Coronavirus (COVID-19) and flu vaccination programme: user journeys and experiences

Executive summary

In January 2021 the Scottish Government in collaboration with PHS established a Covid-19 vaccination programme as part of its response to the pandemic. In Autumn/Winter 2021/22, this was expanded to include both Covid-19 and flu vaccinations. From early 2023 the Scottish Vaccination and Immunisation Programme will be rolled out and this will cover all vaccinations in Scotland.

While overall vaccine uptake rate in Scotland is high, a minority remain unvaccinated (8.2% as of 25 May 2022) and there is evidence that this proportion is higher among certain groups in society – younger people, those living in the most deprived areas and people from some minority ethnic groups. Scotland also developed its flu vaccination programme to take account of the risks of concurrent infection of both Covid-19 and flu as well as the extra pressures on health and social care services due to the pandemic.

The purpose of this research was to understand experiences of the Scottish vaccination programme (Covid-19 and flu) among people who may face additional barriers to vaccination. The two broad aims were to provide rich, qualitative data on:

• The user journeys of a specified set of key groupings within the population, taking into account highly practical experiences of vaccination and provide information that can aid in planning and support for future vaccine rollout
• The wider experiences of vaccination, specifically why people decided to engage with or disengage from the vaccination programme.

Data was gathered from 81 participants who were adults living in Scotland during the vaccination programme and members of groups who may face additional barriers to Covid-19 vaccination. Semi-structured depth interviews, lasting around one hour each, were used. All interviews were conducted via telephone or videocall and took place between 11 March and 3 May 2022 and were structured by discussion guides (available via 'Supporting Documents' on the Scottish Government website). The COM-B behavioural science framework shaped the research to ensure that the full range of influences and experiences of vaccine user journeys were explored.

Key findings

Getting a first Covid-19 vaccination

Traditional news media was the most widely reported information source on the vaccination programme. Other sources included: social media, word of mouth, online searches and official websites, printed promotional materials, religious leaders, and formal channels such as employers or support organisations. Overall, trust was higher for news and official sources (such as the Government or the NHS) than for social media and word of mouth. Participants generally felt they had enough information to make an informed decision and that the information was clear enough, although there were some exceptions to this.

Key considerations involved in decision making around receiving a first Covid-19 vaccination included: perceived personal health risk from Covid-19; the protection of others; the safety of the Covid-19 vaccine; pandemic restrictions; Covid Status Certification; wider attitudes (to vaccines in general and towards government and pharmaceutical companies); and social influences from friends and family.

In regard to practical considerations, factors enabling engagement with the vaccination programme were: having local appointments; being able to drive; a flexible/understanding work situation; having support with childcare; well-signed and stewarded venues; and invitation and reminder letters arriving on time to the correct address. Practical barriers included: venues far from home; accessibility issues for those with autism and/or sensory disabilities; inefficient queuing systems and long wait times; not receiving invitation or reminder letters; insensitive staff; or employers not being flexible.

Getting a second or third Covid-19 vaccination

Overall, information sources used were similar when hearing about and deciding whether to get a first, second or third dose of the Covid-19 vaccine. However, there was some shift over time towards less reliance on formal information sources such as mainstream news or government-issued information and greater reliance on word of mouth and personal experience.

Participants generally felt that they were more informed about later doses compared to the first, particularly about side effects and how the vaccine was working in practice. However, there were a few points of confusion, mainly relating to getting a third dose and the term "booster".

The easing of pandemic-related restrictions, the introduction of Covid Status Certification and the wider context of revelations about Downing Street parties during lockdowns all had an impact on decision making about whether to get a second and third dose of the Covid-19 vaccine.

As time went on, participants also increasingly had direct personal experience of Covid-19, either contracting Covid-19 themselves or close family and friends having the virus. Particularly for those who had mild or no symptoms, this could reduce their perceived personal health risk from the virus, in turn reducing their motivation to get further Covid-19 vaccinations.

While the motivations for getting a second or third Covid-19 vaccination tended to be similar to the motivations for getting a first, there were some important differences in the barriers. Over time, concerns arose about the number of Covid-19 vaccine doses that were required and the effectiveness of the vaccine, largely due to a realisation that the vaccine does not prevent infection. This could lead to disengagement from the vaccination programme, particularly when it came to getting a third dose.

