Views on COVID-19 vaccination among residents of Eldoret, Kenya during the 2021 vaccine rollout

ABSTRACT The Government of Kenya initiated COVID-19 vaccination program in March 2021. However, vaccine uptake remains low, especially in rural areas in Kenya. We interviewed 40 residents of Eldoret town to explore the knowledge, beliefs, and meanings they attach towards vaccines generally, and why they chose to vaccinate or not. Two-thirds of our participants perceived themselves to be at risk of COVID-19 infections. About half demonstrated willingness to be vaccinated and about a third had been vaccinated. All participants were knowledgeable about the broader benefits of vaccination. Yet, widespread beliefs that vaccination programmes target children and pregnant women decreased vaccine acceptance. Also, we found that concerns about vaccine safety, lack of knowledge, misinformation from social media, and conspiracy theories contributed to COVID-19 vaccine hesitancy in Eldoret. Low COVID-19 vaccination rates and hesitancy – even when the vaccines are accessible and free in Kenya – cannot be ignored. The current COVID-19 vaccination prioritisation schedule (distinct from the usual structure where children, childbearing women are prioritised) and beliefs that older people are targeted to test vaccines efficacy must be addressed through improved communication and mass education. More research is needed to investigate the socio-economic, political, and historical factors that influence vaccine hesitancy in Kenya.


Introduction
COVAX, or the COVID-19 Vaccines Global Access facility, has made important strides toward global vaccine distribution around the world.Active in Kenya since March 2021, COVAX distributed many vaccines in East Africa that targeted high-risk groups such as health workers, teachers, and the elderly who primarily resided in cities (Orangi et al., 2021;Shah et al., 2022).While much has been said about the strategy of distributionof who was vaccinated when, were, and with what (Muchiri et al., 2022;Orangi et al., 2021;Shah et al., 2022) few studies have investigated how Kenyans outside the capital think about vaccine distribution and uptake.Some have argued that the difficulties associated with delivery and slow distribution of vaccines caused distrust among many rural communities throughout Kenya (Galadima et al., 2021;Muchiri et al., 2022).While slow delivery of vaccines was beyond the Government of Kenyaas this was influenced by access to sufficient doses in light of the global shortage as well as vaccine nationalism where wealthier countries could hoard vaccinations from manufacturers and increase supply in their own countries (Riaz et al., 2021), this had dire impacts to rural populations in Kenya as residents lacked information about this macro level politics around vaccine supply.These concerns are similar across contexts, where convenience and complacency vary (Afolabi & Ilesanmi, 2021;Larson et al., 2020).Across the globe, vaccine hesitancy has been attributed to factors such as lack of confidence in the products, meaning that people perceived the vaccines received in their communities to be of lesser quality than those administered elsewhere (Larson et al., 2014).A recent study conducted in six sub-Saharan African (SSA) countries has reported concerns about the vaccine safety and its side effects as key factors that hindered vaccine uptake in the regions (Kanyanda et al., 2021).This is also common in the United States, where vaccine hesitancy has been linked to historical narratives of distrust and the expectation that vaccine products distributed to historically black and segregated areas were of lesser quality and value (Cho et al., 2023).Similarly, some studies in Kenya have attributed vaccine hesitancy to deep-seated mistrust in vaccine efficacy and limited knowledge about the COVID-19 vaccine (Shah et al., 2022) as well as conspiracy theories and misinformation (Rego et al., 2023).Others have attributed vaccine hesitancy to public anxiety around the accelerated pace of COVID-19 vaccine development (Chan et al., 2022;Viswanath et al., 2021).Even so, historical vaccine distribution may play an outsized influence on vaccine uptake of new vaccination campaigns (Larson 2020).
