Trust and Willingness towards COVID-19 Vaccine Uptake: A Mixed-method Study in Ghana, 2021

"...trust and willingness to accept the vaccine is nuanced..."

Research has identified an important link between trust (or lack thereof) and vaccine hesitancy. The first phase of nationwide deployment of the COVID-19 vaccine in Ghana began on March 1 2021, with the country's president being the first Ghanaian to receive the vaccine. This action was partly intended to boost the population's confidence and trust in the vaccine and their eventual acceptance of it. On the account of limited doses available to the country at that time, the government created a priority list of persons who would be eligible to receive it. This paper examines how trust informed willingness to take the COVID-19 vaccine among those who were the focus of the first phase of Ghana's COVID-19 vaccination programme.

As explained in opening sections of the paper, trust in the context of vaccine uptake represents a relationship that exists between individuals, as well as between individuals and a system, in which one party accepts a vulnerable position. There are various levers of trust that are external to the vaccine itself, including generalised trust, which describes the extent to which people in a community are willing to trust each other. Viewed as a form of social capital, this type of trust is underpinned by the presence of fair and efficient social institutions, as well as efficiencies in deterring acts that are communally agreed to be wrong. Relative to vaccination programmes, generalised trust can be expressed in the arena of information sharing from official institutions to members of the society. If the information is believed to be accurate (depending on considerations such as the credibility of the institution and its people), generalised trust will advance vaccination acceptance and uptake.

Past experiences also affect trust, such as whether an information source has previously been competent on related matters. Sources of information that can hold influence include friends, family members, non-official medical advice such as from religious networks, alternative health networks, politicians, and celebrities. Furthermore, perceptions about the past performance and the values of a health system are believed to uphold historical influences on trust. In relation to vaccination programmes, historical influences are driven by social trust (defined as shared values of benevolence, fidelity, and morality) and confidence (defined as belief in the competence and capability of the trusted individual). Such trust and confidence may be lacking among populations who have been actual or perceived victims of medical injustices and everyday discrimination; they may view vaccines as simply another mischievous agent threatening their communities.

To understand how these concepts are expressed in the Ghanaian context related to willingness to accept COVID-19 vaccination, the researchers conducted a sequential mixed-method investigation among the priority population: persons 60 years and above, frontline government functionaries, health workers, persons with underlying health conditions, and religious leaders and teachers. They sampled 415 respondents from three cities - Accra, Cape Coast, and Tamale - and also conducted 14 follow-up interviews with religious and traditional leaders based on the results of the survey data.

Overall, the study showed that trust and willingness to take the vaccine are high in this priority population, with 51% of respondents expressing moderate trust in the vaccine and about 34% indicating they very much trust in the vaccine; the rest (14%) had no trust in COVID-19 vaccine. Trust in the effectiveness and safety of the vaccine, rather than socioeconomic characteristics of respondents, predicted acceptance. That is, willingness to accept the vaccine is strongly predicated on trust, and the results are consistent across two bivariate models. Substantially significant positive coefficients were recorded among respondents with moderate trust (Coef.=2.93; confidence interval (CI) = 1.01-3.18) and full trust (Coef.=5.44; CI = 3.23-5.67) in the vaccine; adjusting for control factors, direction and signs remained unchanged.

However, the quantitative survey indicated that a comparatively high proportion of religious leaders were not willing to take the vaccine, which motivated the researchers to undertake further exploration using qualitative methods. The interviews with 5 Christian leaders, 3 Muslim leaders, and 6 traditional leaders revealed both positive and negative accounts of trust in the COVID-19 vaccine and how they connect with intentions to accept the vaccine or not.

When asked whether their religious practices forbade vaccination, all answered in the negative and further affirmed the rights of individual church members to make their own decisions on vaccine uptake. While some religious leaders did not discount their own and households' vulnerabilities to COVID-19, there was constant reference to the absolute protection that God offered. This sense of protection, in their view, surpassed the effectiveness of vaccine and, if the vaccine were offered to them, they would first consult (pray for direction from) God before taking it up.

On the positive note, some participants drew on past successes of public health vaccination programmes to ground their confidence in the COVID-19 vaccine. Those who shared this view noted that vaccines were not new to the global health landscape, and they recounted memories of the scourge of childhood diseases such as polio and measles, noting that mass vaccination programmes have helped to almost eradicate these diseases. They did not see the COVID-19 vaccine as any different from vaccines in use now, except that this (COVID-19) vaccine is new and is perhaps the cause of people's apprehension.

Similarly, one religious leader who together with his wife took the vaccine said their decision was triggered and motivated by a church member who is also a health professional. Apart from the education he had received on the public health benefits of the vaccine, another critical element in the decision-making process was the comfort and assurance he had that his church was not inclined to recommend something that could harm or damage his health. In the same vein, a female religious leader in Accra opined: "I don't have any problem with taking the vaccine because as far as I know, many people have been taking the vaccine and nothing has happened to them."

Yet the researchers heard accounts about lack of trust in COVID-19 vaccines, including not only low pandemic risk perception but also skepticism about the intentions of vaccine manufacturers and the government, feeding into the conspiracies around COVID-19 and its vaccines. One church leader in Cape Coast said: "Look, where these vaccines are coming from, they are not after our welfare. They are wicked people. I don't trust them! The same people who brought this COVID-19 disease are the people who are now bringing these vaccines. So I asked myself, why did they bring this disease to the world in the first place? We have a lot of diseases that occur naturally. But, for this COVID-19, we were made to understand that it was a virus from the lab in China. So, it is difficult for me to accept a lot of things like the vaccine..."

Another source of religious and traditional leaders' mistrust in the COVID-19 vaccine arose from lack of trust in the government and political leadership that is heading up the fight against the pandemic. For instance, one participant questioned whether the vaccination of the President was real, contending that he must have been given a placebo to shield him from any side effects of the true vaccine. Participants were also impacted by information they read on social media, which dovetailed with their lack of knowledge/understanding of vaccine development and has heightened mistrust. A religious leader from Cape Coast said: "I've heard from WhatsApp that the vaccine is made from the virus that causes the disease. So, if you take the vaccine, it will affect you. So, we shouldn't take it."

The researchers conclude that the findings "generally point to a certain level of positivity around COVID-19 vaccine uptake, even though pockets of hesitancy are observed. This finding provides a positive platform for pursuing the vaccination programme through collaborations and partnerships with religious organizations in promoting vaccine uptake. The fact that health workers are considered trusted sources of information means that deliberately involving health workers in communicating the uptake of COVID-19 vaccine will be important for the campaigns."