key: cord-0930682-koyb54jm
authors: Duong, Minh Cuong; Nguyen, Hong Trang; Duong, Mai
title: Evaluating COVID‐19 vaccine hesitancy: A qualitative study from Vietnam
date: 2021-12-09
journal: Diabetes Metab Syndr
DOI: 10.1016/j.dsx.2021.102363
sha: 5dbd57b7922db8e71ffbd92480e58685a266bd87
doc_id: 930682
cord_uid: koyb54jm

BACKGROUND AND AIMS: Vaccine hesitancy is a major threat to COVID-19 vaccination programs. This study aimed to examine the public attitudes towards COVID-19 vaccines, the variance of these attitudes, and associated determinants within a large COVID-19 outbreak in Vietnam. METHODS: Two focus group discussions were conducted online with 20 people from different socio-economic and profession backgrounds. Purposive sampling was used to recruit participants. Discussions were recorded and transcribed verbatim. Key themes were extracted using reflexive thematic analysis method. RESULTS: Four distinct, non-static attitudes including acceptance, conditional acceptance, hesitancy, and anti-vaccination were found. Themes identified as determinants of these attitudes were external factors, internal factors, and risk-benefit self-assessment regarding COVID-19 vaccination. CONCLUSIONS: We found mixed, non-static COVID-19 vaccination attitudes. People's vaccination risk-benefit self-assessment greatly determines the variance of their attitudes over time. Given high public trust in the authorities, the government should take the lead to counter COVID-19 vaccine misinformation. To increase acceptance, vaccine advertising campaigns should focus on providing information about the dangers of COVID-19, the ability to manage side-effects at the vaccination centers, and updated, precise information on both the outbreak and vaccines. Future research is needed to identify the public most common COVID-19 information channels to enable effective community education.

The COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has posed a great threat to human physical and mental health [1] . Despite tireless efforts to contain the virus, it continues spreading globally [1] . The development of vaccines is considered an important strategy to curb the spread of SARS-CoV-2 [2, 3]. Since 27 April 2021, Vietnam has experienced the fourth COVID-19 wave considered as the first "real wave", with 927,495 cumulative incident cases being reported as of 2 November 2021 [4, 5] . In early 2021, COVID-19 vaccine was rolled out to the priority groups including frontline healthcare workers and those working in the outbreak prevention and control [6] . Subsequently, the Vietnam's largest-ever COVID-19 vaccination campaign started in July 2021 [6] . It is documented that the success of any vaccination program is determined by the public vaccine acceptance [7] , which is influenced by various concerns of the public [8] .

Available quantitative studies conducted on specific groups in Vietnam found mixed results regarding COVID-19 vaccine acceptance. A study conducted on 425 adults with chronic illnesses found positive beliefs regarding the vaccine, but they were concerned about the vaccine side-effects, essentialness, and cost [9] . A survey conducted on 398 students found that despite their high perception of the importance of vaccination, 17% of them were vaccinehesitant or refused to be vaccinated [10] . Similarly, another study reported that 39.6% of 651 pregnant women refused to receive the vaccine if it were available for them [11] . Among all these groups, the likelihood of COVID-19 vaccine acceptance is associated with income, selfperceived risk of infection, and perceived risk to people [11] . Determinants of vaccination acceptance also include vaccine knowledge, lack of access to information, and cues to action [9, 10]. These quantitative surveys help identify people's intentions to get vaccinated against COVID-19 and some associated barriers. However, qualitative research is needed to explore in depth the determinants of vaccine acceptance, the potential interaction of these factors in the context of people's experiences of and reactions to the pandemic [12] . Qualitative research also helps examine the variance of COVID-19 vaccine hesitancy over time and the associated factors of such changes [13] . This approach would assist us in understanding why vaccine hesitancy varies over time and across populations and places, which in turn improves the vaccination program [12] . The presenting qualitative research study examined people's J o u r n a l P r e -p r o o f attitudes towards COVID-19 vaccine and associated determiants in Vietnam, bringing in initiatives to improve the vaccination campaign.

