Motivating factors for and barriers to the COVID-19 vaccine uptake: A review of social media data in Zambia

Abstract

The study sought to explore the motivating factors for and barriers to the uptake of the coronavirus disease 2019 (COVID-19) vaccine in Zambia and recommend possible ways of addressing the challenges. The study used a qualitative case study approach, employing online media platforms as sources of data. Thematic analysis was to identify topics from posts, with each topic further grouped into themes. Motivating factors to vaccine uptake include an increase in reported cases of COVID-19, accessibility, and availability of vaccines, vaccine certificates required to travel, and credible sources of information. Barriers to uptake include lack of information, concerns about the safety of the vaccine, mistrust in Western medicine, lack of belief in conventional medicine versus belief in God, confusing information about eligibility, and belief that public figures used in the campaigns were not receiving the vaccine. Some of the strategies to encourage vaccination included the involvement of local scientists, demand generation through media platforms, community sensitization, vaccine materials, and creating an enabling environment for community involvement. The social media interactions on the COVID-19 vaccine revealed several factors that impede the uptake of the vaccine and encourage uptake. However, stakeholders’ involvement in scaling up vaccination programs was reported to be one of the effective strategies to increase vaccine uptake in Zambia.

Keywords:

• social media
• COVID-19 vaccine
• barriers
• motivators
• Zambia

PUBLIC INTEREST STATEMENT

In this paper, we highlight the beliefs, perceptions, and views of people regarding the COVID-19 vaccine in Zambia. We used social media to best capture views of people not controlled by a study environment; people freely express themselves on social media platforms such as Facebook. Even though social media is limited to young people in urban areas in most developing countries, the study findings present areas for the development of effective strategies to increase uptake.. The vaccine is considered as an intervention developed by Western countries who were once responsible for colonialism and a number of medicle abuses which rasies concerns among some sectors of society in developing countries., This could explain why the numbers of people vaccinated in most developing countries such as Zambia are low as compared to the developed countries.

1. Introduction

The coronavirus disease 2019 (COVID-19) pandemic has been one of the greatest public health challenges of the 21st century. To date, it has resulted in more than 5 million deaths worldwide, paralyzed health systems, and damaged livelihoods (Assefa et al., 2022). As of 4 June 2021, sub-Saharan Africa recorded 3,530,845 cases with 131,630 deaths (WHO, 2022). The continent’s case fatality rate, which is the proportion of deaths among confirmed cases, stood at 2.6% against the global average of 2.2%, as of July 2021 (WHO, 2021a). Zambia reported its first COVID-19 case in March 2020 and has since recorded 96, 563 cases with 1,284 deaths, as of 4 June 2021 (Himwaze et al., 2021). The most common symptoms of this viral infection are fever, cold, cough, bone pain, and breathing problems, which can ultimately lead to pneumonia (Haleem et al., 2020). Prevention and management of COVID-19 is now a global agenda with the implementation of restrictive measures such as social distancing, hand washing, masking up, and isolation to prevent further spread of the virus (Bhat et al., 2020).

Concerted efforts by scientists led to the development of several vaccines, with the first available COVID-19 vaccine having 95% efficacy and a good safety profile announced in the press by Pfizer-BioNTech on 18 November 2020, raising the hope of ending the pandemic (Liew & Lee, 2021). Vaccines have been seen as a cost-effective health measure for disease prevention because they are developed to reduce the mortality and morbidity rate of diseases (Andre et al., 2008). The COVID-19 vaccine is important in developing antibodies to the disease, and thus put the virus’ spread into decline (Jeyanathan et al., 2020).

The pandemic, along with the COVID-19 vaccine, has been the most trending and highly discussed topic on social media platforms (Andreotta et al., 2019). Social media, a term used to refer to new forms of media that involve interactive participation by individuals through the creation and exchange of user-generated content (Aichner et al., 2021), has allowed internet users to interact with one another on unlimited topics, among them the COVID-19 pandemic and the vaccine. Anti-vaccine controversies concerning vaccine safety are vigorously circulating on social media, which may lead to hesitancy or resistance (Boucher et al., 2021). Stecula et al. (2020) found that people who were exposed to vaccine-related information on social media were more likely to be misinformed and become vaccine-hesitant. Islam and colleagues (2021) revealed that rumors such as the COVID-19 vaccine contain cells from aborted fetuses or genes from pigs raised religious concerns among Muslim and Jewish communities. Conspiracy theories may also lead to mistrust contributing to vaccine hesitancy (Hartman et al., 2021; Wang & Kim, 2021). Social media thus has the power to influence people’s decision to get vaccinated or not (Steffens et al., 2020) and maybe a major factor in the rise of radical opinions that can be damaging to public health (Bhat et al., 2020; Wilson & Wiysonge, 2020).

