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

2. Getting a first Covid-19 vaccination

Key points

• 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.
• On the whole, 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. However, there were exceptions to this.
• Key considerations involved in the decisions 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); 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 to engagement with the vaccination programme included: venues far from home, accessibility issues for those with autism or sensory disabilities; inefficient queuing systems and long wait times; not receiving invitation or reminder letters; insensitive staff; or employers not being flexible.

This chapter looks at participants' first experiences with the Covid-19 vaccination programme in Scotland. It explores how participants first became aware of the programme and the information sources used, the motivations and barriers to getting a first Covid-19 vaccination, and the practical experiences of those who went on to engage in the vaccination programme.

Information sources and accessing information

This section deals with factors that fall predominantly in the 'capability' element of COM-B, as it looks at the ability of participants to access and understand the information needed to make an informed decision on whether to get a first Covid-19 vaccination. It covers the information sources used and the extent to which they were trusted, as well as the amount and quality of information accessed and any points of confusion or conflicting information.

Extent to which participants sought out information

Participants described different approaches to learning about the Covid-19 vaccination programme – while some actively sought out information, others were content to hear about the vaccination programme more passively through channels they already used.

Among those who did not seek out further information, reasons included having a high level of trust in the safety of vaccines in general, a desire (among those who had decided they wanted to get a vaccine) to avoid reading negative information that could make them feel anxious, or because the amount of information on the vaccine could feel overwhelming and confusing. There was a widespread view that information about the Covid-19 vaccine was 'everywhere' regardless:

"I didn't bother myself because the stories were just too much, […] because the news was just too much, too much information going out there and I didn't want to get any further confused."

Participant, health condition or disability, Black Caribbean, woman, 40+, parent, No Covid-19 vaccinations

Information sources

Participants described a wide range of information sources where they had heard or read about the Covid-19 vaccination programme in Scotland before getting a first dose (or not getting one at all). Common sources included traditional media (such as television, newspapers and radio), social media, looking online for information, word of mouth from family and friends, general promotional material in the form of leaflets, letters or posters/billboards, and religious leaders. There were also cases where participants received information personally via promotion of the vaccine through more formal channels, for example from employers or educational institutions, from support organisations or from medical professionals.

The way each of these information sources was used, understood and the extent to which they were trusted varied and is discussed below.

Traditional news media

The most widely used source of information about the Covid-19 vaccination programme among participants was 'the news' in various forms, and this was typically how participants recalled learning about it for the first time. Participants had been highly engaged with the news in general during earlier stages of the pandemic, including at the time that the vaccination programme was announced.

Participants described accessing a broad range of news sources and media, including TV news programmes, news apps, newspaper articles both online (sometimes via links on social media) and in print, and listening to the radio. Those aged 40 and above were particularly likely to reference watching news on TV or radio. Various national newspapers were mentioned, including The Sun, the Daily Record and The Guardian. Media organisations tended to be those based in the UK or Scotland, such as BBC, STV or 5 News.

Aside from the news, participants got information from other traditional media including the televised daily Coronavirus briefings (both Scottish Government and Westminster briefings), TV adverts encouraging vaccination, and general TV or radio programmes, for example a radio phone-in.

Overall participants reported relatively high levels of trust in the news and other traditional media and seeing pictures or footage to back up information, for example seeing clips of Covid-19 patients in hospitals, could increase this further.

However, there was also a degree of scepticism about traditional mainstream media among some participants. Reasons for this centred on suspicions that the Government or the media can be biased and not share the 'whole story':

"I'm not really sure of facts what [Nicola Sturgeon or Boris Johnson] just told to us are really right. They hide something, definitely they hide something, [the news] is not the whole story definitely."

Participant, White Polish, woman, 40+, 2 Covid-19 vaccinations

There was a feeling among participants who had concerns about getting the vaccination that their concerns were not addressed by the mainstream news media, and one participant found information shared on the news difficult to understand:

"You just think how can you make that so quick – I think if they had maybe explained how they do it more, that would have helped […] you don't really understand when you listen to the news, it's just mumbo jumbo. You just need to trust them, but that's risky."

Participant, White Scottish, woman, under 40, parent, 3+ Covid-19 vaccinations

Social media

Those who used social media said they had seen a great deal of information and discussion about the Covid-19 vaccine across many different platforms, including Facebook, Twitter, YouTube, Instagram, TikTok, WhatsApp and Reddit. While participants of all ages reported using social media, there was variation in the platforms used, with Instagram and Reddit exclusively mentioned under 40s.

Participants had seen both positive and negative information about the Covid-19 vaccine on social media. However, participants had come across more extreme anti-vaccination content on social media. While participants described a range of different anti-vaccination information and theories about the Covid-19 vaccine, specific claims discussed by Black African participants related to the vaccine being dangerous for Black people, which they had heard on social media, but also via word of mouth from friends and family living in Africa.

Trust in social media was mixed. On the one hand, there was a widespread belief that social media is not a reliable information source and is more likely to have incorrect or misleading information compared to official websites or professional journalism. There was a sense that a lot of the misleading information consisted of 'scaremongering' and tended to be negative. While this caused some participants to avoid certain social media platforms, others continued to use them and tried to judge what information was credible themselves. Even when participants acknowledged information on social media may not be true, however, it could still impact their feelings towards the Covid-19 vaccine by 'playing on' their minds. There was also a perception that social media is not a useful information source as it was associated with opinions as opposed to facts.

