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

3. Getting a second or third Covid-19 vaccination

Key points

• 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 the 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 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 cause people to disengage 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 (such as 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.

This chapter looks at participants' experiences of getting a second or third Covid-19 vaccination in Scotland, and specifically how this compared to getting a first dose. It highlights any differences in terms of accessing information, motivations and barriers to getting a second or third vaccination, and the practical experiences of getting second or third vaccinations.

Information sources

In the main, the information sources used were similar when participants were hearing about and deciding whether to get the first, second and third doses of the Covid-19 vaccine. However, there was some shift over time between the first and subsequent doses, towards less reliance on formal information sources such as the mainstream news or government-issued information and greater reliance on word of mouth and personal experience. This became an important information source for informing people's understanding of the side effects and effectiveness of the vaccine, due in part to an increase in first-hand experiences of the Covid-19 vaccine and the virus itself, coupled with a perception that people's experiences of the Covid-19 vaccine clashed with what they had been told.

"It was what I was seeing, it is not so much what I was hearing. Locally around I was seeing friends and family, I was hearing from them, that kind of changed my mind. I'm thinking, yes, we are being treated like sheep and just blindly doing what they ask us to do."

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

This meant that participants 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 also those who did not see the need to engage with further information, as they had already made up their mind to trust the vaccination programme when getting a first dose of the Covid-19 vaccine. There were also signs of fatigue among participants who felt that, as time went on, there was 'too much' information about the Covid-19 vaccine.

"I'll be honest, I started to tune out the news about the vaccine the more it went on. My decision was made."

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

Despite participants feeling generally more informed by the time of their second and/or third Covid-19 vaccinations, there were some specific points of confusion when it came to the third dose. Not all were clear about why a third dose was needed, or on the term 'booster', due in part to some having understood previously that the second dose of the vaccine was a booster. In addition, those who were taking more time to decide about whether to get their third dose were not always clear on whether there was a time limit within which they needed to get it.

Motivations and barriers to getting a second or third vaccination

Shifts in pandemic restrictions and the wider context over time shaped decision making about whether to get a second and third dose of the Covid-19 vaccine. The easing of pandemic-related restrictions, the introduction of Covid Status Certification, and the wider context of revelations about Downing Street parties during the pandemic all impacted on participants' perceptions of the vaccination programme. As time went on, participants 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.

The motivations for getting a second or third Covid-19 vaccination were in the main similar to motivations for getting a first dose. However, there were some important differences which are outlined below.

Shifts in the external context also meant that certain motivations that had been important in deciding to get a first dose were less relevant by the time participants were offered a second or third. These included the removal of domestic Covid Status Certification; realising that being vaccinated would not stop transmission of the virus and the perception that the pandemic was coming to an end.

Among those who decided to get a second or third dose there was a sense that these decisions were easier compared to the first dose because they were familiar with the process and felt reassured that the vaccine was safe.

"The first one was a struggle. That is the one I didn't want to go for, the second one and the third one they were easy to go for. I wasn't bothered after the first one, it was the first one that made me paranoid, but the rest of them were easy."

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

"I'm more pro-vaccine, because I've had it now, I know there's nothing to worry about and I can tell others there's nothing to worry about."

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

There was a tendency to think of the first two doses together while the third dose was seen as a separate decision. This related to the belief that having two doses meant they would be 'fully vaccinated' and that having two doses would provide a high level of immunity – both of which were motivating factors for getting a second dose. In contrast, a third dose could be seen as an optional extra, which related in part to it being termed a 'booster'.

Participants' expectations about the number of doses that would be needed also acted as a reason for some participants deciding not to get a third Covid-19 vaccination in particular. When the first dose of the Covid-19 vaccine became available, they were not necessarily expecting to need further doses in the future. That further doses were being offered led some participants to question the vaccine's effectiveness, as well as the safety of receiving multiple doses in a short space of time. There was also concern about how many boosters might be needed in future. There was a view that it would be preferable for the Covid-19 vaccine to be offered annually, like the flu vaccine.

"We didn't even know there would be so many, or maybe we were told but certainly it wasn't huge, that there would be all these boosters and stuff, certainly I didn't think that. So when I got my 2nd dose I was like 'okay, this should do me good', and then 2 or 3 months later there was chat about a booster, and then a lot of my friends and even I was like 'do I need to get this booster?' Because it's getting a bit annoying now […] how many boosters are you going to need?"