Vaccination programs in Kenya have historically focused on children (Gibson et al., 2015) and are largely considered the highest impact of public health interventions (Dawa et al., 2020), fueling higher survival rates for polio, measles, and pneumococcal diseases (Adetifa et al., 2018).While the high childhood immunisation rates may indicate that vaccination is a widely accessible and accepted, we contend that who was targeted for vaccination, where, and why may have played an outsized role in how people perceived the COVAX efforts during that first year of the vaccination rollout for COVID-19 in Kenya.In this article, we consider how residents of Eldoret towna large town in the Rift Valley of Kenyaperceived and experienced vaccine rollout in 2021.We focus particularly on the meanings people attach towards vaccines, as well as whether they chose to vaccinate for COVID-19 or notand why.

Vaccine hesitancy
The World Health Organization's (WHO) Strategic Advisory Group of Experts (SAGE) on Vaccine Hesitancy Working Group defines vaccine hesitancy as a 'delay in acceptance or refusal of vaccines despite availability of vaccination services' (World Health Organization SAGE Working Group, 2012, p. 7).Public health scholar David Callender (2016) expands on this definition by arguing that vaccine hesitancy can be conceptualised as a spectrum between concern towards and outright rejection of the technology: Some may express general skepticism towards all vaccines, while others may evaluate vaccines on a case-by-case basis and express unique opinions about each one (Tram et al., 2022).In many cases, views on vaccination vary based on changing information and social and environmental circumstances (Betsch et al., 2018, p. 4).Common frameworks on vaccine hesitancy posit that an individual's willingness to vaccinate depends on the interaction of factors such as confidence, complacency, and convenience of access to the technology (Betsch et al., 2018, WHO SAGE Working Group, 2012, p. 7;Larson et al., 2015, p. 3).
In this framework, 'confidence' refers to an individual's trust in the safety and efficacy of vaccine(s), as well as the healthcare infrastructure that distributes them (Larson et al., 2014, p. 4;WHO SAGE Working Group, 2012, p. 11).This may play a fundamental role in rural Kenyans' (dis)trust of vaccines, as disparate access to healthcare servicesparticularly among populations in rural areas and urban informal settlementshas proven to be the biggest challenge for implementing Kenya's universal health coverage policy (Otieno et al., 2020).Moreover, vaccine safety concerns may be related to both side effects and long-term consequences of immunisation, which become rationales for limiting uptake (Callender, 2016(Callender, , p. 2466)).Worries could be magnified by administrative factors such as a multi-dose vaccination course or instances of previous immunisation, as individuals could fear negative consequences from different vaccines' interactions (Rutten et al., 2015).Other clinical studies suggest that vaccine-hesitant people engage in a 'cognitive fallacy' where individuals minimise the positive outcomes of vaccination while inflating the risks of getting vaccinated (Callender, 2016).Yet, Black feminist scholars have critiqued this framing, as it posits that hesitancy is distinct from the embodied experiences of marginalised populations that have been subject to violent technologies from the same institutions that advocate for vaccination (Charles, 2022).When faced with new information and difficult health decisions, this collective trauma can lead individuals to view vaccination with skepticism (Charles, 2022).
Indeed, vaccine confidence heavily depends upon trust in the motivations and actions of government and health authorities that distribute vaccines (Larson et al., 2015).Individuals who mistrust these institutions may have a variety of reasons for doing so.Lack of confidence can be informed by individuals' negative experiences with these authorities, including acute instances of maltreatment or stigmatisation (Larson et al., 2015, 3, Wahlberg et al. 2021: 2), and can lead people to seek alternative forms of care, such as spiritual or traditional healers (Larson et al., 2015).Yet, confidence can also be undermined by systemic, long-standing justifications of mistrust in biomedicine due to individual or community disenfranchisement (Sobo & Elżbieta, 2021, p. 70).Historical and ongoing discrimination can cast doubt on vaccine distributors' intentions.Moreover, it can raise suspicions that healthcare authorities' immunisation advocacy is manipulative or harmful (Charles, 2022, p. 5;Sobo & Elżbieta, 2021).This suspicion can lead to the rise of vaccine 'conspiracy theories'ideas that operate in contrast to accepted understandingthat spread through groups and influential community leaders (Charles, 2022, Smith, 2017, p. 2).Medical anthropologists Sobo and Elżbieta (2021) argue that 'conspiracy theories' are often reflective of an individual or community's deep ideas, values, and fears regarding healthcare authorities' power over citizens (69).Thus, vaccine hesitancy can be an inherently political phenomena, where articulation of 'conspiracies' becomes a part of marginalized groups' '[bids] to be seen' and served by the state (Sobo and Elżbieta, 2021, 71).