On the other hand, there were participants who valued hearing other people's opinions or experiences with the vaccine, particularly those who wanted to hear from people in a similar position to themselves. Examples tended to be for topics where there was a perceived lack of information elsewhere (for example on how the vaccine side effects impacted particular groups) or where participants had a lower level of trust in the traditional media.

Word of mouth

Participants had all discussed the Covid-19 vaccine with friends, family and others in their community to at least some extent. However, the nature of these conversations and the extent to which they were felt to be an influence varied considerably.

On the one hand, there were those who felt information they had heard from others was not always reliable, and participants used words such as 'rumours' and 'theories' to describe some of this.

"Some people can just misinterpret these things happening or misinterpret them based on Biblical versions […] There are lots of theories, I can't remember what half of them were."

Participant, Black African, woman, 40+, SIMD1, unpaid carer, parent, 3+ Covid-19 vaccinations

On the other hand, experiences of family and friends could be more trusted than other information sources, including official information. This was particularly the case where participants knew people who worked in the medical field, who were believed to have more expert knowledge or a higher capability to understand information relating to the vaccine. Personal experiences of family and friends getting the vaccine were also influential; for some participants this was so important that they delayed making a decision to get a first dose of the vaccine in order to wait and see how it affected other people first.

Trust in their own community rather than other information sources was also a strong theme for Gypsy Traveller participants. One participant explained that Gypsy Travellers were particularly distrusting of mainstream information from the 'non-travelling community' and relied more on others in their community for information:

"Travellers are very judgmental people also because we have had to have this guard up our whole life, because we have been getting criticised from the outside world, like the non-travelling community, they criticise us, they judge us, they look down on us, so we have got this guard up all the time that we don't trust them."

Participant, Gypsy Traveller, woman, under 40, SIMD1, unpaid carer, No Covid-19 vaccinations

Online searches and official websites

Participants also researched the Covid-19 vaccination programme online. This ranged from general internet searches to peer-reviewed journals and articles.

Despite a sense that there is a lot of false information online, official websites, such as NHS, WHO or Scottish Government, peer-reviewed journals and information or views shared by medical professionals were typically trusted.

When participants' trust in government was low, however, this could put them off using certain official websites connected with government. Other issues reported with accessing technical information included not being able to understand it (particularly in relation to scientific or medical journals). There were also participants who were unable to access this kind of information due to difficulties with reading, particularly among the Gypsy Traveller community.

Printed promotional materials

Participants had seen promotional material with information about the Covid-19 vaccine and this included leaflets, letters or posters/billboards. Not everyone remembered exactly where they had seen this type of information, but the information in the post consisted of official information either in the 'blue envelope' invitation letters or government information for those who had been instructed to shield during the pandemic. Those who were shielding also recalled receiving text messages with information about the vaccine. One participant who was a member of the Gypsy Traveller community recalled a nurse visiting the caravan site and handing out leaflets about the vaccine.

When information came directly from the government or the NHS this typically increased its credibility. For example, one participant felt the information in their blue envelope was easy to understand as it explained why the vaccine was important and broke down information about getting vaccinated 'step by step'. However, for those who were already reluctant to get the Covid-19 vaccine, this type of information did not seem to cut through. For example, some participants described ignoring letters such as the 'blue envelope' letter.

Religious leaders

Religious and community leaders were another information source, particularly regarding moral questions such as whether the vaccine was permitted: for example, one Pakistani participant specifically asked a local imam whether the Covid-19 vaccine could be taken when fasting during Ramadan. Participants described hearing both positive and negative information about the vaccine from religious leaders.

Other formal channels

There were also cases where participants received information personally via promotion of the vaccine through more formal channels, for example from employers or educational institutions, from support organisations or from medical professionals (such as a general practitioner). Those who worked in health or social care were particularly likely to have received information about the vaccine at work, as they were encouraged to get vaccinated due to working with vulnerable groups. Participants who got information from support groups or a doctor tended to be those with a disability or health condition.

While participants trusted these information sources in general, they also reported engaging with them critically and that they did not always follow the advice given. There was particularly high trust in information from medical professionals.

Access to information

Views on the quality and availability of information varied. Participants generally felt that they had enough information to make an informed decision and that the information was clear enough. However, those who were more cautious about accepting the vaccine felt that there was not a great deal of information or that it was difficult to find, while others felt the amount of information was overwhelming.

Among participants living in more deprived areas (SIMD 1 or 2), information volume and/or quality was a key theme. Within this group though, those who had engaged with the vaccination programme tended to feel that they had enough information overall while those who were disengaged tended not to.

It should be noted that participants in the sample were typically fairly confident at speaking English (despite translator services being offered). Therefore, language barriers did not come out strongly in this research, but this does not mean this was not an issue in the general population.

Motivations and barriers to engaging with the Covid-19 vaccination programme

This section deals with factors that fall predominantly in the 'motivation' element of COM-B, as it looks at participants' decision-making processes.

