By Max Gallien (ICTD/IDS), Umair Javed (LUMS), Shandana Khan Mohmand (IDS), and Vanessa van den Boogaard (ICTD)
Trust in state institutions—and, as a consequence, in the vaccines that they seek to administer—is often thought to be a key determinant of vaccine acceptance. However, a particular gap in our understanding is acceptance amongst marginalised groups in low income countries, who have tenuous connections to the state and to credible information and support networks. Ensuring that everyone is vaccinated across the globe requires that we better understand vaccine hesitancy amongst such groups, especially when these represent large populations.
We report below on a project that explores health-seeking behaviour and, in particular, attitudes towards Covid-19 vaccination programmes, from the perspectives of a group that is typically located at some ‘distance’ from the state—informal workers in the lower-middle-income context of Lahore, Pakistan.
Recent studies have highlighted the fact that informal workers, who make up about half of the global labour force, have been disproportionately affected by the pandemic (Gallien and van den Boogaard 2021; Sabatini 2020; WIEGO 2020). They often face additional hurdles in gaining emergency support or access to health care, see their work disproportionately disrupted by lockdowns, and are particularly vulnerable to protracted income shocks. Critically, however, they also have a different relationship with the state than formal workers: they are more likely to have limited engagement with state institutions and to have these relationships marred by mistrust, extortion, and evasion, while being less likely to have their interests represented by organised groups (e.g., Lindell 2010; Meagher 2014; Resnick 2019).
Grounded in this context, we investigated the degree to which heterogeneous trust in state institutions affect the responses of informal sector workers to get vaccinated. Does the distance to the state, or previous negative experiences with state actors lead to increased vaccine hesitancy among informal workers? And do different relationships with clients or employers, rather than state institutions, shape health-seeking behaviour?
We explore these questions through in-depth conversations with 93 informal workers in Lahore covering four sectors: domestic work, home-based sub-contracting, street vending and retail, and transport. These represent a large section of informal activities in Pakistan, and are some of the most common informal activities in urban centres of the Global South more widely.
Two key findings emerge from our research. First, we find a surprising disconnect between discussions of vaccine scepticism and actual decisions to get the vaccine. Those who got the vaccine were not necessarily “true believers” in its effectiveness, while, contrary to our expectations, trust in the state and public health information did not shape the health-seeking behaviour of informal workers. Instead, some clearly choose to get vaccinated for their own well-being, with the decision being unrelated to their feelings about state institutions, while others described less agency in making the decision. This lack of agency was rooted in both an inability to avoid state enforcement as well as a belief in destiny, which rendered fears about the vaccine or its purported negative effects of secondary importance.
Second, we observe striking sectoral variation in perceptions of the pandemic and willingness to get vaccinated, with greater scepticism and hesitancy among male-dominated street vendors and transport workers, than among female home-based manufacturing and domestic workers. We argue that informal workers’ relationship with gendered geographies of labour and public space shapes health-seeking behaviour, by influencing their experience of lockdowns, the nature of state interactions, class identity and cross-class interactions, and sources of information about the pandemic. Gendered labour geographies and their impacts have thus contributed to heterogeneous attitudes toward vaccinations in Lahore’s informal economy.
As in many cities in the Global South, informal work dominates the economy in Lahore, with an estimated 70 percent of all waged and own account work taking place in the informal economy (Pakistan Bureau of Statistics 2018). While informality is common across all key areas of the economy, our research focused on four key sectors – transport, street vending and retail, domestic work, and home-based sub-contracting. Collectively these sectors cover 74 percent of all informally employed labour in Pakistan’s urban economy and contribute upwards of 45 precent to Lahore’s Gross Domestic Product (GDP) (Lahore Chamber of Commerce 2017).
There is important variation across these sectors in terms of labour demographics, geography of work, and pre-existing interactions with the state and its regulatory apparatus. Street vending and transport are public-facing and primarily made up of male own-account workers, with less than 1 percent of female labour working across both sectors (Pakistan Bureau of Statistics 2018). On the other end of the spectrum, domestic work and home-based sub-contracting consists largely of female employees whose labour remains confined to private spaces, such as within their own or their employers’ residences. The demographic divide across the four sectors maps on to a gendered divide in work practices and experiences of public space, which carried significant implications for the experience of the pandemic as well as existing attitudes towards public health regulations, such as vaccines, lockdowns, and distancing requirements.