In 2021, the World Health Organization listed vaccine hesitancy as one of the top 10 threats to world health, a phenomenon most likely due to misinformation circulating on social media (Wilson & Wiysonge, 2020). Motivation to accept the COVID-19 vaccine has varied considerably across countries over the course of the pandemic. Factors such as knowledge levels about the vaccine, conflicting views from significant others, previous bad experience, the belief that God protects against illness, and environmental factors, as well as faith in doctors, shape the uptake of vaccines, as reported by Kucheba et al. (2021), including rumors and conspiracy theories (Islam, et al. 2021). Vaccine acceptance and hesitancy also depend on the belief in vaccination and its safety, the trust placed in the system that delivers the vaccines, health issues, fear of side effects, and a lack of recommendation by healthcare workers (Pugliese-Garcia et al., 2018). Meanwhile, citizens’ trust in biomedical science has been acknowledged as another factor that might affect people’s attitudes toward vaccination (Palamenghi et al., 2020).

Scaling up and implementation of COVID-19 vaccination programs have received much attention in most low- and middle-income countries like Zambia. The Republic of Zambia, through the Ministry of Health (MoH), officially launched its COVID-19 vaccination campaign on 14 April 2021, after receiving the first consignment of 228,000 doses of the vaccine from the COVAX facility, a global initiative representing a partnership among the World Health Organization, the Global Alliance for Vaccines and Immunization, UNICEF, and the Coalition for Epidemic Preparedness Innovations, working on the equitable distribution of COVID-19 vaccines (Xinhua, 2021). Social media platforms, including Facebook and other bloggers, were used to share vital information on the vaccination exercise. Despite the huge efforts made to achieve successful COVID-19 vaccination rollout and implementation in Zambia, the country remains among one of the countries with the lowest rates of population vaccination among its citizens, with 8,280 individuals fully vaccinated as of 21 December 2021, which translates into 5.4% of the total eligible population (ZNPHI, 2021).

Some evidence exists regarding the epidemiological geographic mapping of COVID-19. Other studies conducted in Zambia focused on reporting on the education system’s responsiveness through the delivery of digital and online teaching during COVID-19 (Mulenga & Marbán, 2021). However, very little has been documented on factors and strategies affecting COVID-19 vaccination acceptability using social media conversations in Zambia. This gap calls for the need to understand the underlying motivators and concerns among those who are and are not intending to receive the COVID-19 vaccine (Carcelen et al., 2021). This study, therefore, seeks to explore the motivating factors for and barriers to the uptake of the COVID-19 vaccine and recommend possible ways of addressing the challenges. Social media offers a novel opportunity to harvest a massive and diverse range of content without the need for intrusive or intensive data collection procedures and offers the opportunity for voices that may not be otherwise heard through more traditional approaches, such as semi-structured interviews (Andreotta et al., 2019). Given the severity of the COVID-19 pandemic and the time pressure to accelerate COVID-19 vaccination, there is an urgent need to gain insight into the psychological proposition of how people think and feel specific to the newly developed COVID-19 vaccines so that effective recommendations or strategies may be proposed to improve vaccine uptake (Liew & Lee, 2021).

2. Methodology

2.1. Study context

As of January 2022, Zambia has a total population of 19.19 million, with 45.8% living in urban centers and 54.2% in rural areas. Young people (aged 25 and under) make up a majority of Zambia’s population. The number of social media users in Zambia is equivalent to 13.9% of the total population, which translates to 5.48 million internet users; these social media users tend to be the younger segment of the population (Kemp, 2021). Although this number may be small, these users might have the power to influence other populations to a large extent because the decision to get vaccinated may depend on significant others.

3. Study design

The study used a qualitative case study approach, employing online media platforms as sources of data, including posts on social media pages such as Facebook, Twitter, Smart Eagles, Zambian Eye, News Diggers, Mwebantu media, and Zambia Watchdog. These posts were written in response to information shared by the MoH and the Zambia National Public Health Institute. With the continued growth of social media and its expanding impact, it was important to understand how social media interactions reflect and shape public discourse. A case study approach enabled us to study COVID-19 vaccine discussion through social media sources in a real-life, contemporary context.

The use of social media data has been encouraged because information emerges from a real-world social environment encompassing a large and diverse range of people, without any prompting from researchers. Thus, in comparison with traditional methodologies, participant behavior is relatively unconstrained, if not entirely unconstrained, by the behaviors of researchers (Andreotta et al., 2019). Other studies that have used social media as a method of data collection include Understanding Patient Anxieties in the Social Media Era: Qualitative Analysis and Natural Language Processing of an Online Male Infertility Community (Osadchiy et al., 2020) and Examining the Utility of Social Media in COVID-19 Vaccination: Unsupervised Learning of 672,133 Twitter Posts (Liew & Lee, 2021).