Literature regarding vaccine confidence therefore suggests that trust in the technology and its distributors are closely linked, often affecting one another (, Smith, 2017, p. 4;Sobo and Elżbieta, 2021).Increased confidence in vaccine technology and its associated distribution system has been associated with greater uptake of that vaccine globally (de Figueiredo et al., 2020, p. 898;Troiano & Nardi, 2021, p. 3).Conversely, a lack of this trust undermines vaccination efforts (de Figueiredo et al., 2020, p. 899;Troiano & Nardi, 2021).Logistical barriers such as long distances, difficulty coordinating transportation, and the time associated with getting vaccinated can impede uptake (WHO SAGE Working Group, 2012, p. 12).Lack of well-publicised information about how and where to receive a vaccine may also undercut convenience (WHO SAGE Working Group, 2012).Betsch and colleagues (2018) argue that, in some instances, vaccine inconveniences may be caused by individuals' complacency.For example, residents may not allocate enough time for vaccination, or may not actively look for vaccine sites (Betsch et al., 2018).
In this article, we ask: how was the COVID-19 vaccine understood in rural towns in Kenya in 2021?How does past vaccine history and experience influence current uptake of COVID-19 vaccines?In other words, how did people make meaning from and add value to the vaccines, from the technology to roll out?In asking these questions, we seek to understand how people perceive vaccination generally, and why and how people navigated decisions to vaccinate for COVID-19.We consider the ways in which society imbues values and beliefs not only on individual decisions to vaccinate, but also what vaccines mean in the midst of an urgent pandemic crisis in relation to their experiences and contextual realities.

Materials & methods
This qualitative study was conducted in Eldoret town, the administrative capital of Uasin-Gishu County in Kenya.Uasin-Gishu County is one of the 47 counties in Kenya situated in Kenya's Rift Valley where access to healthcare services (including immunisation programmes) is limited due to factors such as distance to the hospital and out-of-pocket payments for major health services (Bosire et al., 2018).From October to December in 2020, we conducted a study on COVID-19 that explored the social risks, economic dynamics, and the local politics of COVID-19 prevention in Eldoret town during the first year of the pandemic that demonstrated how trust built early in the pandemic was broken due to individual leaders who eventually dismissed public health promotion and engaged in politics and corruption of funds for COVID-19 relief (Bosire et al., 2022).When COVID-19 vaccines were implemented the following year, we returned to investigate how Eldoret residents perceived vaccine rollout from the government and if they were indeed willing to be vaccinated.
In June and July 2021, we conveniently recruited 40 participantsa different sample from our initial studyfrom Eldoret town to take part in COVID-19 vaccine study.Inclusion criteria was adults aged 18 years and above who originally came from Eldoret town and consented to participate in the study.Exclusion criteria involved participants who were sick or influenced by substances and those who refused to consent to participate in the study.
These participants took part in in-depth qualitative interviews lasting for average of 60-minutes.Open ended questions focused on their knowledge, perceptions of vaccines and whether they were willing or unwilling to be vaccinated.We also asked questions around whether participants had been previously vaccinated against other illnesses and whether their past vaccine experience influenced their current vaccine perceptions and attitudes.Participants were asked if they were willing to be interviewed face-to-face or telephonically.For those who preferred to be interviewed telephonically, we sent information sheet and consent forms to their email addresses and requested them to sign and send back the signed consent forms in order to participate in the study.We then used mobile phones to call and schedule interview appointments with our participants and requested that they speak to us from a private space where they could feel comfortable to discuss the topic with us.Those who agreed face-to-face interviews were interviewed either at their homes or places of work.Written informed consent was obtained from the study participants after reading out the content of the information sheet and explaining the purpose of the study.All interviews were audio-recorded.The interviews were conducted in Kiswahilia common local language in Kenya, and a few interviews used both Kiswahili and English.This study was approved by the Human Ethics Review Committees at Georgetown University USA (STUDY00002592) and Maseno University in Kenya (MSU/ DRPI/MUERC/00885/20).