Participants described a wide range of motivating factors and barriers when discussing their decision to get a vaccine. Many of these influences on decision making were motivating for some participants but off-putting for others. Reflecting this, influences on decision making are discussed thematically below rather than being separated out into facilitators and barriers.

Key influences on decision making included: perceived personal health risk from Covid-19; perceived risk to others; pandemic restrictions (including Covid Status Certification); social influences; trust in government and the pharmaceutical industry; perceived safety of the Covid-19 vaccine, perceived effectiveness of the Covid-19 vaccine; a sense of duty; and pressure from work.

Personal health risk

Perceived personal health risk from catching Covid-19 was strongly associated with the decision whether or not to get a Covid-19 vaccination.

Those who were worried about the effects of catching Covid-19 on their personal health described this as a motivation to take up the vaccine, so that they would be protected. This was a key factor for those with a disability or long-term health condition (particularly when participants had respiratory problems such as COPD).

"If I got the virus, it could be a death sentence for me."

Participant, has COPD, White Scottish, man, 40+, 3+ Covid-19 vaccinations

"[I wanted to get a Covid-19 vaccine] to save taking the Covid and being really ill, cause when you seen it on TV and all these people trying to breathe it was awful, and that scared you, thinking oh, even though I've not got problems breathing you know, to see that on TV it was so sad, I would hate to be in that position."

Participant, disability or health condition, White Scottish, woman, 40+, unpaid carer, SIMD1, rural, 3+ Covid-19 vaccinations

However, participants with disabilities or health conditions could also be particularly anxious about potential side effects of the vaccine, creating a tension.

Among those with caring responsibilities, concern about becoming ill with Covid-19 was heightened, due to the impact it would have on those who depended on them.

"I thought if I get it I am going to end up in hospital for weeks and months, and how is my family going to cope? My kids, you know, they don't have anybody else, so how are they going to cope?"

Participant, disability or health condition, Pakistani, woman, 40+, SIMD1, 2 Covid-19 vaccinations

In addition to concern over perceived physical health risks, there were participants who were further motivated to get vaccinated to reduce mental health risks posed by Covid-19. They felt that getting the vaccine would help to reduce their own anxiety about getting infected with the virus.

For participants who were not worried, or less worried, about catching Covid-19, personal health risks were much less of a motivator. Personal health risk could also be viewed as a reason not to get a vaccine due to a desire not to take any 'unnecessary' or 'extra' healthcare interventions.

Participants who were less worried about catching Covid-19 typically saw themselves as being fit and healthy, with a strong immune system. Those aged under 40 and without a disability or long-term health condition were particularly likely to feel at low risk from the virus.

"We often got told as younger people we have better immunity to Covid, so then initially there were times [I thought] will we really need this though?"

Participant, Pakistani, man, under 40, SIMD1, 3+ Covid-19 vaccinations

There were exceptions though, such as a young person who had witnessed their sister (who was also quite young) suffer severe symptoms from Covid-19.

Aside from personal health and fitness, there were participants who did not see Covid-19 as being a severe disease. There was also a view that it was similar to seasonal flu. Even when these participants were aware of people who had died or suffered severely from Covid-19, there was an assumption that other complications or underlying conditions could explain this.

"I knew people who died from Covid and didn't get vaccination as well, because they didn't, similar like me, they didn't value that work, and few of them was younger than me or in my age and get Covid and die. But I think, in my personal opinion, it wasn't Covid, like [that was] only one reason, that [they had] some other disease."

Participant, White Polish, man, 40+, parent, No Covid-19 vaccinations

Personal experience of having had Covid-19, or knowing close friends or family who had, was another important influence on perceived personal health risk from the virus. In relation to the decision whether to get a first dose or not, this was a more influential factor for disengaged participants, since engaged participants had often made up their mind earlier on in the pandemic when fewer people had had Covid compared to Spring 2022 when fieldwork was taking place. This factor was also influential on decision-making for people aged under 40, as they became eligible for the vaccination later in the pandemic.

"Because my age group was quite far down it did give me more time to think about it […] it was reassuring that they have obviously had it [the vaccine] before me and nothing has happened."

Participant, Disability or health condition, White Scottish, woman, under 40, rural, 2 Covid-19 vaccinations

Disengaged participants tended not to have had particularly negative experiences of Covid-19, and among those who had not picked it up so far there was a sense that they were naturally less likely to pick it up and get it in future.

"I keep telling people I'm a living testimony, I don't wear masks, and I have been around [...] I've not had it."

Participant, Disability or health condition, Black African, woman, under 40, rural, No Covid-19 vaccinations

However, an exception to this was the experience of one disengaged couple who had particularly bad symptoms when they caught Covid-19, and were beginning to reconsider their decision on the vaccine in order to avoid getting it again in future.

Men who had decided not to get vaccinated were more likely to base their decision on feeling at low risk from catching Covid-19, while women who had decided the same were more focused on the perceived health risks from getting vaccinated (concern about side effects is discussed in more detail later in this section).

Protecting others

Protecting others from getting Covid-19 was another important factor that encouraged participants to get a first Covid-19 vaccine. This related to a belief at the time of making the decision that the vaccine would reduce their risk of spreading the virus. This was particularly relevant to those with family members who were considered vulnerable. It was also important for those who interacted with vulnerable people at work, for example those who worked in healthcare.