4. Data collection and extraction

Three major steps were used in collecting social media data: development, application, and validation of search filters (Kim et al., 2016). A set of predetermined keywords were used for data mining, including “COVID-19 vaccination,” “COVID-19 vaccine,” and “2019 novel coronavirus vaccine.” Only posts by individual users, and not organizations or news outlets, were included in this study. The researchers followed social media discussions on reasons for and against getting a COVID-19 vaccine. Social media blogs, posts, and reactions posted by individuals were observed every week during the data collection period, and each observation lasted for about half a day. Social media messages that encouraged people to get vaccinated by posting pictures of prominent individuals who got vaccinated, messages about the efficacy and safety of the vaccine and replies to these messages were reviewed.

Each team member visited online media pages and selected posts to include in the sample based on predetermined themes and discussions. When a data set of posts and comments was complete, each team member reviewed the data and the links to the quotes to ensure that the sample was reflective of the study objective. The team also reviewed the full content of each claim multiple times. Observations were also conducted on the availability, accessibility, and acceptability of COVID-19 vaccination services. Issues reported by social media users regarding barriers to and motivating factors for the COVID-19 vaccine uptake and strategies that may address COVID-19 vaccine hesitancy and improve uptake were also reviewed. Finally, the rest of the remaining months of observations were used to cross-check emerging findings and add new information.

5. Population, sampling procedure, and sample size

The purposeful sampling technique followed and reviewed conversations or reactions starting from April 2021 when vaccination began (the first consignment of the vaccine doses arrived in Zambia on April 14), we collected data until November 2021. A total of 2,400 comments were reviewed by the first author (TFLM) and last author (MPC) and independently and verified by the second author (JMZ) and the third author (LMD). A total of 1,895 conversations that did not discuss the research question were excluded from the study. The data resulted in a final sample of 505 unique posts and comments after excluding ineligible comments (see, Table 1).

Table 1. Comments reviewed

Media source	Total comments reviewed	Eligible responses	% eligible comments
Facebook	400	88	3.67%
Twitter	400	99	4.13%
Smart Eagles	400	96	4.0%
Zambian Eye	400	101	4.21%
News Diggers	400	65	2.7%
Zambia Watchdog	400	55	2.29%
Total	2,400	505	21%

6. Inclusion and exclusion criteria

We followed the conversation on each media platform and included them in a Word document. After reading the comments, only comments that were related to the research question were included in the final data set for analysis. Inclusion and exclusion of comments were based on the following criteria:

6.1. Inclusion criteria

• Comments that were reacting to a post by the MoH and Zambia National Public Health Institute

• Comments that were related to the study question

• Posts by individual users

6.2. Exclusion criteria

Comments that were not responding to the main post

7. Data analysis

Data from the selected social media were analyzed using a thematic analysis approach using NVivo (QSR International Pty Ltd, 2020). We analyzed 505 messages posted on various media platforms such as Facebook, Smart Eagles, Zambian Eye, News Diggers, Zambia Watchdog, and Mwebantu media. Researchers followed social media conversations, including texts, pictures, and documents, on community perspectives on COVID-19 vaccination. Three researchers fluent in Nyanja and Bemba (Zambia’s commonly spoken local languages in the capital city) translated some messages posted on social network sites into English for this analysis. Two types of data emerged: first, messages and statements published by authorities, such as the MoH, the Zambia National Public Health Institute, and blog post supporters; and second, messages reacting to the posts. We were particularly interested in messages and articles posted on COVID-19 vaccinations.

Thematic analysis involved becoming familiar with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Analysis began as the data were being reviewed on social media, by documenting daily discussions, recording summaries of findings, and frequently debriefing with the study team. Anonymized data were extracted from social media platforms, saved in Word, and imported into NVivo 12 qualitative software. NVivo allows for not only textual content analysis but also for the analysis of other meaningful web objects (e.g., video, audio, picture, graph, banner, or poster; Castleberry, 2014). The words and themes that had the highest frequency were critically reviewed to determine the relevance of the data that were extracted on social media regarding COVID-19 vaccination. We defined our unit of analysis as an entire post. Given that we were analyzing free-text data without a word limit, one post could therefore contain more than one code. These preliminary themes were then discussed among all the author. On repeat reviews of the data, themes were finalized and then further divided into subthemes for better characterization.

We then developed codes and themes related to motivating factors for vaccination, challenges, and strategies to enhance COVID-19 uptake in Zambia. These words and appropriate quotes were extracted using NVivo 12ʹs word-query function. Statements and comments were read one by one and coded under predefined themes as indicated in Table 2. The project was shared with members to check for data consistency. When discrepancies in data entry were found, meetings were held to resolve the discrepancies.

Table 2. Themes from data collected

Major theme	Sub-theme
Motivating factors for vaccination	Increase of reported cases of COVID-19
	Accessibility and availability of vaccines
	Vaccine certificates required to travel out of the country
	A credible source of information increased trust in the vaccine
Barriers/challenges affecting vaccination	Lack of knowledge/information on the relevance of vaccination
	Negative perception of the safety of the COVID-19 vaccine
	Mistrust in Western medicine
	Lack of belief in conventional medicine versus belief in God
	Confusing information about who was eligible
	A belief that public figures were not being injected
Strategies to encourage vaccination	Involvement of local scientist
	Demand generation through media platforms
	Community sensitization
	Information communication/COVID-19 vaccine materials
	Creation of an enabling environment for communities to feel involved

8. Ethical considerations

This study involved anonymous, publicly available data, so no ethical permission was sought from the ethics committee in Zambia. This is consistent with previous investigations of research on social media data. The data collection and analysis are also in compliance with the terms of service of the corresponding social media platforms.

