Public Compliance Response to the COVID-19 Vaccination Campaign in Indonesia: A Study in Serang City, Banten, and Padang City, West Sumatra

1.     Introduction

1.1.  Background

Data collected in November 2022 reported 10,185,374 confirmed cases of COVID-19 and 503,862 deaths worldwide, with a fatality rate of 4.9 percent. In addition, the World Health Organization (WHO) (2022) reported that people would have to live with this virus for a long period.

WHO (2021) stated that vaccination was an essential method adopted to reduce the spread of the virus. The main aim of this worldwide strategy was to reduce mortality, disease severity, and the overall burden. Additionally, this also included protecting health systems, supporting socioeconomic activities, and reducing the severity of new COVID-19 variants.

In the health context, a typical way to control the COVID-19 pandemic was to implement proportional public health measures and widespread vaccination. Moreover, full-dose vaccination can reliably protect healthcare workers from hospitalization and death caused by the virus. The vaccine's effectiveness in preventing infection from January to March was 84 percent. This implied that only two in ten fully vaccinated healthcare workers were at risk of contracting COVID-19 (Kementerian Kesehatan, 2021).

The Indonesian government is committed to fighting the pandemic, including through a vaccination policy. The aim was to reduce the long-term effects of the pandemic on the health sector and economy. Based on this perspective, the government has put several policies in place. First, the President of Indonesia issued Presidential Decree No. 18/2020 on September 3, 2020, establishing a COVID-19 vaccine development team under the supervision of the coordinating minister for Economic Affairs.

Second, the President signed and issued a Presidential Regulation (Perpres) on October 6, 2020, regarding vaccine procurement and the implementation of the vaccination program to combat the COVID-19 pandemic. The regulation also stated that PT Bio Farma would supply vaccines through international cooperation. Third, the government, through the Ministry of Health, and in collaboration with international organizations, such as UNICEF, ensured the provision of vaccines. An estimate of 30 million vaccine doses was expected to be received by the end of 2020 through bilateral agreements, with an additional 50 million doses in early 2021 (Survey Penerimaan Vaksin COVID-19, n.d.).

The implementation of the vaccination initiative was appropriate because Global agreements outlined the importance. In line with these agreements, the government imported various types of vaccines produced in different countries. As of August 2021, Indonesia had imported 201.9 million vaccine doses. The following vaccines, Sinovac, AstraZeneca, Sinopharm, Moderna, and Pfizer, were imported. Data from the Ministry of Health showed that Sinovac was the most frequently imported vaccine, with a total of 166.5 million doses.

The Indonesian government started administering the COVID-19 vaccination program on Wednesday, January 13, 2021. President Joko Widodo was the first to receive the Sinovac COVID-19 vaccine. Moreover, this has received Emergency Use Authorization (EUA) from the Food and Drug Monitoring Agency (BPOM), including the Indonesian Ulema Council (MUI). At a January 10, 2021, meeting, recommendations were obtained from members of the National Drug Evaluation Committee, a team of immunology experts, the Indonesian Technical Advisory Group on Immunization (ITAGI), and epidemiologists.

The government's objective was to vaccinate 182 million people, or 70 percent of the population, to achieve herd immunity by 2021. In 2020, the Ministry of Finance allocated a budget of IDR 35.1 trillion to purchase three million doses of the Sinovac vaccine to support the vaccination effort.

The COVID-19 vaccination policy did not instantly gain full public support. An online survey conducted by the Johns Hopkins Center for Communication Programs (JHCCP) from May to September 2021 found that 34 percent of Indonesians did not want to be vaccinated. Douglas Storey of the JHCCP reported that the survey was conducted on 14 million respondents through Facebook. Another result was that individuals aged 55 and above were the most likely to refuse the COVID-19 vaccine. 40% of respondents in this age group reported refusing the vaccine. Douglas identified three reasons most frequently cited by the respondents. The main reason was persistent doubts about the vaccine's safety. The other reasons included a desire to wait, concerns about cost, religious reasons, and the belief that the vaccine was unnecessary. According to the Ministry of Health, vaccine refusal rates in July 2021 were approximately 33 percent. A follow-up survey conducted by Indikator Politik Indonesia found that, in January 2022, 54.8 percent of respondents declined the booster vaccine (Haryanti Puspa Sari, 2021).

