‘Getting the vaccine makes me a champion of it’: Exploring perceptions towards peer‐to‐peer communication about the COVID‐19 vaccines amongst Australian adults

Abstract Objectives Peer‐to‐peer communication approaches have been previously described as the ‘power of personal referral’. Rather than relying on official channels of information, peer‐to‐peer communication may have a role in supporting changes in understanding and possibly behaviours. However, in emergency or pandemic situations, there is currently limited understanding of whether community members feel comfortable speaking about their vaccine experiences or advocating to others. This study explored the perceptions of COVID‐19 vaccinated and unvaccinated Australian adults regarding their preferences and opinions about peer‐peer communication and other vaccine communication strategies. Study Design Qualitative interview research. Methods In‐depth interviews were conducted in September 2021 with 41 members of the Australian community. Thirty‐three participants self‐identified as being vaccinated against COVID‐19, while the remainder were not vaccinated at the time or did not intend on receiving a COVID vaccine. Results Amongst those who were vaccinated, participants spoke about being willing to promote the vaccine and correct misinformation and felt empowered following their vaccination. They highlighted the importance of peer‐to‐peer communication and community messaging, expressing the need for both strategies in an immunisation promotional campaign, with a slight emphasis on the persuasive power of communication between family and friends. However, those who were unvaccinated tended to dismiss the role of community messaging, commenting on a desire not to be like one of the many who listened to the advice of others. Conclusion During emergency situations, governments and other relevant community organisations should consider harnessing peer‐to‐peer communication amongst motivated individuals as a health communication intervention. However further work is needed to understand the support that this constituent‐involving strategy requires. Patient or Public Contribution Participants were invited to participate through a series of online promotional pathways including emails and social media posts. Those who completed the expression of interest and met the study criteria were contacted and sent the full study participant information documentation. A time for a 30 min semi‐structured interview was set and provided with a $50 gift voucher at the conclusion.

attempt to improve immunisation rates did not only reduce vaccinecentric narratives but antagonised users and induced migration to less monitored platforms which contain more radical perceptions of vaccines. 12 Another study sought to understand the communication needs of Australian adults regarding vaccines and determined a number of key recommendations, including the importance of addressing concerns about side effects, sharing true, personalised messages and the need to ensure trust and transparency. 13 There is currently a lack of understanding regarding if and how such recommendations can apply in the peer-to-peer setting as opposed to the top-down or provider-toindividual dynamic. To address this gap, we conducted semi-structured interviews with vaccinated and unvaccinated Australian adults to discuss

| Study design
Semi-structured in-depth telephone interview research was undertaken with COVID-19 vaccinated and unvaccinated individuals.

| Setting and context
The interviews were conducted entirely virtually (either via video conferencing or telephone). This approach supported the inclusion of individuals living outside of Sydney and minimised the risk of exposure to COVID-19, especially for those who were unvaccinated.
Participants were selected based on ensuring adequate distribution of gender and age (18-80 years). There was also representation from every state and territory in Australia, with a few participants maintaining Australian residency or citizenship but taking their interviews overseas. At the time of the interviews, the national adult COVID-19 vaccination rate was approximately 45%-50%. 14 As many parts of Australia were experiencing lockdown, the national and political discourse at the time included the potential for vaccinated individuals to enjoy a relaxation of the public health orders. 15 State health department officials reported local, national and international statistics relating to the pandemic in daily briefings.

| Participants and sampling
This qualitative study recruited participants opportunistically via an expression of interest survey posted via different social media channels.
Eligible participants included Australian adults (currently residing incountry or overseas) or temporary visa holders living in Australia over 18. We had participants who did not intend to receive any COVID-19 vaccine and those who were already vaccinated. Participants were purposefully selected based on age, gender, location, vaccine status and the ability to provide consent. A higher ratio of vaccinated participants was chosen because the primary focus of the study was to investigate perceptions towards peer-to-peer communication.

| Data collection
A trained data collector conducted the interviews using a pretested semi-structured interview guide. The interviews were conducted from 4 September 2021 to 6 October 2021, and interview times varied from 15 to 45 min, depending on the organic flow of the conversation as well as the conciseness of the participant. The semistructured interviews covered sentiments towards vaccination desires to communicate vaccination, effects of peer-to-peer communication and perspectives on best practice communication interventions. A separate guide was used for unvaccinated participants, which included questions intended to understand the potential receptiveness that unvaccinated individuals may have when listening to vaccinated people advocate the COVID-19 vaccine. Interviews were audio-recorded with participant consent, and participants were offered a $40 gift card after the interview as reimbursement for their time and contribution. It is suggested that by the aim of the study, the sample specificity, the quality of the retrieved dialogue and the analysis, the information power is sufficiently high to derive the outlined findings in the study results and discussion section. 16,17