9. Results

This section presents the results from the review conducted through social media, which revealed major factors and strategies affecting COVID-19 vaccination acceptability, as shown in Table 2.

10. Motivating factors for vaccination

10.1. Increase of reported cases of COVID-19

Some people recognized the importance of getting vaccinated because of the increased cases of COVID-19. Moreover, the reported cases of death and associated deaths resulting from the pandemic were high during the third wave. Hence the vaccine was seen to be crucial in protecting the population from developing adverse infections.

It’s now a pandemic of the unvaccinated!! (Facebook user 01)

10.2. Accessibility and availability of vaccines

The easy accessibility and availability of vaccination services were key in motivating people to get vaccinated. Vaccination services helped communities access the vaccine by providing vaccines onsite, hence no transport costs were incurred.. This ensured that all people, including differently-abled people and the elderly, could easily access the vaccine.

Post: The Company in collaboration with the Ministry of Health has set up an onsite vaccination center to encourage staff and their families to access the COVID-19 Vaccines

Response: That’s a welcome move even in our compounds please send some health workers at least one day in a week, more people will be vaccinated. (News Diggers user)

10.3. Vaccine certificates required to travel out of the country

People are getting vaccinated and given a record card that you cannot use when you want to go out of Zambia. Please give us certificates also and not only record cards because you cannot use them in other countries. (Mwebantu Media user)

10.4. A credible source of information increased trust in the vaccine

It is important to use credible sources that both the public and healthcare personnel know and value for important exercises such as vaccination. When information is shared through a trusted person, such as a person of authority, it is welcomed and remembered. The president of Zambia, for example, has been encouraging people to get the vaccine through his social media pages. Several people reacted positively to this encouragement. This positive response could be a result of his popularity and the fact that the president was recently elected.

Yes, Mr. President. Covid19 is real. We must protect ourselves to ensure that we are able to contribute positively to our country.” (Mwebantu Media user)

11. Barriers to COVID19 vaccination

Interactions on social media from the public and public health stakeholders revealed several challenges . These challenges included lack of information, concerns about the safety of the vaccine, mistrust in Western medicine, lack of belief in conventional medicine versus belief in God, confusing information about who was eligible, and the belief that public figures used in the campaigns were not getting vaccinated. These challenges are discussed further in this section.

11.1. Lack of knowledge/information on the relevance of vaccination

Lack of information is a major cause of vaccine hesitancy. Several posts showed that there is limited information about the COVID-19 vaccine and its efficacy. This lack of knowledge was revealed by several responses to social media posts. Many people do not understand why they had to get vaccinated and still wear masks and practice social distancing. In addition, some users did not know why the second consignment introduced a second vaccine that was not previously there, Johnson & Johnson.

I see no point in taking the vaccine when you’re still at risk of being reinfected by the same virus even after being vaccinated. (Facebook user 02)

Will someone explain why the vaccine has been changed from AstraZeneca to Johnson & Johnson? (Mwebantu Media user)

This lack of information left many people with unanswered questions. Even though much had been done to spread accurate information and ensure that the public understands, some social media users still had unanswered questions regarding how the vaccine works in the body and wondered whether the Zambian government had taken time to test the vaccine in a small population before rolling out the vaccination exercise.

Ministry of Health Zambia, kindly answer the following questions; When one gets a COVID-19 vaccine, how long does it stay in the body before the other one can be given to you? What are some of the negative effects of the vaccine on human health? What range of age is recommended for the same vaccine? After receiving the vaccine, do you also need to wear a mask in public? Your prompt response will be highly appreciated. (Facebook user 04)

11.2. Negative perception of the safety of the COVID-19 vaccines

There were concerns regarding the safety of the COVID-19 vaccine, with some people wondering whether the vaccine was safe because it was developed within a short period. Some posts revealed that some groups of people were concerned that they would be used to determine whether the vaccine was safe because they thought it was still in an experimental stage.

We will wait for 3 years to see how you react to the vaccine, then maybe it will encourage us, at this time it’s experimental, and great for people like you who gave their lives to be experimented on. We will observe sir. (Facebook user 05)

Everyone is at war with the virus. What is currently needed are answers to how safe is the drug to the partaker or the patient in particular. We do not want a situation where we become the manufacturer’s lab. (Facebook user 06)

11.3. Mistrust in western medicine

Medical abuse, neglect, and exploitation have resulted in generations of black people being distrustful of Western medicine. This mistrust is linked to theories on social media, including past medical atrocities committed against black people. This mistrust was evident on social media with videos circulating about the elimination of the black race.