"I'm a carer for one of my aunties, so that's why I thought that for their sake as well I need to make sure that I am protected and not giving it to them."

Participant, Pakistani, man, under 40, SIMD1, 2 Covid-19 vaccinations

As well as protecting those immediately around them, participants spoke about wanting to get vaccinated to protect wider society. This was sometimes perceived as a duty, the 'right' thing to do, or as a way in which participants could contribute to the wider pandemic response. While this could be based on personal or religious beliefs, there was also a sense that official messaging around the Covid-19 vaccination had encouraged people to get vaccinated as a way to take responsibility and protect others. While there was a desire to prevent others from suffering from Covid-19, there was also mention of reducing the spread of Covid-19 in order to reduce the strain on the NHS.

There was particular mention of duty to others and a desire to protect family members and the wider community among Pakistani participants.

Pandemic restrictions and the impact of Covid Status Certification

Among engaged participants, there was some hope that getting a Covid-19 vaccine would reduce the need for pandemic restrictions or future lockdowns, and help things return to 'normal'. However, views on Covid Status Certification, or "vaccine passports", were more mixed.

On the one hand, Covid Status Certification for international travel or accessing events in Scotland could be a significant motivator for getting vaccinated, and for some participants this was the sole reason for getting a first vaccine. This was particularly the case among younger people below the age of 40. International Covid Status Certification was an important factor for those from another country or with family living abroad, for whom traveling was especially important.

However, views on these requirements were mixed: while some participants in this situation did not have strong feelings on getting vaccinated, others were unhappy as they felt it meant they needed to get vaccinated against their own will.

Furthermore, Covid Status Certification was not sufficiently motivating for disengaged participants to get vaccinated. These participants typically felt that the risk to their personal health from getting vaccinated was a more important factor on which to base a healthcare decision than being able to take part in leisure activities or holidays. These participants resented feeling forced to get vaccinated, and the fact that the vaccine needed to be incentivised or 'sold' to the public could cause people to further question whether it was in their best interests. It also raised concerns about being tracked by government.

"The fact that we need to get it to travel, it really bugged me. I felt like, 'well why should we all need [a Covid-19 vaccine], if we don't want to get something into our body we're not understanding?' […] you feel like you're being sold it, […] when you feel like somebody else is controlling [your decision] it puts you off."

Participant, Gypsy Traveller, woman, under 40, SIMD1, unpaid carer, No Covid-19 vaccinations

"If you get the vaccine you've got the passport, the vaccine passport, there is another thing, the government want to keep track of you, there is another way of infringement of your rights they will have contact with you wherever you go, whatever you do. So, that was another thing saying, well I don't want that."

Participant, Pakistani, woman, 40+, SIMD1, No Covid-19 vaccinations

There was also a view among disengaged participants that vaccine-related restrictions would not greatly affect them, either because they did not wish to do things that required certification (either domestic or international), a belief that restrictions would only be in place for a short time, or that they felt they could get around these rules to a certain extent.

Attitudes towards vaccines in general

Attitudes towards vaccines in general fed into participants' views on the Covid-19 vaccine. There were participants who were strongly in favour of vaccines in general and described never having any serious doubts about getting a Covid-19 vaccine. They considered themselves to be very pro-science and, in some cases, had family histories that had convinced them of the importance of accepting vaccines.

Participants who were more wary of vaccines in general were less willing to engage with the Covid-19 vaccination programme. This type of belief was typically a strongly held belief and not easily changed.

Social influences

Social influences could act as a direct reason for getting a first Covid-19 vaccination. Participants described how friends or family had encouraged them to get vaccinated, especially if they were seen to be vulnerable. In some cases, participants recalled other people actively intervening to ensure they got vaccinated: for example, one person had a friend book their appointment for them while the wife of another had accompanied him to the vaccination centre to make sure he got vaccinated.

Participants also heard negative opinions on the vaccine, but this was not a direct reason for deciding not to get vaccinated.

Some participants from ethnic minorities described higher levels of distrust in the Covid-19 vaccine within their communities, although they did not feel greatly influenced by this themselves. There was a view among Polish participants that the wider Polish community was generally sceptical of the Covid-19 vaccine. Pakistani participants also discussed their community's attitudes, with one person linking unwillingness to get vaccinated among older generations to the impacts of the British Empire and a lasting distrust in the British establishment. There were Black African participants who described suspicion of the Covid-19 vaccine among people living in Africa as well as the wider African diaspora.

"The people there [in Poland], it is very obvious the people that don't believe in Covid and don't believe in vaccination."

Participant, Disability or health condition, White Polish, woman, under 40, parent, SIMD2, 3+ Covid-19 vaccinations

"I come from an ethnic minority background and with that there's a lot of stigma around vaccinations."

Participant, Pakistani, man, under 40, unpaid carer, 3+ Covid-19 vaccinations

Among disengaged participants, there was a tendency to avoid discussing the Covid-19 vaccine with friends and family who disagreed with them since it could cause people to get angry at their decision.

