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ORIGINAL ARTICLE
Year : 2023 | Volume
: 67
| Issue : 1 | Page : 21-27
COVID vaccine hesitancy among the tribal population and its determinants: A community-based study at berhampore block of Murshidabad District, West Bengal
Arnab Sarkar1, Anirban Dalui2, Paramita Sarkar3, Manisha Das4, Rivu Basu5, Jadab Chandra Sardar6
1 Public Health Expert, Swasthya Bhawan, Department of Health and Family Welfare, Government of West Bengal, India
2 Assistant Professor, Department of Community Medicine, Barasat Government Medical College, Kolkata, West Bengal, India
3 Senior Resident, Dinhata Sub-Divisional Hospital, Cooch Behar, West Bengal, India
4 Senior Resident, Department of Community Medicine, R. G. Kar Medical College, Kolkata, West Bengal, India
5 Associate Professor, Department of Community Medicine, Bankura Sammilani Medical College, Bankura, West Bengal, India
6 Professor, Department of Community Medicine, Raiganj Government Medical College, Raiganj, West Bengal, India
Correspondence Address:
Anirban Dalui
20C, Sri Gopal Mullick Lane, Kolkata - 700 012, West Bengal
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijph.ijph_130_22
Abstract
Background: On January 16, 2021, India rolled out the COVID vaccination drive. A successful and effective vaccination campaign requires much more than the availability of a safe and effective vaccine. This includes identifying vulnerable populations with lower vaccine confidence and identifying the drivers of vaccine hesitancy. Objective: This study aims to find out vaccine hesitancy among the tribal population regarding COVID-19 vaccination. Methods: It was an observational descriptive cross-sectional study, conducted at Manindranagar and Hatinagar gram panchayat of Berhampore Block of Murshidabad district, West Bengal, from June 2021–November 2021, among tribal people aged >18 years. A total of 198 tribal people were selected by applying the probability proportional to size sampling method. Participants were interviewed using predesigned, pretested, and semi-structured schedules. Potential predictors of hesitancy were investigated using the multivariate logistic regression model. Results: Vaccine hesitancy was present among 36.9% of the study participants. Fear of side effects (78.1%) was the most common reason of vaccine hesitancy. Only 30.8% of them received at least one dose of vaccine. Vaccine hesitancy was associated with decreased family income in the last 1 year (adjusted odds ratio [AOR] = 8.23), knowledge regarding vaccine (AOR = 0.41), adherence to COVID-appropriate behavior (AOR = 0.45), and trust on the local health-care worker (AOR = 0.32). Conclusion: Vaccine hesitancy among the tribal population is driven by a lack of knowledge and awareness. Their economic status, attitudes toward the health system, and accessibility factors may also play a major role in vaccine hesitancy. Extensive information, education, and communication activity, more involvement of health-care workers in the awareness campaign, and establishment of vaccination centers in tribal villages may be helpful.
Keywords: COVID-19, India, tribal, vaccination hesitancy, vulnerable populations
Introduction 
Coronavirus disease (COVID-19) is an infectious disease caused by a newly discovered coronavirus (SARS-CoV-2), which has spread rapidly throughout the world. In March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic.[1] While countries, including India, have taken strong measures to contain the spread of COVID-19 through better diagnostics and treatment, vaccines will provide a lasting solution by enhancing immunity and containing the disease spread. In response to the pandemic, the vaccine development process has been fast-tracked. On January 16, 2021, India rolled out the world's largest vaccination drive.[2] Successful vaccination largely depends upon the quality of training conducted for enumerators for beneficiary listing, health functionaries for vaccination activities, social mobilizers for all mobilization activities, and communication training for all workers involved in the process of vaccination.[3] More than 145 crores of vaccine doses were administered in India till December 31, 2021. Vaccination of the age group 15–18 years will start from January 3, 2022.[4] However, this rate of vaccination is not sufficient to halt the pandemic. There are also substantial inequities in gender, class, and rural–urban divide in coverage of vaccines in India.[2],[5] A successful and effective vaccination campaign requires much more than the availability of a safe and effective vaccine. This includes identifying vulnerable populations with lower vaccine confidence and identifying the drivers of vaccine hesitancy.[6]
