This chapter draws together findings from previous chapters under the domains of the COM-B model of behaviour. The theory behind COM-B is that, in order for a behaviour to take place, individuals should have the Capability (both psychological and physical); the Opportunity (both social and physical) and the Motivation (either reflective or automatic) to do so. If significant barriers exist within any domains, undertaking the behaviour is challenging.
The research has identified both enablers and barriers to engagement with the vaccination programme under each of the COM-B domains. Each domain is now considered in turn, in order of influence on engagement with the current vaccination programme. Understanding where the barriers lie facilitates the identification of interventions best suited to addressing them, with COM-B also providing intervention guidance.
In the context of the current vaccination programme, where participants were not typically hindered by informational or practical barriers, motivational factors exerted the greatest influence on vaccination decisions.
COM-B separates motivation into automatic and reflective dimensions with automatic motivation being driven more by emotional reactions or impulses, such as fear and anxiety, and reflective motivation being more considered decision making, such as intentions of behaviours and beliefs about consequences.
Personal health risk was a key factor in vaccination decisions and this was driven, at least in part, by automatic motivation. Whether feelings of fear and anxiety around health risk acted as enablers or barriers depended on whether participants were more anxious about the potential health effects of Covid-19 or of the vaccine. On the one hand, there were participants who were highly anxious about catching Covid-19 and were keen to receive the vaccination as soon as possible. This appeared to be a largely automatic decision with little, if any, consideration given to the possibility of not receiving the vaccination. On the other hand, however, were participants whose overwhelming anxiety about potential side effects of the vaccine (e.g., blood clots) was not something they could overcome.
As noted in Chapter 6 above, automatic motivation as an enabler to vaccination played a greater role at the start of the vaccination programme, due to the context of the pandemic at that time. It became less influential over time as participants felt less at risk from Covid-19 due to, for example, having some protection from vaccinations, having had Covid-19 mildly, or perceiving the Omicron variant to be milder.
There were multiple examples of the role of reflective motivation in the decision making process. The most significant one relates to the 'beliefs about consequences' element of reflective motivation. In making the decision on whether to receive vaccinations, participants' beliefs in relation to the following key questions acted as important enablers and barriers:
- does Covid-19 present a risk to my health?
- will the vaccination prevent me catching Covid-19?
- will the vaccination prevent me becoming seriously ill with Covid-19?
- will I experience side effects from the vaccination?
- will getting vaccinated help protect others?
- will getting vaccinated help ease restrictions?
- will I be able to travel if I get vaccinated?
Views on these topics changed through the course of the vaccination programme and would be expected to continue to do so as the pandemic context evolves.
Physical capability relates to having the physical skill, strength or stamina to engage in a behaviour. In the case of receiving a vaccination, this includes considerations such as being physically able to attend a vaccination appointment as well as feeling physically well enough to cope with any side effects of a vaccine. Given the overlap with accessibility enablers and barriers, covered under the physical opportunity dimension (below), this section focuses only on the latter of these.
For the most part, physical capability did not prevent people being vaccinated. Indeed, being in poor physical health was often a reason for being vaccinated. There were, however, instances of participants (particularly those with heart or respiratory conditions they believed could be affected by the vaccine) describing difficult decisions as they were concerned about the potential health effects of both the Covid-19 vaccination and of contracting Covid-19 itself.
Conversely, a feeling of being in very good health, and not at risk from Covid-19, could act as a barrier to vaccination.
The psychological capability domain of COM-B concerns having the knowledge or psychological skills to undertake the desired behaviours. There are two main elements to this in the context of the vaccination programme. First, do participants have the capability to access and understand the information needed to make an informed vaccination decision, and, second, do they know how to go about being vaccinated?
In relation to the first, participants typically felt that they had been able to make an informed decision from the information available. However, there were exceptions to this. These were not typically linked to a lack of capability to source and assess information but rather to a lack of available information of the type being sought (e.g., detailed statistics on side effects and long-term safety of the vaccine). There was an acknowledgement that this type of information may not yet exist, due to the speed at which the vaccine has been introduced and the ever-changing context of the pandemic. These participants had often not rejected outright the possibility of being vaccinated but were delaying until they had more information.
For other participants, barriers relating directly to psychological capability did exist. These included being unable to understand more technical information of the kind they were looking for (e.g. technical information included in scientific or medical journals) or being unable to access official information due to difficulties with reading (particularly among the Gypsy Traveller community). A more general lack of trust in government and authority also appeared to have negatively influenced interpretation of official information sources or put participants off engaging with them altogether.
In relation to the second point above, participants were clear on how to go about being vaccinated.
Social opportunity considers how interpersonal influences, social cues and cultural norms can influence decisions. In relation to vaccination decisions, it includes the extent to which people are influenced by those around them, both people close to them and wider societal norms.
Overall, social influences had a positive impact on vaccination take up. There were cases of participants explicitly stating the influence of others on their decision to be vaccinated (for example friends and family encouraging them to be vaccinated if they were vulnerable). However, there was also a clear sense of social influences coming through more implicitly. For participants who received the vaccination with little hesitation, there was a feeling that they were doing so because they considered it to be the social norm - the 'right' thing to do.
There was, however, evidence of this more implicit social motivation waning over time with some participants weighing up the decision to have second/third doses or future vaccinations more carefully. In discussing these, they were more focused on the risks and benefits to them personally rather than to society as a whole.
Disengaged participants were clearly not swayed by any social expectation to be vaccinated. In some cases, their disengagement from the vaccination programme appeared to be linked to low levels of trust in government and authority more generally.
Participants who had engaged with the vaccination programme also described more negative social influences (for example, holding different views to friends and family, scaremongering information on social media and greater scepticism in their communities e.g., Polish, Black African). While these had not typically dissuaded them from engaging in the vaccination programme altogether, they made decisions more difficult and contributed to some participants choosing not to receive the booster.
Physical opportunity considers the influence of the external environment (i.e., time, resources, locations, cues, and physical ease). In this case, it includes factors such as the accessibility of venues, timings of vaccination appointments and practical experience of vaccination appointments.
Overall, it is clear that physical opportunity factors acted more as an enabler to vaccination than as a barrier for the current programme, with participants typically describing positive experiences of being vaccinated and, on the whole, being able to overcome any barriers that existed, for example rescheduling appointments to a more suitable location.
However, there were exceptions to this, with the physical environment acting as a barrier or, at least presenting difficulties, in certain circumstances. These included: not having received invitation letters; challenges organising childcare or time off work to attend; difficulties travelling to vaccination appointments without access to a car, resulting in either incurring the expense of taxis or having to rely on others for transport (particularly pronounced in, although not exclusive to, those living in rural areas); and venues and vaccination staff contributing to a less positive experience (e.g., long queues affecting waiting times as well as raising concerns about Covid safety, access difficulties for those with certain health conditions and disabilities, and occasional negative interactions with staff).
Reflecting on their own challenges and considering the needs of others, participants expressed a desire for future vaccination programmes to be inclusive, accessible, flexible, friendly and welcoming.
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