COVID-19 Vaccination Personas in Yemen: Insights from Three Rounds of a Cross-Sectional Survey

"Strengthening the information about the COVID-19 vaccination (safety, effectiveness, side effects) and communicating it through community leaders/healthcare workers could help increase the COVID-19 vaccine coverage in Yemen."

Yemen's civil war has significantly impacted the country's overall quality of life since 2011. Against this difficult backdrop, the first COVID-19 case was registered in Yemen in April 2020, and the COVID-19 vaccination programme was launched one year later. As of September 2022, Yemen had one of the lowest COVID-19 vaccination coverage rates globally, with only 5% of adults in Yemen having received at least one dose. Various barriers have prevented the country from increasing COVID-19 vaccination coverage, including political instability that has impeded the availability of both accurate information and vaccination services. This paper draws on a repeated cross-sectional survey conducted throughout the entire territory of Yemen to: (i) describe the demographic and socio-economic characteristics associated with willingness to be vaccinated; (ii) analyse the link between beliefs associated with COVID-19 vaccines and willingness to be vaccinated; and (iii) analyse the potential platforms that could be used to target vaccine hesitancy and improve vaccine coverage in Yemen.

The survey was implemented in 5 rounds; however, this paper focuses on the last 3 rounds, where questions on vaccination intention were asked (March 2021, August/September 2021, and April 2022). There were about 1,400 respondents per round across the entire country. Between round 3 (March 2021) and round 5 (April 2022), the share of respondents who believed they could become infected with COVID-19 had increased. By the 5th round, almost half of respondents stated they felt at risk of being infected by the virus. Over time, there was an increase in confidence regarding COVID-19 information provided by the authorities, coinciding with enhanced management of COVID-19. By the 5th round, over half of respondents reported confidence or total confidence in official COVID-19 information from the authorities. However, 14.6% of respondents still had no confidence and might resist authorities' appeals for vaccine uptake.

The share of respondents not willing to be vaccinated had decreased between rounds 3 and 4, but there was very little change between rounds 4 and 5. More specifically, roughly 41% of respondents stated they were not willing to receive the COVID-19 vaccination when it became available. Between rounds 3 and 4, there was an increase in the share of people willing to be vaccinated; however, this level had reduced between rounds 4 and 5 at the expense of respondents who were not sure/undecided. By round 5, 28.2% of respondents were willing to be vaccinated, while 30.7% reported they were unsure. The researchers found that gender, age, and educational attainment were significant correlates of vaccination status.

Based on analysis of the data, the paper outlines the following vaccination personas:

1. Willing: Men were more likely than women to be willing to receive a COVID-19 vaccination. Respondents with better knowledge about the virus and with greater confidence in the capacity of the authorities (and their own) to deal with the virus were more likely to be willing to be vaccinated. Consistent with the health belief model, practising one (or more) COVID-19 preventative measures was associated with a higher willingness to get a COVID-19 vaccination. Respondents with more positive views towards COVID-19 vaccines were also more likely to be willing to be vaccinated. Half (50%) of respondents listing community leaders as the most trusted COVID-19 information source in round 3 were willing to be vaccinated; similar findings emerged from the previous 2 rounds. In addition, in some of the previous rounds (e.g., round 3), there was evidence that those who listed community healthcare workers as a trusted source of information were more likely to be willing to receive a COVID-19 vaccination. This persona tends to trust communication materials and community leaders more than other personas trust these sources of information.
2. Undecided: A large share of the unemployed (38%) were undecided regarding a possible vaccination, suggesting a link to employer encouragement being a strong incentive for vaccination. About one-third of those with no opinion regarding potential infection with the virus were undecided regarding obtaining a vaccine. About a quarter of those who believed that the vaccine is effective were undecided regarding taking it (slightly lower compared to those who did not think there were serious side effects). This persona appeared to draw information from a wide range of sources, which may be contradictory.
3. Unwilling: This vaccination persona was older and less educated by a significant margin, compared to the other categories. About half of women were unwilling to obtain a COVID-19 vaccine (about 15 percentage points higher than men). Almost two-thirds (63.5%) of respondents who stated they did not believe they were likely to get infected with the virus were also unwilling to be vaccinated. Those who did not practice public health safety measures were also less likely to be willing to be vaccinated - e.g., 48.3% of respondents who claimed they did not wear a mask in public were unwilling to be vaccinated. This vaccination persona was less knowledgeable about the COVID-19 virus and tended to believe that the virus is not dangerous. Furthermore, this vaccination persona held negative attitudes and beliefs towards the vaccines. Finally, this group of people tended to trust their family and friends more than other personas for information regarding COVID-19.

In discussing the findings, the researchers offer several observations, including:

• Findings on the socio-demographic characteristics of vaccination willingness are consistent with the existing evidence. For example, with regard to the findings on gender, studies have shown that men may be advantaged by their higher level of mobility than women in parts of the Middle East, North Africa, and Eastern Mediterranean region. Men's higher engagement in formal employment may offer additional incentives for vaccination. Research has found that women in this region have been disproportionately affected by misinformation about fertility, which also seemed to affect their willingness to be vaccinated. In addition, it has been argued that women are more likely to embrace conspiracy theories about the virus.
• The study's finding that respondents who were practising some forms of preventative measures (e.g., wearing a mask, washing hands, practising social distancing) were more likely to be willing to obtain a vaccination supports the general health motivation construct in the health belief model and aligns with social identity theory.
• Research in the area of vaccine demand generation has distilled two approaches. The first, more passive, one has relied on the use of mass media (TV and radio) and printed materials (banners, leaflets, posters). The second approach involves deeper face-to-face engagement with households and individual caregivers - often by trained volunteers from the community using interpersonal communication and behaviour change approaches.  Even though the second (community outreach) approach is more labour intensive and more expensive, it may also yield higher returns per contact when it comes to vaccination uptake, especially given the lower trust in health workers in Yemen.

In conclusion: "Any focus on individual motivation for vaccination relies on the basic requirement that adequate vaccination services are made available to all communities. That said, outreach to communities and a localised focus on the needs of those who are undecided about vaccination can be effective in increasing uptake, thereby also increasing the social norm around being vaccinated. Supplying them with information about the COVID-19 vaccines (e.g., safety, effectiveness, and side effects) and access to trusted and skilled health workers could mitigate fears and increase confidence in the vaccines. Identifying vaccination champions among families/communities could further allay some of the fears associated with vaccines (e.g., fears of side effects). Religious leaders and other community leaders (including females) can have a strong influence on communities in Yemen, both positively and negatively - and should be considered key partners, especially in terms of understanding and addressing the needs of local communities."