As India continues to grapple with the socioeconomic and health impact of the Covid-19 pandemic, a huge rural-urban divide in vaccine uptake has emerged due to vaccine hesitancy and fluctuating supplies. With a majority of its population residing in rural areas that have little health infrastructure, India had to bear the brunt of the worst healthcare crisis in more than 100 years.
Virologist and epidemiologists across the world unanimously agree that the participation of rural households is central to the fight against the pandemic. However, reports based on vaccine rollout data suggest that India’s Covid-19 vaccination drive is marred by divides and inequalities. The rural-urban divide, gender gap and digital divide are holding back the country from effective vaccination against Covid-19, disproportionately burdening the low-income households.
The Covid-19 vaccination has gained momentum in the last couple of months after initial hiccups. However, more needs to be done to achieve the target of vaccinating the entire adult population. According to official data , India had administered 1,41,70,25,654 doses of vaccine till December 27. While the vaccine supply and uptake has improved, vaccine hesitancy due to misinformation and poor awareness remains a key hurdle, especially amongst rural low-income households, in achieving universal coverage.
A study was conducted by the Grameen Foundation India in Hardoi district of Uttar Pradesh in June 2021 to understand the level of awareness and reasons for vaccine hesitancy among low-income rural households. It found that while the awareness about Covid-19 vaccines was high at 89%, the level of vaccination was exceptionally low with about 98% of the respondents not having taken even the first dose. People were informed about the availability of vaccines at government healthcare centers, but were not inoculated.
Why vaccine hesitancy
Sangeeta (name changed), a 28 year-old woman in Kaluali village of Hardoi, admitted that she has heard about the ongoing vaccination programme in the local healthcare center. She did not get the vaccine as she feared that it may cause infertility and affect her menstrual cycle. There are a large number of people like Sangeeta and her example highlights the vaccine hesitancy in rural India.
The villagers believe the vaccine has side-effects and can even cause death. During the study, it was found that 65% of the respondents were aware of the vaccine, but did not get vaccinated. They were worried about side-effects like infertility and death (94%). They did not feel the need (3%), believing that Covid-19 did not exist in rural areas (3%).
Vaccine hesitancy is not the sole reason for low vaccination rates. One out of three respondents could not get vaccinated due to lack of information, fluctuating supplies of vaccines and the digital divide between the rural and urban populations. They did, however, show a positive inclination towards vaccination.
These respondents had made attempts to get vaccinated — they visited healthcare centers, tried to register on CoWIN, and enquired from healthcare workers about the ongoing vaccination programme. The respondents were ready to get inoculated if there was an opportunity provided in their neighbourhood.
This is why a blanket approach is not suitable to drive vaccine uptake in rural India. There lies a heterogeneity with varying reasons for not getting the vaccine.
Who is likely to be more hesitant
Through this study, we identified key predictors for identifying segments that were more likely to be hesitant towards the Covid-19 vaccine. Key factors identified were:
Gender: Women were more likely to be hesitant towards the vaccine than men. Women were worried that the vaccine would cause infertility and disturb their menstrual cycle. Restricted mobility outside the community further exacerbated the poor vaccination uptake.
Poverty and education: Study indicated that vaccine hesitancy was greater among low-income households compared with better-off households. Similarly, respondents with lower education levels were more hesitant towards the vaccine. It is also important to note that about 76% of these households are primarily dependent on wage labour as a source of income and may lose their earnings for a couple of days due to side-effects such as fever and body ache after getting vaccinated. This further affected the uptake intent.
Religion: We did find a clear difference in the extent of vaccine hesitation along religious lines. Respondents from minority communities were more likely to be hesitant than others. The underlying reasons for higher vaccine hesitancy could be relatively lower educational status – 88% of the respondents from this segment had never attended school or just had primary education.
There was a higher dependency on agriculture and wage labour as primary source of income in this segment. Therefore, while the difference could be visible along religious lines, the real reason could well be education or livelihood profile than the religion itself.
There has been a huge impetus by the Union and state governments in driving vaccination across the country through continuous and focused campaigns. These communication campaigns identify community-based leaders and frontline workers as key influencers for driving vaccination confidence.
The study reaffirmed this strategy as Accredited Social Health Activist (ASHA)/Auxiliary Nurse Midwife (ANM) were reported as key influencers by 99% of the respondents for driving enthusiasm among community members for vaccinations. Other key influencers identified were community-based leaders such as a sarpanch or pradhan (84%) and government school teachers (51%).
Three ways of improving vaccination confidence
- Using social media and community-level institutions for resolving information asymmetry about vaccine availability and hesitancy – Our research found that a big part of the unvaccinated rural population were fence sitters and can be appropriately targeted for vaccination by providing information about vaccine availability through social media and community-level institutions. This would also drive peer effect among the hesitant population and could be a key driver for increased uptake.
- Using community-based influencers for enhancing vaccination confidence – Multiple studies including ours have clearly established the high level of trust bestowed on community-based health workers such as ASHA, ANM and doctors from the community and local area. Motivational messages from these trusted sources can be delivered through targeted social media channels, local news channels and print media for driving people to vaccination centers.
- Non-financial incentives for promoting vaccination could be considered for low-income households to motivate them. Low-income households dependent on daily wages tend to lose earnings due to the after-effects such as fever and associated symptoms when vaccinated. A combination of financial and/or non-financial incentives could offset their losses partially, if not completely. One can also take a cue from the success of mandatory requirement of vaccination for international travel or gig economy workers.
Poor health infrastructure, digital divide, low literacy level and misinformation about Covid-19 make it challenging to drive vaccination in rural India. However, the solution lies in a tailor-made decentralised approach leveraging trusted community-based institutions, elements of behavioral science and digital mediums to drive vaccine confidence in rural India. Only when the rural India is universally vaccinated can we dream of a Covid-free India.
(Rahul Ranjan Sinha is Associate Director, client insights for impact, and Dr Krishna Sannigrahi is Senior Consultant, health & nutrition at Grameen Foundation India.)