Vaccination anxiety & vaccination hesitancy: Emerging public health challenge during COVID-19

The COVID-19 pandemic has been marked by various mental health concerns, including worries, anxiety, stress, depression, paranoia and hypochondriasis1. A phenomenon known as doomsurfing is also considered responsible for pessimism, fear, anxiety and sadness with respect to the ongoing pandemic. In doomsurfing, the individuals spend excessive time surfing, listening or viewing COVID-19 news online which is disappointing and makes one feel more anxious, apprehensive, sad and uncertain about the future, and still, these individuals are unable to stop themselves from minimizing their online consumption of news from the internet and social media in the expectation of learning positive news2.

After the introduction of COVID-19 vaccination, people reported anxiety reactions and hesitancy for taking the vaccine3. The COVID-19 vaccine efficacy was either considered doubtful or denied by 37 per cent of the 1638 participants in a study, or roughly more than 200 million adults in the Indian context4. Between 29 and 39 per cent of Indians were vaccine hesitant, according to a multi-source study5. Although there have been only a few studies on vaccination anxiety during COVID-19, it becomes crucial to understand the role of psychosocial factors contributing towards vaccination anxiety and hesitancy3. One of the major concerns was that in case there was geographical clustering of people hesitant against the use of COVID-19 vaccine, this might lead to sudden outbursts of cases and then it may be a difficult situation for the local health authorities to curtail the impact of COVID-19 on the general population and on the existing health systems. Thus, an attempt was made to understand the situation of vaccination anxiety by extrapolating the research literature already available for other vaccines.

Magnitude of challenge of vaccination anxiety

The success of vaccine campaigns to control and minimize the impact of COVID-19 is not solely dependent on the efficacy and safety of vaccines. A very crucial aspect is the acceptability of the vaccine among the community population and healthcare workers. There appear to be many barriers leading to lower vaccine acceptance rates by the general population and vaccination anxiety appears to be contributing significantly towards the same. Vaccine anxiety refers to worries, apprehension and anxiety associated with the thoughts or plans to take vaccination. The behavioural manifestation of vaccination anxiety is evident in the form of vaccination hesitancy which refers to the delay in acceptance or refusal of vaccination despite the availability of vaccination services4. Vaccination anxiety and hesitancy are both related to vaccine acceptance rates. A systematic review6 suggests that the highest COVID-19 vaccine acceptance rates and lowest vaccine anxiety rates among the general population were found in Ecuador (97.0%), Malaysia (94.3%), Indonesia (93.3%), China (91.3%) and India (86%). Alternatively, the vaccine acceptance rates (or higher vaccination anxiety) were found to be lowest in Kuwait (23.6%), Jordan (28.4%), Italy (53.7%), Russia (54.9%), Poland (56.3%), the US (56.9%) and France (58.9%)6,7. The vaccine acceptance rates among healthcare workers ranged from lowest being 27.7 per cent in the Democratic Republic of the Congo to highest being 78.1 per cent in Israel6. Thus, there is a need to understand what had led to the initiation and perpetuation of vaccine anxiety and vaccine hesitancy among the general population.

Rumours, social media and vaccination anxiety: It has been established how increased fear and apprehension is likely a by-product of conspiracy theories, misinformation and injected controversies from groups of individuals who often use emotional content to sway the minds of the general public5. In the situation of the pandemic, social media platforms are filled with rumours related to COVID-19 vaccine and the vaccination programme such as ‘Vaccine is not safe’, ‘Vaccine is not tested sufficiently’, ‘After vaccine individuals are getting paralysis attack’, ‘Vaccine leads to death in many countries’, ‘It was developed in a very short time’, ‘Experts are also not sure about its effectiveness’ and ‘Vaccine does not guarantee protection’8.

