Understanding Determinants of Vaccine Hesitancy and Acceptance in India: A Qualitative Study of Government Officials and Civil Society Stakeholders

"These data serve as a baseline for further research and programmatic efforts to understand hesitancy and intervene at individual and group, contextual, and vaccine/vaccination-specific levels to address misinformation and promote vaccine confidence in India."

Vaccine hesitancy is complex, context specific, and driven by multiple influences. India has experienced several high-profile challenges related to vaccine hesitancy; for example, in 2017-2019, during the country's measles-rubella (MR) vaccine introduction campaign, vaccine refusal arose rapidly in several communities, driven by inadequate pre-campaign communications planning and widespread misinformation and rumours on social media. This qualitative study sought to characterise the drivers of vaccine hesitancy and acceptance in India and to identify potential interventions to address these challenges, drawing on perceptions of personnel involved in the design and implementation of vaccination campaigns.

Following Grounded Theory, the researchers conducted in-depth interviews from July 2020 to October 2020 with 21 government health officials and civil society stakeholders from the national level and three states (Uttar Pradesh, Kerala, and Gujarat). Based on those conversations, the paper presents findings on individual-level, contextual, and vaccine/vaccination programme-specific factors influencing vaccine hesitancy in India.

Here are some selected findings:

• Key individual-level influences were low awareness of the benefits of vaccination, mistrust in government and health service quality, and safety concerns, especially related to mild adverse events following immunisation (AEFIs). Witnessing a sick child after immunisation was described as having an impact on vaccination attitudes beyond that individual child, extending to their siblings, neighbours, or even the wider community. Participants shared examples of common misinformation and rumours about harmful effects of vaccines and vaccination. One rumour, which had circulated for years related to polio vaccine and resurfaced during the MR introduction campaign, was that vaccines were being administered to sterilise Muslim children to control growth of this population. Furthermore, there is a perception in some communities that government highly prioritises vaccination, while other health and infrastructure priorities are seemingly neglected.
• Contextual-level factors included communications, the media environment, and social media, which serves as a major conduit of misinformation and driver of hesitancy. Misinformation can appear in messages, infographics, memes, and videos; the latter are particularly impactful, as they can be understood even by those who cannot read. Misinformation that circulates widely is often highly context specific, and messages or visuals often seem intentionally targeted at or framed for certain populations. In addition, sociodemographic factors play a role: Specific drivers varied widely by income, education, urban/rural setting, and across religious and cultural groups. Notably, hesitancy associated with religion may only pertain to specific vaccines and campaign contexts; as one respondent explained: "In routine immunization, for example, the religion-based resistance is not as high as it was for polio." Along these lines, participants discussed historical influences in the context of the impact of vaccine hesitancy on previous immunisation campaigns. Many commented on India's Pulse Polio Programme, noting some similarities to the MR campaign, including circulation of specific rumours in some communities, and also differences, such as the new role of social media platforms like WhatsApp in rapidly spreading misinformation. Influential figures at many levels of society, including high-level political leaders, local community leaders, religious leaders, and celebrities, were recognised as critical determinants of vaccine hesitancy or confidence.
• Among vaccine/vaccination-level issues, vaccine programme design and delivery emerged as a strong determinant of hesitancy. For instance, according to participants, vaccination campaigns are more susceptible to incidents of large-scale spread of misinformation and hesitancy than the day-to-day Universal Immunization Programme (UIP) operations. Issues are more likely to occur for new vaccines and historically mistrusted vaccines. Another salient issue is the role of healthcare professionals. Accredited social health activists (ASHAs), auxiliary nurse midwives (ANMs), and Anganwadi workers were identified as a critical source of information and resource for questions about vaccines and vaccination. However, participants suggested that these frontline health workers often lack the training to disseminate evidence-based information, respond to vaccine safety concerns, and address misinformation and rumours.

In short, this study confirmed that, for vaccine hesitancy in India, as elsewhere, there is no universal set of factors that determine beliefs and attitudes in every local context. Previous research has highlighted individual-level factors (e.g., vaccine knowledge/awareness or health literacy) as reasons for vaccine hesitancy or low coverage. This study demonstrates the equal importance of contextual and vaccine-specific influences, such as the communication and media environment, influential leaders and anti-vaccine voices, socio-cultural differences, historical influences, and the role of frontline health workers.

In conclusion: "approaches to address specific drivers of hesitancy in India must focus not just on individuals, but on communities, health systems, social media, and external influences. Such approaches should operate across multiple levels of government and society and yet allow for flexibility to adapt strategies, champions, and messages to local contexts..., with planning and implementation of different activities at the centre, state, district, and community levels. Focus on vaccine hesitancy in future introduction campaigns is critical..."