General publics’ perception toward COVID-19 vaccines in Afghanistan, 2021

ABSTRACT

As of August 2021, less than 5% of the total population in Afghanistan has been fully vaccinated against COVID-19. Concerns remain regarding low uptake of the vaccine due to several factors. This study was conducted to understand the perception of the public on COVID-19 and its vaccines in Afghanistan. This was a formative study using qualitative method that included FGDs with vaccination target groups and KIIs, using interview guides in local languages in 12 provinces with 300 participants during May–June 2021. Verbatim transcripts were created, and a deductive thematic analysis was conducted with transcripts after the key themes and sub-themes were developed and reviewed. Totally 24 FGDs with male and female COVID-19 high-risk groups, 12 KIIs with EPI managers, and 12 KIIs with prison heads were conducted. Key themes included awareness and perception about COVID-19, its vaccination, motivators for getting vaccinated, barriers for not getting vaccinated, and sources of information. Awareness about the COVID-19 was high in urban areas compared to rural areas. Almost 60% of the participants considered the COVID-19 vaccine effective. However, participants expressed their concerns regarding rumors and misconceptions on content, source, effectiveness, and side effects of the vaccine in their communities. Based on the study results, many participants expressed accurate knowledge about the COVID-19 disease and its vaccines. Significant barriers including misinformation, conspiracy theories, and fear of side effects persist. Collaboration between stakeholders and increasing awareness and engagement of communities about the benefits and effectiveness of the vaccines should be considered crucial.

Introduction

Since December 2019, the COVID-19 pandemic has brought significant challenges to the global health paradigm and posed a major threat to the treatment and prevention of the disease.¹ Although a variety of approaches have been taken, mass immunization has been found to be the most effective, reliable, and time-bound method for virus control and prevention.² To combat the pandemic, a global COVID-19 immunization initiative was launched, aiming to vaccinate those at high risk. Despite significant progress in vaccination, greater populations still require more supply and there is still a need for more vaccines.^3,4 Several vaccines such as Pfizer/BioNTech, Moderna, Johnson & Johnson, Sinopharm, and AstraZeneca have been produced in different settings and are approved by the World Health Organization.⁵ These vaccines have led to a dramatic decrease in the number of COVID-19 cases worldwide; however, public hesitancy, adverse reactions, and acceptance have hindered their administration.^6,7

Understanding public’s perception and attitude toward immunization is critical in dealing with pandemics and curbing further disease spread. COVID-19 vaccines have been proven to be effective is protecting against the disease.^8,9 Despite the administration of billions of COVID-19 vaccine doses, many people are still hesitant to be vaccinated. Globally, numerous studies have been conducted to assess the perception of COVID-19 vaccines in various settings, and the findings have revealed that people living in low- and middle-income countries are more involved in misconceptions, myths, and mistrust on vaccines.^10–13 The success and implementation of vaccination strategies and campaigns highly depend on people’s attitude and perception of the vaccine; therefore, identifying negative perceptions and attitudes is of utmost importance in mass vaccination strategies.^14–16 Although evidence from neighboring countries such as Pakistan and Iran shows high rates of COVID-19 vaccine administration, concerns regarding low knowledge, trust, and safety of vaccines still exist which is in line with the Afghanistan context.^11,17–19

As of February 2023, the Afghan Ministry of Public Health has reported 208,506 confirmed cases of COVID-19 with a case fatality rate of 3.78% and a death toll of 7880 individuals.²⁰ It is expected that there will be underreporting of cases in Afghanistan due to limited public health resources, a lack of interest in COVID-19 testing, and the absence of national death registry system.²¹ In March 2021, Afghanistan made history by becoming the first country in Central Asia to receive vaccines through COVAX, with 468,000 doses of the COVIDSHIELD vaccine shipped.²² A second shipment of 1.48 million doses of the Johnson & Johnson vaccine arrived in July. Additionally, India and China each donated 500,000 and 700,000 doses of the AstraZeneca and Sinopharm vaccines, respectively, to Afghanistan.²³

