Background
As of 9 December 2021, there were a total of 271.9 million people infected by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) globally. In Malaysia, a total of 2,707,402 cases were reported and more than 31,000 lives have been claimed by the COVID-19 pandemic [
1]. This highly contagious infection has resulted in worldwide social distancing and lock-downs to curb the uncontrolled transmission chain [
2]. Currently, there is no approved drug-based therapy available to cure the COVID-19 infection [
3]. Hence, the success of ending the COVID-19 pandemic, or at least achieving the “herd immunity” [
4], largely rests on vaccination. Recent data showed that there are as many as 8 vaccines approved and currently in use all around the world [
5]. In Malaysia, five vaccines were approved by the Malaysian Ministry of Health namely: Pfizer-BioNTech BNT162b2, Oxford-Astrazeneca AZD1222, Sinovac CoronaVac, CansinoBio Ad5-nCoV and Sputnik V Gam-COVID-Vac [
6]. However, the emergence of new COVID 19 variants such as the DELTA [
7] and OMICRON [
8] strains suggest that the original purpose of achieving herd immunity may never be achieved. As such, expectations of the efficacy of the COVID 19 vaccines would have to be managed and such communication is disseminated to the public.
The Malaysian National COVID-19 Immunization Program (NIP) was launched by a special committee known as Jawatankuasa Khas Jaminan Akses Bekalan Vaksin COVID-19 (JKJAV) in February 2021 and aimed to be “run smoothly, safely, effectively and in an orderly manner in the effort to curb and end the COVID-19 pandemic” [
6]. It comprises three stages: Phase 1 target frontliners comprising public and private healthcare personnel, essential services, defence and security personnel; Phase 2 prioritizes senior citizens (those aged 60 and above), high-risk groups with chronic diseases such as heart disease, obesity, diabetes and high blood pressure, and people with disabilities; while Phase 3 (the current phase which is expected to end by February 2022) gives priority to adult population aged 18 years and above. The aim was to ensure that at least 80% of Malaysia’s adult population receive vaccines by February 2022 to reduce the spread of infections, hospitalization and death. The COVID-19 vaccination is voluntary and is provided free of charge to all people living in Malaysia (citizens and non-citizens) [
6]. By September 2021, the NIP program was fully taken over by the Ministry of Health Malaysia with the change in portfolio of the Minister of Health [
9].
Despite the rapid advances in COVID-19 vaccine development, the free vaccines offered in Malaysia and the roll out for population aged 12–17 years since September 8. 2021, the ultimate goal to break the coronavirus transmission chain is highly dependent on the acceptance and uptake of people towards these vaccines, a vital element that has been complicated by mixed perceptions regarding the spread of the virus, the safety of the fast-tracked vaccines, wrong information received/read/disseminated in social media or online and access issues.
According to the World Health Organization (WHO), vaccine hesitancy refers to a delay in the acceptance or refusal of vaccines despite the availability of vaccine services. It is a complex and context-specific phenomenon that varies across time, place and vaccines [
10]. In Malaysia, a study conducted by June et al
. in August 2020 (before the availability of the COVID-19 vaccine) found an intended vaccine acceptance rate of 93.2% via the survey conducted [
11]. Subsequently, the intended acceptance rate was reduced to 67% (December 2020) [
12] and 83.3% [
13] (June 2021) respectively. As of December 2021, a total of 78.2% of Malaysians were fully vaccinated and 4,430,656 of them have completed their booster doses [
9].
The theoretical basis of vaccine hesitancy transpired in the 1990s when researchers endeavoured to depolarize the gulf of pro-and anti-vaccination beliefs [
14]. Various health behaviour models have been developed to depict vaccination intention and the associated factors that influence the decision to accept vaccination, including the Theory of Planned Behaviour (TPB) [
15] and the Health Belief Model (HBM) [
16]. In our study, we chose to adopt the “3Cs” Behavioral Model developed by the Strategic Advisory Group of Experts (SAGE) on Immunization, a multidisciplinary working group of scholars and practitioners with the WHO [
14], due to its overall fit with our context of the study.
The three elements proposed by SAGE in the “3Cs” Model include complacency, convenience and confidence. Complacency refers to individual perception of risks and values of vaccines. It is manifested when the self-assessed risk of vaccine-preventable diseases is low and a vaccination program is not deemed as a solution. In other words, complacent individuals are often reluctant to conform to regulations when they feel that the risks are negligible [
17]. Subjective probability proposed by Tversky and Kahneman indicated that personal judgement on risk is situational and is based on current information [
18]. Consequently, 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 immunization services impede the acceptance of vaccination. For instance, Luz et al
. reported that the availability of vaccination on-site in a workplace positively affects vaccine uptake among working-age adults [
19]. Bedford et al
. argued that convenience includes physical barriers to vaccine uptake, instead of comprising only a psychological state of mind. Convenience therefore, should encompass factors such as lack of a vaccine offer, difficulty accessing immunisation clinics due to long distances, and lack of communication about vaccine programs [
20].