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

Concern about the impact of multiple vaccinations on their body was also raised by participants who were eligible for multiple vaccinations due to a health condition and/or their age, and could be a key factor in their decision whether to get a third Covid-19 vaccination or not.

"I thought I've had my flu jag, two Covid jags, and now the pneumonia jag, for heaven's sake I'm going to be a walking inoculation! So I thought I'm going to call a halt on the Covid thing, as I say I took two, and I think that's it, if my body's no developed its own immunity by now well, it'll just have to take its chances."

Participant, White Scottish, woman, 40+, SIMD2, unpaid carer, low digital skills, 2 Covid-19 vaccinations

Key barriers to take-up of a second or third vaccination also included:

• Increased concern about side effects, due to their own personal experience of these, hearing about others' experiences (a particular barrier mentioned by Gypsy Travellers) or becoming aware of risks which were officially recognised after the first dose of the vaccine was rolled out.

"I thought at first it would protect me from the virus. Then I started to know people, family, getting strokes and heart attacks. People with no health risks, no underlying conditions. That changed my mind"

Participant, Disability or health condition, Gypsy Traveller, woman, under 40, parent, SIMD2, low digital skills, 1 Covid-19 vaccination

• If they had had a negative experience with a previous Covid-19 vaccination, whether side effects or another off-putting experience.
• The realisation that the Covid-19 vaccine did not prevent infection, leading to some participants questioning how useful or effective the vaccine was

"For the second one I thought I might have been saved from it because of the first vaccine. Now I'm wondering if it's really the vaccine or me being really cautious? […] People with all three now are still getting it, I'm thinking more about the effectiveness than the beginning"

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

• Covid Status Certification, which acted as an important driver for some participants to get their first and subsequent vaccinations, particularly younger participants who were more likely to want to go to high risk settings such as clubbing or football matches (where domestic certification was required) and those for whom travelling internationally was important (where international certification was required). When domestic Covid Status Certification was removed, or participants believed it was no longer necessary to travel to particular countries they wished to visit, this led to some participants disengaging from the vaccination programme. However, it is important to note that Covid Status Certification remained operational for international travel and was required in most countries at the time fieldwork took place.
• Reduced perception of personal health risk from Covid-19, which related in part to participants being more likely to have personal experience of catching Covid-19 as the vaccination programme progressed. For those with no symptoms or mild ones, this could lead to reduced motivation to get another vaccination. This was particularly a reason for not getting a third vaccination, as there was a perception that two doses provided sufficient immunity.
• An erosion of trust in government more widely and in the vaccination programme specifically, which related both to news about Downing Street parties held during lockdown and to what could feel like continuously changing vaccination advice (for example, changes to eligibility for pregnant women and for children). This led some participants to question whether the threat of Covid-19 had been exaggerated and whether authority figures knew what they were doing. It could also diminish the sense of duty that some participants described feeling when getting their first vaccination, once they realised that not everybody in charge was following official guidance.

"The messages you get from the government is, if they don't follow these rules, it can't be that severe. You're scaring us all off. You all had get-togethers and whatnot last year, you have not followed the rules and you are absolutely fine, so why are you scaring the public? So, I thought, 'no, I don't need it'."

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

Participant story: Azrah

Azrah is in her late 40s and lives in Dundee. She lives with her adult son and has not worked for the past few years due to health reasons. She was very careful through the pandemic, making sure to follow the rules and not take any risks as she knew she would be at high risk if she did catch Covid-19.

She got her information about the vaccine from the internet, the TV, news programmes, and newspapers. When she got an invitation for a first dose of the Covid-19 vaccine in the post, she chose to accept it because she trusted government guidance and thought it was the right thing to do. Another crucial reason was that she was concerned for her health and wanted protection from the virus. She was also encouraged by her family to get vaccinated.

Her first appointment was at a convenient location that she was already familiar with, near her house and accessible to her. It was important to her that it was a venue she was comfortable with and that she knew she could access.

"If I was told to go somewhere else I didn't know, I would have been stressed out, really stressed out and I probably wouldn't have gone."

The venue offered enough privacy and felt safe, and the nurse seemed knowledgeable. She was glad to not experience any major side effects, especially given her existing health conditions. She was happy there was not a long queue, as standing for long periods is difficult for her. Her second vaccination was also straightforward – it was a similar decision for her and it was in the same venue.