As a public health policy, COVID-19 vaccination should elicit a positive response from recipients. Leung et al. (2020) reported that willingness to accept the vaccine was crucial to achieving high vaccination coverage and combating evolving infectious diseases. Previous studies have shown that several factors affect personal acceptance of a vaccine, particularly when it concerns influenza. These consisted of resistance to the word "vaccination," perceived risk of use, including safety and efficacy, convenience, price, and sociodemographic factors (Wang et al., 2021).

Many people were against the vaccination due to personal, religious, social, and political reasons, as well as rumors regarding the negative effects of the COVID-19 vaccine. For a country with 237.53 million Muslims, equivalent to 86.9 percent of the total population, resistance was faced even before efforts to vaccinate the people were implemented. Moreover, in Muslim-majority countries, there were doubts about vaccines because of religious and social beliefs (McNeil & Purdon, 2022). Another serious problem was misinformation, such as claims that the Sinovac coronavirus vaccine was haram (forbidden). This had not been certified halal by MUI (Indonesian Islamic Religious Council). Therefore, public acceptance and willingness to be vaccinated against COVID-19 posed a challenge for the government (Leung et al., 2020).

Based on this perspective, three factors, namely knowledge, social, and religious dynamics, affected the attitude of the public towards the vaccination. Therefore, the government needs to understand why vaccination is refused and how to gain public compliance. The essence is to support implemented programs as well as reduce the severe impact of the pandemic. Rejection among some citizens suggested a significant challenge that should be addressed to ensure the success of the vaccination policy. Additionally, public awareness campaigns should be carefully designed to ensure that the benefits of vaccination are recognized by the public.

This result was consistent with the United Nations (UN) directives, which stated that managing a pandemic or crisis mainly depended on coordination and communication. Furthermore, there should be clarity in accountability and decision-making to foster shared knowledge and understanding (Jo Nurse, 2023).

During the UN General Assembly on September 23, 2020, President Joko Widodo stated that the COVID-19 vaccine would be a game-changer in fighting the pandemic (Detik.com, 2020). Additionally, Montty Girianna (Kementerian Koordinator Bidang Perekonomian Republik Indonesia, 2021) reported that vaccination was among the steps the government took to restore normalcy. It also enabled people to resume normal activities as well as drove the country's economic recovery.

An online survey conducted by the Johns Hopkins Centre for Communication Programs (JHCCP) among 14 million respondents on Facebook from May to September 2021 found that 34 percent of Indonesians did not want to be vaccinated. According to Douglas Storey of JHCCP, this reluctance stemmed from lingering doubts about vaccine safety, concerns about cost, religious beliefs, and the conviction that vaccination was unnecessary. A 2020 survey conducted by the Ministry of Health, ITAGI, WHO, and UNICEF showed that 65 percent of respondents were willing to receive the vaccine if provided by the government, while 8 percent refused. The remaining 27 percent expressed doubts about the government's plan to distribute the vaccine. Public confidence in the vaccine varied due to limited information about its type, availability, and safety profile.

The Ministry of Health, ITAGI, WHO, and UNICEF recommended developing a communication plan that addresses the diverse information needs of the public regarding vaccine safety, effectiveness, and fair distribution before, during, and after vaccination. The push to speed up vaccination for the citizens was based on predictions that the country would need approximately ten years to reach herd immunity. The study at Johns Hopkins University, as reported by Detik.com on February 8, 2021, stated that herd immunity was reached when 70-85 percent of the population had been vaccinated. Data compiled by Bloomberg on February 5, 2021, also reported that Indonesia recorded a daily vaccination rate of 60,433 doses. It is estimated to take more than ten years to reach the vaccination objective of 70-85 percent of the population, supposing the rate does not increase.

Based on this data, vaccination is the solution for a quick recovery from the pandemic. Public policy should be practical, beneficial, and gain support and compliance to successfully emerge from the pandemic. Appropriate, concrete public communication messages should also be conveyed, as regulatory support alone is not sufficient.