There are rumours on social media posts that ‘COVID-19 vaccination causes infertility’9. This myth claims that the vaccine causes infertility by generating antibodies that involuntarily react with a protein in the placenta called syncytin-19. In addition, social media is also becoming a common hotspot for ‘anti-vaccine’ groups that systematically encourage mistrust in evidence-based healthcare treatments, services and experts, by using emotionally laden information and conceptualizing it out of context by relating it to current or past shortcomings of medical treatments or medical regulatory bodies7-9. Anxiety and despair caused by the pandemic is often fuelled by this misinformation. The other part of the rumour cycle is contributed by the individuals who have anxious personality traits or have health anxiety or for whom social media is a modality to ventilate and regulate their emotions. Such individuals are more likely to consume and share misinformation, misconceptions with others without verifying the source. This completes the vicious cycle of rumours, anxiety and apprehensions with contributions from both social media platforms and anxious individuals which leads to the perpetuation of vaccination anxiety and hesitancy10,11. A crucial reason behind this spread of misinformation through social media are likely individuals who actively campaign against the use of vaccines. Such individuals appear to deliberately spread misinformation12. Other studies have discovered that worries about the safety and adverse effects of the current vaccines are the main causes of vaccine hesitancy and refusal in India. Such misinformation during the uncertain times of a pandemic is sufficient for individuals who are vulnerable to influence or incitement of emotions to experience worries, apprehension and anxiety and develop an exaggerated risk perception13. Rural residents with low formal education and a wider digital gap are two additional characteristics that contribute to vaccine anxiety and hesitancy14.

Vaccine acceptance: In countries like Turkey, UK, France, Germany, India and China, people with higher risk perception, higher occupation-related health risks, receiving logical advice from relatives or friends, with a higher need for travel, encountered facts based information through official social media platforms, having trust in vaccine awareness campaigns and had higher levels of COVID-19 anxiety demonstrated notably higher vaccine acceptance15-17. Younger age, female gender and lower educational level and excessive use of social media were associated with lower vaccination acceptability1,15,18. In addition, learning about COVID-19 vaccination from medical professionals was found to be associated with a greater perception of the efficacy of self to execute required behaviours, greater belief about the effectiveness of the recommended responses and knowledge gained with respect to COVID-19 vaccination, leading to higher vaccine acceptance17. However, when similar information is received from co-workers or through online platforms, it is usually associated with a higher response cost of vaccination, lesser addition to knowledge and lower effectiveness to accept vaccination17.

Individuals who were experiencing symptoms of mild depression and anxiety and were gainfully employed in a stable occupation were reported to have better vaccine acceptance19, whereas patients with substance use disorders showed a lack of readiness and trust as potential obstacles to receiving the COVID-19 vaccine20.

Conclusion

The anxiety and hesitancy towards the COVID-19 vaccine can be tackled by health authorities by engaging in effective communication strategies with the public using primarily online platforms inclusive of social media applications. It must also be ensured that the public has access to information from health authorities in a transparent and timely manner about the positive effects of vaccine, prompt management of adverse effects and information about the availability of vaccines for the public and people with medical and psychological comorbidities19. In addition, the vaccination education needs to include awareness campaigns and establishment of communication mechanisms for effectively managing the misinformation created by the rumours and myths, which the general population consumes through social media platforms. On an individual level, techniques like motivational interviewing could be used to reduce concerns and increase vaccine acceptance. In addition to the responsible and proactive role of health authorities, the media, government and members of the general population must also engage in responsible reporting of public health problems inclusive of the COVID-19 pandemic and vaccination drives11.

Further, the health authorities and health experts, i.e. physicians, pharmacists and the like, need to disseminate the information in a more clear, simple and compassionate manner. This stance will likely help in creating messages of vaccine education that actively address the misinformation, myths and fallacies and educate users about the facts of vaccination and its role in overcoming the pandemic as well as in the promotion of using masks and following social distancing. When misinformation is directed at specific communities, the vaccine education must be strategically disseminated in a manner which addresses the specific rumours for the intended population. The individuals who have this misinformation should not be stigmatized for raising such concerns. Instead, these concerns must be addressed as quickly as possible. The health agencies also need to request the endorsement of the vaccine education messages by noteworthy public figures to restore the confidence of community in health systems and safety of vaccines. Public healthcare experts and first-line professionals can also propagate effective vaccine administration and model to the public by taking the vaccination themselves21.

Thus, health authorities and experts in collaboration with media need to create vaccine education messages and information in a clear, simple and transparent manner and disseminate the same as widely as possible among the general population primarily through social media platforms. Effective communication mechanisms need to be created to address the emergent questions, rumours, fallacies and misinformation in a quick and compassionate manner by health experts and public figures which facilitate the vaccination acceptance22. These strategies would surely be effective in enhancing vaccine education, minimizing vaccine anxiety, vaccine hesitancy, building tolerance against misinformation. In terms of future research perspective, considering India’s diverse population, research should be done on the best ways to spread the information about the advantages of receiving the COVID-19 vaccine, disentangle the role and interaction of different social media platforms and other media formats to alleviate worries and dispel myths and false information surrounding the COVID-19 vaccine.