Factors associated with COVID-19 vaccination in two provincial hospitals of Papua New Guinea
Ian Umo A * , Alexia Wangnapi B , Venessa Soctine A , Dorothy Adilawa A , Prisca Joroto A , Michealynne Kulai C and Robert J. Commons D EA
B
C
D
E
Abstract
COVID-19 vaccination rates are extremely low in Papua New Guinea (PNG), placing a huge burden on the health system. This study aims to identify factors associated with COVID-19 vaccination in PNG in order to direct public health interventions to improve vaccination uptake.
A survey of hospital workers, patients and guardians was conducted in two provincial hospitals in Papua New Guinea. A standardised questionnaire was used to collect data. Univariable and multivariable logistic regression were used to analyse factors associated with COVID-19 vaccination uptake.
273 participants undertook the survey. Independent predictors for COVID-19 vaccination were female sex (adjusted odds ratio (aOR) 2.1, 95% confidence intervals (CI) 1.1–3.9, P = 0.024), vaccine awareness (aOR 3.9, 95% CI 3.1–4.9, P < 0.001 and having a family member with COVID-19 (aOR 3.8, 95% CI 3.4–4.3, P < 0.001). Predictors of reduced vaccination were rural residence (aOR 0.3, 95% CI 0.3–0.4, P < 0.001), primary education (aOR 0.3, 95% CI 0.1–0.5, P = 0.001) and secondary education (aOR 0.5, 95% CI 0.5–0.5, P < 0.001) compared to tertiary education, and a preference for herbal remedies (aOR 0.2, 95% CI 0.1–0.8, P = 0.016).
PNG’s COVID-19 vaccination rate is among the lowest in the world. Factors associated with vaccination uptake are important to inform public health messaging and interventions to increase vaccination coverage and achieve herd immunity.
Keywords: Alotau Provincial Hospital, COVID-19, Kavieng Provincial Hospital, low to middle income country, Papua New Guinea, provincial hospital, vaccination, vaccination hesitancy, vaccination uptake.
Introduction
Since the emergence of COVID-19 in December 2019, 5.9 million deaths have been reported worldwide, with developing countries accounting for 42% of the global mortality.1,2 With the subsequent emergence of the Delta and Omicron variants, transmission has escalated in most low- to middle-income countries (LMICs), increasing pressure on health systems that were already underfunded prior to the pandemic.3
COVID-19 control measures, such as social distancing, face masks, and temporary lockdowns, have been shown to reduce transmission by 79–84%.4,5 However, widespread vaccination coverage is the public health measure with the greatest potential to reduce transmission in the longer term. An estimated 11 billion COVID-19 vaccines are needed to vaccinate 70% of the world’s population and achieve herd immunity.6 By July 2021, only 1% of the population in LMICs had been vaccinated.6
Barriers to vaccination uptake can be varied and complex. In Bangladesh, low literacy levels, low adherence to health safety regulations and low confidence in the healthcare system were factors associated with reduced COVID-19 vaccination.7 In comparison, female sex and age were significantly associated with lower vaccination rates in France.8 Reduced availability of vaccines and anti-vaccine advocates on social media have further deterred efforts to achieve widespread vaccination coverage.9,10
The Western Pacific region represents a quarter of the world’s population.11 In 2020, the region reported only 1.4% of confirmed COVID-19 cases globally.11 In mid-2021, Papua New Guinea (PNG), in the Western Pacific region, saw a surge in COVID-19 cases due to the introduction of the Delta variant. Increased Delta variant transmission has been linked to low COVID-19 vaccination coverage.12 By December 2021, it was estimated that less than 4% of PNG’s adult population had been vaccinated.13 The surge of Delta cases in PNG led to substantial pressure on the health system, with many hospitals requiring periods of closure due to shortages of drugs, consumables, personnel and funding.
Other Melanesian countries in the Western Pacific region have been successful in vaccinating against COVID-19. Fiji has achieved more than 95% vaccination coverage of its adult population, with Vanuatu vaccinating more than 80% of people in priority groups, such as health workers and the elderly.14,15 In PNG, there are limited data identifying factors associated with poor uptake of COVID-19 vaccination. This study aims to identify factors associated with COVID-19 vaccination in PNG, in order to inform evidence-based interventions to improve uptake and reduce COVID-19 transmission.
Materials and methods
Study design
A survey of hospital workers, patients and guardians was conducted over a two-week period, 1–15 August 2021, using a self-collected questionnaire across two provincial hospitals in PNG.