The same people said we are finding a way to eliminate Africans because Africa is not adding any value to the world, but we have forgotten so easily. And what we should not forget is that whites are not blacks who start things and fail to finish. They will definitely do that. What we should not forget is that whites know the weakest part of black’s but we don’t know theirs. So be wise when fighting whites. Slowly they’re coming, starting with leaders who can think or sense danger easily. (Facebook user 07)

11.4. Lack of belief in conventional medicine versus faith in God

Several users indicated that they would never use the vaccine because they are protected by God and do not trust modern medicine. Some people believed that if one believed that God protects against illness, one would not suffer from COVID-19 and would not need to get vaccinated. Surprisingly, even some healthcare providers seemed to share this view.

When I asked the doctor, he told me to say God is greater than the vaccine and when you call upon his name he will answer!!! Work up from your deep sleep!! (sic) (Facebook user 08)

11.5. Confusing information about who was eligible

When the vaccination exercise was launched, the minister of health indicated that the first phase was meant for priority groups and that a vaccination protocol would be followed. The minister informed the gathering that the country would use the entire 228,000 doses to provide the first dose of vaccines to priority groups. With this at the back of the minds of the public, many of them got confused when several people who may not be considered as part of the priority groups were seen getting the vaccine and posted on the MoH FaceBook page.

It’s good for you Mr … why the vaccine is just for the elderly only, no teenager or toddlers has been vaccinated so far or as rumors are that, this vaccine was meant for a certain age group. Tell us if this is not the same as eugenics. As for my body no vaccine (sic). (Mwebantu Media user)

11.6. The belief that public figures were not being injected

Several social media rumors were going around indicating that pictures showing some of the world leaders receiving the vaccine are not true. Some videos indicated that the injections used did not contain the vaccine but water.

I don’t think if the drug they are taking is for Covid-19, maybe it’s water they just want to convince us, please Zambian people, let’s open our eyes why should the vaccine be given to 18 years and above? Does it mean that Covid-19 only attacks 18 and above? It’s like it is selective to let them do it with their families? (Facebook user 09)

12. Strategies to encourage vaccination

In response to the challenges identified above, some strategies were identified in the data to encourage vaccination. Populations among whom vaccine hesitancy is evident should be urgently addressed, as discussed below.

12.1. Involvement of local scientists

There is a need for more local scientists to get involved when it comes to vaccine development and testing because most people have had mistrust regarding American and European agendas for the black community around the world. The fact that the vaccine was developed in the West and came as a donation from Western countries, which have had a long history of racism and exploitation, resulted in several social media users reacting to posts indicating that there was a hidden agenda regarding the vaccine.

Has raised some issues on this drug, no one has answered, when are we going to find solutions on our own, what is education for? Doctors, scientists, etc., if some undeveloped and developed countries are relying upon their solutions why can’t we also do the same, are we colonized or free. (Zambian Eye user)

What really surprises me is we have so many qualified doctors, biologists, and scientists in Africa, but we don’t put our minds together to come up with a cure or vaccine … We rely on America to make decisions for us. Almost like we can’t think for ourselves … I bet they wouldn’t donate the money for the research of a Vaccine … What is the point of going to university for 7 whole years n you still can’t think for yourselves? (Facebook user 10)

12.2. Demand generation through media platforms

The study found that demand generation to encourage the community to get vaccinated was critical. Therefore, the MoH, working with other stakeholders, created a multisectoral team that has been promoting the uptake of COVID-19 services. In addition to face-to-face meetings with the public, other channels of communication, such as radio and digital and social media, were adopted to encourage the community to get vaccinated. These communication channels helped engage different stakeholders.

Effective multi-sectoral coordination and planning; social listening, digital engagement, and misinformation management; risk communication and community engagement; crisis communication; known feedback loops for each level of management exists COVID-19 vaccine data collection system: social media and rumor management, data collecting systems have been established; assessment of behavioral and social data has been established. COVID-19 vaccine materials: communication management and crisis communication preparedness plan has been developed; messages on COVID-19 developed and adapted; materials for public communication aligned with the demand plan. (MoH, COVID-19 vaccine plan, 2021)

However, the demand generation programs have had less effect because they did not integrate with existing infection prevention health systems. There have been inadequate radio and TV programs to educate the public on the benefits and disadvantages of getting vaccinated.

Please come on National TV and Radio stations to help many citizens who are already using it and those who are planning to use it! A wider population needs to understand the consequences of using this drug by themselves including other would-be dangerous drugs for humans. (Facebook user 11)

12.3. COVID-19 community sensitization

Respondents reported that COVID-19 sensitizations activities were scaled up throughout the country. However, little community-based sensitization has been conducted in many settings. Perhaps this was due to inadequate engagement of the community health actors to take part in vaccination sensitization, which affected turnout. People are more likely to trust local people they know. Thus, an effective approach is to engage community actors such as community health workers with megaphones to encourage the community to go for vaccinations. Leveraging existing community networks, such as churches, bars, schools, villages, and markets, to educate the public on the importance of vaccination may also be effective approaches.