In psychology, compliance-gaining is a foot-in-the-door method that involves gradually persuading individuals. Previous studies reported that compliance-gaining focused on persuasively achieving set objectives, but within predetermined, specific, or restrictive options. This conflicts with persuasion, which centers on changing beliefs, attitudes, desires, motivations, and behavior (Gass & Seiter, 2018).

Gass & Seiter (2018) reported that compliance-gaining strategies could be examined from three main methods. This included analyzing the type of compliance-gaining strategy used (Gerald Marwell and David Schmitt, 1976), context dimensions (Cody, Woelfel, and Jordan, 1983), and the perspectives of power, legitimacy, and politeness (French and Raven, 1960).

The COVID-19 vaccination campaign messages discussed were initiated by the government and widely spread through various communication channels. The messages examined were from the Ministry of Communication and Informatics. Based on a review of mass media coverage and COVID-19 campaign materials, the government has stated that the vaccination appeal was communicated systematically and consistently, supported by related technical policies to promote public compliance. Indonesians who followed the vaccination recommendations encountered appeals that were widely disseminated through mass media, both above- and below-the-line. These persuasive messages that caused the public to become aware of, understand, and acknowledge the importance of the vaccination would be examined and evaluated for their suitability within Compliance Gaining Theory.

This study aimed to identify the reasons behind public acceptance and rejection of vaccination in Serang City, Banten, and Padang City, West Sumatra, using Focus Group Discussion (FGD). Moreover, the study is expected to make a significant contribution to the literature on public compliance with government health messages about vaccination. The importance evolved from the limited testing of compliance-gaining theory applied to mass health messages.

Considering that the pandemic has ended, this study remains significant from a health communication perspective. The Theory of Reasoned Action (TRA), Elaborative Likelihood Model, Self-Protection and Compliance Achievement Theories allowed factors to be identified and analyzed, leading to public compliance with vaccination against COVID-19. Furthermore, compliance was motivated by the persuasive messages preceding the vaccination.

1.2.  Health Communication

WHO reported that the pandemic caused the global health and socioeconomic crises. The managerial process mandated the government to implement risk communication strategies and people engagement initiatives. The vaccination recommendation was categorized under risk communication due to potential effects on recipients’ bodies. However, to address the pandemic, vaccination had to be carried out without public resistance. There is a need for persuasive messages to raise awareness about the importance of following the vaccination guidelines. This could be realized by using the PHF (Persuasive Health Message) Framework and Compliance Getting Theory. The framework comprised three theoretical components: TRA (Fishbein & Ajzen, 1975), the Elaboration Likelihood Model (Petty & Cacioppo, 1986), and Protection Motivation Theory (Rogers, 1983).

TRA is a psychological model that was developed by Martin Fishbein and Icek Ajzen in 1975. According to this model, a person's behavior is determined by personal intentions. Fishbein and Ajzen stated that humans tend to behave rationally, considering available information and the consequences of their actions before deciding to act. In terms of persuasion, norms were among the most important elements to consider when crafting persuasive messages. Ajzen (1991) and Fishbein & Yzer (2003) reported that these norms play an essential role in the behavior-maintenance and change model. Additionally, TRA comprised four major components, including Beliefs, Attitudes, Subjective Norms, and Intentions, which were described as follows.

Figure 1: Four Elements of TRA

Source: simplypsychology.org

Respondents' responses to persuasive messages about the vaccination process were analyzed from a TRA and compliance-gaining perspective.

1.1.  Public Compliance

Compliance-gaining refers to a type of persuasive communication that exerts influence, altering both attitude and behavior. This influence is intentional or unintentional communication intended to change the beliefs, attitudes, intentions, and behavior of individuals or groups. Furthermore, compliance-gaining strategies included both verbal and nonverbal communication, often accompanied by rewards and punishments.

John French and Bertram Raven, along with Littlejohn and Foss (2009: 155), reported five basic forms of power used in social interactions. These five basic forms of powers were reported as follows:

•    Reward power, namely, the ability to provide benefits to others.