Study setting
This study was conducted in Kavieng Provincial Hospital (KPH) and Alotau Provincial Hospital (APH). KPH serves as the major referral hospital in New Ireland Province, which had an estimated population of 301,380 people in 2021.16 APH serves as a referral hospital of Milne Bay Province and caters for a large maritime population of an estimated 353,959 people.16
The COVID-19 vaccination campaign was launched in May of 2021 by the Prime Minister of PNG, Honourable James Marape. This saw the roll out of the first 100,000 Astra-Zeneca vaccines within the country.17 These were distributed to all major provincial townships. By February of 2022, 243,000 people had been fully vaccinated, with more than 303,000 having at least had one dose of the Astra-Zeneca vaccine throughout the country.18 Other vaccines subsequently introduced include the Johnson & Johnson and Sinopharm vaccines. Booster vaccines were approved in January 2022 for fully vaccinated individuals.
Milne Bay and New Ireland provinces conducted active COVID-19 awareness campaigns, though these were largely limited to urban areas. As of 17 October 2021, Milne Bay recorded 50 COVID-19 cases, while New Ireland reported four. However, accurate data on vaccination uptake for both provinces was unavailable.18
Data and variables
Data were collected using a standardised questionnaire. Data transfer from questionnaires to a central database were cross-checked by two separate investigators prior to analysis. The variables collected were age, sex (male/female), residence (urban/rural), marital status (married/single), presence of children (yes/no), education level (primary/secondary/tertiary), health worker status (yes/no), occupation, social media use (yes/no), vaccine knowledge (yes/no), vaccination awareness (yes/no), vaccination hesitancy (yes/no), vaccination discouragement (yes/no), use of herbal remedies (yes/no), comorbidities, past history of COVID-19 test (yes/no), a known relative with COVID-19 (yes/no) and vaccination status (yes/no).
Rural residence was defined as people who lived outside of provincial towns. Marital status was defined as married if an individual had ever been married, including those who were divorced and widowed. People were considered to have children present if they had biological or adopted children. Education level was defined as primary if an individual had completed elementary education up to or including grade eight (middle school), secondary if they had completed grade nine to grade twelve, or tertiary education if they had undergone education in universities, trade schools or colleges. All participants had some formal education and were literate.
A health worker was defined as being a medical officer, health extension officer, nursing officer, community health worker, laboratory scientist, pharmacist, physiotherapist or radiography technician. Employment was defined as having regular paid work. Social media use was defined as a participant having at least one social media account of either Facebook, WhatsApp, LinkedIn, Instagram or TikTok.
Vaccine knowledge was defined as being present if participants could explain and understand the purpose of the COVID-19 vaccine: that it helps protect against serious COVID-19 infection. Vaccination awareness was defined as the participants having received COVID-19 education from hospital or public health staff. Vaccination hesitancy was defined as participants who felt uncertain about the COVID-19 vaccine compared to those who were sure they either wanted or did not want the vaccine. Vaccination discouragement was defined as being present if participants had been advised against receiving the vaccine by relatives, friends, social media anti-vaccine advocates or professionals.
Use of herbal remedies was defined as a participant who preferred to take herbal remedies over conventional medical therapy. Comorbidities included any pre-existing chronic medical condition. A previous COVID-19 test was considered to have been undertaken if the participant had had a rapid diagnostic test or polymerase chain reaction test for COVID-19 previously. Participants were considered to be vaccinated if they had received at least one dose of vaccine against COVID-19.
Study population
Hospital workers, patients and guardians in KPH and APH were enrolled using convenience sampling. People less than 18 years of age and those who did not consent to be interviewed were excluded from the study. Verbal and written consent was obtained from the participants.
Analysis and statistics
Statistical analysis was performed using Stata version 17. Categorical variables were reported as numbers (percentages) and continuous variables as mean (95% confidence intervals, CI) or medians (inter-quartile range) depending on their frequency distribution. The outcome of interest was vaccination status. Factors associated with vaccination were assessed using logistic regression to determine odds ratios (ORs). The association of factors with vaccination was further explored using a multivariable logistic regression model with the following variables forced into the model: sex, location of residence, level of education, vaccine awareness, preference for herbal remedies and history of a family member having COVID-19. Due to strong correlation with education level, social media use was not included. Similarly, vaccine knowledge and vaccine hesitancy were correlated with vaccine awareness and knowing someone who had died was correlated with location of residence and were not included. A P-value <0.05 was considered significant.
