Perceptions of Youth regarding COVID-19 Vaccination in the Mafikeng Subdistrict in North West Province of South Africa

1.1. Background

In 2019, the coronavirus disease (COVID-19) was first detected in Wuhan, China [1]. The causative agent was identified as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [2]. To mitigate the impact of the pandemic, global efforts were directed toward developing vaccines to prevent the spread of the virus [3]. By 2020, vaccination emerged as an effective strategy for containing COVID-19 [2]. Conversely, the continued high rates of morbidity and mortality have been partly linked to the lack of widespread vaccination [4]. The study was deemed important because its outcomes may support efforts to curb COVID-19 transmission and boost vaccination uptake among youth.

Between January 2020 and March 2023, South Africa recorded 102,598 deaths and over 4 million confirmed COVID-19 cases [5]. A study conducted in Gauteng province revealed that young people’s reluctance to vaccinate was largely influenced by mistrust in medicine and the spread of misinformation, particularly through unregulated social media platforms, which served as their main sources of information [3]. The findings of youth vaccine reluctance, along with rising mortality and confirmed COVID-19 cases, indicate the need for more rigorous studies in South Africa. Thus, the focus of this study was on understanding youth perceptions of COVID-19 vaccination. Statistics from the North West province facility, where this study was conducted, revealed low COVID-19 vaccination uptake among youth. The facility had set a target of vaccinating 150 youths per month, amounting to 450 per quarter; however, only 76 youths were vaccinated in the first quarter, and 68 in the second quarter [6]. Thus, the total number of youths vaccinated fell significantly short of the Primary Healthcare (PHC) facility’s set target for North West province.

Despite the reported low uptake of vaccinations by youth, there is a dearth of literature regarding research focused on youth perceptions of COVID-19 vaccination in the North West province of South Africa. This prompted the researcher to investigate and describe young people’s perceptions of the COVID-19 vaccine. The research questions applied allowed the youth to reveal their perceptions regarding COVID-19 vaccination at the facility where they received the service and, further, to express their views on what can be done to improve COVID-19 vaccination uptake among youth. In this context, the research questions are informed by the Health Belief Model, which highlights that individuals may perceive barriers to taking action [7]. Therefore, it is important to clearly articulate youths’ perceptions of COVID-19 vaccination and identify the obstacles they face. Using the Health Belief Model as a framework, participants were able to articulate the perceived benefits of behavior change that could enhance COVID-19 vaccination uptake among youth.

2.1. Study Design

The study investigated young people’s perceptions of the COVID-19 vaccine using a qualitative research approach [6, 7]. To gain insight into their attitudes toward vaccination, the researcher adopted an exploratory, descriptive, and contextual design [8, 9].

2.2. Study Setting

The study was carried out in Mafikeng, located in the North West province, one of South Africa’s nine provinces. Mafikeng is mostly a rural community with diverse values and cultural beliefs. Setswana is the most widely spoken language in this province, with other languages including Afrikaans, Sotho, Xhosa, Tsonga, English, and Zulu. Data were gathered from the youth using field notes and unstructured, in-depth Focus Group Discussions (FGDs). This approach to data collection encouraged participants to share their views openly, engage with one another, and articulate their perspectives on COVID-19 vaccination.

2.3. Characteristics of the Participants

The participants in this study were young people visiting the selected PHC institution in the Mafikeng subdistrict. Young people who visit PHC facilities were more likely to provide detailed information for the study, since they had everyday access to knowledge about health-related topics compared to those who do not use such facilities. Purposive sampling was used to select youth who reported knowledge of the vaccine.

2.4. Study Population and Sampling

2.5. Data Collection Tool and Process

Five unstructured, in-person FGDs were conducted by the researcher, a female first author with an Honours degree in Nursing. At the time of the study, the researcher was employed as a professional nurse; she was trained on the research methodology prior to data collection. Two days before data collection, the researcher built rapport by meeting participants to introduce herself and outline the purpose of the study. One FGD was conducted prior to the actual data collection of the major study.