•    Coercive power is the power focused on the ability to punish others.

•    Expert power, including power centered on expertise or competence.

•    Legitimate power, namely, power based on a person's official rank or formal position.

•    Referent power, such as power related to people admired or respected. A person would obey the orders of someone respected.

Compliance-gaining theory explored the dynamics between doctors and patients. During each interaction, doctors frequently suggested that patients take specific medications or avoid unhealthy habits. This theory, proposed by Gerald Marwell and David Schmitt, outlined 16 common strategies for gaining compliance, including promises, threats, aversive stimuli, moral appeals, and debt collection.

Marwell and Schmitt used the exchange theory as the basis for formulating the compliance-gaining model. This states that a person would comply in exchange for something given by another. For example, if you do what I want, I will give you something in return, including esteem, approval, money, relief from obligations, and good feelings. This model is fundamentally power-oriented, implying that a person can obtain compliance from others when they have sufficient power, such as resources, as well as by providing or withholding something wanted.

The most important theoretical question about tactics for gaining compliance is how to reduce the set of all possible plans to a manageable set of general strategies or dimensions that explain what people do when persuading others. To create this set of principles, Marwell and Schmitt developed five strategies or groups of tactics to address various situations that lead to compliance. The strategies include rewarding (e.g., promising), punishing (e.g., threatening), demonstrating expertise (e.g., showing knowledge of rewards), making impersonal appeals (e.g., moral appeals), and making personal commitments (e.g., debt). Marwell and Schmitt (1976), as cited in Roberts and Gass (2018), outlined 16 tactics for applying compliance-gaining strategies, and these were stated as follows.

Table 1: 16 Tactics for Compliance-Gaining

The government expected the public to follow the COVID-19 vaccination policy when it was introduced. This implied adhering to recommendations or calls for vaccination. However, as the vaccination discourse was promoted, resistance emerged among some. The resistance or rejection raised critical questions about the efficacy rate, the effects of vaccination on the recipient's body, and the vaccine's halal status. These questions could potentially decrease public compliance with the vaccination call. Of the 16 compliance-gaining tactics, not all were used during the vaccination campaign. Additionally, this study reviewed some critical questions from the perspective of Compliance Gaining Theory.

2. Method

A qualitative method was adopted, and according to Creswell (2021), this investigative method followed traditional procedures for study in the social, behavioral, and health sciences. The process entailed reviewing an issue, as well as proposing and answering questions that contributed to the problem. The questions were reviewed using data collected and analyzed from participants in the answering process. A study report was written, and the results were summarized after collecting and analyzing the acquired information.

This study employed three data collection methods: in-depth interviews, FGDs, and document reviews. The aim was to present a systematic, factual, and accurate description of the facts associated with the messages delivered by the COVID-19 vaccination campaign, including the focus objects. Various subjects were interviewed and grouped accordingly to gather the diverse facts. This study was conducted in Serang and Padang Cities, in Banten and West Sumatra, respectively. Previous studies in Serang and Padang focused on exploring respondents' opinions and perceptions of COVID-19 vaccination campaign messages through FGDs. Data was also collected through FGD with selected respondents in Serang and Padang Cities.

3. Result and Discussion

The public compliance responses to the COVID-19 vaccination campaign in Indonesia included several respondents from Banten and West Sumatra Provinces. These respondents were interviewed to understand their responses and perceptions after exposure to the vaccination campaign messages delivered by the Directorate General of Public Information and Communication (DJIKP) of the Ministry of Communication and Informatics (Kominfo).

The FGD in Serang and Padang Cities took place on May 14 and June 2, 2024, respectively. Both cities were selected based on the vaccination acceptance rate in the country. Banten ranked among the regions with the highest acceptance rate, according to a 2020 UNICEF survey. This outlined that nearly 69 percent of the people were willing to be vaccinated, with hesitancy below 20 percent (Ministry of Health, 2021). However, West Sumatra had the highest resistance, with an acceptance rate of approximately 65 percent, and public doubts about the vaccine's effectiveness exceeded 30 percent. The selected respondents in Banten and West Sumatra Provinces totaled 7 and 9, respectively. Based on the analysis, these individuals were categorized under three age groups, as shown in Table 2.