Results
A total of 273 persons were surveyed, 173 (63.4%) from APH and 100 (36.6%) from KPH, with a response rate of 100%. The mean age was 37.2 years, ranging from 18 to 61 years, with 42.1% (n = 115) older than 40 years of age. Females comprised 65.9% (n = 180) of participants. The COVID-19 vaccination rate was 37.0% (n = 101) (Table 1).
Variables | Kavieng Provincial Hospital, n = 100 | Alotau Provincial Hospital, n = 173 | Total, n = 273 | |
---|---|---|---|---|
n (%) | n (%) | n (%) | ||
Gender | ||||
Male | 15 (15.0) | 78 (45.1) | 93 (34.1) | |
Female | 85 (85.0) | 95 (54.9) | 180 (65.9) | |
Age groups | ||||
18–29 | 40 (40.0) | 55 (31.8) | 95 (34.8) | |
30–39 | 19 (19.0) | 44 (25.4) | 63 (23.1) | |
40–49 | 41 (41.0) | 74 (42.8) | 115 (42.1) | |
Residence | ||||
Urban | 81 (81.0) | 113 (65.3) | 194 (71.1) | |
Rural | 19 (19.0) | 60 (34.7) | 79 (28.9) | |
Marital status | ||||
Married | 60 (60.0) | 125 (72.3) | 185 (67.8) | |
Single | 40 (40.0) | 48 (27.7) | 88 (32.2) | |
Children | ||||
Yes | 66 (66.0) | 129 (74.6) | 195 (71.4) | |
No | 34 (34.0) | 44 (25.4) | 78 (28.6) | |
Education level | ||||
Primary | 5 (5.0) | 39 (22.5) | 44 (16.1) | |
Secondary | 12 (12.0) | 48 (27.7) | 60 (22.0) | |
Tertiary | 83 (83.0) | 86 (49.7) | 169 (61.9) | |
Health worker | ||||
Yes | 53 (53.0) | 45 (26.0) | 98 (35.9) | |
No | 47 (47.0) | 128 (74.0) | 175 (64.1) | |
Employment | ||||
Yes | 58 (58.0) | 110 (63.6) | 168 (61.5) | |
No | 42 (42.0) | 63 (36.4) | 105 (38.5) | |
Social media | ||||
Yes | 67 (67.0) | 65 (37.6) | 132 (48.4) | |
No | 33 (33.0) | 108 (62.4) | 141 (51.7) | |
Vaccine knowledge | ||||
Yes | 93 (93.0) | 135 (78.0) | 228 (83.5) | |
No | 7 (7.0) | 38 (22.0) | 45 (16.5) | |
Vaccine awareness | ||||
Yes | 85 (85.0) | 85 (49.1) | 170 (62.3) | |
No | 15 (15.0) | 88 (50.9) | 103 (37.7) | |
Vaccine discouragement | ||||
Yes | 88 (88.0) | 132 (76.3) | 220 (80.6) | |
No | 12 (12.0) | 41 (23.7) | 53 (19.4) | |
Herbal remedies | ||||
Yes | 59 (59.0) | 132 (76.3) | 191 (70.0) | |
No | 41 (41.0) | 41 (23.7) | 82 (30.0) | |
Comorbidities | ||||
Yes | 8 (8.0) | 35 (20.2) | 43 (15.8) | |
No | 92 (92.0) | 138 (79.8) | 230 (84.2) | |
COVID-19 test | ||||
Yes | 29 (29.0) | 16 (9.2) | 45 (16.5) | |
No | 71 (71.0) | 157 (90.8) | 228 (83.5) | |
Family member with COVID-19 | ||||
Yes | 31 (31.0) | 26 (15.0) | 57 (20.9) | |
No | 69 (69.0) | 147 (85.0) | 216 (79.1) | |
Know someone who has died from COVID-19 | ||||
Yes | 30 (30.0) | 70 (40.5) | 100 (36.6) | |
No | 70 (70.0) | 103 (59.5) | 173 (63.4) | |
Vaccinated | ||||
Yes | 65 (65.0) | 36 (20.8) | 101 (37.0) | |
No | 35 (35.0) | 137 (79.2) | 172 (63.0) |
Among the total cohort, 71.1% (n = 194) of participants resided in urban areas. Those with tertiary education made up 61.9% (n = 169) of the group. Hospital staff constituted 35.9% (n = 98) of the participants, with 61.5% (n = 168) being employed. The majority (83.5%) reported having a fair understanding of COVID-19 vaccination, while 62.3% (n = 170) had received some form of public health awareness regarding COVID-19. However, 51.3% (n = 140) of participants reported feeling hesitant about receiving the COVID-19 vaccines and 80.6% (n = 220) reported being discouraged from receiving the vaccine.