Data analysis
All interviews were transcribed directly into English, and data analysis was conducted thematically.To begin with, we used the third and fourth authors' extensive field notes from interviews as a jumping off point for the development and definitions for our codebook.The first author developed a codebook, which was reviewed by all authors.These authors discussed the codebook, proposed codes, provided definitions, then reviewed and revised codes based on mutual agreement.Codes were then manually applied to relevant blocks of text in the transcripts.Identified new codes were added to the codebook, and all transcripts were reviewed again in an iterative process.LWK and ENB were the primary coders -LWK coding 30 transcripts and ENB coding the remaining transcripts.They then discussed the key identified themes in an iterative manner while going back and forth to transcripts and addressing any identified discrepancies.Key themes and sub-themes were presented and reviewed by all researchers involved in the study.Any discrepancies were identified and resolved.LWK then proceeded with new classification and later summarised the findings into six broad themes with various subthemes as discussed below.

Socio-demographic information
We interviewed 40 participants who resided in various estates in Eldoret town, including 23 men and 17 women.Our interlocutors were between 18 and 40 years of age, with the majority between 26 and 30 years.Most participants were educated to college or university level, with a few not having gone to school or educated up to primary level.Many participants were either self-employed or worked as casual labourer's and about a quarter reported that they were unemployed.While about two thirds of our participants cited that they were at risk of COVID-19 infections, about half were willing to be vaccinated; and about a third had already been vaccinated for  In what follows, we discuss six key themes identified in this study: vaccine beliefs, perceived benefits of vaccines, who is prioritised in vaccination programmes in Kenya, previous experiences with vaccination, perceptions and attitudes of COVID-19 vaccines, and Differing opinions about COVID-19 vaccines.

Vaccines beliefs
Everyone we spoke to had an understanding of what vaccines were.For instance, a 25-year-old man said, 'I will define a vaccine as an inactive form of a microorganism that cause infection that is introduced into a person's body to improve the immunity system and fight the disease when infected'.A 34-year-old woman explained it more simply: 'according to me, vaccines are medication offered to prevent a person from a certain disease'.A 25-year-old man said, 'vaccines, they can be generated from a subspecies of the viral form that is generated by laboratory procedures'.A 32-year-old man said, 'Yeah, they are made to look like the disease itself, so that when the antibodies are produced in the body, the vaccines are there as soldiers who know the enemy well'.These responses demonstrate that some participants' understandings of vaccines and where they come from were very sophisticated.
Others were less familiar with where vaccines came from and therefore associated them with the government or international agencies.A 40-year-old woman said, 'They just come from the Ministry of Health, now the source I can't know where exactly' and a 33-year-old woman said, 'to be honest, I don't really know where vaccines come from'.Others believed that vaccines were manufactured abroad in wealthy countries and imported to Kenya.A 28-year-old man said, 'They come from developed countries, for example, we have South African vaccine, we have Russian vaccine'.Another man said, 'They are manufactured by pharmaceutical companies, and they are very expensive to manufacture'.Such variations in knowledge and origin of vaccines influenced how people perceived vaccines including its benefits and which populations were targets for vaccines.

Perceived vaccine benefits
All participants believed that vaccines were important.First, many described how vaccination was recommended by the government and ministry of health in Kenya, substantiating their importance.A 40-year-old man explained pragmatically: 'I believe that all vaccines are important because the Ministry of Health has directed people to be vaccinated'.Others described how they learned about vaccines and vaccine boosters when they were young and have always understood why they were important: 'According to my primary school science, I learnt that people need vaccines in order to strengthen their immune system and prevent them against certain diseases like polio'.[46-year-old man] Most people linked vaccination benefits explicitly to children, who were perceived to need immunity booster to thrive: Like babies, it is recommended that a child must be vaccinated against diseases such as polio, measles and rotavirus.You know the vaccines boosts their immunity.By the time a child grows; the difference is clear.Those who have not been vaccinated are usually weak and prone to diseases.[26-year-old woman] A 31-year-old woman similarly explained that vaccines are important: 'To fight diseases […] and when children are small, they are vaccinated so that as they grow up, they have the antibodies to fight diseases like Polio and measles'.