Table 2: List of FGD Participants in Serang City

Table 3: List of FGD Participants in Padang City

During FGD, respondents answered several questions regarding: (1) Perception of risk in receiving information about the vaccination process, (2) confidence or self-efficacy in controlling feelings related to the reception of the vaccine, and (3) perception of the message cues, which included accessibility in getting the relevant information concerning the vaccination.

3.1.  Risk Perceptions in Receiving COVID-19 Vaccination Information

The rumors were conflicting during the early stages of the vaccination campaign. The government described the vaccine's benefits, including protection for individuals and their family members. However, both mass and social media paid considerable attention to the possible side effects. Some media outlets formulated and released frightening news, leading to differing risk perceptions among the public, including doubt, fear of vaccination, delays, and refusals. The results of FGD in Serang and Padang Cities showed varying public perceptions of these risks, which subsequently influenced vaccination acceptance. The respondents' initial perceptions regarding receiving information on COVID-19 vaccination are as follows.

Table 4: Initial Perceptions of the Respondents in Serang City

The FGD in Serang City showed that most respondents expressed a positive attitude toward the vaccination. Moreover, of the seven respondents, four had accepted the vaccine from the start. The reasons given were related to trust in the government and considerations of protecting themselves and their respective families. R (62) stated that government policies could not be made without careful consideration, and it was natural for the public to follow the directions given. The remaining two respondents were more cautious, not refusing the vaccine but postponing the process to seek additional information. For example, a student named Arifah stated that she wanted to be certain of the vaccine's validity and safety before being immunized. C further reported that she had to "check and recheck" before making decisions regarding her personal health. A particular respondent, A, a 45-year-old entrepreneur, explicitly refused at the start. It was reported that the social conditions of his people influenced his decision. Considering that most people in the village had postponed vaccination, he decided to follow suit, despite being in good health.

Table 5: Initial Perceptions of the Respondents in Padang City

The FGD in Padang City found that six respondents accepted the vaccine from the start, but not all reasons were based on personal beliefs. Several respondents received the vaccine due to administrative requirements. SM, a student, stated that she was vaccinated because it was required to return to in-person school. According to RJ, a housewife, she was vaccinated due to repeated government recommendations, not out of personal preference.

Two other respondents were hesitant or reluctantly accepted the vaccination. W admitted to taking the vaccine, even though she was initially unsure. This was simply because she felt "uncomfortable" in refusing the vaccine invitation. YP agreed to be vaccinated when she contracted COVID-19 and suffered from declining health problems. This personal experience with the disease was a decisive factor compared to the government's intensive campaign messages.

Another respondent, RF, refused at the initial stage due to distrust in the vaccine. The vaccination process was considered after further information regarding its safety was provided. This refusal showed that the narratives about side effects and issues surrounding the vaccine ingredients affected people's perspectives in Padang. Although the majority of respondents accepted the vaccine, their decision was driven by administrative coercion or personal experience rather than by absolute confidence in government messaging.

The comparison of the two provinces showed that initial acceptance levels were similar, but the drivers differed. Respondents' acceptance of Serang was based on trust in the government and healthy bodies. Meanwhile, people from Padang often appealed to administrative needs or to strong personal experiences, factors they regarded as driving acceptance. The hesitancy in Serang was overcome through alternative explanations, whereas in Padang it developed into a refusal or a forced acceptance.

The results suggested that the initial perceptions of the respondents regarding vaccination against COVID-19 were influenced by two main factors: self-efficacy (beliefs about being healthy and deserving the vaccine) and social authority (influence from the government, schools, and the surrounding environment). Individuals who were initially confident in their respective physical condition and trusting of government authority were likely to accept the vaccine willingly. However, those who were still unsure or refused to suggest the need for more explanation either in the form of descriptive medical information or real-life examples from their closest associates.