The vaccination rate for KPH was 35.0% (n = 35), compared with 20.8% for APH. Fifty-three per cent (n = 53) of participants in KPH were health workers, compared to 26% (n = 45) in APH. Social media use, vaccination awareness, vaccination hesitancy and COVID-19 testing were higher in KPH (Table 1).
There were significantly higher odds of being vaccinated against COVID-19 among participants who were female (OR 2.7, 95% CI 2.5–3.0, P < 0.001), had children (OR 1.5, 95% CI 1.4–1.5, P < 0.001), were health workers (OR 6.5, 95% CI 3.5–12.0), used social media (OR 4.0, 95% CI 1.6–10.2, P = 0.004), had vaccine knowledge (OR 7.6, 95% CI 6.4–9.0, P < 0.001), had vaccine awareness (OR 6.0, 95% CI 4.4–8.2, P < 0.001), were vaccine hesitant (OR 32.7, 95% CI 16.5–64.7, P < 0.001), discouraged against COVID-19 vaccines (OR 3.0, 95% CI 1.2–8.0, P = 0.002), had been tested for COVID-19 (OR 2.8, 95% CI 2.6–3.1, P < 0.001), had family members with COVID-19 (OR 6.0, 95% CI 4.2–8.5, P = 0.001), or knew someone who had died of COVID-19 (OR 2.0, 95% CI 1.8–2.1, P < 0.001). There were reduced odds of being vaccinated in participants who lived in rural areas (OR 0.2, 95% CI 0.1–0.3, P < 0.001), had completed education at primary (OR 0.1, 95% CI 0.1–0.2, P < 0.001) or secondary levels (OR 0.3, 95% CI 0.3–0.3, P < 0.001) compared to tertiary education, or preferred herbal remedies (OR 0.2, 95% CI 0.1–0.7, P < 0.001),
After adjustment for confounding factors, independent predictors for COVID-19 vaccination were female sex (adjusted OR (aOR) 2.1, 95% CI 1.1–3.9, P = 0.024), vaccine awareness (aOR 3.9, 95% CI 3.1–4.9, P < 0.001) and having a family member with COVID-19 (aOR 3.8, 95% CI 3.4–4.3, P < 0.001), whereas predictors of reduced vaccination were rural residence (aOR 0.3, 95% CI 0.3–0.4, P < 0.001), primary education (aOR 0.3, 95% CI 0.1–0.5, P = 0.001) and secondary education (aOR 0.5, 95% CI 0.5–0.5, <0.001) and a preference for herbal remedies (aOR 0.2, 95% CI 0.1–0.8, P = 0.016) (Table 2).
Variables | Vaccinated | Unvaccinated | OR | aOR | |
---|---|---|---|---|---|
n (%) | n (%) | (95% CI) | (95% CI) | ||
Gender | |||||
Male | 21 (20.8) | 72 (41.9) | Reference | Reference | |
Female | 80 (79.2) | 100 (58.1) | 2.7 (2.5–3.0)* | 2.1 (1.1–3.9)* | |
Age groups | |||||
18–29 | 33 (32.7) | 62 (36.0) | 1.0 (0.8–1.1) | – | |
30–39 | 27 (26.7) | 36 (20.9) | 1.4 (0.6–2.9) | – | |
>40 | 41 (40.6) | 74 (43.0) | Reference | – | |
Married | |||||
Yes | 72 (71.3) | 113 (65.7) | 1.3 (0.7–2.3) | – | |
No | 29 (28.7) | 59 (34.3) | Reference | – | |
Children | |||||
Yes | 77 (76.2) | 118 (68.6) | 1.5 (1.4–1.5) | – | |
No | 24 (23.8) | 54 (31.4) | Reference | – | |