Concerns about administered vaccines were widespread, with a lack of vaccines, rumors, myths, and low trust being particularly prominent among the public.²² Several studies assessed public hesitancy toward COVID-19 vaccine in the country, including an online survey in which the majority of the 806 respondents from Afghanistan expressed willingness to take the vaccine when it became available. However, a significant 37% people in different provinces were hesitant to receive the vaccine due to concerns about its safety and quality.²⁴ Another population-based survey conducted by Afghanistan National Public Health Institute and UNICEF found that 69% of respondents were interested in receiving the COVID-19 vaccine, while only 17% did not intend to get vaccinated and 14% did not respond.²⁵ These findings align with studies conducted in Pakistan, which showed that although many people were willing to be vaccinated, they had concerns about the vaccine’s source, quality, and safety.^11,17,18

However, as the novelty of virus intended to create obstacle, vaccines production increased the concerns, conspiracies, and false rumors. Consequently, rumors and conspiracies may lead to vaccine hesitancy and mistrust.²⁶ This has been a main concern in war-torn and developing countries like Afghanistan, not only for COVID-19 vaccine but for other vaccines as well. However, despite the decline in the number of COVID-19 pandemic cases globally, there are still vaccination efforts in Afghanistan. The rapid collapse of the government and overtake of defacto leadership during mid-August 2021 in Afghanistan to some extent disrupted the normal process of COVID-19 vaccination in Afghanistan. Although, there are efforts to continue mass immunization through vaccination campaigns, the number of Afghan people receiving the COVID-19 vaccine is still not satisfactory. Contrary to previous studies conducted in Afghanistan,^24,25 the current study focuses on assessment of community’s perception through Focus Group Discussion (FGD) and Key Informant Interview (KII) in two rural and urban provinces of each region in the country. The study findings provide evidence regarding perceptions of vaccine uptake. Among other low- and middle-income countries, the findings and recommendations of this study could be contextualized and used, especially when it comes to the introduction of new adult vaccines. Adult vaccination programs have been weak or non-existent in many countries to date. The study findings and recommendations will help address critical concerns of the public while planning for introduction of novel vaccines or any pandemic preparedness and response. This will allow quicker roll-out and uptake of vaccines in the future.

Methodology

This was a qualitative formative study that utilized Focus Group Discussions (FGDs) with communities and Key Informant Interviews (KIIs) with provincial staff responsible for the Expanded Program on Immunization (EPI) under the Basic Package of Health Services (BPHS) and head of prisons. The study employed interview guides specifically developed for this purpose.

To collect data, the research team conducted an extensive literature review of the relevant documents on COVID-19 vaccination and similar studies on EPI in Afghanistan to contextualize this study and guide analysis. The review included academic papers, gray literature, reports, and official policy documents sourced from databases, such as PubMed, Cochrane Collaboration, Google Scholar, Global Index Medicus, and open-source journals.

A total of 24 FGDs were conducted in Kabul, Wardak, Kandahar, Urozgan, Nangarhar, Kunar, Herat, Ghor, Balkh, Faryab, Kunduz, and Takhar, including both urban and rural centers to ensure representation of diverse contexts and settings. The purposive sampling method was used to select participants in consultation with community health supervisors and EPI staff in the target provinces. Participants were 18 y old and over who were prioritized by the National Technical Committee to prepare the National Vaccine Deployment Plan as vulnerable groups to receive COVID-19 vaccines first, such as doctors, vaccinators, internally displaced persons, journalists, teachers, social activists, chronic disease patients, community health workers and supervisors, elderly people, and nomads.