Confidence is crucial to promote engagement between members of the public and the government and subsequently, is a predeterminant of public compliance [
21,
22]. Transparencies on the availability of vaccines and the occurrence of adverse events after immunization is a key component to gain public confidence [
23]. However, intensive coverage on the incidences of adverse reactions globally like anaphylaxis [
24], thrombocytopenia [
25], cerebral venous sinus thrombosis [
26] and death [
27] from COVID-19 vaccines by social media or local media may discourage people from being vaccinated. Adverse after-effects experienced by the vaccine recipients themselves or their close family members influenced the confidence in vaccines. Likewise, extensive reporting on vaccine administration errors such as inadequate dosing negatively impacted public confidence [
28]. Trust or mistrust in social institutions is a key to public compliance with preventive measures developed during SARS (2003) [
29], Influenza A/H1N1 [
30] and COVID-19 [
31]. Moreover, both theoretical and empirical literature showed that contemporary societies are built on very low levels of trust [
32], precipitating a trust-deficient response to immunization programs.
In this 3Cs Model, communication is considered not as a specific determinant in vaccine hesitancy, but more as a significant tool for the success of any immunization program [
10]. However, there was agreement that deficient or poor communication about vaccines (e.g. their safety and effectuality) by institutional authorities can contribute to vaccine hesitancy. Some individuals who were beset by the lack of news or influenced by fake news were then influenced to refuse or hesitate on their intention to vaccinate [
33]. In 2020–21, there was a predominance of fake news and widely circulated conspiracy theories regarding the efficacy of vaccines [
34,
35]. As of March 2021, a study identified 578 rumours and conspiracy theories related to COVID-19 vaccines from 52 countries [
36]. Additionally, some studies demonstrated a significant association between social engagement and positive health behaviours [
37,
38]. Hence, it may be necessary to re-evaluate this 3Cs Model to determine the role communication plays in COVID 19 vaccine hesitancy and vaccine uptake. This is the gap in knowledge that this study also aims to explore and determine the significance of communication in vaccine hesitancy in this COVID-19 pandemic.
A later, more complex matrix formulated by SAGE, the Vaccine Hesitancy Matrix depicted the contextual influences like socio-cultural, economic or political influences; individual and group influences and vaccine-specific issues that correspond to vaccine hesitancy [
10]. This is a more context-specific model that acknowledged the importance of context, society and individual and group differences in the success of a vaccination program. Studies on vaccine hesitancy have shown the significance of context-specific factors such as risk perception, social norms, group dynamics and political ideology as important determinants of vaccine hesitancy and refusal [
39,
40]. A recent study in Malaysia by Syed Alwi et al
. showed that religious and cultural reasons contributed 27.6% of the hesitant respondents [
13].
The widely accepted definition of vaccine hesitancy by the SAGE Working Group [
10] has been contested as its 3Cs Behavioural Model and the Vaccine Hesitancy Matrix have been critiqued as inadequate to cover the complex issue of vaccine acceptance and uptake [
20,
41]. The 3Cs Model of Complacency, Convenience and Confidence are arguably psychological states of mind or sentiments held by people during an immunisation programme [
20]. Some researchers argue that this model of vaccine hesitancy is problematic as it places vaccine uptake within the individual’s control and situates responsibility on the individual even if a vaccination system does not successfully reach him or her [
20]. Vaccine hesitancy and uptake may be due to a combination of social and behavioural factors. Studies have shown that access barriers are an important factor to economically disadvantaged children not receiving vaccinations as their families face financial and logistical challenges [
42,
43]. An alternative model proposed by Thomson et al. focused on the root causes of the vaccine coverage gap: the 5 As Taxonomy: Access, Affordability, Awareness, Acceptance and Activation. Thus, this study aims to evaluate the 3Cs Model to determine if this model is able to capture the social and behavioural factors that determine vaccine hesitancy and vaccine uptake through the findings of this study.
In this study, the lived experiences of participants during the COVID-19 Immunization Program in Malaysia are investigated. Through the meanings extracted from these lived experiences, a fuller picture of vaccine implementation, vaccine hesitancy and vaccine refusal would emerge. The research questions in this study are as follows:
1. What experiences are associated with vaccine hesitancy and vaccine refusal during the COVID-19 vaccination programme in Malaysia?