Two focus group discussions (FGDs) were conducted in May 2021 when Vietnam experienced the fourth COVID-19 wave, and COVID-19 vaccine was rolled out to priority groups. A few COVID-19 vaccine-related deaths had been reported on local media [14, 15] .

Two one-hour focus groups of 10 participants each were organised in line with the accepted methodology [16] [17] [18] . A moderator guide comprised of 13 questions was pre-determined covering personal attitude towards COVID-19 vaccines and historical influences; contextual influences; vaccine cost, safety, number of injections; and cues to action (Appendix 1). All questions were developed based on the vaccine hesitancy survey questions developed by the European Centre for Disease Prevention and Control and World Health Organization (WHO) [19, 20] .

Vietnamese residents aged 18 years and above were invited to participate in the study. A diverse sample was selected using the principle of maximum diversity based on a set of key sampling focuses including different socio-demographic parameters (age, gender, socioeconomic and education status), working status (students, working people, and retirees), professions (physicians, other health professions, and non-health professions), COVID-19 vaccination status, chronic health conditions, and geographical locations (South, North, and Central Vietnam). The initial participants in each profession were identified by three authors who had significant local knowledge. The purposive sampling technique was used to recruit further participants. When 10 participants had been recruited, gaps in the key sampling focuses were identified, and the remaining 10 participants were recruited to fix these gaps. Given COVID-19 restrictions in Vietnam, the two FGDs were conducted on Microsoft Teams platform. The participants' baseline characteristics were not introduced in the FGDs unless they voluntarily introduced themselves. This aimed to minimize the possibility that those who J o u r n a l P r e -p r o o f worked in the health sector would influence other participants. A discussion for each question continued until it reached saturation. The discussions were digitally recorded.

The study was approved by the Phenikaa University Ethics Committee (reference 216/QĐ-ĐHP-KHCN). All participants provided written informed consent by email and re-confirmed consent verbally at the beginning of the discussions [12] . Participants were informed their FGDs would be video-recorded. Those who did not want to be visually seen could turn off their webcam. After the discussions, audio files were separated from the video files and were subsequently transcribed. Only de-identified information was published.

The recordings were transcribed verbatim in Vietnamese and translated into English by the bilingual researcher. All identifying information was removed and participants' names were pseudonymized. By using reflexive thematic analysis [21], authors independently analyzed transcripts for group interaction along with field notes and assigned preliminary codes describing the interview content [22, 23] . Then, the results were validated by all authors for consensus. Finally, the first author wrote up the findings and performed sense checking with the remaining authors as necessary. The analysis was inductive and was not structured based on any existing theoretical frameworks. This analysis approach has been validated elsewhere [12] .

Participants showed mixed attitudes towards vaccine acceptance. Some expressed their strong, positive attitudes (quotes 1-4, Table 1 ), or conditionally accepted the vaccine (quotes 5-6).

Others felt hesitant (quotes 7-8), and few had anti-vacination attitudes (quotes 9-13). Three main themes were identified as determinants of vaccine acceptance ( Figure 1 ).

All participants confirmed waiting time at a vaccination center did not affect their vaccine acceptance. However, given the huge economic impact of COVID-19 on individuals, the travel cost associated with vaccination may hinder the community's willingness to get vaccinated (quote 14). Although vaccine cost is not the participants' main concern in general (quote 15), in the context of a low efficacy COVID-19 vaccine, the high cost would affect their vaccination decision (quote 16). Also, with the increasing unemployment rate due to COVID-19 and the income disparity between the rurals and urbans in Vietnam, vaccine cost is strongly believed was a risk of developing side-effects with all vaccines (quote 32). Regarding COVID-19 vaccines, the non-fatal side-effects were not an issue (quote 33). However, severe side-effects including deaths, shock, and blood clot were major concerns despite the small risk (quotes 33-38). Even those who had been vaccinated felt scared and anxious before getting vaccinated due to the negative information (quote 33). Another important concern was the vaccine's effectiveness provided that people vaccinated with two jabs still acquired infection (quotes 43-45). Participants expected the Ministry of Health and mainstream media cover more information on the COVID-19 vaccine safety and effectiveness to convince them of getting vaccinated (quotes 38-39). Similarly, lack of these information made participants including health professionals hesitant to encourage people to get vaccinated (quotes 40-41).