To gain a comprehensive understanding of COVID-19 vaccine knowledge and perception, 24 KIIs were conducted with National Expanded Program on Immunization staff and the head of the target province prison, as prisoners are a high-risk group and a vaccine target.²⁷ In general, the research team defined perception as the organization, identification, and interpretation of sensory information to represent and understand the presented information or environment about COVID-19 and its vaccine, also known as SARS-CoV-2. Field researchers underwent a 2-d intensive training on qualitative data collection techniques and best practices.

Data collection

Data for this survey was collected between May 11^th to June 17^th, 2021, in coordination with provincial government, local health authorities, EPI representatives, and prison heads simultaneously. To gain a better understanding of perceptions, FGDs and KIIs were conducted with groups and individuals using Interview guides in form of a questionnaire to collect information on knowledge, perception, reasons for not getting vaccinated and vaccination motivators. Two FGDs and two KIIs were conducted per province in 12 target provinces. FGD target groups were identified through purposive sampling and approached by field researchers who explained the study`s objective and asked for participation. People who agreed were told about the time and location of the FGD. The KIIs were conducted similarly through face-to-face interviews with EPI staff or prison heads in private rooms. All FGDs and KIIs were recorded with participant consent and uploaded to a password protected online cloud server. Experienced qualitative researchers supervised the data collection and provided on-spot feedback to the data collectors who made the necessary rectifications.

The Ministry of Public Health’s Institutional Review Board (IRB) approved this study. All participants who agreed to attend the interview signed a written consent form. Participant`s permission was obtained before audio recording the interview and confidentiality of collected information was guaranteed.

Data coding and analysis

Field notes were transcribed and reviewed by the quality assurance team to ensure accuracy, as they capture non-verbal communication. Verbatim transcripts were created using a transcription protocol and translated into English for analysis. Coding rules were developed and consistently applied to the cleaned data files. Identifiers such as key informant names were hidden to ensure anonymity.

A deductive thematic analysis was conducted with the transcripts using Dedoose (Version 4.12), a qualitative data analysis software, as well as MS Excel. For the coding process, first, priori codes were developed based on the existing themes. These provided a general framework for the major themes and subthemes which were generated later through an iterative process. The transcribed notes were reviewed by a team leader multiple times, enabling the team to correctly label or group certain areas in the dataset. The team looked for similar views and opinions and grouped them together to support a particular theme. The purpose was to group themes in a hierarchical structure, with subthemes placed under each major theme in a way that supported the major theme. The grouping of subthemes took place by reviewing their meaning in relation to the major themes. The major themes were as follows: 1) Perceptions and Knowledge of the COVID-19, 2) Perceptions and Knowledge of the COVID-19 Vaccine, 3) Reasons for Not Getting the Vaccine, 4) Motivation for Getting Vaccinated, 5) Communication and Messaging, and 6) Change Mechanisms.

After organizing and transcribing the data, systematic analysis and interpretation of qualitative data were performed, and a core set of codes were prepared to further support the analysis and interpretation of data. To elaborate on the significance of each code, frequency tables were developed; the unit of analysis was either FGD or IDI/KII. Additionally, while reading the text under the themes and adding thoughts and ideas about a particular theme, the evaluator tried to identify and assess the relationship between different variables, including similarities and differences between themes and how they interact with each other. Furthermore, when presenting views from different respondent groups, “Verbatim” quotes were added to further support a particular theme or argument.

Results

Socio-demographic characteristics of study participants

In this study, a total of 300 participants were interviewed, consisting of 163 (54.33%) males and 137 (45.66%) females. The FGDs involved various groups of individuals such as healthcare workers, teachers, IDPs, returnees, journalists, students, nomads, Imams, and elderly people. On the other hand, the KIIs were conducted with prison heads and EPI staff from the target province (Table 1).

Table 1.

Characteristics of participants (FGD and KII) n = 300.