The purpose of conducting the pilot FGD was to enhance the facilitation and communication skills required to conduct FGDs effectively. The two broad research questions were condensed by the researcher as follows: Can you tell me about your perceptions of COVID-19 vaccination at the facility where you receive health services? What more can be done to improve the low rate of youth COVID-19 vaccination uptake at the facility where you receive health services? Each simplified question had further addition questions, depending on the interviewees’ responses.

Each FGD consisted of five participants, to ensure that all individuals had the opportunity to express themselves. The discussions lasted between 30 and 45 minutes each. To minimise disturbances, the sessions were held in one of the consulting rooms in the maternity ward, which was identified as the quietest location. Data collection continued until data saturation was reached for each group, guided by open-ended questions posed consistently across all five groups. Additional probing questions were asked when clarification was needed. To ensure accuracy, credibility, and dependability, field notes were taken, and the interviews were audio-recorded and transcribed verbatim. No follow-up interviews were conducted after verbatim transcription, as the conversations were expressed with sufficient clarity.

2.6. Data Analysis

The researcher and co-coder independently analysed the data using a thematic analysis approach [9, 10]. In the first step, the researcher familiarised herself with the collected data by repeatedly reading the field notes while listening to the recorded audio. The second step focused on organising the data set; the researcher examined words, phrases, and expressions with significant or related meanings. The third and fourth steps focused on developing codes and grouping them to identify patterns and connections, which led to the emergence of themes. The fifth step outlined the key features of the data that were extracted for inclusion in the final report. Lastly, a consensus meeting was conducted to achieve the final refinement of the themes. The process concluded with the writing of the research report and comparison of the findings with those from other published studies.

2.7. Rigour

The model of trustworthiness comprising credibility, dependability, confirmability, and transferability was applied to ensure the rigour of the study [7, 9]. Credibility was strengthened by the use of a tape recorder, which safeguarded the authenticity of participants’ responses, as well as through prolonged engagement with the participants. To establish dependability, the researcher carefully documented every step of the research process, ensuring that the procedure was logical, traceable, and replicable, so that similar results could be obtained if the study were repeated. Field notes were incorporated into the data collection records, and the audio recordings were securely stored to enhance confirmability. Transferability was addressed by providing readers with rich, detailed descriptions of the research context, participants, and procedures, enabling them to determine whether the findings apply to their own contexts or experiences.

3.1. Demographic Information of Participants

A total of 25 volunteers aged 18–34 years, who were all Black South African citizens, participated in this study. Among them, eight were employed, five were university students, and 12 were unemployed. Of the eight employed participants, three held a tertiary qualification, while the remaining five had completed matric. Among the 12 unemployed participants, two had only completed primary school education, four had not finished matric, and six had completed matric. The sample included five men and 20 women; 12 of the participants were unvaccinated, and 13 had been vaccinated. Among the unvaccinated parti-cipants, four were men, and eight were women; among those vaccinated, one was a man, and 12 were women. During the FGDs, participants shared their perceptions and experiences regarding the COVID-19 vaccine. Once data saturation was reached, the researcher, together with an independent co-coder, analysed the data and identified four overarching themes and 13 subthemes.

3.2. Themes and Subthemes

The themes and subthemes that emerged from the unstructured FGDs are shown in Table 1.

4.1. Theme 1: Perceptions related to Reasons for Vaccinating for COVID-19

The youth in this study had perceptions regarding the reasons for vaccinating against COVID-19. In this regard, the participants revealed internal and external factors that motivated and demotivated them from vaccinating. A study conducted in the United States of America examined internal and external motivations, as well as risk perceptions influencing youth vaccination decisions [11]. Similar to the present research, it included both vaccinated youth to identify what motivated them and unvaccinated youth to explore the factors underlying their hesitancy [11]. The youth who were vaccinated reported that they knew someone who got COVID-19 and died, and this became a motivation for them to vaccinate [12]. This effect became a threat to them, making them fear contracting COVID-19 and dying from it; hence, it became a positive driver for vaccination. Those participants who were working were forced to choose between their feelings and supporting themselves financially [12, 13]. Participants in this study felt compelled or pressured to vaccinate, as proof of vaccination was required for them to continue working. Similarly, another study reported that participants were vaccinated only so they could go to work [14, 15].

