Attitude towards COVID 19 vaccines and vaccine hesitancy in urban and rural communities in Tamil Nadu, India - a community based survey.

BACKGROUND: Effective and safe COVID 19 vaccines have been approved for emergency use since the end of 2020 and countries are actively vaccinating their people. Nevertheless, hesitancy towards the vaccines exist globally. OBJECTIVES: We conducted this study to understand the attitudes towards COVID 19 vaccines and hesitancy to accept it among urban and rural communities in Tamil Nadu, India. METHODS: We conducted a community based cross sectional study in urban and rural communities among 564 persons who had not been vaccinated yet, selected through multistage random sampling. The vaccine attitude scale (VAX) was used to measure attitudes towards the vaccines and their acceptance of the vaccine was captured by responses to a direct question. RESULTS: More than 50% of the respondents had positive attitudes towards the COVID 19 vaccines. Based on their attitudes, they were segmented into four clusters, first with preference for natural immunity compared to vaccines and low concern regarding adverse effects. Second with high level of trust in vaccines and low mistrust. The third cluster members had high level of concern regarding the adverse effects and low levels of mistrust in vaccines and the fourth had high trust in vaccines and low preference for natural immunity. Older individuals with higher education and occupation were more likely to belong to cluster four with high trust in the vaccines. Younger individuals, women, rural residents, belonging to low income labourer class were highly mistrusting of the vaccines. The prevalence of vaccine hesitancy was 40.7% (95% CI - 36.67 - 44.73%), while 19.5% (95% CI = 16.23 - 22.77%) of the respondents were vaccine deniers. While vaccine acceptance was greatest in cluster 1, it was least in cluster 3. CONCLUSIONS: Vaccine hesitancy was high in urban and rural Tamil Nadu. The population could be effectively segmented into groups based on their attitudes and this understanding can be used to develop targeted behaviour change communication campaigns.

A qualitative inquiry into stigma among patients with Covid-19 in Chennai, India.

INTRODUCTION: The Covid-19 pandemic has left a serious impact on the lives of people globally. One key social consequence of the infection has been the stigma associated with it. OBJECTIVES: This study was conducted to explore the lived experiences of stigma among persons who have recovered from Covid-19 in Chennai, India. METHODS: In depth telephonic interviews were conducted among 12 persons who had recovered from Covid-19 in Chennai. The participants were encouraged to narrate their experiences of stigma. The telephonic interviews were transcribed and coded by both the researchers. The codes were then grouped into meaningful themes and the lived experiences of stigma described with the help of rich narrative quotes. RESULTS: The common manifestations of stigma were exclusion from public spaces and essential services, loss of livelihood, loss of social support and, in an extreme case, physical violence. The stigma was also manifested in health facilities in the form of neglect, and rude and insensitive treatment of patients. The factors that aggravated the stigma included fear of infection, lack of information, legitimisation of segregation by forced public health interventions, involvement of police in contact tracing, and isolation. Stigma was associated with psychosocial consequences such as loneliness, uncertainty, anxiety, anger, and humiliation. Demonstration of empathy, advances in communication technology, solidarity in communities and protecting confidentiality could potentially mitigate stigma. The intersectionality of age, gender, poverty, and disability worsened the experience of stigma. CONCLUSIONS: People who had recovered from Covid-19 experienced various degrees of social stigma. The future impact of the pandemic will depend strongly on the ability of health systems to address stigma.

Doctor-patient communication and trust in doctors during COVID 19 times-A cross sectional study in Chennai, India.

BACKGROUND: The COVID 19 pandemic created a global public health crisis. Physical distancing, masks, personal protective equipment worn by the doctors created difficulties in effective doctor-patient communication. OBJECTIVES: This study was conducted to assess the difficulties faced by patients in communicating with their doctors due to the COVID 19 preventive measures, and its impact on the trust on their doctors. METHODS: A cross sectional study of 359 persons attending a tertiary care center in Chennai, sampled in a non-probabilistic manner selected from the outpatient department, wards, and isolation facilities, was conducted using a questionnaire containing items covering three dimensions namely difficulties faced in accessing the health facility, difficulties in doctor-patient communication and trust in the doctors. The data were collected using Google Forms and analyzed using GNU PSPP open-source statistical software version 1.4.0. RESULTS: More than 60% of the participants complained of difficulty in accessing the health facility. More than 60% had difficulties in communicating with the doctors. There was a high level of trust in doctors among more than 80% of the participants. Comparison of the mean scores revealed that accessibility was a problem across ages, sexes, education and occupation groups. Communication barriers decreased with age and increased with education, but trust increased with age, but reduced with increasing education. Multivariable linear regression analysis revealed that difficulties in communication had a negative impact on trust (ß = -0.63, p<0.001) and increasing education had a negative impact on trust (ß = -0.42, p = 0.034). CONCLUSIONS: The COVID 19 pandemic and the preventive strategies such as lock-down, physical distancing, face mask and personal protective equipment created barriers to effective doctor patient communication and led to some compromise in trust in doctors during this time.