2. What could make people who hesitate and refuse vaccines accept the COVID-19 vaccines in Malaysia?
Discussion
The findings from this study are consistent with results from other studies prior to and during the COVID-19 Pandemic [
13,
57,
58]. Explicating from the 3C Model of Vaccine Hesitancy [
10], a lack of
confidence in the effectiveness and safety of vaccines was a major determinant of vaccine hesitancy and refusal in this study. Additionally, from the participants’ lived experiences, there appears to be a high trust deficit in the JKJAV, the politicians who were policymakers, and the reliability of the healthcare system. As proposed by the Vaccine Hesitancy Matrix [
10], contextual and issue-specific factors like personal, political and community belief systems added to the confidence or mistrust of certain brands of vaccines [
13,
57].
Complacency was detected among the younger participants and their friends as they perceived risks of the COVID-19 disease as low, and vaccination was not deemed a necessary preventive action. This was probably because communication on the dangers of the virus was not directed to them as a specific group, and they assumed they were immune to the disease. We found that the attitudes of vaccine hesitancy towards the immunization program were not fixed. On the contrary, there appears to be the willingness to be counselled, and be provided with the correct information from their trusted leaders or heroes. A change of mind to embrace vaccination was deemed possible. This finding concurs with the results of other studies that reported peer effects on vaccination through various tools, such as imitation and information sharing [
57,
59].
Convenience also emerged as a determinant of vaccine hesitancy and refusal in this study. The less digitally savvy sector of the community deemed the MySejahtera mobile application as 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 and this would affect their attitudes and trust in the NIP. These access issues involved logistics and mobility issues related to accessing the vaccination centres during the lockdowns. The lack of assistance and services together with poor communications undermined vaccine uptake [
60]. Such access issues stemmed from systemic flaws in the administration of the NIP. Arguably, this factor of determining vaccine hesitancy in the 3 Cs Model may not be fit for purpose, as it places the responsibility of vaccine uptake and hesitancy on the individual where manifestly, the individual may have very little control on the social and physical factors that prevent him or her to get the vaccination [
20].
Communication appears to be an important component to strengthen vaccine intent. In the Vaccine Hesitancy Determinants Matrix, communication and the media environment were proposed as contextual factors influencing vaccine hesitancy and refusal [
10,
60]. Findings from this study reiterated the importance of communication, revealing that participants and their communities were inundated with misinformation in the form of fake news and conspiracy theories. In addition, there were incongruent influences such as the lack of timely information on the NIP, in particular, on the efficacy and safety of the vaccines [
13].
The health communication strategies employed tended to rely on scientific facts and evidence, which probably failed with people who mistrusted biomedical research. Some studies also reported that logical and scientific evidence in health communication campaigns did not resonate with some individuals who were more influenced by the emotional appeals in misinformation [
57,
59,
61].
Limitations
The relatively small sample size and non-probability sampling of this study mean that the findings cannot be generalized. However, there can be transferability of the findings in other similar contexts, as the study results were consistent with other studies on COVID-19 vaccine hesitancy and refusal.
Conclusion
From the themes that emerged from the participants’ lived experiences of the COVID-19 immunization program in Malaysia, it becomes apparent that there was incongruence between the official aims of the NIP and the realities, as well as needs on the ground. Paradoxically, while there was a trust deficit in the government and the health authorities, the people would believe their family members and local vaccination leaders. There was also incongruence in communication between the official media and local social media used by the people in their multiple settings.
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. Hence, the significance of this study lies in its rich details of the phenomenon. Confidence, complacency and to some extent, convenience were found to be important determinants of vaccine hesitancy and refusal. We used the 3Cs Model to determine if the vaccine uptake and hesitancy attitudes during the NIP in Malaysia were based on Confidence, Convenience and Complacency. We found that while confidence in the vaccines and the health authorities did affect trust in the vaccines and the NIP, thus leading to accounts of vaccine hesitancy and refusal. Complacency was seen in the medical and postgraduate students’ accounts of how some of their peers and younger community members had an indifferent or ‘cannot be bothered’ attitude as they felt that since they were young and healthy, they would not be infected by COVID 19. Access issues were found to be an important deterrence to certain groups of people like the elderly, the disabled and the rural community. Hence, the factor of convenience does not adequately explain the institutional, social and physical factors that may influence vaccine uptake. The 3Cs Model would have to be updated to take into consideration such factors.
Communication and the media environment emerged as an important influence of vaccine hesitancy and uptake. In this twenty-first century, societies are beset by fake news and conspiracy theories through social and traditional media on an everyday basis. It is, therefore, important for health authorities to design effective communication campaigns to counter the misinformation. Context, group, individual and vaccine-related issues were also found to be significant determinants and should be factored into the design of health communication strategies.
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. which would thus, be useful to other Southeast Asian contexts which have similar settings. 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.
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