There were also participants who were encouraged by hearing about public figures such as the Queen or celebrities taking the Covid-19 vaccine. However, there was also a view that this could seem inauthentic, as one participant imagined celebrities had been paid to promote the vaccine, while another highlighted that the vaccine impacts people differently, so did not find this type of promotion convincing.

Attitudes towards government and the pharmaceutical industry

Participants' attitudes to the government and the pharmaceutical industry could shape their decision-making processes about the vaccine. When participants trusted the government and their advice on the Covid-19 vaccine, this facilitated engagement with the vaccination programme. When there was distrust, this tended to be a more significant factor and a barrier to engaging with the vaccination programme, particularly among disengaged participants. Distrust in government was particularly discussed by those aged over 40, Pakistani and Polish participants.

There was some concern that the UK and Scottish Governments were so focused on promoting the vaccine that they refused to acknowledge any negative side effects and were sharing biased and incomplete information. The sense that any negative information had been 'swept under the carpet' caused participants to feel distrustful and worry about being able to make an informed decision.

"The government was pushing for one thing and if you want to have all the information from both sides you have to do the work […] because just going with what government said, it was all perfect and pink and pretty and it's not like that."

Participant, Disability or health condition, White Polish, woman, under 40, parent, SIMD2, 3+ Covid-19 vaccinations

"During the pandemic I think some scientists and all that research when they are doing on the vaccination programme can be like maybe manipulated by government […] they tell people propaganda."

Participant, White Polish, man, 40+, parent, No Covid-19 vaccinations

There was also scepticism around the motivation of governments to encourage widespread vaccination, with participants suggesting that the government wanted to roll out the vaccines quickly for political reasons. Doubts were expressed that the UK Government was being honest about the scale of threat posed by Covid-19, due to perceptions that MPs did not take pandemic restrictions seriously.

"I think any government hasn't [any] idea how to deal with Covid [...] in my opinion, that vaccination was like [an] attempt to do something, that maybe can help, but we are not sure, we will see. So I wasn't sure if that was okay."

Participant, White Polish, man, 40+, parent, No Covid-19 vaccinations

"Before I didn't have a problem with vaccines, not that I do, but […] with this Covid vaccination they actually made the word vaccine a total put off for me because like I said it was too controlling."

Participant, Disability or health condition, Black African, woman, under 40, rural, No Covid-19 vaccinations

When participants referenced distrust in the pharmaceutical companies that manufactured the Covid-19 vaccines, key concerns included worries that they were primarily focused on making money and not producing the best quality vaccine, that there was a lack of accountability due to not being able to sue companies over vaccine side effects, and concerns about individual companies.

Pressure from work

Among those who worked in public-facing roles, especially those working in health or social care and with vulnerable adults, there was some experience of feeling pressured to get vaccinated from their employer. However, this was not a key driver and participants in this situation tended to get vaccinated for other reasons.

Perceived safety of the Covid-19 vaccine

While there were participants who did not question the safety of the Covid-19 vaccine, safety concerns were the most significant barrier to getting vaccinated, even among those who had decided to get all doses they were eligible for. This was a particular concern among those living in more deprived areas (SIMD 1 or 2).

This centred on three main worries: that the Covid-19 vaccine was new and therefore long-term side effects were unknown, that it had been developed very quickly and therefore may not be as high-quality and rigorously tested as other vaccines, and that there were risks of dangerous side effects.

There was widespread acknowledgement that the Covid-19 vaccine was new and this caused some to question how thoroughly it had been tested. There were participants who had delayed getting a first dose to 'wait and see' how the vaccine affected other people, while there were some concerns that the vaccine was effectively still being trialled, with participants describing feeling like a 'laboratory rat' or a 'guinea pig'. Participants cited the detection of a rare side effect (blood clots) of the AstraZeneca vaccine during the vaccine rollout as evidence that there was still unknown information about the vaccine and its side effects. It was also highlighted that long-term impacts of getting vaccinated were currently unknown.

"It was a new thing that we know nothing about, we're winging it. 'Here are four to five vaccines available because nobody knows what's going to work or not'. I don't feel confident in that. They tried to claim they know what they're doing but they don't have a clue."

Participant, White Scottish, man, under 40, No Covid-19 vaccinations

When participants gained a better understanding of the development process this could counteract these worries, for example one person highlighted how they were reassured after learning that the vaccine development process was based on the development of previous similar vaccines and was not completely new.

Concern about side effects

The risk of side effects from the Covid-19 vaccine was a strong theme when it came to barriers to getting a first dose, for both engaged and disengaged participants. Concern mostly related to severe or long-term side effects, but there were also those who were nervous about temporary or milder side effects.

Commonly discussed, particularly by women aged under 40, were concerns about impacts on fertility, menstrual cycles and impacts on unborn babies or pregnancy. There was a view that information on this could be hard to find, and some concerns that advice for pregnant women had changed regarding the vaccine.

Risks of blood clots (specifically in relation to the AstraZeneca vaccine) and heart issues were another theme and could be very frightening, especially to participants who had related conditions such as heart issues or risks of high blood pressure.

"The point of a vaccine, it's to save your life, but a lot of folk don't want it, don't want to take it because of all the rumours. I was the same when I heard the rumours, like blood clots and I was like, oh, I might die if I get this jag."