Participants felt uncertain because the vaccine was developed so fast and caused severe sideeffects (quotes 32-35). The vaccine was also new, and little had been known about the risk of side-effects (quote 22). However, participants recognized that the benefit of vaccine was outweighed that of being non-vaccinated which could lead to infection (quote 46). They understood that the risk of side-effects was small. Hence, it was unable to conclude if COVID-19 vaccine was risky (quote 46). Participants performed their risk-benefit assessment regarding COVID-19 vaccination in relation to the nature of their jobs which may or may not put them at risk of infection. Those who were health professionals or outbreak control volunteers were willing to get vaccinated (quotes 47-48). Contrastingly, those working from home were reluctant but expressed their willingness to get vaccinated if their situations changed and put them at risk of infection (quotes 49-52). Participants also expressed their vaccine acceptance in relation to an evaluation of their health conditions and COVID-19 vaccine types aiming to minimize their risk of developing severe side-effects (quotes 5-6).

Although participants were not affected by their previous negative vaccination experiences Our participants' intention to get a COVID-19 vaccine was influenced by their own risk-benefit assessment which is a dynamic factor. Indeed, people' willingness to accept a vaccine is not static, relying on the epidemic phase and perceived risk of acquiring infection [44] . Our findings concur that participants who did not intend to get the vaccine expressed their willingness to accept the vaccine if their situations changed and put them at risk of acquiring COVID-19. We also found that vaccine knowledge is an important internal determinant having mixed influences on attitudes towards COVID-19 vaccine among our participants. A previous study found no association between vaccine knowledge levels and positive attitudes [2].

However, another study found that vaccine hesitancy was attributed to personal knowledge, which had been amplified by recent exposure to published information [12] . Also, the more J o u r n a l P r e -p r o o f confused people feel during COVID-19, the more likely they are to be hesitant to accept the vaccine [12] . Hence, it is crucial to provided updated and precise information on both the disease outbreaks and vaccines to enable the public to make their own decision on vaccination.

Our study has some limitations. Interviews were running at the beginning of the fourth COVID-19 outbreak in Vietnam which may have impacted on participants' vaccine attitudes. However, we have identified a dynamic theme that can help predict the variability in vaccine acceptability over time. Although we selectively included participants from a diverse socioeconomic and profession backgrounds, findings that are derived from only two FGDs may not be widely generalizable.

In conclusion, we found mixed, non-static COVID-19 vaccine attitudes which are influenced by people's risk-benefit self-assessment regarding vaccination. Our findings highlight the importance of the government's measures to counter COVID-19 vaccine misinformation. The vaccine advertising campaign should focus on providing information about the dangers of COVID-19, the ability to manage side-effects at the vaccination centers, and updated, precise information on both the outbreak and vaccines to enable the community decision-making regarding vaccination. To enable effective community education, future research is needed to identify the public most common COVID-19 information channels. 

Footnote: Circle sizes visually represent the level of impact of sub-themes on themes Table 1 

3 "If the vaccine is available to me, I will get it" (34 years-old, male, non-health professional).

Conditional acceptance 5 "I agree to get vaccinated, but it is conditional agreement. This means I will not get vaccinated with any COVID-19 vaccines. My vaccine acceptance is based on my selection of vaccine" (39-years-old, female, non-health professional).

6 "I would get vaccinated for sure with a condition that I am not allergic to any foods and medications which make me feel somehow assured when getting vaccinated" (39 years-old, vaccinated, female, health professional).

Hesitancy 7 "I am hesitant to take this vaccine" (39-years-old, female, non-health professional).

Anti-vaccination 9 "A vaccine that has not been adequately investigated may have some risks (of severe side-effects).

Unfortunately, if someone acquires these (side-effects), it will be very bad for him/her and his/her family. 

"If we worry about our health, it's best to get vaccinated at public hospitals. I will do so as it is a new vaccine with suspected high risk of adverse events following immunization. If it is needed, I can be referred to the well-equipped ICU located inside this tertiary hospital immediately" (39 years-old, vaccinated, female, health professional).