Disconnect between Vaccine Hesitancy and Vaccinations
We asked respondents about both their willingness to get vaccinated as well as their perceptions of the costs and opportunities associated with that choice. A substantial number of those we spoke to had either received the vaccine or were planning or willing to get it. Broadly, our sample splits into thirds. Of 93 respondents, 30 reported that they had been vaccinated, and a further 28 indicated that they had already made concrete plans to get vaccinated or were thinking about it. If most of these people got the vaccine in the time since our interviews in 2021, then this would roughly match the most recent figures on the national vaccination rate. Only 29 (31 percent) reported that they were not vaccinated and did not plan to get vaccinated.
To understand vaccine acceptance or hesitancy among informal workers, however, it is important to look beyond just the act of getting vaccinated. Indeed, getting vaccinated did not mean that individuals did not have doubts or concerns about the vaccine. Where opposition to public health strategies existed, it was often based on misinformation or conspiracy theories about the virus and the vaccine. A particularly pervasive rumour, for example, was that those who get the vaccine would die within two years. And yet, notably, believing these rumours was not in itself indicative of whether respondents were or were willing to get vaccinated. Some respondents who explicitly expressed concern about dying in two years still got vaccinated. Further, even among those who received the vaccine, there were often doubts about its efficacy or concerns about adverse health effects.
Respondents highlighted a wide variety of factors influencing their evaluation of the pandemic, including, first, the need to take care of themselves and their families. One female domestic worker who did get vaccinated, answered our question on whether she followed public health guidelines because of government directives, as follows:
No. The government is very incompetent. We did that to save ourselves, and our children, from the virus. We have lived our life, the children have a lot in front of them now. They need to take care. We took a lot of care, and still do. (DF16)
This was not an untypical position. A male transport worker who got vaccinated not only expressed mistrust in the government, but argued:
I’ve gotten one dose and am waiting for them to call me for the second dose. But we honestly can’t really say anything about whether it will work or not. The night that is to be spent in the grave is not known to anyone and no vaccine can save us from it. But I didn’t get the vaccine out of fear that they would disable my SIM card or anything. I got it for the sake of protection. And they treated me well so I am happy with it. We’ve heard rumours from Facebook of some Nobel prize winner that those who get the vaccine will die in two years but what can we say – when your time comes, nothing can save you from it, and everyone has to die at some point anyway. But I believe that all people should get the vaccine regardless. (TM06)
This is in line with a recent study of vaccine hesitancy in 10 low- and middle-income countries that finds that vaccine acceptance in these contexts is primarily explained by an interest in personal protection, while concern about side effects is the most common reason for hesitancy (Solís Arce et al. 2021).
We also found a substantial difference in perceptions of Covid-19 and of the vaccination campaign across sectors in the informal economy. The largest difference was in the evaluation of the pandemic more broadly. This same pattern is also reflected in informal workers’ attitudes toward the vaccination program and, somewhat more weakly, in their personal decisions to get vaccinated. We find higher numbers of street vendors and transport workers stating that they are sceptical of the vaccination program and have no plans to get vaccinated. Strong positions against the vaccination program are rarer among women in domestic work and home-based manufacturing.
We argue that the gendered nature of the sectors in the informal sectors economy and their relationship with public space provide a more convincing explanation of the differences in behaviours towards vaccines. Informal workers in different sectors perceive and construct the risks of operating in public space differently, with those operating in male-dominated public spaces—street vendors and transport workers—more likely to be sceptical about the pandemic’s existence or severity than those working in female-dominated sectors that operate in private spaces, whether at home or in an employer’s home. Informal workers’ heterogeneous access to and interaction with public space influences factors that interact and reinforce one another to produce different opinions on public health interventions.