3.2.    Individual Confidence or Self-Efficacy in Controlling Feelings as a Vaccine Recipient

The individual responses were explored after understanding respondents’ perceptions to assess their respective abilities (self-efficacy) to receive the COVID-19 vaccination. Additionally, the self-efficacy dimension was related to the belief that the vaccine had no serious adverse effects, including the ability to manage emotions under widespread news coverage of the side effects.

At this stage, the FGD focused on respondents’ understanding of the physical conditions and their doubts about the vaccine's eligibility. This question is relevant because many people weighed respective vaccine decisions against administrative obligations and government directives, as well as confidence in their own health. Furthermore, vaccine side effects are among the factors that most influence self-confidence. Health communication strategies often require a threatening message (fear appeal), outlining that the risks of not being vaccinated far outweigh the discomfort caused by the vaccine. This method was crucial for motivating individuals who are still hesitant to become more confident in accepting the vaccine to protect both their own and their family's health.

Table 6: Respondents’ Confidence in Serang City to Receive the Vaccine

In this context, 5 of 7 respondents from Serang stated that they were fit to be vaccinated. For example, RY reported feeling healthy but was ready to be vaccinated. R and CEA also had similar sentiments, stating that the vaccine was required to sustain long-term immunity. For these respondents, being healthy without comorbidities was a sufficient reason to be vaccinated. Two respondents remained hesitant; AI acknowledged the need for further confirmation despite feeling she was fit to receive the vaccine. G also postponed vaccination until he received confirmation from a medical examination and was willing to be vaccinated only when declared healthy.

Table 7: Respondents’ Confidence in Padang City to Receive the Vaccine

Three of the nine respondents in Padang City reported being fit for vaccination. For example, EE reported that her family had been accustomed to vaccination programs since childhood; hence, the COVID-19 vaccine was not unfamiliar. This reflected a belief based on positive experiences. Six respondents felt unfit or were still hesitant to receive the vaccine for various reasons. In addition, the reasons ranged from personal experiences of dizziness or fever after vaccination to worries about contracting the illness after hearing negative news from others. Others were forced to get vaccinated because it was required for school or travel. Another respondent, Salsa (SA), reported being afraid after hearing several stories of people getting sick from the vaccine.

In both cities, 9 of 16 respondents were considered eligible for vaccination, while the remaining 7 were unfit or still hesitant. In Serang, many respondents reported feeling healthy and ready to receive the vaccine, with a few waiting to be examined by a doctor. However, in Padang, more respondents expressed negative feelings about the vaccine, influenced by circulating negative narratives.

All respondents were asked to share their respective views on the acceptance of the vaccination. This was in line with personal beliefs or self-efficacy regarding health, references to credible communicators, and exposure to negative news coverage about the vaccine.

Table 8: Informants' Perceptions in Serang City Regarding the Receipt of COVID-19 Vaccination Information

The seven respondents from Serang reported that the choice to get vaccinated was based on self-efficacy. This included the belief that people were healthy and willing to take the vaccine. For example, CEA stated that being confident in her physical condition was not because she had seen officials or others who had been vaccinated. Similar narratives were reported by other respondents, who felt healthy with no comorbidities. This was the actual cause of the willingness to get vaccinated, even before external influences were considered. The results suggested that in Serang, self-confidence in physical condition and the belief that vaccination strengthens long-term immunity strongly influenced vaccine acceptance.

Table 9: Informants' Perceptions in Padang City Regarding the Receipt of COVID-19 Vaccination Information

The nine respondents in Padang City focused on external factors in vaccination decisions. Five people were willing to be vaccinated because of administrative obligations imposed by the government or schools. According to SM, she was vaccinated because the school mandated it to enable her to continue studying. Others took the vaccine due to work demands, travel needs, or doctor recommendations after suffering from COVID-19. However, only a few respondents, such as RF, reported that the reason for vaccination was personal belief in health, given its effect on school obligations.

The acceptance of 8 out of 16 respondents from the two cities was determined by self-efficacy, while external factors influenced the remaining. Serang showed a dominance of self-efficacy, with physical readiness as the main reason. Padang was strongly influenced by external factors, including regulations, social pressure, and personal experience with the virus's impact.

