"On the Last Day of the Last Month, I Will Go": A Qualitative Exploration of COVID-19 Vaccine Confidence among Ivoirian Adults

"Social and behavior change interventions can influence individual knowledge, attitudes, and intentions as well as community norms to facilitate widespread vaccine uptake."

Vaccine acceptance, which is critical for pandemic control, has a variety of context-specific drivers that operate at the individual, group, and sociopolitical levels. In Côte d'Ivoire, rumours and conspiracy theories circulated about the origin and response to COVID-19 and the safety of vaccines, including controversial statements from scientists in April 2020 about vaccine trials in Africa that led to widespread condemnation of a colonial mindset that would consider African volunteers as "guinea pigs". Critical to successful risk communication and community engagement (RCCE) is a nuanced understanding of context-specific knowledge, attitudes, beliefs, intentions, and norms that precede and enable protective behaviours, such as vaccination. This analysis was conducted to investigate perceptions of and barriers to accepting a COVID-19 vaccine among health workers and the general population in Côte d'Ivoire.

The researchers collected data in Abidjan, Côte d'Ivoire, in November 2020; COVID-19 vaccines were not yet available in the country at this time. The in-depth interviews involved individuals who had recovered from COVID-19 (n=8), people who had lost a family member to COVID-19 (n=4), and health providers (n=17). The researchers also conducted focus group discussions with 127 members of the general population (n=24 groups) to explore social norms and community perceptions related to COVID-19, including prevention behaviours, stigma, and vaccines.

Just as the literature identifies three categories of determinants of vaccine hesitancy - complacency (factors related to perceived risk and severity of the illness), confidence (in the vaccine and in the health system/providers), and convenience (factors around cost and access) - the researchers found that the participants weighed perceived severity of rumoured side effects or safety issues (confidence) against perceived risk and severity of the disease (complacency) in their decisions to accept the COVID-19 vaccine or not. Beliefs related to confidence and complacency were both strongly fueled by rumours and misinformation spread online and person-to-person. Convenience was a secondary, albeit important, consideration.

In more detail:

• Confidence: Participants expressed mistrust in the COVID-19 vaccines as well as in those developing, authorising, and delivering the vaccines. Health workers tended to express concerns about the safety of vaccines that were rapidly developed and deployed. Non-health workers shared similar concerns but tended to focus on distrust of those developing and delivering the vaccines. Trust (or lack thereof) - in the Ivoirian government and in foreign governments and companies - was a consistent theme, with people believing that foreigners created the SARS-CoV2 virus and subsequently vaccines to make money. There was a rumour circulating that COVID-19 itself was designed to control the population; this idea was extended to COVID-19 vaccines, specifically the perception that vaccines were promoted to exterminate African people. A health worker who survived COVID-19 referenced videos circulating on social media. Participants said that, as a result, people in their communities had become more resistant to routine vaccinations already approved for use, such as childhood vaccines like the polio vaccine. People who were not staunchly against COVID-19 vaccines took a "wait and see" approach to see how the vaccine affects others. Participants who were ambivalent or cautious about the vaccine expressed a desire for transparency about the vaccine origins, testing process, and efficacy. One health worker described the need for trusted information and careful consideration of who should promote vaccines.
• Complacency: Overall, there was low risk perception based on the conviction that COVID-19 only affects Westerners or does not exist at all. For those with low risk perception, the motivation to get a vaccine that might be unsafe or could have side effects was lower than awaiting a treatment that could cure them in the event they became infected. Health workers tended to have a stronger sense risk perception, along with those who had survived COVID-19 or lost a family member.
• Convenience: The suggestion that the vaccine should be free was often framed not as the main determinant but a secondary or enabling factor for vaccine intention.

In summary, participants who expressed an intention to be vaccinated or thought others like them would get vaccinated cited as motivators perceived risk and perceived severity, a desire to protect others, and the possibility that vaccines would provide a way back to normalcy. Those who were "on the fence" about vaccination tended to be uncertain about the purpose of vaccines and had concerns about vaccine safety in light of its rapid development. Conspiracy theories and distrust in vaccine policymakers and distributors were key drivers of intention to refuse the COVID-19 vaccine.

In discussing the implications of the study, the researchers describe an uphill battle for health communicators. For one thing, with the exception of health workers, few participants in this study were aware of vaccination as a prevention method for COVID-19. In fact, vaccines were rarely top-of-mind for participants. Going forward, the researchers suggest that:

• Behaviour change interventions must: raise awareness and address misunderstandings about the purpose of vaccines, transparently communicate about vaccine safety and development processes, and engage trusted influencers to build an enabling environment for COVID-19 vaccine roll out. For example, risk communicators can lay the groundwork for vaccine acceptance through education and transparency about vaccine eligibility, timelines, cost, and anticipated side effects. One way to message on the COVID-19 vaccines is to situate the development of COVID-19 vaccines in a long history of research and technological advances. This type of messaging can be challenging for people to understand or believe, so focusing on the urgency of the pandemic and informing people about the regulatory processes may be a straightforward option.
• The global health community must ensure that vaccines against SARS-CoV2 are distributed equitably across the globe and avoid using vaccine hesitancy as a way to chastise people while doses are monopolised by wealthy countries. In the case of COVID-19, hardest hit areas like the United States and the United Kingdom are serving as a testing ground for the rest of the world, and positive outcomes in these areas can reassure hesitant citizens in countries receiving vaccines later.
• RCCE can influence perceptions and norms to the extent that trusted influencers are involved and the true concerns of the population addressed. Participants themselves underlined the need to consider who should deliver the messages about vaccines in order to convince those who are uncertain. It is critical to engage local communities and local governments not only to influence beliefs, but to provide an enabling environment for vaccine uptake, such as by offering certificates of achievement for places of business where employees have all been vaccinated. Measures to communicate a social norm around vaccination, such as engaging journalists to showcase people being vaccinated, can lay the groundwork for vaccine roll-out in settings where mistrust is the current reality.

The research team shared vaccine-related insights from this study with stakeholders in Côte d'Ivoire in order to demonstrate the need for awareness campaigns that would specifically address different barriers to vaccine confidence and uptake. Such a campaign is underway as of this writing.