In 2015, the WHO Strategic Advisory Group of Experts on Immunization defined vaccine hesitancy as a “delay in acceptance or refusal of vaccination despite the availability of vaccination services,” which can vary across time, place, and vaccines and is influenced by factors such as complacency, convenience, and confidence.[7] Concern about vaccine hesitancy is growing worldwide; in fact, WHO identified it as one of the top ten global health threats in 2019.[6] In many countries, vaccine hesitancy and misinformation present substantial obstacles to achieving coverage. Available research data suggests that many countries, including India, had faced vaccine hesitancy previously.[7],[8],[9] In June 2020, Lazarus et al. surveyed 13,426 people in 19 countries to determine potential acceptance rates and factors influencing the acceptance of a COVID-19 vaccine. Of these, 71.5% of participants reported that they would be very or somewhat likely to take a COVID-19 vaccine, and 61.4% reported that they would accept their employer's recommendation to do so.[10] A survey, conducted by Umakanthan et al. in four states of India, found that in June 2021, 36% of Indians were COVID-19 vaccine-hesitant and 6% were COVID-19 vaccine-resistant.[11] Multiple studies in India have reported the presence of vaccine hesitancy regarding COVID-19 vaccines.[11],[12],[13],[14],[15] Sikder et al. reported in their study that in an urban area of West Bengal, vaccine hesitancy was present among 29% of the residents.[14]
Past research has indicated lower vaccination rates among the marginalized sections of society in the past.[16],[17] The marginalized groups in India that consist of scheduled tribes have a long history of exclusion. Inequitable access to the health system and mistrust in the system are possible reasons for lower vaccination rates among the marginalized sections of society.[6],[17] Karpaga Priya et al. and Dasgupta et al. also found lower vaccine coverage and the presence of vaccine hesitancy among vulnerable populations including residents of slum areas.[9],[18] Vaccination drive against COVID-19 disease will not be successful if the drivers of vaccine hesitancy are not addressed, especially among the marginalized population such as scheduled tribes. There is a paucity of data regarding the uptake of the COVID-19 vaccine among the tribal population and no information regarding vaccine hesitancy and factors that contribute to vaccine hesitancy. Therefore, this study aims to study vaccine hesitancy and its related factors among tribal populations.
Materials and Methods It was an observational descriptive study with cross-sectional design. The study was conducted at Manindranagar and Hatinagar gram panchayat (G. P.) of Berhampore Block of Murshidabad district, West Bengal, from June 2021–November 2021. According to Census 2011, most of the tribal people of Berhampore block were residing in Manindranagar and Hatinagar G. P.[19] Data were collected during August 2021–September 2021. Study population included the tribal people who were aged >18 years and were permanent residents of the study area. Individuals suffering from COVID-19 or similar symptoms were excluded from the study. Those who did not give consent to participate in the study, or, could not be contacted after three attempts, were excluded also from the study.
A pilot study was conducted in a village of an adjacent block among 33 tribal people. It was found that 28 (84.8%) of them were willing to take COVID vaccine. Therefore, considering the anticipated prevalence of vaccine hesitancy among the tribal population as 15.2%, allowable error as 5%, and confidence interval (CI) as 95%, the sample size was calculated using the formula:
Therefore, the sample size was taken as 198.
All the villages of these two G. P. were included in data collection for better representation. Number of study subjects to be selected from each village was calculated by applying probability proportional to the size of the scheduled tribal population. With the help of local health-care workers, a list of all tribal household present in each village of the study area was prepared. Using simple random sampling, tribal households to be visited were selected. One person from each selected tribal household was interviewed. If more than one adult individual were present in the household at the time of the interview, then the head of the family or the senior most member of the household was interviewed. If the selected individual was excluded as per exclusion criteria, then he/she was replaced from the sampling frame by simple random sampling.
The study participants were interviewed using predesigned, pretested, and semi-structured schedule. Literature review was done to identify the variables for the study. The schedule was prepared including variables such as sociodemographic characteristics, adherence to COVID-appropriate behavior, knowledge regarding COVID vaccines, vaccine hesitancy, and current status of vaccination. Vaccine hesitancy was considered to be present among those who refused, were reluctant, or delayed any of the scheduled COVID vaccine doses. Vaccine hesitancy was considered to be absent among those who had received the vaccine or were willing to take the vaccine whenever available. To elicit adherence to COVID-appropriate behavior, during data collection, participants were interviewed and observed whether they were adhering to the COVID-appropriate behaviors addressed by the Ministry of Health and Family Welfare.[20] Finally, the face validity and content validity of the prepared schedule were ascertained with the help of five experts. House-to-house survey was done for data collection. After obtaining written informed consent, data were collected by carrying out face-to-face interviews. All COVID-related protocols were followed during data collection.