"I would get vaccinated at a vaccination center that is a health facility or more specially, a public hospital"

(34-years-old, vaccinated, female, health professional).

"First, the knowledge and skills of healthcare professionals including resuscitation and emergency care at tertiary (public) hospitals are better (than those of non-tertiary hospitals). Second, these tertiary hospitals are well equipped. Although the non-tertiary hospitals can manage emergency cases, severe cases must be referred to a tertiary hospital" (39 years-old, vaccinated, female, health professional).

"I would select hospitals with good facilities, such as Bach Mai, Viet Duc, and Cho Ray (major public hospitals where staff can treat patients with anaphylaxis properly" (38-years-old, female health professional).

"To me, I prefer to be vaccinated at a vaccination center that is less overcrowded such as private hospitals, hence low risk of acquiring COVID-19. But these hospitals should have an ability to treat anaphylaxis. J o u r n a l P r e -p r o o f "My biggest concern is about the true effectiveness of ( J o u r n a l P r e -p r o o f "I understand that there are some risks of developing side-effects with vaccination, but they will disappear after a few days. Also, I am registering to work as a volunteer to control COVID-19 in the community.

Hence, I agree to be vaccinated" (21-years-old, female, health student). 

"I would get vaccinated. Although being vaccinated is risky, its risk is much lower than that of acquiring infection. Also, if I was infected, I could transmit the disease to the community due to the nature of my job (contacting many people). I think getting vaccinated should be done. There is no need to be afraid"

(39-years-old, male, health professional).

"Vaccination does provide some levels of protection with the new (COVID-19) strains" (44-years-old, female, non-health professional).

"Vaccination is a social responsibility" (35-years-old, female, non-health professional).

"Without vaccination, the virus can spread easily in the community. But yes, the recommended nonvaccine preventive measures are needed even post vaccination" (39-years-old, female, non-health professional).

"We have been successfully using social distancing and lockdown which are just travel-related measures (to control the outbreak). If the number of vaccinated people increases, each of them will be an immune shield to protect them from infection and to minimize the spread. Without vaccination, we cannot travel anywhere because the risk (of infection) is still there even the outbreak is being control" (32-years-old, male, non-health professional).

We are unable to examine the long-term, negative impact of COVID-19 five to 10 years post vaccination at this stage. However, in the context of the ongoing pandemic with continuous outbreaks and some countries have returned to normalcy, I think vaccination is needed to do so

The ability to induce effective immunity of the vaccine is different in different people. And the immunity wanes over time

Regarding COVID-19 vaccine, my most concern is about its low effectiveness, which means I wonder whether it can protect us against infection. This is my main determinant of getting vaccinated

I feel uncertain because this is a new vaccine that was developed so fast and can cause blood blot

Even scientists agreed that the COVID-19 vaccine has been produced so fast. Hence, we, being laymen without any knowledge about medicine, fear of risk of death. Obviously, the current vaccine targets the strain circulating last year. There are U.K. strain and Indian strain. Can vaccine protect against these strains? I would continue with the non-vaccine preventive measures, regardless of what people say about the effectiveness of vaccine. Although the risk of developing vaccine severe side-effects is small, I do not want to take risk

A vaccine that has not been adequately investigated may have some risks (of severe side-effects)

it will be very bad for him/her and his/her family…Therefore, I have not got vaccinated. I work in medical field, and I understand this issue. They J o u r n a l P r e -p r o o f asked me if I have any allergy with food or medications during the pre-vaccination screening. I reported I developed allergic reactions after eating silkworm pupae. Indeed, I never eat this and do not have any allergic reaction. The reason is that I fear death…I declare…People fear of death. I said this so that they removed me from the vaccination list

I am not so sure if it (complications) only occurs a few days post-vaccination or it can occur a longer time later

Vietnam controlled the outbreak very well, but it does not guarantee that we can do it next time. And our healthcare resources are very limited. If a severe outbreak (of COVID-19) occurred, we would not be able to control it

We were controlling the outbreak very well…but a few community cases can create a severe outbreak