The results suggested that self-efficacy and external influences play a crucial role in shaping public attitudes toward vaccination. Respondents with high confidence in their physical health were more open to voluntary vaccination. In contrast, those who expressed hesitancy required further validation, such as government mandates, institutional requirements at school or work, or professional medical advice. Furthermore, public perception was heavily shaped by how individuals processed information and their ability to manage anxiety regarding rumored side effects.

Table 10: Respondents' Perceptions of Self-Efficacy in Serang City

Among the 7 respondents in Serang, 4 reportedly received negative information about the vaccine's side effects. Some stopped after the first dose out of fear, such as A, who decided not to go for the second dose after learning about many people falling sick. Additionally, two others expressed regret for having been vaccinated too quickly without being fully informed. A particular respondent postponed the next dose due to concern.

In this context, three of the respondents had a high level of self-confidence. The RN stated that, despite hearing the bad news, he did not readily accept the doctor's message because he felt healthy. Moreover, it was believed that vaccination was important for boosting immunity. CEA was hesitant, but after the first dose, she felt well and continued with the rest of the process. This showed that in Serang, aside from the negative rumors, most people were able to control their personal emotions and proceed with the vaccination.

Table 11: Respondents' Perceptions of Self-Efficacy in Padang City

Six of the nine respondents in Padang City admitted to being influenced by news about the vaccine's negative effects. These respondents accepted the vaccine despite the pressure or anxiety they faced. For example, SM reportedly drank fresh coconut water before being vaccinated because she was afraid of becoming weak after the shot.

Regarding health communication, several messages were transmitted through formal written or visual stories, such as action cues and experiences of public figures. During the campaign, the government used the vaccination of prominent state officials as a symbol of trust while ensuring the program's inclusive implementation. Logistical accessibility dimensions, such as location distance, quota availability, and vaccine distribution mechanisms, played a significant role in gauging whether government messages aligned with the realities experienced by the public.

Table 12: Respondents’ Perceptions of Vaccination Accessibility Barriers in Serang City

Among the seven respondents in Serang City, four reported experiencing no significant obstacles in accessing vaccination. RN stated that the local government opened a vaccination service at the village office, very close to home, allowing people to receive the vaccine without traveling long distances. The other respondents shared similar sentiments regarding the easy accessibility of the vaccination site.

Three respondents faced challenges associated with low quotas and large queues. AI reportedly visited the health center (Puskesmas) at dawn to get the queue number. Additionally, when these numbers were exhausted, she had to visit other health centers. CEA had similar experiences in trying to gain a spot at another hospital or health center. Furthermore, G added that during peak vaccination periods, quotas were often full, so not everyone could be served immediately.

Table 13: Respondents’ Perceptions of Vaccination Accessibility Barriers in Padang City

Among the nine respondents in Padang City, six reportedly experienced no significant obstacles in accessing vaccination. For example, RF stated that getting vaccinated at school was easy and free, and that no obstacles were encountered. Similar experiences were reported by other respondents who were vaccinated at health centers, schools, or through special channels, such as health cadres.

Certain challenges were faced; for example, EE had her vaccination put off because of hypertension. YP was only able to get the vaccine after recovering from a bout with COVID-19 and had to wait for supplies to become available. Furthermore, W reportedly found another location because she was out of town. This enabled her get vaccinated without any significant difficulties. Some positive experiences outside the official channels were also encountered. DY received a free vaccine in a bank promotion and avoided having to queue at public facilities.

Based on this view, 10 of the 16 respondents in the two cities had not experienced any significant obstacles in accessing vaccination, while the remaining 6 encountered major challenges. The survey conducted in Serang found that people often faced quotas and long queues, particularly during the busiest vaccination periods. Respondents in Padang City found it relatively easier, despite personal challenges related to health conditions or the need to find alternative locations.

4. Conclusion

In conclusion, the analysis of respondents who accepted the vaccination, including those who refused, showed that the evaluation of outcomes, or behavioral consequences, was a major determinant of attitude formation. Respondents who assessed vaccines positively, based on their health benefits, the legitimacy of the policy, and trust in the government, had a strong disposition to accept the procedure. However, those who weighed the negative frameworks, such as the possibility of side effects, lack of clarity, or distrust of authorities, did not get vaccinated or were reluctant to do so.