Integrity during pandemic times: The case for flexible adamancy.

The Covid-19 pandemic has dominated people's lives since late 2019, for more than nine months now. Healthcare resources and medicine have been completely consumed by the Covid 19 illness globally. This is a particularly difficult time for health systems because of the onerous responsibility to care for large numbers of sick people, protecting populations from contracting the infection by effective quarantine, isolation, and containment measures. In addition to this burden of work, healthcare providers are also overcome by fear of contracting the infection and transmitting it to their loved ones. It is during such difficult times that the integrity of healthcare providers is challenged. In this paper I will describe some challenges that a healthcare provider in a typical low resource setting faces during this pandemic time, and will propose the idea of "flexible adamancy" to address these challenges to the health system's integrity.

Up close and personal with Covid 19: An interview with Dr Usha Sriram.

The ongoing Covid-19 pandemic, starting in China in late 2019, has spread to every corner of the world, and thrown up several important ethical challenges. The rising numbers of infected persons and of death rates are keeping the health systems of most countries on their toes. However, the heightened focus on infection prevention and control have left several aspects of peoples' social life unaddressed. The stringent lockdowns in many countries including India, the mandatory public health measures, such as quarantine, isolation and contact tracing, have left a deep impact on the lives of the people.

COVID-19 Pandemic: a Litmus Test of Trust in the Health System.

The pandemic caused by the SARS-CoV2 novel coronavirus is creating a global crisis. There is a global ambience of uncertainty and anxiety. In addition, nations have imposed strict and restrictive public health measures including lockdowns. In this heightened time of vulnerability, public cooperation to preventive measures depends on trust and confidence in the health system. Trust is the optimistic acceptance of the vulnerability in the belief that the health system has best intentions. On the other hand, confidence is assessed based on previous experiences with the health system. Trust and confidence in the health system motivate people to accept the public health interventions and cooperate with them. Building trust and confidence therefore becomes an ethical imperative. This article analyses the COVID-19 pandemic in the south Indian state of Tamil Nadu and the state's response to this pandemic. Further, it applies the Trust-Confidence-Cooperation framework of risk management to analyse the influence of public trust and confidence on the Tamil Nadu health system in the context of the preventive strategies adopted by the state. Finally, the article proposes a six-pronged strategy to build trust and confidence in health system functions to improve cooperation to pandemic containment measures.

Response to Covid-19: An ethical imperative to build a resilient health system in India.

China reported cases of a severe form of pneumonia in December 2019 from Wuhan city, Hubei province. The virus causing this illness was identified as the novel Coronavirus 2019, which has now been christened Covid-19. The illness is characterised by fever, cough, body pain and in a few cases, progression to acute respiratory distress syndrome (ARDS) which marks very serious damage to the lungs (1-4). Apart from Wuhan, China, the virus has spread to 26 other countries as on February 18, 2020. Of these 26 countries, the cases of Covid-19 have been exported directly from China in 23 of them. As on February 23, 2020, a total of 78,811 confirmed cases, 2445 deaths have been reported globally. The World Health Organization declared this as a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 (5).

Clinical ethics during the Covid-19 pandemic: Missing the trees for the forest.

The SARS-CoV2 pandemic has exposed the acute vulnerability of the health systems of countries worldwide. While countries are scrambling to contain the spread of the infection, the focus is largely on infection prevention strategies such as isolation, quarantine, physical distancing, hand hygiene, cough etiquette and country-wide lock-down. Important ethical concerns arise in the context of the public health interventions. However, while focusing on the forest, the population, attention must also be paid to the trees, the individuals who suffer the illness. This article focuses on the ethical conflicts between the largely public health- driven focus of the Covid19 prevention and containment measures versus patient-centred care for those who suffer the illness and the consequent moral distress of healthcare providers. The key argument is for countries to mainstream clinical ethics considerations for care of patients with Covid-19 as well as "non-Covid-19" illnesses. Keywords: SARS-CoV2, Covid 19, clinical ethics, duty to care, allocation of scarce resources, moral distress.