Participant, Disability or health condition, White Scottish, man, 40+, parent, 3+ Covid-19 vaccinations

There was also a fear of unexpected or unpredictable side effects, for example, whether the vaccine might trigger previously undetected underlying conditions in individuals.

"Who knows, the people who got vaccinated and died, maybe the vaccine triggered something else? One of our family friends, a doctor, had Covid vaccines early on [and it] brought out some underlying health condition in him."

Participant, Pakistani, woman, under 40, rural, 2 Covid-19 vaccinations

Temporary side effects, for example getting flu-like symptoms after getting vaccinated could also be off-putting. For those with health conditions, the prospect could be alarming. However, for others the concern was more that this would be unpleasant but also inconvenient, especially in terms of carrying out day to day responsibilities such as childcare or work.

"Not a big concern but just the symptoms, 'would I recover quickly?'. 'Would it affect my wellbeing?'. 'Would I be able to go to the gym?'. Silly things, not that big, but you hear people saying 'oh I sorted out dinner for the next two nights because I'm getting my vaccine', because they didn't know how they'd feel."

Participant, Pakistani, woman, under 40, rural, 2 Covid-19 vaccinations

There was a worry among those with a disability or health condition and those from ethnic minorities that the Covid-19 vaccine had not been tested on enough people or a diverse enough range of people.

"[I would consider getting vaccinated if] they had done research on a wider range of people with different health issues, different skins, different backgrounds."

Participant, Disability or health condition, Black African, woman, under 40, rural, No Covid-19 vaccinations

Fears around side effects were influenced by hearing about other people's experience with the vaccine. Those who knew others who had been vaccinated without serious side effects found this reassuring, while hearing about negative experiences from people who had recently been vaccinated could be alarming.

"People that I know […] had some kind of reaction to it. Someone that my mum works with had a reaction to it as well, and that […] made me quite frightened."

Participant, White Scottish, woman, under 40, No Covid-19 vaccinations

Another mitigating factor was when participants looked into the probability of experiencing certain side effects: for example, while the risk of blood clots was frightening, there were participants who felt comfortable getting vaccinated nonetheless due to the very low probability of this side effect occurring.

Participants who were concerned about side effects from the Covid-19 vaccine typically weighed up the perceived risks of such side effects against the perceived health risks from becoming infected with Covid-19 while unvaccinated. This meant that side effects could act as a particular barrier to those who saw themselves as being at low risk of severe Covid-19, such as younger people.

"I thought I'm not in the age demographic that Covid would be really bad for me and I don't have any sort of underlying health conditions, so I felt as if I would personally rather take my chances with Covid than I would with the vaccine."

Participant, under 40, White Scottish, woman, No Covid-19 vaccinations

Participant story: Hamza

Hamza is a young Pakistani man living with his parents and younger sister in Aberdeen. He has worked from home since the first lockdown. He isn't too worried about catching Covid-19 himself but has been careful throughout the pandemic to try not to pass it onto his parents, who both have long-term health conditions.

He didn't seek out much information on the vaccines, but he did read about it in the newspapers and had lots of conversations with people he knew. He was unsure about getting vaccinated at first, as the vaccine had been developed quickly.

"Not that I ever wanted to not take it, maybe it was a bit delayed [...] [I] was like 'oh it came out a bit too fast'."

When he did decide to get the vaccine, his motivations were to protect others (particularly his parents) and to allow him to go to football games and other events. He also felt a sense of duty as a practicing Muslim to take care of the people in his close-knit community. His Imam had encouraged everyone at Friday prayers at the mosque to get it and had cleared up a lot of misconceptions.

When the booster was introduced, Hamza felt frustrated. It didn't make sense to him that he needed another vaccine, only a few months after his second dose.

"I've had a Covid vaccine, I've had a second dose as well, I've had Covid multiple times, I've got some antibodies there, so why do I need another booster?"

However, he did eventually decide to get it because he wanted to travel soon. Hamza's user journey is illustrated below.

User journey: Hamza

This is the user journey of Hamza, a young Pakistani man living with high-risk parents.

• Influences on decision to get the vaccination – Views of family and friends. The influence of his Imam.
• Motivations to get 1^st vaccination – Health risk to parents and desire to go to events.
• 1^st vaccination experience – Filled in a form online. Drove to venue 20 mins away. Was turned away due to AZ risk of blood clots for under 30s. He got another appointment which he felt was all positive and straightforward. Side effects were minor - just a sore arm.
• Motivations to get 2^nd vaccination – Same reasons as before (health risk to parents and desire to go to events).
• 2^nd vaccination experience – He felt more concerned about side effects. He went to the same venue and it was all fine. The side effects were worse this time – took time off work.
• Motivations to get 3^rd vaccination – Desire to travel.
• 3^rd vaccination experience – In his own words: "We didn't even know there would be so many […] do I need to get this?". The experience at vaccination venue was all fine. He did not experience side effects.

Experiences of receiving a first Covid-19 vaccination and practical considerations

The findings reported in this section largely relate to the opportunity element of the COM-B behaviour change model. The opportunity element includes both social and physical enablers – the focus in this section is on the physical factors (i.e. the physical opportunity afforded by the environment involving time, resources, locations, environmental cues, and physical ease).