Data obtained were properly coded, compiled, and put in Microsoft Excel. IBM SPSS version 23.0 (SPSS Inc., Chicago, Illinois, USA) software was used for data analysis. The results were presented in terms of proportions and percentages. Continuous data were summarized using mean (±standard deviation) or median (±Interquartile range [IQR]). There were items which were assessed using the Likert scale. For bivariate analysis, these items' responses were clubbed and divided into two groups. Items related to COVID-appropriate behavior and knowledge of the COVID vaccine were clubbed and categorized into two groups. To achieve this categorization for each item, positive response was scored as 1 and negative response as 0. Then, the total score of each participant was calculated for these two domains. Then, the median domain score of all participants was calculated. With the help of the median score, all participants were categorized into two groups. Those who had better score than the median domain score was considered “good” and others were considered “poor.” All categorical variables were analyzed by Pearson's χ2 test. Potential predictors of contribution were investigated using univariate binary logistic regression. Further analysis was conducted using the forward LR multivariate binary logistic regression model. Ninety-five percentage CI with statistical significance at 5% level was considered.
Necessary clearance was obtained from the Institutional Ethics Committee of R. G. Kar Medical College and Hospital. Permission from district and block health authorities was also taken before data collection.
Results Background characteristics of the study participants
The median age of the study participants was 41.5 years (IQR: 19 years). Majority (43.9%) of them were between 31 and 49 years of age. Males (54%) were predominant and the rest were females (46%). All of the participants (100%) were Hindu. Majority of them attended secondary school (42.9%), followed by illiterate (39.9%) and primary school (15.2%). Only 2% attended higher secondary or above. Majority of participants were married (83.8%). All of them (100%) belonged to joint family. Majority was daily laborer (36.9%), followed by service (14.1%), businessman (5.6%), and others (16.1%), whereas 27.3% of them were not involved in any occupation. Most of them (86.4%) had history of substance use in the last 1 year. History of using any substance during the last 1 year was taken. Smoking tobacco was the most common (57.6%) substance used, followed by alcohol (33.3%) and smokeless tobacco (12.1%). In the last 1 year, the family income had decreased among 85.9% of them.
All of them had heard about COVID-19 disease and 11.1% had suffered from COVID-19 disease. When the participants were asked about their perception on whether they have any chance of getting COVID-19 infection, 0.5% strongly agreed, 66.2% agreed, 22.2% disagreed, and 11.1% strongly disagreed to that they may suffer from COVID-19 infection. Overall, 51.5% of them were adhering to COVID-appropriate behavior, whereas 48.5% were not. Most of them (86.9%) stated that they had trust on local health-care workers.
Knowledge regarding COVID vaccine
All of them had heard about COVID vaccine and ongoing vaccination drive. Everyone (100%) preferred government health facilities for their vaccination. Majority (54.5%) of them believed that the vaccine will not protect from COVID [Table 1].
Vaccine hesitancy
Vaccine hesitancy was present among 36.9% of the study participants. About 30.8% of them had received at least one dose of COVID vaccine. Rest 32.3% were willing to take vaccine. Only 10.6% have received two doses of vaccine. Those participants who had received the first dose were willing to take the second dose also. Among those who were unwilling to take the vaccine (n1 = 73), fear of side effects was the most common (78.1%) reason. Among those who were willing but did not get the vaccine yet (n2 = 64), majority (79.7%) were unable to take the vaccine due to lack of nearby vaccination centers. Among all participants, 77.8% stated that they will encourage adult family members/relatives and 88.9% stated that they will encourage aged <18 years family members/relatives for vaccination [Table 2].
