for immunization programs. Identified gaps such as logistical implementation and health communication strategies could be mitigated using training and capacity building in the health and community-based institutions. The present study also identified local culture, traditions and religion as determinants of vaccine hesitancy....The greater significance of this study lies in its finding that communication probably plays a larger and more influential role in influencing vaccine refusal and hesitancy than in previous pandemics as the communication and media environment has changed irrevocably from previous decades."