The Ministry of Health Zambia has done a great job in taking the vaccine to all parts of the country, the only challenge now is getting the people to be vaccinated. There is a lot of apathy among the people, especially in the compounds. At ........... Level One Hospital, for example, only a few people go there for the vaccine, there is a need for serious sensitization. (Facebook user 12)

12.4. Information communication/COVID-19 vaccine materials

Furthermore, the MoH created information education and communication (IEC) materials to encourage the community to get vaccinated. Participants also indicated the need for people to go beyond following health guidelines to get vaccinated and avoid the effects of COVID-19, including mortality.

Communication management and crisis communication preparedness plan has been developed; messages on COVID-19 developed and adapted; materials for public communication aligned with the demand plan. (MoH, COVID-19 vaccine strategic plan, 2021)

Through appropriate communication strategies, more community members accepted and appreciated the importance of vaccination. They stated that it might contribute to less severe infection and later a return to normal life and lead to a better economic situation. However, some social media users reacted negatively to the nature and appearance of the IEC materials, which, according to them, were not clear and poorly done. Hence there is a need to engage specialized personnel to appropriately design IEC materials. The health education information also lacks information regarding where and when the vaccinations will take place in specific regions for people to prepare.

Make sure you get the vaccine, in America, they’re using the same vaccine, as we’re talking right now COVID-19 there is low. Things are back to normal, even the economy is rising, and COVID-19 is down. (Mwebantu Media user)

12.5. Creating an enabling environment for communities to get involved

Communities and individuals need to be able to understand why the vaccine is necessary. This can be done by educating the masses through different platforms. The users also narrated that the current vaccination environment was not friendly and inclusive for certain categories of people in society. It was highlighted that the vaccination schedule should be flexible, if possible, to operate for 24 hours every day, including weekends. This could allow people to get vaccinated during unconventional hours.

Why close on Sunday and yet weekends are times when many people are usually off?? Surely, you can’t find people to be exchanging shifts and days? Zambia, please! In some developed countries, these vaccinations have been made a 24hrs service. That should give you an idea that timing is critical. You don’t even need to go for 24hrs too, but allow this to be done even over the weekend when those in formal employment are off from work. For those that go to church on Saturdays, let them find the sites open on Sundays. For those that go to church on Sundays let them find the sites open on Saturdays. Simple, a non-critical health matter like Voter registration, shifts, and 24hrs service was provided. Yet a serious global pandemic like Covid-19 we have the luxury of even having closure? (Facebook user 13)

There is a need to increase resources for vaccination programs, including the number of healthcare providers conducting the vaccinations. The current demand for vaccinations is increasing, but there are few providers. Hence, the clients are dismayed, and some are not likely to get vaccinated when they have to stand in the queue for a long time.

13. Discussion

We identified both barriers to and motivating factors for COVID-19 vaccine uptake in Zambia. Notable motivating themes include the increase of reported cases of COVID-19, accessibility, and availability of vaccines, vaccine certificates required to travel out of the country, and credible sources of information. Barriers to uptake included lack of information, concerns about the safety of the vaccine, mistrust in Western medicine, lack of belief in conventional medicine versus faith in God, confusing information about who was eligible, and belief that public figures used in the campaigns were not getting injected. In response to these barriers, some strategies were identified to encourage vaccination, including involvement of local scientists, demand generation through media platforms, community sensitization, creation of IEC materials, and creation of an enabling environment for communities to get involved.

Even though there has been significant progress made regarding vaccination, the number of adult Zambians vaccinated against COVID-19 is still very low at almost 10% (Mudenda et al., 2022). This is below the expected target number, according to a list of 15 African countries with more than 10% of their population fully vaccinated against COVID-19 as published by the WHO (2022). The 15 countries that have reached the target population fully vaccinated against COVID-19 are Seychelles, Mauritius, Morocco, Tunisia, Comoros, Cape Verde, Eswatini, Lesotho, Botswana, Zimbabwe, South Africa, Mauritania, Equatorial Guinea, Rwanda, and Sao Tome and Principe. COVID-19 vaccine hesitancy has been reported to be due to many factors, such as myths and misinformation about COVID-19 and COVID-19 vaccines, fear of adverse side effects, and concerns about vaccine effectiveness.

Worldwide reporting of the COVID-19 pandemic has brought attention to the seriousness of its effects. Reporting cases of death and associated deaths resulting from the pandemic motivated some people to get vaccinated to protect themselves. A study by Shmueli (2021) showed that perceived benefits, cues to action, and perceived severity were significant predictors of intention to get vaccinated against COVID-19. In Israel, other important factors played a major role in encouraging vaccination, such as building public trust through an integrated and familiar health system, familiar technology, transparency regarding vaccine safety information, culturally appropriate messages in digital and offline media, acknowledging diverse health literacy needs, and active participation and role-modeling by political/religious opinion leaders. In addition, our study shows that a credible source of information, such as the Zambian president, was important in encouraging the citizenry to get vaccinated. The need to travel out of the country also played a major role in the vaccination exercise, hence the need for concerted efforts by all governments to ensure that international travel continues.