Practical experiences were also generally similar to experiences of the first dose, although some had doses at different venues. Practical barriers (for example, childcare and work commitments) could lead to participants not always receiving their second dose at the appropriate time, and there were concerns about meeting these types of responsibilities if side effects were severe. This appears to have been a greater concern for later doses.

Getting a flu vaccination

Participants had typically been aware of the flu vaccination programme for a number of years. Key information sources included: NHS invitation letters, GPs and nurses, posters in GP surgeries and pharmacies, television advertising and workplace communications (particularly for NHS employees).

Personal health risk was a key factor influencing decisions about the flu vaccine. Other factors acting as both drivers and barriers to receiving a flu vaccination included: perceived effectiveness of the vaccine; views on its safety and side effects; and Covid-19 and flu being in circulation at the same time.

Similar to practical experiences of the Covid-19 vaccination, experiences of receiving the flu vaccination were largely positive. Views on getting the flu vaccination at the same time as the Covid-19 vaccination were mixed. It could be appealing as it saved time and was convenient. However, concern about increased side effects could be off-putting.

Views on children getting vaccinated against Covid-19 and the flu

Parents typically felt they and their children were in agreement on getting a Covid-19 vaccine. Older children tended to be more involved in decision making compared to younger children.

Those with strong views on the Covid-19 vaccination typically felt similarly regarding whether their children should be vaccinated. Those who had not had any Covid-19 vaccinations themselves were particularly against having their children receive it. Where there was divergence in views, it was among participants who had engaged in the Covid-19 vaccination programme themselves but were not confident in their children receiving a Covid-19 vaccination. There were two key reasons for this: (1) a perception that children did not need the vaccine due to being low risk and (2) believing that they had taken a risk by getting a newly developed vaccine and feeling uncomfortable with taking this decision on behalf of their children. Risks that were more of a worry when considering whether children should be vaccinated or not included impacts on puberty and fertility, which participants were less concerned about for themselves personally.

Parents tended to be more comfortable with children receiving a flu vaccine than a Covid-19 vaccine (in line with greater overall trust in the flu vaccine).

Future considerations

In considering whether to have future Covid-19 vaccinations, automatic motivations, often driven by fear and urgency earlier in the pandemic, had been largely replaced by more reflective motivations, with participants weighing up the risks and benefits.

Views towards future Covid-19 vaccinations varied. Among those who would not hesitate to take up further vaccinations, personal health risk was a key factor. Among other participants, views ranged from being likely to take up a future vaccine, albeit with careful consideration, to being certain not to. Barriers to future

take up included:

• perceived (low) health risk
• vaccine fatigue
• views on vaccine efficacy
• concern about side effects
• original reason for vaccination no longer valid (e.g., Covid Status Certification travel requirements removed for certain countries).

Changes to (or new evidence on) the above factors may change participants' minds about receiving future vaccinations.

Overall, participants who had engaged with the Covid-19 and flu vaccination programmes felt they had been well organised. Participants suggested minor improvements to future Covid-19 and flu vaccinations programmes. Several themes cut across these suggestions for improvements; participants felt it was important for the vaccination programme to be: inclusive; transparent; flexible to users' needs; friendly; and welcoming.

While this research exclusively looked at Covid-19 and flu vaccination, these findings have wider applicability for other vaccinations. Therefore these themes for improvement will be used to inform the design of future vaccinations generally.

Conclusions

The theory behind COM-B is that, in order for a behaviour to take place, individuals should have the Capability (both psychological and physical); the Opportunity (both social and physical) and the Motivation (either reflective or automatic) to do so. If significant barriers exist within any domains, undertaking the behaviour is challenging. The research has identified both enablers and barriers to engagement with the vaccination programme under each of the COM-B domains.

In the context of the current vaccination programme, however, where participants were not typically hindered by informational or practical barriers, motivational factors exerted the greatest influence on vaccination decisions. This included both automatic motivation (e.g., fear and anxiety in relation to both the effects of catching Covid-19 and of vaccine side effects) and reflective motivation (more considered decision making around the consequences of being vaccinated or not).