How Health Workers Are Fighting Vaccine Hesitancy In Villages

While urban Indians flock to vaccine centres, grassroots health workers in villages are facing vaccine hesitancy. We report from rural Maharashtra on how frontline health workers are countering vaccine hesitancy, and what support they need.

Update: 2021-05-19 00:30 GMT

Healthcare workers use school buses to ferry villagers to vaccination centres in Nandurbar’s Dhadgaon. Villagers are hesitant to take COVID-19 vaccines because they believe it has serious side effects.

Nashik: Villagers in Maharashtra's Trimbakeshwar, about 50 km from Nashik city, would promptly approach Anusaya Dolas, a health worker, if they ever fell ill. An accredited social health activist (ASHA), she had, over the years, painstakingly earned the trust of villagers, she told IndiaSpend over the phone in April 2021. But nowadays, the same people run away as soon as they see her coming. "They run out from back doors of homes or tell their children to make excuses and say that nobody is at home," Dolas said, ruefully. This mistrust is a result of the COVID-19 vaccination drive, as villagers feel the vaccine has side-effects and can even result in death, Dolas explained.

With the majority of India's 1.3 billion population still living in villages with little health infrastructure, the country is currently seeing the worst of the pandemic as the virus has reached rural India.

In Maharashtra, by May 12, the five districts with the lowest vaccination coverage among the eligible population over 45 years were Hingoli (14%), Palghar (17%), Gadchiroli (17%), Nandurbar (17%) and Solapur (18%), data from Maharashtra's public health department show. Over 75% of the population in four of these districts, other than Solapur, lives in rural areas.

Grassroots health workers told IndiaSpend of rumours--that vaccines can cause impotence, for instance--and suspicions that the COVID-19 vaccine is a ploy by the government to kill people. Some people, they said, also believe that they simply do not need vaccination. All of this is making it harder for them to convince people.

"Like infection, misinformation is now trickling into rural areas," said Naveen Thacker, a Gujarat-based vaccination expert and president-elect of the International Pediatric Association, based in the U.S.

"I even go to people's farms to convince them to take the jab. In one case, someone told me that they heard on the television that the vaccine's side-effects will show up two to three years from now. No matter what I tell them, people believe what they want to believe. I feel helpless," Dolas said. In one vaccination drive at the primary health centre (PHC) in Nashik district's Vavi village in April 2021, only 20-25 people above the age of 45 years turned up, even though the centre was only 4 km from the village, she said.

Doctors and administrators said an information and awareness campaign is urgently needed. They are trying door-to-door counselling and providing transport to vaccination centres, especially for remote villages, to convince people to take the jabs, they told us.

Rumours, suspicion and fear

Villagers in Aurangabad's Soygaon expect their ASHA, Nirmala Gadri, to assure them that the vaccines will not have side effects. "When I ask people if they have taken the jab yet, people turn around and ask me if I can guarantee that they will not suffer any side effects. How can I? If something happens, people will catch hold of me. They fear that they will die of the vaccine," she said.

Villagers also ridicule her for simply doing her job, which entails visiting homes all through the village. "They say, 'This woman has no other work, she just goes around carrying the gun'," Gadri said. The gun here is a reference to an infrared thermometer.

Gadri's PHC in Banoti village of Soygaon taluka caters to a population of around 2,000. Currently there are about 10 COVID-19 patients in her village and some people are isolating on their farms. There are 100-150 people in the 45-59 age group but none of them have taken the jab yet. Of the 140 people aged above 60 years, only 40 had taken it as of April 20, she told IndiaSpend.

Rural vaccine hesitancy exists not just in Maharashtra but also in other states. One of India's most backward districts, Haryana's Nuh, had vaccinated less than 1% of its targeted population, IndiaSpend reported in April.

One reason people in Soygaon are hesitant is because an elderly woman in her 80s died within 15 days of getting the vaccine, Gadri said. She had fever and high blood pressure and died of a heart attack, she said, adding that public health authorities told her that the death was not because of the vaccine. But now, people do not even allow Gadri to check them for fever, saying, "You will mark us COVID positive for no reason."

India's online vaccination portal, CoWIN, says there have been 20,543 adverse events following immunisation (AEFIs) reported until 3 p.m. on May 18, a rate of 0.011%. There have been concerns, however, about how well AEFIs are being tracked, reported, recorded and investigated by the Indian government, IndiaSpend reported in March.

