SAMBHAL DISTRICT, UTTAR PRADESH - For a long time, local officials seeking to drive up Covid-19 vaccination rates in Uttar Pradesh's Sambhal district were up against a giant roadblock - the local Member of Parliament, Mr Shafiqur Rahman Barq.

The 91-year-old had described Covid-19 as "God's punishment for our sins" in July last year and steered clear from being vaccinated. In April, he fired another salvo saying he did not need a jab.

"My life and death is in Allah's hands who is protecting me," he had said, reinforcing the region's endemic vaccine hesitancy and frustrating health officials who tried to get him to change his stance.

So when the veteran leader who wields significant influence finally got vaccinated on June 25, Dr Neeraj Sharma, a local medical officer, knew it was a turning point that had to be exploited.

He recorded a video of the MP singing praises of the vaccine and explaining why it is important to get jabbed. The ringing video endorsement was then circulated in local WhatsApp groups.

"The video indeed helped drive up vaccination in the region," Dr Sharma told The Straits Times.

This is one of the innovative strategies Sambhal's officials have deployed to try and overcome stubborn vaccine hesitancy in the district, where Muslims as well as Hindus remain apprehensive of getting jabbed.

Their fears emanate from falling ill and incurring additional expenses or even being killed or rendered impotent by the vaccine, besides a reckless assumption that Covid-19 is a disease that primarily affects urban folk and not villagers who "toil in the sun or breathe in rural fresh air".

If India has to immunise all its adults by December this year - an elusive target it has set for itself - key battles against vaccine hesitancy will have to be fought in villages such as Semla and Azimabad in Sambhal.

The foe here is entrenched. A daunting combination of widespread illiteracy and aggressive spread of misinformation overwhelms the government's inadequate counteroffensive in Sambhal's narrow sewer-lined village lanes.

Mr Avinesh Kumar Sharma, 45, a farmer in Azimabad, has dug in his heels and decided he is not going to get vaccinated at any cost, after hearing that people have died from Covid-19 vaccines.

"Death is inevitable, it has to come. So why should I get jabbed to die?" he said. "Why should I get jabbed to die," he repeated for emphasis.

"Fever, cold, cough or an upset stomach (common Covid-19 symptoms) - these are illnesses that have been around for ages," Mr Sharma said, surrounded by several other unvaccinated locals who added that they, too, will not get jabbed.

A government panel has confirmed only one death in India due to adverse reaction from a Covid-19 vaccine. Yet, resistance in its villages is stubborn, exasperating local foot soldiers such Mr Bhagwan Singh, 31, who mobilises locals to get vaccinated in Semla.

"You die, we don't want to die," that is what people tell him when he sets out to convince locals. Only around 10 individuals showed up at a recent vaccination camp held on June 25 and 26 in Semla that has a target population of 2,800.

A school teacher ran away from his house when Mr Singh and others went to convince him to get jabbed. "Even today when he sees me near his house, he is afraid and asks if vaccination is on again," added Mr Satendra Kumar, 28, another volunteer in Semla.

"People ran away to their fields on the days when vaccination was organised in the village. Those who were really scared didn't even sleep at home the night before," added his wife, Ms Kusum, 28, a local government health worker in Semla.

At times, volunteers are even threatened with violence. "Call as many officials as you like. If officials come, we will beat them with sticks," locals told Ms Kusum recently.

The district, with a population of more than 2.2 million people, has recorded 104 Covid-19 deaths, which is widely held to be an undercount. This low but misleading tally has, however, led to an assumption in many villages that Covid-19 is not really a threat, further strengthening the reluctance to get vaccinated.

As at July 5 in the age 45 and above category, only 5 per cent of the 475,621 people had been fully immunised, putting it at the bottom of the pile of districts in Uttar Pradesh that have an average of around 8 per cent coverage.

The performance for those between 18 and 45 is worse, with just 225 individuals fully vaccinated out of the one million target population in Sambhal. A June analysis in Scroll, an Indian news portal, ranked Sambhal as the country's second-worst district in vaccine coverage.

Dr Manoj Chaudhary, the district surveillance officer who oversees vaccination efforts in Sambhal, told ST that vaccine hesitancy was aggravated in the district as some elderly people died after receiving their first dose in April, the month when vaccination was opened to all those above 45 as well as a period when the devastating second wave crashed into India.

"The deaths happened because of Covid-19 or some other cause (not related to vaccination), but the fact that the person had got jabbed stayed on in people's mind," Dr Chaudhary said.

"This created a feeling among some that the deaths happened because of the vaccine and this message spread from one village to 10 villages, creating strong vaccine hesitancy."

Irresponsible statements from local influential political leaders also added to the dangerous mix. An opposition leader and the state's chief minister Akhilesh Yadav had in January termed the vaccines scheduled to be rolled out as "Bharatiya Janata Party vaccine" and said he would not take a shot. He has since changed his position and his father Mulayam Singh Yadav, a veteran politician, was vaccinated last month.

The Yadavs have a significant following among locals in Sambhal, and the turnaround has helped change opinion on the ground as well. It was evident when one such villager walked into a vaccination camp in Barahi village on July 9 asking for the "same vaccine" that was given to Mulayam Singh Yadav.

A network of mobilisers deployed in each village - comprising the local village head, ration dealer, teachers as well as healthcare workers - has helped overcome hesitancy to a certain extent. Religious and community leaders have also been vaccinated on priority and asked to pitch in with their support.

Acknowledging that vaccine hesitancy is still a problem in certain villages and that the state's outreach needs to be better, Dr Chaudhary said dispelling misconceptions related to the vaccine among people in rural areas remains the biggest challenge. "100 per cent vaccination is only possible when every person is clear that vaccines are being administered in good faith and not to cause harm," he told ST.

A wider availability of vaccines and relaxed vaccination norms for the public has allowed a more expansive roll-out since the beginning of this month. While the district administration was organising just around 80 camps each day in June, administering fewer than 3,000 doses daily, this number has now gone up to more than 200 camps with a daily average of around 7,500 doses.

With a little over 250,000 doses given in Sambhal, fully vaccinating the estimated 1.5 million people by December will require a significant ramp-up in daily coverage - to more than 17,000 doses.

Dr Chaudhary is optimistic though. "We have the capacity of administering more than 20,000 doses daily and hope to achieve our target if people support us and vaccine supply is adequate," he said.

Vaccinating the entire target population will also require a sharper public campaign, along with medical follow-ups post-vaccination, to reassure those worried like Mr Jamuna Singh, 30, a farmer in Semla.

He said his father fell ill for a month after getting his first jab in April, even requiring hospitalisation and medical expenses of 9,000 rupees (S$164). It is not known if the illness was caused by the vaccine or if it was Covid-19 that struck him down as he was not tested.

"I am willing to get vaccinated but I need a guarantee that I will be looked after. I also have three kids. Who will take care of them if something happens to me after vaccination? I need a guarantee as well that someone will look after them," Mr Singh said.

Mr Amulya Nidhi, the national co-convenor of the People's Health Movement (PHM)-India, said the government's on-ground outreach to counter vaccine hesitancy has been woefully inadequate, particularly when it comes to the use of printed material to create awareness as rural Internet penetration is still low.

The PHM-India has created a Covid-19 booklet that has been updated for a second edition and translated into several Indian languages for wider distribution in different parts of the country.

"If you will not give information, not create awareness, then how will people come forward and get vaccinated? And if people refuse, they are termed as uneducated or not intelligent," Mr Nidhi added, calling for an equitable distribution of vaccines for all sections of the society.