Participant type FGD	Female N = 136 (%)	Male N = 140 (%)
Health workers	32 (57.1)	24 (42.8)
Teachers	18 (51.4)	17 (48.5)
IDP/Returnee	11 (44)	14 (56)
Shura member/CHW	15 (53.5)	13 (46.4)
Government employees	11 (47.8)	12 (52.1)
Journalists	9 (50)	9 (50)
Vaccinators	8 (47)	9 (53)
Community Health Supervisors	0	8 (100)
Civil Society Organization	5 (41.6)	7 (58.3)
Self employed	0	6 (100)
No Job	0	6 (100)
Students	7 (63.6)	4 (36.3)
Elders	1 (25)	3 (75)
Nomads	5 (62.5)	3 (37.5)
Imams	0	3 (100)
Chronic Illness	3 (60)	2 (40)
Housewives	11 (100)	0
Total	136	140
Participant type KII	Female N = 1 (%)	Male N = 23 (%)
Provincial Expanded Program on Immunization staff (REMT, PEMT, EPI Supervisor)	0	12 (100)
Prison Heads	1 (8.3)	11 (91.6)
Total	1	23

The qualitative findings are presented in a conceptual model that indicates the factors influencing people’s decision-making and are distinct in the dual domains of study (Figure 1). The green portion represents factors that drive individuals and communities to get vaccinated, while the red shaded area includes barriers to vaccination. The vaccine acceptance equation consists of:

• Perceptions pertaining to the COVID-19 or SARS-CoV-2, which show beliefs on the reality and danger of the virus. Positive beliefs can facilitate motivation to get vaccinated, while low trust in health system and misinformation about the virus present significant barriers toward vaccination.

• Perceptions of COVID-19 vaccines which include trust in vaccines, the obligation to protect oneself, family, and community on a larger scale. The data on the red side of the equation indicate many rumors and associated fears about side effects that lead to barriers for vaccination.

• The data on communication indicate the most used messaging channels, trust of individuals in MoPH, community elders, and religious leaders. The MoPH provides accurate and scientific information. However, Information from elders and religious leaders can impart inaccurate information. The same duality can be found for social media.

• Change agents which are effective in demand generation for vaccines among public.

Figure 1.

Summary of study results using a driver [green]/barriers [red] – conceptual model.

Theme one: perceptions and knowledge of COVID-19

The findings show that awareness about COVID-19 among people who attended focus group discussions is 92% in urban and 83% in rural areas. The highest awareness is among female participants who believe that COVID-19 is dangerous, and this increased their faith in prevention measures. One focus group participant mentioned:

If we talk about vaccines, in general, most people in society believe that the vaccine is the only remedy that can fight against any disease. And when we talk about the COVID-19 vaccine, I believe on the vaccine as it is the only way that can prevent COVID-19. Male FGD participants of Herat Province

Despite increasing awareness about proper preventive measures, it is essential to inform people about consequences of improper practice. In addition, it is important to plan the translation of awareness into practice which will eventually help change the behavior (Figure 2).

In terms of controlling virus spread, we see that the virus has brought the world and health systems to their knees. Generally, we see people in our community who do not believe in SARS-CoV-2, nor consider preventive measures, such as wearing masks, social distancing, or washing their hands frequently with soap. As a result, we are witnessing the spread of SARS-CoV-2 every single day and mortality is extremely high among those infected by the SARS-CoV-2. Female FGD Participants in Herat Province

Figure 2.

Results of FGD on COVID-19 perception in rural and urban settings.

Participants stated that observing individuals, who became extremely ill and/or died due to COVID-19, convinced them of the existence and the reality of the virus. This view is captured by the following quote:

Before the vaccine was introduced, we saw a lot of deaths due to COVID-19 particularly among those with hearth diseases and diabetes. They could not tolerate the COVID-19. Nowadays, we encourage older people to get vaccinated. Female participant, FGD Faryab Province

Theme two: perception and knowledge of COVID-19 vaccines

Two of the most stated opinions were regarding preventive measures and the effectiveness of the COVID-19 vaccine. Trust in the vaccine was reported by 67% of male FGD participants, 50% of female FGD participants, and 33% of prison staff and prisoners by prison heads. These themes emerged strongly across all groups regardless of gender or geography (Figure 3).