A lack of information on social media can prevent people from deciding to get vaccinated. Comments from participants showed that they did not have sufficient information on the vaccine, which is why several people could not decide to get vaccinated. A study by Guljaš et al. (2021) reveals that lack of knowledge and mistrust toward vaccines represent a challenge in achieving the vaccination coverage required for population immunity. Social media influencers are also important in getting information to people, and our data includes comments from various people, including social media influencers, indicating that their comments could lead to people deciding to get vaccinated or not.

Concerns regarding the safety of the COVID-19 vaccine were a large discussion on the different social media platforms. Because the COVID-19 vaccines were developed in a very short time, many participants were worried that the vaccines are not safe because vaccine development must go through many stages before reaching approval for human use. For a novel vaccine such as the COVID-19 vaccine to be successful, its safety and efficacy and its wide acceptance need to be ensured. The speed of development, production, and mass rollout of the COVID-19 vaccine has led to concerns around the safety and efficacy of vaccination (Boucher et al., 2021). Although some national and international health agencies and fact-check organizations debunked claims related to safety and efficacy, the time gap between tracking and debunking misinformation, and its limited reach, may leave some populations vulnerable to vaccine hesitancy (Islam, et al. 2021).

Lack of information may lead to misconnections regarding the vaccine, and in addition, misconceptions during pandemics increase the risk of anxiety or depression (Bendau et al., 2021). Our study found that some people did not trust the intentions behind the vac

cine. This mistrust is tied to several conspiracy theories that have been shared on social media about the planned elimination of black people around the world. Some call such skepticism the “Tuskegee effect”—distrust linked to the U.S. Government’s once-secret study of black men in Alabama who were left untreated for syphilis (Bates & Harris, 2004). Several social media users also had a mistrust of Western medicine. Similar to this finding, a study conducted to explore perceptions on vaccine acceptability, hesitancy, and accessibility at three informal settlements in Lusaka, Zambia during cholera vaccination revealed that the association of vaccines with “white” or “Western” medicine created hesitancy among participants to get vaccinated, which can be linked to past colonial exploitation (Pugliese-Garcia et al., 2018). Samarasekera (2021) reports a survey conducted by the Africa Centers for Disease Control and Prevention and the London School of Hygiene & Tropical Medicine across 15 African countries that detailed the need to increase confidence in COVID-19 vaccination on the continent. This survey reveals that the reasons for vaccine hesitancy include the belief that COVID-19 was a planned event by foreign actors and that Africans are being used as Guinea pigs for vaccine trials.

The belief and practices of Christianity can be characterized by views that promote and acknowledge the notion that signs and wonders, miracles, and other supernatural occurrences are part of everyday life (Fosu-Ankrah & Amoako-Gyampah, 2021). As a largely Christian nation, many of Zambia’s citizens believe in the Christian tenets, including in the supernatural power of healing and protection. Our study further found that several people believed that they are protected by God and do not trust conventional medicine. The link between vaccine hesitancy and belief in God has also been well documented (Kucheba et al., 2021; Pugliese-Garcia et al., 2018). Thus, Christians may turn to prayer rather than medicine when they fall ill or get afflicted with a disease, as others have reported (Kleinman, 2007).

Adults are eligible for the COVID-19 vaccine in Zambia, as in many other countries around the world. When the vaccination rollout began in Zambia, a lot of confusing information was circulating regarding who was eligible for vaccination. Some people seemed to not know whether they were eligible for the vaccine, and this was further complicated by the different types of vaccines available. Reports of confusion about who would go first among those eligible plagued efforts to ensure that eligible people got vaccinated. One of the strategies used to encourage vaccination was the use of influencers sharing their pictures while taking the vaccine (Aloweidi, Bsisu et al. 2021). Some comments on social media showed that although the COVID-19 vaccination campaigns used public figures to encourage vaccination, some people believed that this was not true, with some media platforms circulating videos showing that there was no direct contact with the injection or that water was used instead.

One of the major challenges identified with vaccine hesitancy in our study is the lack of trust in Western medicine, also referred to as white medicine, that is linked to the past exploitation of black people. Because of this past exploitation, some people think that there is a Western agenda to eliminate black people. This hesitancy is further compounded by the history of medical colonialism in Africa which often involves Western medical initiatives enrolling Africans into studies to test the efficacy of drugs (Lowes & Montero, 2021). Involving local scientists in the development of the COVID-19 vaccine can therefore greatly reduce some of the mistrust, reduce the fears that people have, and enhance uptake. This could be achieved by empowering local scientists through capacity building, infrastructure, and funds to carry out independent research in a consortium, as reported by Dinga et al. (2021).