Residence | |||||
Urban | 90 (89.1) | 104 (60.5) | Reference | Reference | |
Rural | 11 (10.9) | 68 (39.5) | 0.2 (0.1–0.3)* | 0.3 (0.3–0.4)* | |
Education level | |||||
Primary | 5 (5.0) | 39 (22.7) | 0.1 (0.1–0.2)* | 0.3 (0.1–0.5)* | |
Secondary | 12 (11.9) | 48 (27.9) | 0.3 (0.3–0.3)* | 0.5 (0.5–0.5)* | |
Tertiary | 84 (83.2) | 85 (49.4) | Reference | Reference | |
Health worker | |||||
Yes | 63 (62.4) | 35 (20.3) | 6.5 (3.5–12.0) | – | |
No | 38 (37.6) | 137 (79.7) | Reference | – | |
Employment | |||||
Yes | 74 (73.3) | 94 (54.7) | 2.3 (0.7–7.0) | – | |
No | 27 (26.7) | 78 (45.3) | Reference | – | |
Social media | |||||
Yes | 70 (69.3) | 62 (36.0) | 4.0 (1.6–10.2) | – | |
No | 31 (69.3) | 110 (64.0) | Reference | – | |
Vaccine knowledge | |||||
Yes | 97 (96.0) | 131 (76.2) | 7.6 (6.4–9.0) | – | |
No | 4 (4.0) | 41 (23.8) | Reference | – | |
Vaccine awareness | |||||
Yes | 86 (85.1) | 84 (48.8) | 6.0 (4.4–8.2)* | 3.9 (3.1–4.9)* | |
No | 15 (14.9) | 88 (51.2) | Reference | Reference | |
Vaccine hesitancy | |||||
Yes | 92 (91.1) | 41 (23.8) | 32.7 (16.5–64.7) | – | |
No | 9 (8.9) | 131 (76.2) | Reference | – | |
Vaccine discouragement | |||||
Yes | 91 (90.1) | 129 (75.0) | 3.0 (1.2–8.0) | – | |
No | 10 (9.9) | 43 (25.0) | Reference | – | |
Herbal remedies | |||||
Yes | 49 (48.5) | 142 (82.6) | 0.2 (0.1–0.7)* | 0.2 (0.1–0.8)* | |
No | 52 (51.5) | 30 (17.4) | Reference | Reference | |
Comorbidities | |||||
Yes | 16 (15.8) | 27 (15.7) | 1.0 (0.8–1.3) | – | |
No | 85 (84.2) | 145 (84.3) | Reference | – | |
COVID-19 test | |||||
Yes | 26 (25.7) | 19 (11.0) | 2.8 (2.6–3.1) | – | |
No | 75(74.3) | 153 (89.0) | Reference | – | |
Family member with COVID-19 | |||||
Yes | 40 (9.6) | 17 (9.9) | 6.0 (4.2–8.5)* | 3.8 (3.4–4.3)* | |
No | 61 (60.4) | 155 (90.1) | Reference | Reference | |
Know someone who has died from COVID | |||||
Yes | 47 (46.5) | 53 (30.8) | 2.0 (1.8–2.1) | – | |
No | 54 (53.5) | 119 (69.2) | Reference | – |
* P-value < 0.05.
Discussion
COVID-19 vaccination rates remain desperately low in PNG, placing it as one of very few countries outside of sub-Saharan Africa that have failed to vaccinate over 30% of their adult population.19,20 The vaccination coverage in this study was 37%; a rate much higher than the national rate of 3.6%.21 This increased rate likely reflects the inclusion of a high proportion of health workers in the survey, but remains a long way off the estimated 70% rate required to achieve herd immunity.6 Moreover, the high vaccination coverage also reflects the population likely to be in urban settings, and not the rural population where vaccination access remains limited.