Figure 3.

Results of FGD, perception on COVID-19 vaccines.

The most frequently mentioned misperception about the vaccine was that it can cause death. Other less commonly expressed misperceptions about the COVID-19 vaccine included infertility in men, harm to pregnancies and in-effectiveness. This is illustrated in the following quote:

People have different opinions about the vaccine. Initially, some said that the COVID-19 vaccine sterilizes men, some others think that COVID-19 vaccine was ineffective, and it causes blood clot in body. Female FGD participants of Faryab Province

Theme three: motivation for getting the COVID-19 vaccines

Participants were also asked to give reasons why people in their community have been or are willing to be vaccinated. The most common responses were trust in the vaccine and beliefs in its effectiveness along with the understanding that COVID-19 is dangerous, and the need to protect oneself, family, or community from the virus (Figure 4). Participants also expressed trust in health workers and the MOPH:

Really, we don’t know about the quality of this vaccine, but 100% we believe on Ministry of Public Health messages mentioning that vaccine is effective. How would we know about the quality of vaccine if Ministry of public health does not inform people. Female FGD Participant Faryab Province.

Figure 4.

Motivations for getting COVID-19 vaccine.

Theme four: reasons for not getting vaccinated

Concerns about vaccine side effects (e.g., fever, body pain, etc.) were mentioned in most focus group discussions and key informant interviews. Commonly cited reason for not getting vaccinated was a general low trust in vaccines, meaning that people have low trust on the effectiveness of the vaccine and think that vaccine is not to protect them and it is used to test new products under the name of vaccine. In addition, the most frequently cited reasons for vaccine hesitancy were the fear as the vaccine causes death, sterilizes men, and causes blood clots (Figure 5, Table 2).

Young prisoners were concerned that COVID-19 vaccine reduces sexual potency, and they will not be able to become fathers in the future. The married ones with no children were not interested in the vaccine. KII Prison Head Balkh Province

Our young female soldiers are worried about infertility due to vaccine. KII Prison Head Kunar Province

Figure 5.

Reasons for not getting COVID-19 vaccine.

Table 2.

Reasons for not getting vaccinated (urban vs rural) n = 300.

FGD			KII
Codes	Rural (n = 12)	Urban (n = 12)	Codes	Rural (n = 12)	Urban (n = 11)
Low trust in vaccine	42%	25%	Mistrust vaccine	17%	36%
Side effects – real	33%	8%	Rumours – vaccine kills, weaken immune system, sterilizers, infidels plan	25%	27%
Rumours – vaccine kills, weaken immune system, sterilizers, infidels plan	33%	8%	Rumour – just the flu (corona virus not real)	25%	0
Imam spreads fear	17%	17%	Fear of blood clots	8%	0
Fear of blood clots	17%	17%	Lack of awareness	8%	0
Inaccessible/Mistrust logistics	17%	8%	Not allowed by age	8%	0
Foreign source (testing on us, malicious intention, money motive)	17%	8%
Rumours (Harms pregnancy)	8%	8%
Waiting to see the effects	17%	0
Mistrust the clinics	0	8%
Social media spread fear	8%	0

The FGD participants expressed their concerns about the vaccine being distributed in Afghanistan, as it is made in India. Several participants were suspicious of why India wanted to export its own produced vaccine, while many Indian citizens are dying due to COVID-19. This suspicion added to the belief that India was testing its vaccine on Afghans.

India has a large population and could not reach all the different people there, so why they help our country although more COVID-19 cases are in their own country? Female FGD participant of Faryab Province

Theme five: communication and messaging

The most common messaging channel is through mass media, such as TV and radio. Social media such as Facebook is also a highly cited source of information. Less commonly mentioned sources of information include community elders/teachers, Imams, mobile health teams, health workers, CHW, leaflets, and banners. Note that the frequency distribution is almost identical between men and women and across geographies (Figure 6). However, these information sources can spread both accurate and inaccurate information.