Some people pointed out the risks of not being vaccinated for polioa highly visible disability that occurs somewhat widely when people are not vaccinated and a campaign that has received a great deal of visibility in global health.A 30-year-old woman described a scenario she witnessed saying: I have seen on television people who are disabled due to failure of their parents taking them to hospital to be vaccinated for Polio,' and in some cases death, 'Because if you don't vaccinate polio can cause crippling and tetanus is also very dangerous, it kills people The frequency for which people discussed polio demonstrates not only a working understanding of polio disease and the impacts of vaccination but also the success of public health education for this well-funded vaccination program.

Who is prioritised in vaccination programmes?
People were quick to say that vaccines were important to everyone, and then shift to emphasise how vaccination was a requirement in Kenya for all children under five years of age.A 35-year-old man said, 'It's important for everyone, and especially the young children, this is according to the requirements of the Ministry of Health'.These comments emphasise the salience and acceptance of childhood vaccination by the Kenyan Ministry of Health.However, only a few people discussed why adults needed to be vaccinated.It was repeatedly mentioned that children needed vaccines for their growth and preventing them from getting sick: 'Children from 0-5 years are more prone to infections compared to adults.They need to be vaccinated to provide immunity'.A few participants suggested that adults could get vaccinated (e.g. against flu), although the cost of getting vaccinated as an adult was perceived to be very expensive.This was discussed in relation to the fact that the government provided free medical care including vaccination for children under the age of 5, while adults needed to pay out of pocket for this vaccination.As a 38-year-old man said: 'Of course in general, it's mostly children.I mean, government provides free care for children.I have never taken any vaccine because it is very expensive'.
Participants also revealed that there were some restrictions on vaccination.For example, pregnant women were said to be exempted from some vaccines; 'Pregnant women have restrictions on what type of vaccines they should receive in order to protect both the mother and child' [32-year-old woman].Yet, most people believed that the elderly or most at risk populations were the key targets for COVID-19 vaccination; this made some of the participants to believe that they might not need to be vaccinated due to their youth; 'I believe the government knows better those who are vulnerable like the elderly, that is why young people like us have not been targeted' [26-year-old male].

Previous experiences with vaccination
Almost two thirds of the participants cited that they had been vaccinated in their lifetime, such as a young woman who said: 'In my adulthood, I have received vaccines for tetanus, pneumonia, typhoid and Hepatitis B'.Two participants (a man and a woman) revealed that they had been vaccinated for typhoid while five participants (two men and three women) reported having been vaccinated for Hepatitis B and yellow fever.These participants explained that they were vaccinated because it was mandatory for children to be vaccinated as directed by the government of Kenya.Most women also expressed that they were vaccinated due to mandatory vaccines given during ante-natal clinics (ANC).For these women, tetanus was the most common vaccines that was discussed and said to be administered during first trimester of pregnancy.A few men reported that they had received tetanus vaccine due to injuries resulting from coming into contact with metal, a 28-year-old man said, 'oh yes.I received a tetanus jab last year when I was pricked by a nail at a construction site'.Others mentioned that they were vaccinated as adults as a requirement for travelling: A 26-year-old man said, 'I was vaccinated against trachoma and yellow fever when I was travelling outside the country.And recently, I was even vaccinated against COVID-19'.No one described any major side effects from vaccination.
However, a third of our study participants revealed that they had never been vaccinated for anything.The reasons for non-vaccination included religious beliefs against immunisation; 'My parents could not allow me or any of my siblings to be vaccinated as it is against our religion', [34-year-old woman].Another 38-year-old man said, 'My church is against vaccines, it is believed that vaccines can alter reproduction especially for women'.

