Barriers affecting COVID-19 vaccination in Phalombe District, Malawi: A qualitative study

Background. In Malawi, only 1 072 229 people out of a national target population of 13 546 324 had received at least one dose of the AstraZeneca COVID-19 vaccine by 26 December 2021, and only 672 819 people were classified as fully vaccinated. Phalombe District in Malawi had particularly low COVID-19 vaccine uptake, with only 4% (n=8 538) of 225 219 people being fully vaccinated by 26 December. Objectives. To explore reasons for vaccine hesitancy and refusal among people living in Phalombe District. Methods. This cross-sectional qualitative study employed six focus group discussions (FGDs) and 19 in-depth interviews (IDIs) to collect data. We purposefully selected two traditional authorities (TAs), Nazombe and Nkhumba, as study areas, and conducted FGDs and IDIs in 6 randomly selected villages in these two TAs. Participants were religious leaders, traditional leaders, youths, traditional healers and ordinary community members. We explored reasons for vaccine refusal and hesitancy, how contextual cultural beliefs influenced people's decision to receive the COVID-19 vaccine, and which sources of information were trusted in the community. Data were analysed using thematic content analysis. Results. We conducted 19 IDIs and six FGDs. Themes that emerged from the data were reasons for vaccine refusal and hesitancy, contextual cultural beliefs affecting the decision whether to be vaccinated, ways to improve COVID-19 vaccine uptake, and means of communicating information about COVID-19 vaccines. Participants mentioned that myths contributing to vaccine refusal and hesitancy circulated in the community through social media. With regard to contextual cultural beliefs, most participants believed that COVID-19 was a disease of rich people, while others believed that it signalled the end of the world and that it could not be cured. Conclusion. Health systems should recognise and acknowledge the reasons leading to vaccine hesitancy and refusal and address these appropriately to improve vaccine uptake. Effective community sensitisation and engagement should be enhanced to clarify myths and address misinformation about the COVID-19 vaccine.