Covid vaccine uptake hesitancy in Malawi

LIFE-CHANGING— Covid vaccines

By Gray Kalindekafe:

The Covid Vaccine Access (Covax) facility shipped 360,000 doses of Oxford- AstraZeneca vaccine from the Serum Institute of India to Malawi on March 5 2021.

The arrival of the jabs marked a milestone for Malawi, where Covid-related complications have claimed over 1,850 lives and created a heavy burden on health facilities.


Through the Covax Facility, the Malawi Government also received 360,000 bundled syringes and 3,625 safety boxes for safe disposal of syringes.

Malawi has experienced a surge in the number of Covid cases. Blantyre and Lilongwe cities are contributing the bulk of the cases.

We are now deep into the third wave of the pandemic. The good news is that more vaccine doses are coming; the bad news is that a lot of people are still not willing to get the shots.


The Malawi Government identified priority groups who would be among the first to receive the vaccine. These include healthcare workers, including those working in the private sector, who are at higher risk of Covid infection than the general population due to the nature of their work.

Also included in phase one were officers from the police, Department of Immigration and Citizenship Services, the Malawi Defence Force, Malawi Prison Service, those with underlying conditions and those above 60 years.

Afterwards, access got opened for everyone above 18 years.

Somehow, there has been a huge demand and scramble for the jabs to the extent that stocks in most vaccination centres in Blantyre, Lilongwe and Zomba run out of jabs within three and four days.

This sudden interest to have the shots mainly in cities is mostly attributed to the fact that there has been enormous evidence that the vaccine is working. In the 2020 Uefa Euro, over 65,000 fans were allowed to into a stadium without masks.

Mainstream media have also reported cases where, in Britain for example, life has been returning to normal due to the vaccination process, with bars and restaurants opening to the general public without the mandatory wearing of face masks.

In the United States (US), they are calling Covid a disease for the unvaccinated, since research has shown that over 99 percent of those dying or getting hospitalized are not vaccinated.

All this evidence is compelling city dwellers and others, who easily access information, to accept to have the jab.

The opposite is true for rural areas, where acceptance levels are very low and hesitancy levels remain high. Poor access to information and general myths about Covid vaccines are some of the factors contributing to the problem.

There is, for example, unsubstantiated information that the vaccine makes one impotent or a deliberate plot to depopulate the world.

Some even claim the vaccine is linked to the end of the world. In other cases, some politicians are using various ways to discourage people from taking up the shots. They are claiming that the government is giving the citizenry vaccines instead of food.

The other factor undermining the uptake of Covid is contradictory messages from scientists and health experts.

The other factor which might lead to vaccine hesitancy is the fear of getting expired shots. For example, health authorities recently destroyed 19,610 doses of expired AstraZeneca shots, stating that the move would boost public confidence in the country’s vaccine programme.

Health Minister Khumbize Kandodo Chiponda put some of the vials of the expired doses into an incinerator to start the destruction at Kamuzu Central Hospital in Lilongwe.

Trust is an intrinsic and potentially modifiable component of successful uptake of any vaccine. Trust in government is strongly associated with vaccine acceptance and can contribute to public compliance with recommended actions.

Lessons learned from previous infectious disease outbreaks and public health emergencies—including ebola, Middle East Respiratory Syndrome and Severe Acute Respiratory Syndrome — remind us that trusted sources of information and guidance are fundamental to disease control.

However, addressing vaccine hesitancy requires more than building trust. It is a multifactorial, complex and context-dependent endeavour that must be addressed simultaneously at global, national and sub-national levels.

Clear and consistent communication by government officials is crucial to building public confidence in vaccine programmes.

This includes explaining how vaccines work, as well as how they are developed, from recruitment to regulatory approval based on safety and efficacy.

Effective campaigns should also aim to carefully explain a vaccine’s level of effectiveness, the time needed for protection (with multiple doses, if required) and the importance of population-wide coverage to achieve community immunity.