Almost half of the surveyed cohort in this study were over the age of 40 years. The female gender was significantly linked to higher vaccination uptake, consistent with findings among female health workers in Italy and two studies from China, where vaccination rates among women ranged from 81.9% to 89.5%.22–24 Similar correlations were seen in other studies in LMICs, where female health workers were associated with increased vaccination uptake.25–27
Social media is associated with increased vaccine hesitancy and reduced vaccine acceptance.28,29 Over 31 million people follow ‘anti-vaxxers’ on Facebook and individuals who rely on social media for information were found to be more hesitant to vaccines.30 Contrary to this, our study showed that individuals who engage in social media had a four-fold higher odds of getting vaccinated.31 Basch et al. evaluated the 100 most viewed videos on YouTube with the word ‘coronavirus’ and found that one-third of the videos elaborated on preventative measures.32 Governments and health organisations have now realised the role of social media in the fight against COVID-19. The shift from mainstream television and newspapers to more content-driven partnerships online has become a strategy to disseminate accurate health information and combat anti-vaccination activists.31 Supporting this approach, COVID-19 awareness was associated with vaccination uptake in our study and awareness has been correlated previously with effective government programs that emphasised COVID-19 vaccination knowledge.33
In this study, those who described vaccine hesitancy had a 32-fold increased odds of getting vaccinated. Vaccine hesitancy exists not as a binary outcome of either acceptance or refusal, but rather on a continuum ranging from overt acceptance to uncertainty, delay, and outright refusal.34 Vaccination hesitancy does not necessarily equate to vaccination refusal, it is derived from political and cultural roots and is commonly related to anti-vaccination propaganda.35,36 Rather, vaccine-hesitant individuals may be uncertain about fears like needles.37 They may have distrust in the health system, have concerns about vaccine safety or have been discouraged against vaccination, which in this study was also associated with increased vaccine uptake.36 Despite hesitancy, they may accept vaccination once their concerns are addressed.37 This may have been the case in this study, whereby concerns were addressed through awareness and knowledge about vaccinations. In addition, it is possible that some individuals who refused vaccination did not describe vaccine hesitancy and were certain in their decision to not undergo vaccination. The high rate of vaccine hesitancy in those undergoing vaccination (> 90%), may also reflect a community environment of concern about COVID-19 vaccines, rather than the majority of individuals feeling reassured and comfortable about undergoing vaccination.
A global survey showed 4–60% of people had either been tested, knew someone who had tested positive or knew someone who had died from COVID-19.38 A study from Bangladesh identified that key experiences such as these are significantly associated with early vaccination.39 In our study, all three of these experiences were associated with increased vaccination uptake.
More than 80% of PNG’s population live in rural locations and this study shows rural residence to be a strong predictor of reduced COVID-19 vaccination.16 Similar findings have been reported in rural Ethiopia40 and in other LMICs where the barriers of COVID-19 vaccination were vaccination hesitancy, demographic factors and misinformation.41 As with rural residence, primary and secondary level education were associated with reduced COVID-19 vaccination. Education is important as it plays a pivotal role in LMICs, where higher levels of education can lead to improved health literacy and higher awareness and knowledge of COVID-19, which improves vaccination acceptance.42 Non-educated individuals in PNG may face greater barriers to vaccine uptake due to misinformation, lack of trust in healthcare systems, cultural beliefs, and limited access to vaccination services.
Herbal remedies are an integral part of Papua New Guinean culture.43 In this study, those who opted for herbal remedies had a significantly reduced odds of vaccination. Although reports have emerged of COVID-19 being cured with traditional Chinese medicine,44 there is no published peer-reviewed clinical evidence to support the use of herbal treatments at this stage.45
This study had a number of limitations. Firstly, this was a hospital-based survey compared to a population-based survey. The study had a relatively small sample size and although the present vaccination rate was high (37%), it did not represent the national prevalence and coverage profile of PNG. The use of convenience sampling may not have given a representative result of the general population and restriction to two sites may have prevented variations of experience across different populations. Many participants were health workers and, as such, likely had increased education, increased understanding of COVID-19 and better knowledge of vaccination. Furthermore, the study did not capture the occupation of those patients and guardians surveyed. Despite these limitations, the study provides important insights into why PNG’s vaccination rate may be so low.
In light of the increased availability of COVID-19 vaccines in PNG since April 2022, this study aims to examine the current barriers and enablers of vaccine uptake among key populations. By identifying factors associated with low vaccination rates, the study underscores the urgent need for targeted public health interventions to improve vaccine coverage and strengthen pandemic preparedness at both local and national levels.
Potential public health interventions could involve women in rural outreach programs to disseminate information among young girls, mothers and other women. A public–private partnership could address vaccination literacy in workplaces, improving communication and providing a system for vaccination counselling and uptake. Furthermore, vaccination awareness programs need to assume low levels of education and health literacy, and in conjunction with social media, advertising should focus on building confidence in the vaccination program. There is minimal literature on COVID-19 in PNG and more research is needed to identify social determinants and system failures affecting COVID-19 vaccination.
Conclusion
PNG’s COVID-19 vaccination rate is among the lowest in the world. This survey of individuals from two hospital sites identified key factors associated with reduced vaccination uptake. These factors are important to inform public health messaging and interventions aimed at increasing vaccination coverage and achieving herd immunity through social media use and community awareness, and through improved primary health care and vaccination supply.
Acknowledgements
The authors would like to thank Mr Patterson Marengas and Dr Jacob Morewaya for their support in approving the survey in both provincial hospitals.
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