COVID-19 vaccines: perceptions and attitudes
In our previous COVID-19 study in Eldoret, we found people believed that COVID was a 'political tool' used by politicians for their own interest (Bosire et al., 2022, Larson, 2020).Such perceptions around COVID-19 seemed to influence how people perceived the COVID-19 vaccine roll-out during the current study.A 35-year-old man said, 'I cannot accept to be vaccinated because, COVID-19 is not real'.While, two in five people that we spoke to stated that they would accept vaccination once vaccines were available, a third of the participants reported that they will not accept vaccination, and a few were unsure whether they should be vaccinated (see Table 1).

Differing opinions about COVID-19 vaccines
Participants provided various reasons why they would accept or refuse to vaccinate for COVID-19.First, trust in the World Health Organization (WHO), and the Kenyan Governmentthrough the ministry of health were repeated by many participants to be a key reason why they would be vaccinated, noting that the WHO would not approve harmful vaccines.In addition, trust in vaccines was described in relation to people having witnessed others vaccinated without anything bad (side effects) happening to them.A 35-year-old man said: 'I will accept to be vaccinated since most people have been receiving the vaccines and have not presented any side effects'.Many opined that; 'Nothing can ever be 100 percent safe, but they are important in order to stop the spread of the virus'.[34year-old man] Others believed that vaccination was important, 'Because people who have been vaccinated are less likely to get severe symptoms of COVID-19'.[31-year-old woman] Similar thoughts were also reported by others who were willing to be vaccinated to go back to their routine work and feel safer in doing so for their health and the health of potentially vulnerable family members.This was closely linked to those who revealed that they were vaccinated due to a workplace requirement.Others were vaccinated due to family pressure, such as a father who said: 'My wife forced me to get the vaccine.I probably would not have taken it'.
Nearly one in three reported that they were either unwilling to be vaccinated and one in eight suggested they were unsure whether to be vaccinated or not.This was attributed to various reasons.Mistrust about the safety of the vaccine as well as doubts around the short time used to develop vaccines was key concerns to vaccination hesitancy.A 30-year-old man said: I cannot say they are safe neither are they harmful.This is because, for a vaccine to be considered safe for use it has to be tested for some time and it cannot be less than a year.Its effectiveness has to be tested before it is declared safe or harmful for use.
Others wondered why COVID-19 vaccines were developed in a rush while diseases such as HIV/ AIDS had not been addressed: 'I think that the vaccines have been developed within a very short time which is making many people question the safety of the vaccines.Why has it taken decades to come up with HIV/AIDS vaccines or cure?' Second, some participants raised concerns around negative side effects of vaccinesarguing that no one really understood what can happen few years after being vaccinated.An elderly man said, 'I think the vaccines are not safe for use.This is because of the negative side effects including dizziness, fevers, body chills, and blood clots.We don't know other side effects that can happen in future'.
Third, some people were concerned about certain groups that were being prioritised over others in COVID-19 vaccination.This issue was raised especially amongst male participants who wondered why the government was targeting 'older people', while it was commonly understood that children were more vulnerable and should be prioritised for vaccination.'I have never understood why they target the older people and not children', said a father in his early forties.Others were unsure why healthcare workers were prioritised for COVID-19 vaccines, suggesting that prioritising healthcare workers was a way of hoodwinking the citizens to trust the 'unsafe vaccines'.A 30year-old man: The medical personnel have lined up to receive the vaccine just to fool the ordinary citizens.There is a clip I watched on WhatsApp showing how the medics did not inject each other with the vaccine and rather used water to fool the public.Overall, while targeted initiatives intended to boost vaccination rates and overall public health safety, their focus on specific groups and poor communication resulted in negative effects on other's uptake.