We heard about this vaccine from social media, health education given by health workers, and the ministry of public health, so we trust this vaccine. Female FGD in Faryab Province

Imams of mosques and peoples advocate they can be effective, during the Jumma prayer imam gives awareness to people so the people can believe more and get vaccinated. Female FGD participant in Faryab Province

Indeed, social media and community elders/Imams have significant influence over individual beliefs and motivations. Such influence can be used to either spread rumors and fear or promote accurate public health information. This duality is represented in the conceptual model. Male FGD Participant in Herat Province

Figure 6.

Places where people receive messages on COVID-19 KIIs (EPI & prison).

Theme six: change mechanisms

Sub-theme one-change agent

A change agent potentially influences beliefs and motivations toward a particular direction, resulting in more individuals getting vaccinated. One theme that commonly emerged throughout the data was the concept of “seeing is believing.” This sentiment was expressed with respect to the seriousness of the virus:

In this village, there were a lot of people like me who were infected by Coronavirus, and they did not go to the hospital because of fear of death, and most of them died. Also, there were a lot of people like me, who went to the hospital, and we all recovered. after my recovery, I told everyone that the health workers always work for the health of the people. Female FGD Participant Balkh province

Before I get the vaccine, people used to say that whoever gets vaccinated will die. I got vaccinated and thank God I am still well. Fortunately, no cases of death after vaccination have been reported in our clinic. Female FGD in Faryab province

I received two courses on the COVID-19 vaccine. And I suggest people, who want to protect themselves, their families, and their community, should get the COVID-19 vaccine. Female FGD participant in Faryab Province

Sub-theme two-trust

A common theme that emerged across all geographies (men and women) was trust in the MoPH. Individuals sought MoPH approval for the vaccine before taking it, as well as trusted information that was presented by the MoPH. Some participants explicitly expressed the desire for the MoPH to do more advertising and messaging around COVID-19.

This sense of trust also extended to local health workers. In general, there was a notable increase in awareness about the dangers of the virus and the benefits of the vaccine through education, training, and widespread positive publicity by the Ministry of Public Health, imams, community elders, health workers, and social and other media. Sources of misperceptions that persist are attributed in part to misinformation from social media and imams or to lack of literacy and lack of awareness due to low literacy or low access to media. There is a division of opinion on the best source for correcting this misinformation:

The best way to convey information is through mosques and pulpits. Our people are religious oriented, and they give value to the words Mullahs. Some people do not believe on Internet and media and most of our people have no access to the Internet.

The health workers should act and plan with the community’s elders and Islamic scholars. also, through Radio, Television, print banners and posters to inform people from this platform. KII, EPI Manager Kandahar Province

Discussion

We have presented a conceptual model reflecting both the pull and push factors regarding decision-making for COVID-19 vaccination in the country based on the findings. Apparently, perceptions of the SARS-CoV-2 are linked to vaccine beliefs, community motivation, infodemics, rumors, and trust in the quality of vaccines. The barriers that are mostly found in this study are low trust in vaccines, side effects, rumors, and foreign sources, which are in accord with several studies conducted in different settings.^28,29 It is quite evident that barriers are affecting COVID-19 vaccination equally as they affect immunization for other preventable diseases, such as when the location of health facilities is too far to reach or there are no available vaccinators or vaccination sessions in the community.