Instilling public confidence in regulatory agency reviews of vaccine safety and effectiveness will be important. Credible and culturally informed health communication is vital in influencing positive health behaviours, as has been observed with respect to encouraging people to cooperate with Covid control measures.

This includes preparing the public and leaders of civic, religious and fraternal organisations that are respected within various sectors of society and local communities, as well as the private sector, for a mass vaccination programme with credible spokespeople.

Generally, most countries which have succeeded in reducing vaccine hesitancy and encourage vaccine acceptance have used existing population-based interventions. Some of them include launching vaccination campaigns with an emphasis on the importance of vaccination; providing tailored information to describe evidence on the risks and benefits of vaccines through common modalities (e.g., radio/podcasts, television, email alerts and reminders, text messages, face-to-face (in-person), social media (including web-based advertising) and through less frequently mentioned modalities (e.g., financial incentives, reminder-recall notifications); engaging healthcare providers to provide information and address concerns from vaccine-hesitant individuals during clinic visits; and combating myths and misinformation about vaccines through community engagement and transparency of the vaccine development process.

Literature on vaccine acceptance identifies some essential strategies: Simple, easy-to-understand language; messaging that emphasises science over politics; endorsements by diverse and well-regarded celebrities and opinion leaders; and emphasis on facts and evidence over myths and disinformation.

For the Covid vaccine, attention must be given to rebuilding trust in communities that have historically experienced medical exploitation, unconsented experimentation if any in Malawi and social and economic marginalisation.

Those getting vaccinated also need to be warned about transient adverse effects of the vaccines to avoid negative publicity from unprepared individuals.

This viewpoint proposes five strategies, informed by insights from behavioural science, for a national Covid vaccine promotion programme.

These strategies are proposed with the recognition that many uncertainties remain: The timing of approval or authorisation of one or more vaccines; the safety and efficacy profile of the vaccine(s); the implementation of priority allocation schemes by state and local authorities; the capacity of existing immunisation programmes and channels to support Covid vaccine promotion and distribution; and the further politicisation of vaccine approval and acceptance.

Make the vaccine free and easily accessible. Ample research has shown that reducing friction (such as difficulty signing up for programmes) and hassle factors (such as wait times, inconvenient service locations and paperwork) increases uptake of services.

To reduce time and other barriers, it will be important to make vaccines accessible through a wide variety of outlets (healthcare centres, clinicians’ offices, retail pharmacies, occupational health offices of employers and school clinics).

It is refreshing to note that, here in Malawi we have vaccination centres in most government hospitals and other sites.

Still, given the current vaccine hesitancy and the complexity of administering some of these vaccines, it is necessary to make it as easy as possible to be immunised.

Many retail outlets and restaurants have made face coverings mandatory for the protection of employees and other customers. In a similar way, access to certain settings could be made conditional on receiving the Covid vaccine.

These could be healthcare clinical settings and facilities such as college dormitories, schools, government offices, shopping malls and football pitches.

Individuals could also be required to show proof of vaccination to enter stores, cinemas, in-restaurant dining, amusement parks, gyms, bars and other public places with substantial risk of transmission.

Some experts have proposed offering monetary incentives for vaccination. Paying people to engage in activities including vaccination can, in theory, make sense in situations where an individual’s actions benefit other people.

However, considerable research shows that payments in some contexts can send the signal that an action is undesirable, unpleasant or even dangerous and not worth taking based purely on personal benefit.

Financial incentives are likely to discourage vaccination. Instead, contingent nonfinancial incentives are the desired approach. The development and distribution of safe and effective Covid vaccines will be an extraordinary achievement.

Vaccine acceptance must start with transparent safety and efficacy data.

In conclusion, to ensure a successful Covid vaccination campaign, it is necessary for sponsors to invest in time-critical investigations on human factors related to vaccine acceptance and for public health authorities and other stakeholders to act on the social and behavioural proposals in this piece.

The author is governance, human rights and civic education specialist.

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