Finally, there were anxieties around the quality of vaccines being shipped or donated to African countries including Kenya.A 38-year-old man noted that there were information circulating on social media that the vaccines being given to African countries were of poor quality or were already expired: 'The safety?I doubt the safety, I doubt the safety especially the one, this AstraZeneca, the one that is coming to Kenya and Africa.In my own opinion, I think that AstraZeneca is of lower quality'.In addition, beliefs, myths and conspiracies around COVID-19 vaccines were reported and played a crucial role in influencing individual's refusal to vaccinate.Some participants believed that they would become zombies if they get vaccinated.Similarly, others believed that vaccines would cause a far reached consequences such as infertility especially for women; 'I have heard people discourage the Astra Zeneca vaccine, some people have argued that it causes infertility in women, headaches', [37-year-old woman] and for men, concerns over low libido were noted, 'first, I have heard people talk about reduced libido in men if one gets the vaccine ' [25-year-old man].A few others believe that vaccination was a plot to get microchips to people's bodies.

Discussion
To the best of our knowledge, this is the first in-depth qualitative study of Eldoret town resident's views on COVID-19 vaccination safety, delivery, and uptake.We found that historical understandings of what vaccines are, who they are for, and what they do played a powerful role in how people thought about COVID-19 vaccines.Because most people were vaccinated when they were young and only received vaccines in adulthood if they worked in the formal sector or travelled internationally (a sign of privilege), there was some confusion around why elders and healthcare workers were prioritised for vaccination and children were least prioritised.Further, our findings show that there was some trust in the government as well as international bodies such as the WHO, as people believed these groups' involvement suggested that COVID-19 vaccination campaigns were trustworthy.At the same time, there was also distrust of the government because healthcare workers were prioritised, suggesting some type of dubious behavior.Understanding these key findings is crucial for government responses to future pandemics, as well as the introduction of new vaccines, particularly when they are prioritised for some groups (elders) and not others (children).
First, we found that around half of those we spoke to were willing to be vaccinated in part because they had access to information on COVID-19 vaccines and were fearful of acquiring the virus, similar to what has been reported from other countries in SSA (Kanyanda et al., 2021).Although many people did not believe COVID-19 was real in our previous study (Bosire et al., 2022), we found many people changed their minds after having family and friends suffer from COVID-19 and observing many people receiving vaccinations with minimal side effects.Others were motivated by their family members to get vaccinated.Trust in the government as well as the WHO illuminated why and how vaccine hesitancy diminished among many of the middleincome study participants we spoke to for this study.
Yet, many people still cited a disbelief that COVID-19 was real as a reason to forgo vaccination (Bosire et al., 2022;Rego et al., 2023), as well as anxieties around the short time used to manufacture the vaccines and a perceived poor quality of vaccines supplied to African countries.Further, some perceived severe side effects may emerge if they took the vaccines, such as infertility for women and decreased libido for mencommon conspiracies that circulated (McNeil & Purdon, 2022).Such findings resonate with other broader studies of vaccination concerns (see Larson, 2020) and recent studies conducted in Kenya which have reported that distrust in government and conspiracies around COVID-19 played a key role why some people refused to vaccinate (Rego et al., 2023;Shah et al., 2022).Thus, participants' lack of willingness to vaccinate was a 'protective response' to protect their health, and their concerns could be conceptualised as an 'an aspirational vision of citizenship based on political rights, social recognition, and access to high-quality public services delivered by a robust, responsible state' (Chigudu 2019: 415).Nevertheless, others described disinterest in vaccination in part because they perceived themselves too young to worry about COVID-19a finding that appeared unchanged from our previous study (Bosire at al., 2022) as well as other findings in Kenya that revealed how people who perceived themselves to be at low risk of COVID-19 infections refused COVID-19 vaccines (Rego et al., 2023).
Second, a historical commitment to childhood vaccinations and the lack of emphasis on adult vaccination outside of work and travel appeared to somewhat undermine the COVID-19 vaccine rollout among some people.Most people were comfortable with the idea that children were the most vulnerable group who needed to be vaccinated.In addition, many suggested childbearing women should be given second priority for immunisation to protect unborn children from infections.These assumptions were conflated with COVID-19 vaccine protocols that were organised around priority groups to be vaccinated based on the novel SARS-CoV-2 viruswhich was still somewhat of an enigma to many people we spoke to.Although there was understanding that this was a new disease and many people had successfully been vaccinated, why essential workers and elderly populations were prioritised (see Muchiri et al., 2022;Orangi et al., 2021;Shah et al., 2022) remained confusing based on the historical prioritisation of children and childbearing mothers.
