Understanding determinants of vaccine hesitancy and acceptance in India: A qualitative study of government officials and civil society stakeholders.

Introduction: Few studies have described the drivers of vaccine hesitancy and acceptance in India from the perspective of those involved in the design and implementation of vaccine campaigns-such as government officials and civil society stakeholders-a prerequisite to developing approaches to address this barrier to high immunization coverage and further child health improvements.
Methods: We conducted a qualitative study to understand government officials and civil society stakeholders' perceptions of the drivers of vaccine hesitancy in India. We conducted in-depth phone interviews using a structured guide of open-ended questions with 21 participants from international and national non-governmental organizations, professional associations, and universities, and state and national government-six national-level stakeholders in New Delhi, six state-level stakeholders in Uttar Pradesh, six in Kerala, and three in Gujarat-from July 2020 to October 2020. We analyzed data through a multi-stage process following Grounded Theory. We present findings on individual-level, contextual, and vaccine/vaccination program-specific factors influencing vaccine hesitancy.
Results: We identified multiple drivers and complex ways they influence vaccine beliefs, attitudes, and behaviors from the perspective of government officials and civil society stakeholders involved in vaccine campaigns. Important individual-level influences were low awareness of the benefits of vaccination, safety concerns, especially related to mild adverse events following immunization, and mistrust in government and health service quality. Contextual-level factors included communications, the media environment, and social media, which serves as a major conduit of misinformation and driver of hesitancy, as well as sociodemographic factors-specific drivers varied widely by income, education, urban/rural setting, and across religious and cultural groups. Among vaccine/vaccination-level issues, vaccine program design and delivery and the role of health care professionals emerged as the strongest determinants of hesitancy.
Conclusions: Drivers of vaccine hesitancy in India, as elsewhere, vary widely by local context; successful interventions should address individual, contextual, and vaccine-specific factors. While previous studies focused on individual-level factors, our study demonstrates the equal importance of contextual and vaccine-specific influences, especially the communication and media environment, influential leaders, sociodemographic factors, and frontline health workers.
Competing Interests: The authors have declared that no competing interests exist.