Vaccine hesitancy was high among those whose family income decreased in the last 1 year (adjusted odds ratio [AOR] [CI] =8.23 (4.48–15.12)). Those who thought that may suffer from COVID-19 were more willing to take the vaccine (AOR [CI] =0.59 [0.17–087]). Those who got vaccine-related information from health-care workers had significantly greater chance of taking the vaccine (AOR [CI] =0.19 [0.12–0.39]), whereas those who got vaccine-related information from neighbors (AOR [CI] =1.85 [1.12–3.05]) and local administration (AOR [CI] =1.6 [1.01–2.53]) had significantly greater chance of vaccine hesitancy. Chances of vaccine hesitancy were lesser among those who were following COVID-appropriate behavior regularly (AOR [CI] =1.85 [1.12–3.05]), had good knowledge regarding COVID vaccine (AOR [CI] =1.85 [1.12–3.05]), and had trust on the local health-care worker (AOR [CI] =1.85 [1.12–3.05]) [Table 3].
Discussion It was a community-based survey of attitudes toward COVID-19 vaccine and vaccine hesitancy among the tribal population. Sociodemographic characteristics of the studied people were comparable to the Census 2011 data of Berhampore C. D. block.[19] This indicates the representativeness of the sample population. Although 63.1% of them had a positive attitude toward the vaccine, still a large number of them (36.9%) were hesitant to take the vaccine. Sikder et al. reported in their study that in an urban area of West Bengal, vaccine hesitancy was present among 29% of the residents.[14] A survey, conducted by Umakanthan et al. in four states of India, found that 36% of Indians were hesitant and 6% resistant to take COVID vaccine.[11] Among those who were hesitant (n1 = 73), fear of adverse events after immunization was the most cited (78.1%) reason. Many (68.5%) thought vaccines will not be effective against COVID, whereas 57.5% of them refused to take the vaccine because they heard negative comments regarding the vaccines. Multiple studies reported that being a newly discovered vaccine, its safety and efficacy are a concern to many people.[2],[11],[12],[21],[22],[23] More than half (53.4%) of them believed that there is no need of COVID vaccine. This finding may be related to their belief in the indigenous system of medicine. About 46.6% of them reported that they will not need vaccine as they follow the indigenous system of medicine. In a study by Danabal et al., preference for natural immunity compared to vaccine was also reported as a reason of hesitancy.[2] Due to poor economic and literacy status, smartphones and Internet are still not easily accessible to a large number of tribal populations. In this study, 43.8% complained that registering in online platform is inconvenient for them, whereas 10.6% and 6.8% of them were hesitant because of fear of injection and prohibition from family members, respectively. There is a paucity of studies among tribals on this topic. Therefore, there is a lack of published data to compare these findings.
The main factors associated with COVID vaccine hesitancy were self-perceived chance of suffering from COVID, nonadherence to COVID appropriate behavior, effect on family income in the last 1 year, lack of knowledge regarding COVID vaccines, source of information regarding COVID vaccine, and lack of trust on local health-care workers. Till now, literacy status is poor among tribals. Majority of them were working in unorganized sectors with low-wage jobs. Substance use is very common among them. Most of them (85.9%) had faced a decrease in family income in the last 1 year due to the pandemic. That is why majority of them (59.6%) were not in favor of lockdown or COVID restrictions. Those who faced decrease in family income were 8 times more likely to be hesitant. This problem is mainly faced by those who earn in daily wage jobs. Already, lockdown and COVID restrictions had troubled them badly. They feared that any side effects after COVID vaccination may lead to loss of working days, which again would lead to further economic loss. This fear was preventing them to take the vaccine. Government may plan for some social or economic assistance to those people who will face loss of work days due to the side effects of the vaccine. This may be useful to encourage them for COVID vaccination.