Through their work in public spaces, street vendors and transport workers have seen their work affected differently because of public health policies. Through the more direct interactions with lockdown regulations in particular, the perception that these regulations are excessive has become more common among street vendors and transport workers and has contributed to their more sceptical stance.
Similarly, for workers in public spaces, encounters with public authorities are regular occurrences. Predation and coercion are more common, especially in the guise of anti-encroachment operations against street vendors and ad-hoc transport regulations against informal transport providers. Such interactions with state officials are overwhelmingly negative, influencing their scepticism about the state and its pandemic response. For example, two street vendors said:
“Out of fear, people did wear masks. They were afraid of paying fines, not afraid of the virus. No one did it by choice.” (SM13)
“I think that those who do [comply], it’s mostly because of regulations. That’s all. The people don’t want any trouble.” (SM03)
Street vendors and transport workers more commonly highlight themes of class identity, especially as explanations for why they do not abide by public health regulations. To illustrate, we cite a few statements below:
“Those people should get vaccinated who live a life of luxury and thus have weaker immunity. For people like me, flu and cough happen every year and its never something to worry about. I fear that the government might also force us to get vaccinated when we really don’t need it.” (TM3)
“I’ll tell you one thing. Corona has mostly affected those who sit in air-conditioned rooms, you know? It’s there. As far as we go, we work hard with our blood and sweat out in the open every day. We have not seen corona affect any of the poor.” (TM4)
Crucially, key differences in access to information exist across the gendered sectors. Men working outside rely more heavily on intra-class interactions and personal observations to come to their conclusions. Information is gathered by working outside, by talking to others in their sector, and observing whether they had gotten sick. This same point was made far less frequently in our conversations with domestic workers and home-based manufacturers. Interactions with other workers was less frequently mentioned as a source of information. Instead, particularly among domestic workers, there are more frequent references to learning about the virus through the experience of family members, and in particular reporting on TV.
Conclusion and Policy Implications
Through our conversations with informal workers, we uncover a surprising disconnect between vaccine scepticism and decisions to get vaccinated, with the former not necessarily determining the latter. Contrary to expectations, trust in the state and public health information did not consistently shape the health-seeking behaviour of informal workers. Rather, trust in the state, perceptions of the pandemic and the vaccination programme, and the economic precarity facing informal workers are all intimately wound together.
From these dynamics follow important policy considerations. First, the heterogenous dynamics and inter-sectoral differences that we highlight underline the importance of not treating informal workers with broad-based policy. Second, we suggest that attention in combatting vaccine hesitancy, or ensuring compliance with future public health measures, does not just need to be focused on those at the largest ‘distance’ to the state, such as atomised home-based workers or rural communities, but that some pockets of hesitancy are also ‘hiding in plain sight’ among informal workers in urban public spaces. Third, trust in the state may not explain health-seeking behaviour, but it is low overall and intimately linked to economic precarity. Informal workers do not appear to be staunchly vaccine hesitant, but they are not vaccine eager either; engaging them more effectively with vaccination programs requires a more secure economic situation. At the very least, a better understanding of vaccine hesitancy among informal workers is necessary to increase vaccinations worldwide.
The authors would like to acknowledge the Covid Collective project, the platform through which this research was carried out.
The article has been co-authored by Dr. Umair Javed (Assistant Professor of Politics and Sociology at the Lahore University of Management Sciences (LUMS)), Dr. Max Gallien (Political Scientist at the Institute of Development Studies(IDS), UK), Dr. Shandana Khan Mohmand (Social Scientist at the Institute of Development Studies (IDS), UK) and Dr. Vanessa van den Boogaard (Research Fellow at International Centre for Taxation and Development (ICTD)).
 Sixty percent of the national population received at least one dose as of 31 March 2022.
 For 6 interviews we did not feel comfortable assigning any of these 3 categories.
 The fact that we find a starker difference in perception than in actual behaviour connects with Solís Arce et al.’s (2021) assertion that there may be a mismatch in intentions and action when it comes to the vaccine (though in this case it seems that vaccine scepticism does not stop people from actually getting a vaccine, as noted above).