There were also significant financial concerns around vaccination for adults.While childhood vaccinations are provided by the government free of charge, many people expressed how vaccinating adults was expensive in part because most of the vaccines such as flu and yellow fever vaccines required payments.The few who had been vaccinated for these diseases revealed that they only did so due to travel or other requirements (e.g. to be allowed to work).This brings in another dimension of inequalities as those who can travel and afford vaccinations are often more privileged and able to benefit from these vaccines (Ali et al., 2022).This is not surprising given the unevenness of the Kenyan health system, where global agendas set the terms for what can be covered for whom, where, and why (Okungu & Chuma, 2017).We found elsewhere how diabetes patients picked and chose when they took medication and followed medically prescribed diets based on their financial needs; conversely, those with HIV described how their HIV remedies were always followed because medications were provided free-of-cost (Bosire et al., 2018).It was those contexts where injections were free, accessible, and inclusive where people were vaccinated; while in some cases decisions were based on trust, most based this decision on awareness, availability, and access in relation to where people lived and who cared for them (Bosire et al., 2018) Finally, this data illustrates why political-economic and cultural contexts where vaccines are delivered are crucial for vaccine uptake (Leach et al., 2022).The government of Kenya and other stakeholders must take seriously how diverse publics interpret public health policy and implementation.In this way, our study contributes to broader vaccine literature by highlighting how even strongly pro-vaccination health systems can be undermined by historical vaccination policies and misinterpreted information.Given our findings, we argue that the government of Kenya should normalise engaging and involving a diverse group of citizens in public health preventive efforts when experiencing pandemics such as COVID-19, ensure constant communication, and create awareness of situations that warrant changing vaccine prioritisation.These results suggest that even strong vaccination messaging can be limited by altering healthcare delivery protocolssomething that can and should be considered by healthcare authorities both in Kenya and beyond.
This study is not without limitations.We conducted in depth interviews with 40 Eldoret residents who were largely middle age and middle class.These findings may not be generalised to the entire population in Eldoret or Kenya.In addition, findings may not reflect the perceptions or experiences of the very wealthy or very poor, or the very young or elders.Yet, qualitative research does not aim at having representative samples or producing generalisable findings.Instead, the intention is to generate an in-depth understanding of a phenomenon and explore 'transferability' to other contexts (Ritchie & Lewis, 2003).Relatedly, we spoke to few people within the priority groupsincluding those who were elders or healthcare workers who were vaccinated first.It would be particularly interesting to learn if they received any prejudice based on their prioritised status or had any hesitancy sharing that they had been vaccinated due to community perceptions of misplaced priorities for government workers.Nevertheless, our findings emphasise how recognising the influence of historical priorities for vaccinationsuch as children and expectant mothers on how people think about a vaccination campaign targeting very different high-risk groups for different reasons is crucial when planning public health education for vaccine rollout.

Conclusion
Generally, the people of Eldoret were knowledgeable about vaccines and understood the roles they played in protecting peopleespecially childrenfrom diseases and their importance.However, the number of people who report that they are unwilling to vaccinate, despite improved access, cannot be ignored.Constant communication about vaccine safety, access, and cost is crucial to communicate with a broader public.This is particularly important in the case of emergent viruses and new vaccine technologies.In this case, the usual structure where children and childbearing women were prioritised was confusing and undermined vaccine interest for younger men in particular.On the other hand, prioritising the elderly populations was misinterpreted as targeting groups to test vaccine efficacy.Without access to universal health coveragewhere people can access routine healthcare for both routine and acute health careit will be difficult to elevate health across the population.This barrier makes individual-case histories and perceptions overtake decision-making for families who may have had financial hardship or poor experiences with the health system.Elevating education around vaccine access is fundamental for advancing health in times of crisis, particularly when conspiracies abound, and vaccines are free for those who can access them.