When they were asked about whether they may suffer from COVID-19, more than 1/3rd of them (33.2%) thought they do not have a chance to get COVID infection. Those who thought that they might suffer from COVID were more willing to take the vaccine. Odds of vaccine hesitancy were higher among those who thought that they might not suffer from COVID. Similar findings were reported by Jain et al. in a study among medical students.[12]
In case of following COVID-appropriate behavior, their adherence was also poor. Although majority of them (87.4%) were wearing mask, other COVID-appropriate behaviors were ignored by majority. Lack of awareness and poor literacy may have played a major role here. Nonadherence to COVID-appropriate behavior was significantly associated with vaccine hesitancy. Those who were not following COVID-appropriate behavior were more likely to refuse COVID vaccine. Odds of vaccine hesitancy were lower among those who were adhering to COVID protocols. Multiple studies have reported that lack of awareness and poor literacy was associated with vaccine hesitancy.[6],[10],[13],[18],[23],[24]
Although every participant had heard about COVID vaccine, still knowledge regarding COVID vaccine was poor among 44.9% of them. Poor knowledge was associated with higher vaccine hesitancy. Odds of hesitancy were lower among participants with good knowledge of vaccine. Almost all previous studies had reported lack of knowledge as a predictor of vaccine hesitancy.[2],[6],[11],[12],[13],[16],[18],[21],[22],[23],[24] In this study, findings suggest that the source of information regarding COVID vaccine was also associated with vaccine hesitancy. Those who got information from local healthcare workers were more willing to take the vaccine, whereas the chances of hesitancy were higher among those who got information from neighbors and local administrative authorities. Negative rumors were mainly spreading through neighbors which may have role in increased hesitancy. Study participants also mentioned lack of confidence over local administrative authorities which may have related to hesitancy, whereas media information did not have statistically significant association. Previous studies from India and abroad reported that rumors and negative comments were associated with increased vaccine hesitancy.[10],[11],[13],[24] Dani et al. reported in their study that involving local leaders and collaborating with media were associated with an increase in vaccine confidence among the general population, which is different from the findings among the tribal population of this study.[25]
It was evident in previous studies that mistrust in health-care system was associated with increased vaccine hesitancy.[2],[12],[24],[26] This also found out that those who have trust in local health-care workers were more willing to accept the vaccine. This indicates engagement of health-care workers in information, education, and communication (IEC) activity and awareness campaigns may be helpful. Few studies reported sociodemographic factors were associated with vaccine hesitancy in the general population which is in contrary to the findings of this study.[2],[11],[24],[27]
Only 30.8% of the study population had received at least one dose of vaccine till the period of data collection. Coverage of double-dose vaccination was very low (10.6%). Among those who were willing to take the vaccine (n2 = 125), majority (40.8%) complained the absence of nearby vaccination centers as a reason of not getting the vaccine. Many (27.2%) were unable to wait at the long queue of vaccination centers for offline doses, whereas 23.2% of them were unable to book slots in the online platform due to unavailability. There were 8% of them who still do not know how to get the vaccine. Extensive IEC activity, awareness campaigns, and the establishment of new vaccination sites nearer to the tribal villages may be helpful to address these issues.
There are some limitations of this study. As it was conducted among the tribal population of a particular geographic location in West Bengal, representation of the whole state was not possible. This study was conducted after the COVID-19 vaccination had started. Therefore, it could have underestimated the initial vaccine hesitancy of those who subsequently converted to the vaccine acceptance group and were ultimately vaccinated. Self-reports of variables should be interpreted with caution, as well as there may be recall and information bias. Due to the pandemic situation, the scope for proper observation of COVID-appropriate behavior was limited. Finally, the data were collected in a cross-sectional survey. Therefore, we cannot describe causality to any of the associated factors. A longitudinal study can be done to investigate the determinants of vaccine hesitancy.
There is worrisome level of COVID-19 vaccine hesitancy among the tribal population. This hesitancy is driven by their knowledge and awareness toward the disease and the vaccine. Apart from these, their economic status, attitudes toward the health system, and accessibility factors also probably play a major role in vaccine hesitancy. This study will help design effective behavior change communication campaigns. As the main concern for COVID-19 vaccine hesitancy is vaccine safety and side effects, the strategy should be formulated to enhance effective communication by providing evidence of the vaccine's safety and efficacy. Already vaccinated persons should be involved to share their experiences to resolve the misunderstanding among the people. Extensive IEC activity, more involvement of health-care workers in the awareness campaign, and establishment of vaccination centers in tribal villages should be helpful to alleviate the COVID vaccine hesitancy among the tribal population. In addition, policies need to be implemented to minimize the impact on people's lives, especially jobs and health status.
Acknowledgment
We are grateful to Mr. Subal Sarkar, a renowned social worker of Berhampore block, for his help to get access and trust of the tribal people. We also acknowledge the invaluable help of all the local healthcare workers, especially ASHA workers of Manindranagar and Hatinagar gram panchayat area, for their help in data collection. We would also like to thank all the study subjects for their kind participation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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