Scheduling the first Covid-19 vaccination appointment

Participants were invited to a vaccination appointment in various ways:

• a 'blue envelope' in the post
• emails with a link to book an appointment through their work or study in a clinical setting (for example, for participants who worked for the NHS)
• phone calls or texts from GP surgeries (for those who had existing health problems and needed to receive their vaccination in a GP or hospital setting).

There were also participants who had not received an invitation for their vaccination, and instead had to proactively seek out an appointment themselves. While some participants did not feel this was a problem, for others it was frustrating.

Other participants chose to attend 'drop-in' vaccination sessions instead, and either ignored their original appointment or had not received an appointment to begin with.

Participants typically reported that their appointment was convenient enough for them in terms of location and time. Where participants did find the location of the vaccination appointment inconvenient, this largely related to the venue being far away from their home. This was a particular problem for those living in rural locations, and those with a long-term illness or disability.

Those living in remote areas reported that the venue for their vaccination appointment was further away than they would ideally like – for example, they were invited to get vaccinated in a high school in the nearest town rather than their local village's GP clinic. For participants (or their family members) who did not have a vehicle or a driving license, this had caused difficulty as they were dependent on lifts from people they knew, or on often unreliable public transport links.

"If [my teenage children] would be able to walk safely, they would probably [get vaccinated], yes. But the distance, planning with others, you know, a lot of planning [around lifts from parents] and oh, it is just difficult to say, because we are staying where we are staying. The connection to the town is horrendous"

Participant, White Polish, woman, 40+, rural area, 3+ Covid-19 vaccinations

"[If you don't drive], then you have to rely on buses and our bus system is a joke. From my point of view, it was fine, but it could have been better if it was in the village because that way I could have walked and been back quicker."

Participant, white Scottish, woman, 40+, rural area, 3+ Covid-19 vaccinations

Those with a disability or long-term health condition had sometimes received an initial invitation to a venue which would be difficult or impossible for them to travel to, due to their health conditions. However, these participants were generally able to reschedule to a more suitable location.

"My appointment came through and it was for [location]. And I thought, right, so I'm getting this appointment through, I've got really bad concentration and memory problems. And you're sending me somewhere I've never been before, and I've got to be there at 9:15 in the morning."

Participant, health condition or disability, woman, 40+, 1 Covid-19 vaccination

Although there were local authority and health board schemes offering support for people to travel to their vaccine appointment, these were not mentioned at all by participants, indicating a lack of awareness of these schemes. Where necessary, participants were able to reschedule their vaccination appointment to a more convenient time/location. Those who used the online system to change their appointment found it to be an efficient and straightforward process. However, there were participants who were unaware that they could have changed their appointment, and others who tried to change their appointment but were unable to find a suitable alternative appointment.

Attending the first Covid-19 vaccination appointment

On the day of the appointment, participants reported a range of emotions:

• Excitement and eagerness to receive the vaccine – looking forward to being less at risk, and the 'start of the end' of the Covid-19 pandemic
• Anxiety about Covid-19 exposure at the vaccination centre (particularly high-risk participants, who were typically vaccinated earlier in the pandemic, during periods of higher risk)
• Worries about possible side effects
• Nervousness about the needle and the injection
• Unease related to whether they should accept the vaccination or not.

Other participants experienced no particularly strong emotions on the day; they felt 'fine' about getting the vaccination, and 'just wanted it done'. There were also participants who felt a mix of positive and negative emotions around receiving their first vaccine – for example, they were pleased at the thought of having more protection against Covid-19, but also anxious about being in a busy venue.

Participants in work were generally able to schedule their appointment around their work commitments without too much trouble. There were participants who were furloughed at the point at which they were invited to be vaccinated, while others either took time off work or had the appointment on a day they were not scheduled to work.

There were also participants who found that their employers supported them to go and get vaccinated – they were able to take a longer lunch break, or, for those employed by the NHS, get vaccinated at their place of work. However, others had employers who were less understanding.

"I think I took half an hour extra off for lunch or something like that which they really weren't very happy about, but I just suppose in any hospitality right now they run everything really, really, tight, so yes, it just feels like they could have had an extra person in on a few shifts so that we could go and get our vaccine, that would have been the best time for us to do it."

Participant, white Scottish, woman, under 40, 2 Covid-19 vaccinations

Caring commitments did not appear to be a major barrier to being vaccinated. Parents and carers described having family or friends help out with childcare or taking children along to vaccination appointment with them.

Overall, participants spoke positively about the venue and the staff at their first vaccination. The venues were generally perceived to have been well organised, with short wait times. Staff were considered knowledgeable, competent, friendly and helpful. Participants appreciated how professional the staff were, and it was particularly reassuring for those who were more nervous about being vaccinated.

"They were very nice, very friendly. Like nurse just explain everything what she will do, how she just give me the vaccination, what can I expect after, kind of side effects, what can I feel, and of course that was like they ask me to stay like 15 minutes longer to see how I feel, if something wrong just let them know."

