What Indians Think of the COVID-19 vaccine: A qualitative study comprising focus group discussions and thematic analysis.

BACKGROUND AND AIMS: The study aims to interpret current knowledge, attitude, perceptions and concerns regarding COVID-19 vaccine in the Indian population.
METHODS: Eight focus group discussions were conducted. Participants were recruited via purposive sampling. Discussions were recorded and transcribed verbatim. Key themes were extracted using thematic analysis method.
RESULTS: There were 19 males and 24 females, with a mean age of 36 ± 11 years. Sub-themes identified were knowledge, attitude, perception and concerns regarding COVID-19 vaccine, leading to the main theme, i.e., views about the COVID-19 vaccine.
CONCLUSION: People have mixed perceptions regarding COVID-19 vaccine. Channelling correct messages may improve people's willingness to get vaccinated.

Introduction

The unprecedented COVID-19 disease spread has infected millions, causing deaths of hundreds of thousands [1]. One of the strategies to curb its spread was the development of COVID-19 vaccine [2].

The COVID-19 vaccine was launched in India on 16th January 2021 for healthcare and frontline workers in Phase 1 [3]. The healthcare and frontline workers were initially not found to be very accepting of the vaccine and were hesitant to receive the vaccine due to several reasons [4]. Currently, the phase-2 vaccination drive includes senior citizens over 60 years of age and persons between 45 and 59 years with comorbid conditions [3].

The success of any immunization drive depends on its coverage and acceptance rate [5] but there might be various concerns among people regarding the vaccine [6]. In order to have a wide coverage of the population by vaccination and shun hesitancy towards the vaccine, it is critical to comprehend peoples’ views regarding the vaccine [5]. Therefore, this study aims to interpret current knowledge, attitude, perceptions, concerns and acceptance of COVID-19 vaccine among Indians.

Methods

An exploratory descriptive study was carried out using focus group discussion (FGD) after seeking approval from the Institutional Ethics Committee of All India Institute of Medical Sciences, New Delhi with reference number (IECPG-194/24.02.2021). A diverse sample was selected using the principle of maximum diversity on the basis of different socio-demographic parameters such as age, gender, socio-economic and education status. Purposive sampling technique was used to identify the participants. Indian residents above 18 years, who could speak and understand Hindi and/or English were enrolled in the discussion. Informed consent was taken from the participants which was audio-recorded as the part of the discussion. A moderator guide was used to direct the discussion given in supplementary table 1. Detailed methodology [[7], [8], [9]] has been depicted in Fig. 1 .

Fig. 1

Methodology.

Results

Eight FGDs were conducted comprising 43 participants with the mean age of 36 ± 11 years, including 19 males and 24 females. Participant characteristics of each group are given in Supplementary table 2.

A comprehensive analysis of Indians’ knowledge, attitude, practice and concerns about COVID-19 vaccine was done in two ways: (i) collective analysis and (ii) group wise analysis. The responses for both the groups were assessed via generation of various codes and sub-themes. The following themes were knowledge, attitude, perception and concerns regarding COVID-19 vaccine. The details of the themes and sub-themes are given in Table 1 .

Table 1

Themes and sub-themes.

Theme	Views about the COVID-19 vaccine
Sub-themes	Knowledge	Attitude
Codes	Awareness about vaccines launched for COVID-19.	Mixed views regarding acceptance of the vaccine. Some accepting readily while others being skeptical.
	Awareness about names of vaccines rolled out in India.	Trust/mistrust in the safety and efficacy of the vaccine.
	Awareness about the number of vaccine shots to be administered.	Trust/mistrust in scientists and healthcare professionals.
		Willing/Unwilling to recommend it to their family and friends.
Sub-Themes	Perception	Concerns/Barriers/Opinion)
Codes	Mixed views regarding government approach towards the vaccine.The phased manner of vaccination is the right approach.People have become careless after the introduction of COVID vaccine. They are showing a casual attitude towards COVID precautions.	Concerns regarding side effects.
		Concerns regarding the rapid development and approval of COVID vaccine.
		Concerns regarding the unforeseen future effects of the vaccine on the comorbid and immunocompromised patients.
		Concerns regarding the duration of protection from the vaccine.
		Concerns about availability of the vaccine in the entire nation.
		Concerns regarding the price of the vaccine.
		Concerned about the piracy/authenticity of the vaccine.
		Concerned about the politics that might affect the vaccination drive.

Group wise analysis of views on COVID-19 vaccine

The key highlights of different views on knowledge, attitude, practice and concerns regarding COVID-19 vaccine amongst participants in the eight focus group discussions is presented in Table 2 and excerpts for the same are given in Supplementary table 3.

Table 2

Group wise analysis of views on COVID-19 vaccine.