As a general concept, Afghanistan has consistently recorded low vaccination rates for diseases that are preventable to various antigens, among which COVID-19 could not be an exception. Different studies have shown low coverage rates for immunization, which lets us imagine the COVID-19 immunization status as well.^30,31 For instance, the results of the Afghanistan Health Survey suggested that only 51.4% of children aged 12–23 months are fully immunized. Specific antigen coverage rates for Penta3, OPV3, measles, and BCG are 61%, 71%, 64%, and 77%, respectively.³² This grave situation is mostly due to many factors, including lack of motivation among community members.³⁰ The proportion of males and females is different in our study and quite manifest in KIIs. This situation shows that most of the provincial health managers and heads of prisons are males, which is common in cultural communities.

Trust has been identified as a main domain in accepting or rejecting vaccination. So, the information epidemic about vaccines is another challenge in a country like Afghanistan. Misconceptions vary from the belief that vaccines cause infertility to the idea that vaccines are made of pork fat, which is prohibited in Islam.^33,34 According to our findings, knowledge and awareness about vaccines are high, mostly among females, which is consistent with other national studies, such as an online survey in Afghanistan that found that a higher proportion of females knew about the COVID-19 vaccines and were willing to take them²⁴ and the national EPI KAP survey conducted in Afghanistan and found that vaccines are the most effective way of preventing disease in children (72%).^35–37

In addition, 1 y of exposure to the pandemic and the spread of fear via several medias on transmission of virus is the reason for increased knowledge on various aspects of the disease in the community. Factors influencing the community’s decision to get vaccinated include the desire to protect one’s own and one’s family’s health, trust in health workers’ messages, fear of high morbidity and mortality, and faith in the effectiveness of vaccines. Such factors have been reported and seen in other studies.^38,39

This study found that the most prevalent channels of communication were TV, radio, and social media such as Facebook, which is almost identical in other studies.⁴⁰ It puts policymakers in a better position to focus on such channels and provide timely updates and real information for communities. Furthermore, the provision of health education sessions to provide information and answer questions about the COVID-19 vaccine will provide an opportunity to address concerns, rumors, and misconceptions about the vaccine, which will ultimately increase vaccine uptake. This is also an effective way to increase knowledge for prisoners whose connection to social media and TV is limited.

The COVID-19 vaccination programme main concern is equitable access to vaccines for Afghans, especially vulnerable groups, such as people over 50 y old, those with co-morbidities, health workers, and prisoners. Attention is required to reach the mobile and displaced populations, such as nomads and people who moved from their homes due to conflict and drought, people living in remote and harsh geographical areas, and drug addicts. Focusing on effective risk communication and community engagement strategies will ensure high-risk populations and first-line service providers realize the importance of the COVID-19 vaccine. Addressing misinformation and negative rumors with respect to the vaccine will pave the way for better immunization against the disease. Even though the pandemic is winding down, immunization against COVID-19, like other vaccine-preventable diseases, will most likely be hampered by insufficient logistics, insufficient health workers, infodemics, and uncertainty.²² The recommendations outlined in this study regarding immunization barriers and expansion are worth discussing with decision makers and must be designed in sets of interventions to improve the situation.

Moreover, various sources of information such as health-care workers, family, and friends, government agencies, news from TV/radio and social media platforms are affecting the knowledge and perception of people regarding the vaccine. Although many people are relying on authentic information sources, the issue of concern is the information obtained from social media as it might provide false information, thus increasing vaccine hesitancy among people. Some of the factors serve as both a barrier and a motivator; for example, social media, teachers, elders, and religious leaders were thought to be sources of both misinformation and correct information. A study conducted in India found that people relying on social media were unwilling to take the COVID-19 vaccines.⁴¹ The Ministry of Public Health should therefore focus on these factors and optimize their utilization for spreading the right information on COVID-19 and its vaccination by educating religious leaders, teachers, and elders on the right information on COVID-19 and its vaccination.

Strengths and limitations

Having conducted this study in a country like Afghanistan that is lacking much reliable and valid research data are promising. The findings could be used by other researchers to build up on and policymakers to develop interventions for such pandemics in the future.