It is integral that public health institutions deploy a multilayered approach to vaccine hesitancy, which includes collaborating with faith-based organizations, traditional leaders, community health workers, and drama groups to reach all populations. Vaccine hesitancy is a multifactorial issue that requires many players to handle (Mudenda et al., 2022). Similar to other studies (Evans & French, 2021), our study found that in addition to face-to-face meetings with the public during vaccine information dissemination, other channels of communication, such as radio and digital social media, can create demand for the vaccine alongside vaccine brand promotion strategy, service marketing as it relates to vaccine distribution, and competition strategy. The use of participatory and interactive methods such as role-play, group discussion, and drama can enhance understanding of vaccination and demystify messages against vaccination (Chavula et al., 2021). Integration and collaboration in the delivery of vaccination sensitization into various community health systems settings, such as schools, community networks, markets, bars churches, workplaces, and primary health centers, is essential to sustain implementation (Chavula et al., 2021; Schneider et al., 2022; Zulu et al., 2021), and can therefore play a critical role in the vaccination exercise.

The lack of adequate information requires different approaches; for example, health professionals also need to act as educators. Supporting healthcare professionals in their role as educators will ensure that people have adequate and accessible information from a trusted source, to optimize vaccine uptake and ultimately reduce community transmission of the virus (Kumar & Preetha, 2012). This approach can be effective because health professionals are seen as trusted by the community (Kucheba et al., 2021). Involving vaccine communication experts and the public in developing messaging and a long-term vaccine strategy is crucial, and the government should intensify these strategies. There is also a greater need to understand and address citizens’ concerns that can prevent optimal uptake of the COVID-19 vaccine and build motivations into messaging. Carefully thought-out communication strategies to address these concerns over COVID-19 vaccines are therefore needed (Samarasekera, 2021).

The current crisis has psychologically affected a significant portion of the population. Information-related factors, such as the use of social networks and misconceptions, can increase the risk of confusion among adults and lead to depression. This, therefore, calls for concerted efforts into creating health-promoting messages and interventions that give people and the community at large relevant information. People need accurate information and effective communication to be able to make decisions that benefit their health. More must be done to create a favorable environment for people to trust the vaccine and receive as much information as possible to help them make the right decision on whether to receive the vaccine or not. This involves creating an enabling environment that supports trust-building, collaborative dialogue between science and the community, and the use of positive approaches. In this direction, adopting a scientific citizenship approach that involves considering the active engagement of citizens in developing strategies will improve the partnership between the public and the scientific community.

An environment that enables the community to get involved is important to enhance uptake as it creates trust among citizens. This approach uses community engagement. Mutombo et al. (2021) highlight that community engagement becomes the single most powerful mechanism to successfully combat any vaccine hesitancy and resistance. There is need to promote an atmosphere of shared interest between science and the community, in which scientific expertise is advocated, established, and maintained (Dhama et al. 2021). The involvement of the community cannot be over-emphasized because the community plays a very big role. The government needs to prioritize public trust by informing and involving the community in the process. As countries are going through the vaccine distribution exercise, an environment that enables the involvement of different stakeholders must be created.

14. Study limitation

This study used results from social media platforms, so care must be taken when using the findings of the study to develop policies and strategies because it is based entirely on the views expressed by social media users. Such views might not represent the views of the general population because social media accessibility might be limited to the major urban areas, and the users tend to be the younger segment of the population. However, to our knowledge, no study in Zambia has been done to explore the acceptability of the COVID-19 vaccine in Zambia using social media, and as the first of its kind, this study forms the foundation for a larger study to be conducted.

15. Conclusion

In conclusion, the social interactions regarding the COVID-19 vaccine revealed several factors that impede the uptake of the vaccine. These factors are important to consider in developing effective strategies to achieve herd immunity. The vaccine development process must be transparent to increase public trust in safety and effectiveness, even for those who are already willing to get vaccinated. There is a need to explain the reasons for vaccine refusal and distrust, which may include ignorance or misunderstanding of science by the public. This requires educational strategies and extensive community sensitization.

Abbreviations

COVID-19 Coronavirus disease 2019

IEC Information Education and Communication

MoH Ministry of Health

Acknowledgements

We would like to thank Cindy Young Turner for her editorial support.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Tulani Francis L. Matenga

Tulani Francis L. Matenga is a public health researcher and a teaching assistant. His research interests cut across several disciplines including social and behavioral aspects of HIV/AIDS, maternal and child health, health promotion, community resilience, and power dynamics in health care. My research focuses on reducing inequity in health through intersectoral collaboration and on partnership as a vehicle to leverage diverse ways of knowing and power for promoting health and wellbeing. I’m particularly interested in North-South partnership and promoting equity in global health research and socio-cultural beliefs, perceptions, and views of people regarding modern health intervention such as vaccines and the use of technology in health care. The current study is part of the team’s efforts to improve COVID-19 vaccine uptake efforts by the ministry of health in Zambia.