Based on this perspective, the effect of positive information strengthened attitudes towards vaccination. Negative information triggered attitudes of vaccination refusal or hesitation, and the basic principles of TRA supported this pattern. The principle stated that attitudes toward behavior are formed from cognitive evaluations of the benefits and risks of an action by individuals.

Subjective norms played a critical role in the decision-making process regarding vaccination, in connection with an individual's perception of social pressure or the influence of significant others on a particular behavior. Fishbein & Ajzen (1975) stated that subjective norms are derived from normative beliefs and the motivation to comply. In the case of the vaccination, it was exemplified through pressure from schools, the government, and public figures.

Respondents reported being influenced to receive the vaccine by the government, schools, and leaders. For example, some respondents were vaccinated because schools mandated in-person learning, RF, SM, and LA, or because government regulations required vaccination for travel. Furthermore, television broadcasts of President Jokowi receiving the vaccine served as a symbolic social norm, boosting confidence in some communities.

Considering that social norms motivated individuals to receive the vaccination, FGD results suggested a contradictory side. Some respondents expressed distrust of official norms or authoritative sources that should guide behavior. This situation suggested that subjective norms often reinforced behavioral intentions and could also become a source of resistance when trust in public institutions declined. Therefore, social norms were dual in nature: they served as a motivating factor when the source was credible, and as a deterrent when suspicion arose about the motives or transparency of public policies. This phenomenon confirmed that the effectiveness of vaccination norms was highly dependent on the level of public trust in the figures and institutions conveying the messages.

Behavioral intention was a significant element in social psychology and the study of consumer behavior. This attribute referred to the degree of strength of an individual's intention to exhibit a particular behavior. The essence of this study was to determine the behavioral intentions of several respondents who had received a vaccination. The respondents' intention to receive the vaccine was developed through a reciprocal relationship between personal attitudes and existing subjective norms. Respondents with positive attitudes who supported social norms showed a strong intention to be vaccinated. However, vaccination intentions decreased when negative attitudes clashed with weak or distrusted norms.

In some cases, respondents initially refused but later accepted due to normative pressure. For example, some were forced to accept the vaccine because of school or travelling long distances. This implied that subjective norms overrode the effect of individual attitudes, causing individuals to be influenced by social pressures rather than subjective factors. Respondents’ accounts showed that TRA was inadequate for determining a person's reason for complying with vaccination. Additionally, external factors such as information exposure, trust in institutions, and government-level policies had dynamic effects on subjective norms.

The results of the FGD showed that a trade-off between perceived benefits and risks influenced public attitudes toward vaccination. Respondents with brain biases used vaccines to protect themselves and their family members. Meanwhile, people exposed to the side effects of vaccines or rumored information were hesitant and refused to be vaccinated. Schools and government agencies served as enforcers of social norms that motivated compliance. The motivation was often external and not entirely based on personal conviction. As a result, the need for credible public communication has become an important factor, as misinformation disseminated through the media has been shown to decrease trust levels and undermine the public's positive attitude.

Public attitudes were formed based on an assessment of both the benefits and risks of the vaccination. The majority considered vaccines beneficial for boosting immunity, while others were concerned about side effects and safety. This suggested that the vaccination campaign failed to develop a sustainable positive attitude. Therefore, a method of messaging grounded in belief was required to present evidence of the vaccine's benefits and safety, using credible, factual, and empathetic procedures. This method was designed to ensure that an attitude change was achieved through compliance and the public's rational and emotional beliefs.

Subjective norms increased behavioral intentions, which declined at low levels of trust in institutions or related sources. Institutional norms such as government, schools, workplaces/services were heightened, but appeared fragile without trust.

Author Contributions: All authors contributed to this research.

Funding: Not applicable.

Conflict of Interest: The authors declare no conflict of interest.

Informed Consent Statement/Ethics Approval: Not applicable.

Declaration of Generative AI and AI-assisted Technologies: This study has not used any generative AI tools or technologies in the preparation of this manuscript.