| Data analysis
An inductive approach to analysis was utilised with relevant thematic concerns determined and coded with NVIVO12. Such an approach allowed for the ability to synthesise the raw data and establish links with the research objectives and the potential for unexpected findings. 18 Codes and concepts were derived through open coding of interview transcripts, which were then tested and consolidated into higher-order themes. Initial coding was conducted by Author 1 and independently reviewed by Authors 2 and 3, with codes, concepts and higher-order themes discussed and approved by all authors. The first author is a PhD Candidate with expertise and experience in public health policy and global health strategy in communication. Authors 2 and 3 have in-depth expertise in qualitative research methodologies about public health research, including immunisation intervention strategies.

| RESULTS
One thousand two hundred and eighty-one people returned an expression of interest to participate, of which forty interviews were undertaken. The characteristics of the interviewees are described in Table 1 using the CORE-Q reporting format (17). Unvaccinated participants tended to frame their responses around 'myself vs. others', suggesting that while both promotional pathways may work on some, it is less effective for themselves. They tended to dismiss the role of community messaging, commenting on a desire not to be like one of the many who listened to the advice of others. There were several mentions of arguments and disagreements that had occurred between participants and family and friends who disagreed with their decision not to vaccinate. Unvaccinated 20 (8) reported no change in their desire to communicate the vaccine after receiving it. They expressed a want to complete their duty as a local citizen and just 'move on'.
No, I'm trying not to let it be anything more than I've done the right thing. I've followed the health orders,  in their own responses, especially in regard to the fact that they described being left with no alternative but to 'turn towards information that was not reported by mainstream media due to conflicting information everywhere'.
Both vaccinated and unvaccinated respondents also stated that initially, they did not want or care to research the subject at all. These sentiments were driven by a variety of motivations, including a lack of care or concern for the virus, the idea that they trust what they have heard previously about vaccines or in some cases, that they are being mandated to have it administered anyway, therefore research would not make a difference. A small number spoke passionately and described a lack of patience and short-tempered response to the topic. Some simply want to move on from speaking about the topic. shared in the unvaccinated cohort, who viewed this same situation from a highly disparate viewpoint. This is not a new finding, with such polarising standpoints being observed in other studies. 21 The findings also suggested that people drew from a wide array of sources, depending on their perceived trustworthiness, to make a decision on whether to vaccinate or not.
There are risks with peer communication, especially in online spaces where mis-and disinformation are easily disseminated. This may be due to the increasing prevalence of mis-and disinformation easily accessible online or through social media apps and networks. 22 where conflicting information was emerging relating to its safety.
Another may be when there an individual within a community experiences a negative side effect and special attention to reiterating the rare nature of such an occurrence would be beneficial.

| Limitations
The following are noted as limitations for this work: (1) interviews were only undertaken with a select group of participants, so the possibility of other important themes emerging cannot be ruled out; (2) due to the highly subjective, controversial and stigmatised nature of the topic, there is the potential for individuals to have felt the need to perform for the interviewer or place emphasis on points that did not align with their true feelings or opinions. This cohort was a selfselecting group with internet access, meaning this cohort maintained motivation to partake in the study and excluded people without internet access. Lastly, the authors acknowledged that they may have inadvertently and without conscious knowledge, brought their own biases into the analysis phase, although this was consciously avoided to the best of their abilities.

| Conclusion
The vaccinated Australian adult population may constitute an important part of the continued effort to achieve high vaccination rates amongst its population due to their increased desire to promote the COVID-19 vaccine and correct any misinformation about it. Data from this qualitative study also provisionally suggest that those who are vaccinated feel that they are doing the right things, for their community and for themselves, while the direct opposite is considered by those who are unvaccinated. All individuals reported making use of many different platforms when seeking to have their questions relating to the vaccine answered. Further research to investigate how public health officials may be able to harness the overwhelming majority of Australians more effectively to improve health outcomes for communities around Australia and potentially, the world is encouraged.

ACKNOWLEDGEMENTS
Funding for the gift card reimbursement was provided by funding from A/Prod Holly Seale.

CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.

DATA AVAILABILITY STATEMENT
Data may be made available on request.

ETHICS STATEMENT
Approval for this study was provided by the UNSW Ethics Committee (HC: 210615). Participants were informed that their contribution was voluntary, and they could refuse to answer any question or terminate the interview at any time. All participants provided authorisation of the use of data for research purposes only. During data collection, researchers emphasised that any questions about immunisation should be discussed with a healthcare professional.