Participant, White Polish, woman, 40+, 3+ Covid-19 vaccinations

However, there were also exceptions where participants had experienced more negative interactions with staff and the venue. For example, one participant felt that the nurse was 'short' with them when they asked for more information about which vaccine they were going to receive and for more time to decide whether to accept it. Another participant described how she felt embarrassed and annoyed when a staff member in a receptionist role loudly said that she must have a health condition as she was not part of the older age group which was being vaccinated at that point. A third participant had a negative experience where he had found the injection itself very painful and the nurse had said that this was his fault for moving. These negative experiences could present a barrier to future engagement with the vaccine programme, as discussed in the next chapter.

Concerns were also raised about venues. These included: a lack of privacy; a feeling that the venue was too busy and not well-managed for Covid-19 safety; the venue being confusing and poorly signed; the venue feeling very clinical and frightening; and the queue process being disorganised.

"Then I got to the main hall, there was, like, 15, 20 people in front of me and it just looked like…it was like a factory, there was so many little seats, so many little desks, and there was various people doing [the injections]. […] It was too open, people could hear, there was no privacy."

Participant, Pakistani, woman, 40+, 2 Covid-19 vaccinations

There was also a view that the vaccination centres themselves were not always accessible for people with disabilities. For example, one participant who was blind said that if she had not been able to attend with the support of family, it would have been impossible for her to navigate on her own. She also found it frustrating that she was invited to the vaccination by letter, a format inaccessible to her. Another participant felt that staff at the venue were not equipped to support her son with autism.

After the vaccination, positive emotions felt by participants included happiness, relief, and a feeling that it was 'a step in the right direction'. There was also a feeling of togetherness and being part of something bigger. However, there were participants who still felt uneasy, scared, and uncertain about whether they had made the right choice. Participants also reported fear that they might develop side effects.

For those who did experience side effects, these ranged from minor symptoms (flu-like symptoms or aching arms) to more serious ones (allergic reactions to the vaccines, flare-ups of existing health conditions). There were also participants who experienced no side effects from their vaccination. As will be discussed later, having side effects influenced participants' decisions about whether to accept their second and third vaccinations.

Reflecting on the first Covid-19 vaccination appointment

Participants were asked to reflect on what could have been improved about their first Covid-19 vaccination. There were participants who felt that nothing could have improved the experience – everything had been very well organised and they had been treated well. Participants recognised that the vaccination programme had been efficient overall in vaccinating large numbers of people in a short space of time. This was taken into account when suggesting improvements.

For those who did have suggestions for improvements, these included a feeling that the venue should have been less busy, so that the queues moved more quickly and the risk of Covid-19 transmission was lower.

As mentioned in previous sections, there were also participants who had a preference for a certain vaccine over another. These participants tended to be more hesitant about accepting vaccination and had sought out information on the relative benefits and possible side effects of the different vaccines available. Reflecting this, there were participants who suggested they would have liked to have been told in advance which vaccine they would receive or be given a choice. There was also a desire for more information about possible side effects at vaccination venues.

Lastly, as discussed, a key desired improvement was that vaccination could take place closer to home – particularly for those in rural areas without good public transport links, and for those with long-term health conditions that made it difficult for them to travel to get vaccinated.

Participant story: Jessica

Jessica lives with her husband and two children, one of whom has autism. She works from home and is also an unpaid carer to her son. She found the pandemic very stressful at first and was worried about how it might affect her family.

Overall, Jessica feels positively about vaccinations. She did worry that the Covid-19 vaccine had been developed very quickly, but eventually she did decide to get it after her husband was vaccinated with no problems.

Her experience of the vaccination was positive and straightforward. However, she encountered practical difficulties trying to get her son vaccinated and felt that the staff were not prepared to support people with learning disabilities to be vaccinated.

Her journey with the Covid-19 vaccination programme is illustrated below.

User journey: Jessica

This is the user journey of unpaid carer Jessica and her son who has learning disabilities.

• Influences on decision to get the vaccination – Trusted the TV briefings from Scottish Government. Husband invited for vaccine and had positive experience.
• Motivations to get 1^st vaccination – Decided to get the vaccine to protect herself and her family. Felt she needs to stay healthy as her son's primary carer.
• 1^st vaccination experience – No concerns before attending. Reassuring staff explained things and were professional. Side-effects were sore arm and tiredness – but didn't put her off having a 2^nd dose.
• Motivations to get 2^nd vaccination – "Why not?" Had already had the first dose so didn't even think about not getting the second.
• 2^nd vaccination experience – Straightforward and positive. It was at a familiar venue. Her arm was less sore than with first vaccination.
• Motivations for son to get 1^st vaccination – Decided her son should get the vaccine, to keep him safe and since it would be needed for travelling.
• Son's 1^st vaccination visit experience – Staff were not autism friendly. Her son could see needle beforehand and refused to get vaccinated.
• Motivation for her booster and flu vaccinations and son's 2^nd visit – Tried again to get her son vaccinated, mainly for travel reasons to see family living abroad.
• Her booster and flu vaccinations experience and son's 2^nd visit experience – Her vaccinations were straightforward. She contacted centre in advance and explained son mustn't see needle and asked for an experienced nurse. Her son was vaccinated but was a difficult experience, he was screaming and both parents held him down.