The current study reflected a similar pattern to those mentioned above. Participants explained that they chose to vaccinate because their family members had fallen ill, although the exact cause was unknown. The fact that it occurred during the COVID-19 period created fear, which ultimately motivated them to vaccinate. For participants in the current study, witnessing loved ones get sick motivated them to vaccinate. A similar phenomenon appeared in another study, as participants recounted experiences of morbidity and mortality caused by COVID-19. They spoke about losing relatives and witnessing family members contract the virus [16].

4.2. Theme 2: Perceptions about Information on COVID-19 Vaccination

The findings of this study suggest that who provides the information, how it is communicated, and where it comes from significantly contribute to youth vaccination hesitancy. The study reveals that social media is reported to have a powerful influence on decision-making, especially when rumours run contrary to expectations. The participants reported that Facebook influenced them not to vaccinate at the time, and that they now feel regret about it. Another study found that youth mostly use Facebook and TikTok for their social lives [14]. If there was negative news circulating about the vaccine on Facebook or TikTok, the youth would easily have doubts, as they spend most of their time on those platforms, which give them a sense of community as they are able to speak their minds there [14]. This was also stated in a study in South Africa, where participants said: “We didn’t know enough, there was a lack of accurate information about the vaccine and COVID-19 itself” [15, 16].

The findings of the current study suggest that incorrect and misleading information can cause youth to have mistrust and change their perceptions about vaccinating. The participants in this study received information from social media, which changed the way they viewed the vaccine. In another study, the researcher stated that being faced with different information about the vaccinate can cause confusion, distress, mistrust, and a less positive perspective towards the vaccine [12, 15].

Information regarding the side effects of the vaccine seemed to be a burning issue for most youth in this study. Similarly, a study conducted in the United Kingdom found that 36.2% of youth had concerns about the information they received regarding vaccine side effects [12, 16]. Participants also indicated that they were concerned because their parents experienced severe side effects after vaccination, which led them to decide against vaccinating. In a study conducted in Nigeria to record COVID-19 hesitancy among the youth [14], it was recorded that 21.3% were afraid of the side effects. Among a few youth who received vaccinations, the side effects they reported scared those considering vaccination, leading them to change their minds [14].

4.3. Theme 3: Perceived Dangers of COVID-19 and its Vaccine

In this study, some participants reported being scared of COVID-19, which they perceived as a threat, prompting them to vaccinate. Others genuinely questioned how efficient the vaccine was. The participants reported deaths among their family members, and even though it was not confirmed that COVID-19 was the cause, the mere fact that they were vaccinated and still died led to questioning the efficacy of the vaccine. Some of the participants who were vaccinated reported unbearable side effects, which changed how others viewed the vaccine, leading to a dilemma in choosing whether to vaccinate or not.

Participants in this study also held the view that, despite vaccination, COVID-19 remains a deadly virus, so it does not matter whether you are vaccinated or not. The disease outcome depends on the uniqueness of the individual: if it was meant to be fatal, regardless of the vaccine status, the person will still die. Therefore, the participants were not necessarily considering the vaccine, but rather COVID-19 itself as a disease. Consistent with the findings of the present study, another study reported that the hesitant group cited continued deaths among vaccinated individuals as a major reason for their reluctance [12, 16]. The study further reported that 20,1% of youth queried efficacy [12, 16].

4.4. Theme 4: Suggested Strategies to Encourage Youth to Vaccinate

The youth in this study recommended that providing accurate and comprehensive information would allow them to make a more informed decision about whether to vaccinate. One study had a different recommendation, that the government should have a positive compensation system [17, 18]. This compensation system would encourage the youth to vaccinate, knowing that should anything happen relating to the vaccine, the government will be accountable [19, 20]. Even though this generation of youth is technically informed, community outreach campaigns were seen as essential [20, 21]. This is also recommended in another study, which reported that nurses should educate youth through community outreach programmes [22]. Other forms of treatment, instead of injection, were suggested by many participants. Non-injection methods should be considered to ensure that all groups of people are covered, especially those with phobias [18, 21]. Mandatory vaccination is considered ethically justifiable, particularly when the condition being prevented poses a threat to public health [23, 24]. The youth in this study reported that they are a stubborn generation, and therefore, only forceful laws can work on them [25].