<!--Col Count:2-->Group	Views on COVID-19 vaccine
Doctors	Knowledge: Updated with the current research and government policiesa
	Attitude: Positive outlook towards the vaccineb
	Perception: Acceptability of COVID-19 vaccine amongst doctors will impact overall acceptability in the general populationc
	Concerns: The gap in Information, Education and Communication for the acceptance of the vaccined
Subject experts	Knowledge: Updated with the current research and government policiese
	Attitude: Mixed views, some willing to promote it while others being skepticalf,g
	Perception: Vaccine should be taken and/or promoted for correct reasonsh
	Concerns: Misinformation spread from social media about the vaccine and limited direction given by the governmenti
Paramedics	Knowledge: Information obtained from scientific data and news channelsj
	Attitude: Mixed views, some supporting while others being skepticalk
	Perception: Vaccine has been launched without adequate data as compared to other vaccines being used worldwidel
	Concerns: Safety and efficacy of the vaccine for elderly and comorbid individualsm
Other hospital staff	Knowledge: Obtained knowledge/information from doctors and paramedicsn
	Attitude: Positive outlooko
	Perception: Vaccine is crucial to curb COVID-19 spreadp
	Concerns: Initiation of the process of vaccination for other family members especially pregnant women, children and elderlyq; rumours spread on social mediar
Middle-aged and elderly	Knowledge: Obtained information from news channels and by discussing it with family and friendss
	Attitude: Many were skepticalt
	Perception: Found the vaccine important but doubtful for its safe use on themu
	Concerns: Concerned about the safety and efficacyu; authenticityv; rumoursw
Working professionals	Knowledge: Limited interest and knowledgex
	Attitude: Casual attitude towards the vaccinex
	Perception: People of this age do not need any vacciney
	Concerns: About the efficacyz; rapid development and approval of the vaccineaa
Young adults	Knowledge: Lacked complete information as were dependent on google and news applications installed on their phonesab
	Attitude: Mixed outlooks, some were positiveac while others being skepticalad
	Perception:The vaccine should be made available to college students and teachersae
	Concerns: Unforeseen future effects of the vaccineaf
Housewives	Knowledge: Obtained through news channels, youtube videos and discussions with neighbours, family and relativesag
	Attitude: Most were skepticalah, ai
	Perception: Introduction of the vaccine has made people carelessaj
	Concerns: About the safety and efficacy, use for children and elderlyah, price of the vaccineai

Discussion

COVID-19 has made an impact on various aspects of people’s life [[7], [8], [9], [10]]. Currently, one of the prevalent discussions is prevention of COVID-19 infection through COVID-19 vaccine. There are diverse sources of information ranging from scientific evidence to social media providing contradictory information leading to confusion amongst the general public [11]. Similarly, in our FGDs we found that some groups such as senior citizens, working professionals, young adults and housewives depend on social media, local news and discussion amongst friends and family as platforms for getting informed about COVID-19 vaccines. Besides, these groups ranked lower in interest and correct information regarding COVID-19 vaccine, which may be due to dependency on less reliable information sources. Contrary to this, hospital based groups (doctors, paramedics etc) had slightly better understanding regarding the COVID-19 vaccine. The development of proper Information, Education and Communication (IEC) channels to spread awareness about the availability, procedure and benefits of the vaccine through mainstream media and social media, in order to build a positive attitude towards the vaccine becomes essential for its acceptance.

We also found that the level of knowledge did not correlate with a positive attitude towards COVID-19 vaccine as both hospital-based groups and groups from the general population had mixed perceptions. The identified drivers for positive attitude amongst participants towards vaccine acceptance were trust in the perceived safety of vaccines, free access to vaccines (healthcare and first line workers), national duty towards eradicating COVID-19, perceived limited/no risk in vaccination, access to reliable sources of information on COVID-19 vaccine and easy availability of vaccine (hospital staff). The concerns contributing to negative attitudes related to vaccine hesitancy were lower number of active COVID-19 cases, preference to natural immunity, misinformation regarding the vaccine, lack of perceived safety, fear of having side-effects, fear of faulty/fake vaccine, government conspiracies etc. Current literature also reported perceived safety of the vaccine as a prime contributing factor to vaccine intention [12].

The public willingness to accept the vaccine (practice) is not static and is highly dependent upon the information and sentiment regarding the COVID-19 vaccine [13]. In the FGD with subject experts, it was distinctly mentioned that government should take initiative in engaging social media to provide correct and accurate information in order to alleviate any concerns on vaccine related issues (safety, efficacy, availability etc), individual/community based issues (beliefs, knowledge, health related behaviours and mistrust etc.) and contextual issues (historical influences, conspiracy theories and non-transparency etc) [14]. Besides, channelling correct messages via local community leaders, celebrities can also prove beneficial in improving people’s willingness and motivation to get vaccinated in the near future [14].

Strengths and limitations

To our knowledge, this qualitative study is the first attempt to understand the knowledge, attitude, practice and concerns regarding the COVID-19 vaccine in different population groups in India. This information can be used by the healthcare professionals and government agencies to tailor make their communications to channel appropriate messages as a part of the vaccination campaign for strengthening positive attitude in masses regarding COVID-19 vaccine. The findings of this study can be further used in development of a survey tool for conducting pan-India cross sectional surveys to gauge the opinion of the public on COVID-19 vaccine.

The limitations of the study are as follows: findings are derived only from one discussion in each group and qualitative analysis was not performed by any statistical software.

Financial support and sponsorship

None.

Declaration of competing interest

The Author(s) declare(s) that there is no conflict of interest.