Using a qualitative method provided in depth understanding of the factors around COVID-19 and vaccination. To ensure the rigor of this study, Verbatim transcripts were created from the recordings using a standardized transcription protocol. For the coding process, first priori codes were developed based on the existing themes by the investigation team. Priori codes provide a general framework for major themes and subthemes that were generated later through an iterative process. Coding was conducted by two independent coders. Then, the technical lead reviewed transcribed notes multiple times so the team could label or group certain areas in the dataset consistently.

Like other studies, this study also has limitations. One was the limited sample size. Although two FGDs per province can identify the most held experiences and perceptions pertaining to the study topic, the qualitative nature of the method, and the small sample sizes do not permit any inferences or conclusions about the relative extent and variability of responses. A structured survey, employing a probability sample, would be required to achieve this aim. Another limitation has to do with the nature of focus group discussions and the study topic. Emotions about the COVID vaccine are often strongly felt. And substantial stigma exists on both sides of the vaccine issue (pro-vaccine and anti-vaccine). Therefore, a degree of social desirability bias affecting responses, particularly in FGDs that have both vaccinated and unvaccinated individuals, could be expected. Furthermore, the number of female participants in KIIs was limited due to male dominancy in the country and probably the viewpoints are not reflecting their perceptions.

Conclusion

Overall, the level of knowledge related to the COVID-19 and its vaccines was mixed. Knowledge of COVID-19 prevention was also mixed. Research data suggest that significant barriers remain to scaling up immunization efforts. Misinformation [about viruses and vaccines], conspiracy theories, and fear of side effects are obstacles to motivating people to get vaccinated. On the other hand, many study participants provided accurate knowledge about the COVID-19 and vaccine. It highlights that concerns about the threat of COVID-19 disease were higher among participants. Many also spoke of a desire to preserve themselves and protect others as a valid reason to get vaccinated. There is something called the ‘seeing is believing’ group. These types of people are waiting to determine how the virus and vaccine will affect others before committing to vaccination. I said I saw people die in, and many people got vaccinated and did well, which motivated me to get vaccinated. Participants also spoke more generally about the situation. Their responses suggest that Afghans, especially young people, and those living in urban areas, are more likely to be vaccinated. The trend toward vaccination may increase in the elderly and in rural areas.

Recommendation

Based on the findings of this study, the recommendations are focused on the following areas:

1. Data revealed that most FGD participants had knowledge of the SARS-CoV-2 and vaccine. It is important to encourage people to move from knowledge to action. Governments should improve people’s access to vaccination. To increase access to COVID-19 vaccines, the Ministry of Health can expand vaccination sites or organize vaccination campaigns to reach target populations in both urban and rural areas.

2. The results showed that people are concerned about vaccine side effects and rumors that vaccines kill or are ineffective. We encourage EPI program managers to focus on targeted awareness campaigns. Knowledge is the foundation for increasing vaccination coverage. It is also recommended to raise awareness through various media such as radio, television, social media, and other digital platforms.

3. Governments and partner organizations should develop risk communication strategies to address myths and rumors. In addition, mechanisms for dialogue and two-way communication should be set up so that people are free to express their concerns, ask questions, and receive appropriate responses. This can be achieved by establishing a COVID-19 vaccine call center which is always available.

4. Results showed that people appreciate what community elders, religious leaders, and health workers are saying about COVID-19 and its vaccine. Governments and partner organizations should focus on community engagement mechanisms and educate religious leaders on the importance of vaccines in preventing COVID-19. Focus channels for sharing information through facility health workers, CHWs, community elders, and religious leaders. Because these channels were the most trusted sources of information for families. These influential and trusted community, her members, health workers, and role models (those who are already vaccinated and agents of change) must be tapped and engaged in the dialogue.

5. The government can organize health education sessions in prisons to address the young prisoners’ concerns about reduction in sexual potency and infertility.

Funding Statement

This work was supported by GAVI-The Vaccine Alliance and the UNICEF country office in Afghanistan.

Disclosure statement

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