Nevertheless, the benefits of vaccines for most people would outweigh their risks. Early data from Mumbai and Pune and from three southern states show that the share of the elderly in COVID-19 deaths and cases has declined since March 2021, when vaccination for this cohort began, and this could be a result of vaccination, we reported in May.

Aarti Korgaokar, an anganwadi sevika (worker) from Sawantwadi taluka in Sindhudurg district, has had to battle with conspiracy theories and a belief that villagers do not need vaccines, she told IndiaSpend. People would say that the vaccine kills and that Korgaokar, working for the government, would get money if any villager died, they would tell her, she said. "There were a lot of misconceptions about the vaccine initially including that they cause infertility or affect a woman's periods," she said.

Some would question her on whether they really needed the vaccine. It was only when COVID-19 cases started increasing in villages, with almost every village in the area reporting around 10 cases each, that some people turned up to take the vaccine at a centre about 15 km away, Korgaokar said.

Others believe that working on farms gave them stronger immunity against COVID-19, said Namrata Thakur, an ASHA from Tawa PHC in Dahanu in Palghar district, which caters to three hamlets of 975 people in all. Those who have taken the jab are those working in urban areas or those who are more educated, she said.

"Besides, vaccines lead to fever, which hampers those who depend on daily wage," said Thakur, adding that of the 975, at least 500 people are over the age of 45 years but few have taken the vaccine.

Venu Vare, an ASHA from another part of Trimbakeshwar, would tell people of her own experience getting vaccinated but people would tell her that they would be given a poor quality vaccine and not the one that she got, she said. The vaccination centre is about 30 km from the two villages her PHC caters to, but she said that even if the vaccination centre were closer, not many would agree to get the shot.

The process of vaccinating those above 45 is relatively easy: People can walk in with an Aadhaar card and get registered on the spot.

Vaccine shortage

"The rate of vaccination is low in rural areas, hesitancy has been discussed extensively in meetings of the task force and there is a plan for that but right now the major problem is availability of vaccine," said Rahul Pandit, director of intensive care at Fortis Hospital in Mumbai, and a member of Maharashtra's COVID-19 task force. "We need crores of doses at the moment."

"We are doing awareness through various media and folk art but now vaccine availability is an issue," said Rajendra Bharud, the district collector of Nandurbar, who is a trained medical doctor.

Vaccination across India has slowed down due to vaccine shortages, IndiaSpend reported in April.

Combatting vaccine hesitancy

Doctors say that only an information, education and communication (IEC) campaign can combat vaccine hesitancy.

Initially, Nandurbar was at the bottom of the list when it came to the vaccination rate, but its vaccination campaign has improved things somewhat, Bharud said. Almost 80% of the district is rural, he said, with two remote talukas and low literacy. Yet, the district has vaccinated 210,000 people, of which 120,000 are above the age of 45 years and the rest are healthcare workers and those above 18 years. The district, with a targeted vaccination coverage of 600,000 people above 45 years, is now at number four from the bottom, government data show.

The district has 16 mobile teams and 17 school buses to take people to 90 vaccination centres, especially those from remote areas who would have otherwise spent a lot to get to a centre, Bharud said. District officials and health workers also hold camps to counsel those above 45 years to get vaccinated, he said.

But progress is slow. The first time that people are counselled, hardly 10-15% of them agree to take the vaccine. "It is very difficult to convince people that this is in their best interest. Some people run away, some say this is a plan to make them impotent," said Bharud, blaming social media posts for such rumours.

Some days, anganwadi sevika Sangita Naik walks kilometres, counselling people door to door to get vaccinated in Nandurbar district in Maharashtra.

"We had to counsel people from door-to-door, but some are still not convinced," said Sangita Naik, an anganwadi sevika from Vadphali in Nandurbar district. Her anganwadi covers four villages with a population of around 800, she said. One of the rumours was that legs swell up because of the vaccine, Naik said. She would tell those people: "So what if it does? You apply wet cloth over it."

In Nashik district, Dolas, the ASHA, approaches villagers in the fields and reminds them of the vaccines they were given as children and how those did not cause adverse effects. When that does not work, she tells them about healthy individuals who died of COVID-19 before they could get medical attention or even a test, all the while hoping that the horrors of the virus overcome their fears of the jab.

"When us frontline workers took the vaccine and came down with a fever, news spread in our villages. That also contributed to the fear. But I don't know how else to convince them when I am here, alive, in front of them," said Dolas.

"You have to engage with people," said Thacker, the vaccination expert. "People need to be aware of what to expect upon taking the vaccine… [That] it is like wearing a seatbelt that will prevent you from serious injury but it won't protect you from an accident," he said.

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