In general, Azrah trusts vaccines, but she says her trust in them has been reduced by her experience of the Covid-19 pandemic. Azrah decided not to get a booster vaccination. This was partly because she missed her appointment due to illness and found the system for re-booking complicated, but it was also because she no longer trusted the vaccines. The main reasons for this was that the development of the Covid-19 vaccines felt rushed, the information from the government had been unclear, and because the vaccine does not prevent transmission.

"Nothing has been crystal clear, you know, the government's signals, what they have been saying, you know, what they have been doing, everything has been so rushed I just don't trust it anymore."

Experiences of receiving a second or third Covid-19 vaccination and practical considerations

Practical experiences of the second and third doses were generally similar to experiences of the first dose. This section focuses on where experiences did differ between the first, second and third doses.

While some participants received the second and third doses in the same venue as their first one, others went to a different venue. This was either because they were invited to a different venue, because they had selected a different venue themselves, or because they chose a drop-in venue for their next vaccination.

A practical barrier to vaccination for those with work, study or caring responsibilities related to the fear that if side effects were severe this could make it difficult to meet their other responsibilities. This appears to have been a greater concern for later doses, linked to a belief that the side effects for later doses were worse.

"Whenever my second one was due, it was during exam season and I couldn't afford to mess that up, I couldn't afford to be ill. I was scared of the second dose more than the first one after hearing from friends and other people [that they had experienced worse side effects after later vaccinations]"

Participant, Pakistani, man, under 40, 1 Covid-19 vaccination

There were participants who said that their experience had improved over time, largely due to the fact that they knew what to expect. However, others felt that the process had been more rushed, and queues had been longer, for their third dose than their first two.

"That one was probably a bit of a nightmare. […] it was a drop-in centre, so it was the [brand] shop that had turned into a Covid clinic, and the queue literally went on for hours, I remember being in that queue for hours, it was horrible […] People were just kind of coming in at their time of the appointment, everything was pushed back, so the security people who were checking the queues were slotting people ahead of you because they had been late."

Participant, Pakistani, woman, under 40, 3+ Covid-19 vaccinations

Participant story: Kristen

Kristen is in her late 30s and lives in the centre of Glasgow. Shortly before the pandemic, Kristen was diagnosed with cancer. She had surgery and was in chemotherapy during the first lockdown. She took time off work, and her mum moved in to support her. The pandemic was very difficult for her – because of her diagnosis, she shielded very carefully and did not do much other than stay home and go to hospital appointments.

She received regular letters and text updates from the Scottish Government due to being on the shielding list, and that was where she got most of her information on the vaccine programme. She liked being kept updated and felt looked after.

"I felt valued. [There was] value placed on my life that I would never have thought about prior to this happening. I would never have thought that the government would put so much emphasis on keeping me protected."

Looking forward, Kristen plans to get any Covid-19 or flu vaccines she is offered until she has recovered from her cancer. She wants to protect her health as much as she can, but once she is in remission she does not expect to get the flu vaccine – as until she was diagnosed with cancer she considered herself to be young and healthy. Kristen's journey with both vaccine programmes is outlined below.

User journey: Kristen

This is the user journey of Kristen, a woman in her thirties diagnosed with cancer.

• Influences on her decision to get the vaccination – Advice of her doctors, in context of increased risk due to cancer. Trust in the science of vaccine development.
• Motivations to get 1^st vaccination – Never any doubts that she would get it. Desire to protect herself and others.
• 1^st vaccination experience – No concerns on the day. She was vaccinated at her GP. No queue, felt safe, helpful staff she already trusted. Side-effect was some fatigue.
• Motivations to get 2^nd vaccination – Wanted to get second dose before her scheduled cancer surgery.
• 2^nd vaccination experience – Had to call GP to set appointment. Straightforward, positive experience, similar to first dose.
• Motivations to get 3^rd vaccination – Protecting herself and others.
• 3^rd vaccination experience – 'A nightmare'. The appointment venue was far away. Asked if she could go to local venue instead. Helpline staff said no, and offered her two other venues, both far away. She dropped by local venue anyway and they were able to vaccinate her. In her own words: "So why didn't the person on the phone tell me that?"
• Motivations to get flu vaccination – Was recommended by GP due to her cancer diagnosis.
• Flu vaccination experience – Difficult to get an appointment. Pharmacy was very disorganised. Pharmacist treated her poorly despite her explaining she had cancer. Painful injection, nurse left the needle in.