Making COVID-19 vaccines accessible is crucial. It’s just as important to ensure that as many people as possible feel confident enough to take them.
While access to COVID-19 vaccines remains an obstacle in many low- and middle-income countries, yet another challenge looms: vaccine hesitancy.
Vaccine hesitancy, defined as reluctance or refusal to get vaccinated despite the availability of vaccines, has become a major global concern¾threatening to fuel more virulent variants and contribute to more COVID-19 hospitalizations and deaths.
Understanding the factors driving COVID-19 vaccine hesitancy and developing strategies to build trust in COVID-19 vaccines are critical to countries’ ongoing response efforts and to managing a virus that many experts now believe will become endemic.
What do we know about vaccine hesitancy?
In 2019, WHO identified vaccine hesitancy as one of the top ten threats to global health and resistance or refusal to get vaccinated is not unique to COVID-19. In the Asia-Pacific region, human papillomavirus (HPV) vaccine hesitancy among parents in Japan increased precipitously after 2013, when the vaccine was linked to reports about unconfirmed adverse effects. In the Philippines, controversy over the dengue fever vaccine, Dengvaxia, was believed to erode vaccine confidence in the country and contribute to a dramatic fall in childhood immunization rates. Elsewhere, hesitancy peaked in the US and UK for the measles, mumps, and rubella (MMR) vaccine when it was erroneously associated with autism.
Vaccine hesitancy is complex and not only fueled by concerns about vaccine efficacy and safety. Socio-cultural, environmental, economic, and political factors are drivers as well. Some communities, for example, believe that vaccines can cause infertility as a form of population control.
Distrust of vaccines by minorities and disadvantaged communities who have suffered from marginalization and discriminatory practices (e.g., ethnic minorities, migrants, people fleeing conflict or persecution) is yet another barrier to vaccine uptake. For others, vaccine complacency¾not considering vaccination necessary or a priority¾has delayed uptake.
What is driving vaccine hesitancy in the era of COVID-19?
Reluctance to receive COVID-19 vaccines is driven by similarly complex factors. It persists despite the vaccines’ wide use and real-world effectiveness, and the high number of COVID-19 cases and deaths around the world.
Studies have shown that in many high-income countries, COVID-19 vaccine hesitancy can be attributed to a combination of factors. These include suspicions about the safety of the mRNA technology used to develop the Pfizer and Moderna vaccines; fears that the highly compressed “fast-track” research, development and approval process has compromised the quality and integrity/safety of the vaccines; religious beliefs; the influence of traditional and social media in spreading misinformation; and the politicization of COVID-19.
In low- and middle-income countries, studies have suggested that the widespread acceptance of routine childhood immunization¾including against many vaccine-preventable infectious diseases¾appears to translate to a higher acceptance of the COVID-19 vaccines. However, hesitancy within specific communities remains a challenge and has been driven by several factors. These include previous negative experiences with foreign-led vaccination campaigns (e.g., Pakistan), religious beliefs (e.g., Indonesia), and worries about fake COVID-19 vaccines (e.g., Philippines).
In both high- and low- and middle-income countries, myths, misperceptions, and misinformation about vaccines abound, fueled via social media. At the same time, external events, such as early reports of the side effect of clotting from Astrazeneca and Johnson and Johnson vaccines, have also contributed to vaccine hesitancy.
How can vaccine confidence be built?
Distribution of COVID-19 vaccines has been plagued by equity issues, supply constraints, structural barriers, and logistical challenges. As a result, significant coverage is yet to be achieved in many low- and middle-income countries in the Asia-Pacific region.
However, this delay has created an opportunity.
As countries in the region have waited for COVID-19 vaccines to trickle down, they have also been able to prepare and test-run their vaccine distribution, administration, and monitoring systems. These lessons, along with those learned from the rest of the world, have provided governments with valuable information that can be used to strengthen vaccine confidence, which refers to trust in recommended vaccines and the range of entities (government, health providers, private sector, etc.) behind it.
As experience in wealthy countries has shown, making COVID-19 vaccines accessible is only one part of the solution. Moving from willingness to uptake of vaccination requires multi-pronged strategies that integrate individual, social, and environmental factors.
Moving from willingness to uptake of vaccination requires multi-pronged strategies that integrate individual, social, and environmental factors.
Current evidence suggests that the following three interconnected approaches could be used to address vaccine hesitancy and expand COVID-19 vaccine uptake:
1. Strengthening trust in vaccines using established sources
Health care workers are a highly trusted source of information and health care provider–patient encounters provide an opportunity to reinforce vaccine safety and efficacy concerns. Training health care workers to strengthen their role in increasing awareness, knowledge, and dispelling myths at an interpersonal level is critical to promoting vaccination uptake. In several countries, other cadres (community-based workers and volunteers) have also been recruited and trained to support outreach and vaccination.
2. Developing contextually targeted risk communication campaigns
Hesitancy around COVID-19 vaccines has been exacerbated by a raging “infodemic” – or deluge of unreliable information – primarily via social media. Analyses of infodemic trends can identify gaps in knowledge, myths and misinformation, which can inform contextual approaches to risk communication. In the Philippines, for example, where the country’s vaccine supply includes a mix of vaccine brands but public trust of certain brands was higher, vaccine confidence improved after the government launched an information campaign that promoted the safety and efficacy of all nationally-approved vaccines regardless of the brand. Evidence has also shown that aspects such as tone/delivery style (e.g., authoritative vs. emotional and personal story vs information based) and communication medium (e.g., digital, radio, print) have proven to be particularly important in shifting attitudes and should be carefully considered for the audience.
3. Leveraging public, private sectors and civil society partnerships and enforcing vaccine mandates
In many countries, institutional and social pressure is growing to address COVID-19 vaccine hesitancy. This has led many businesses to require either a negative COVID-19 test result or proof of vaccination in an effort to persuade or “nudge” people towards uptake. In other cases, vaccine mandates, while controversial, have been used as a strategy to increase vaccination rates.
What next? Betting on vaccines for the future
Rejection of COVID-19 vaccines threatens to extend the global pandemic spiral. Moreover, with many experts now projecting that the virus is unlikely to disappear and will probably become endemic, vaccines offer the best strategy for reaching safety from COVID-19. Vaccines will help to ensure that COVID-19 becomes less of a threat by significantly lower the risk of death and severe disease. They will also help to keep variants in check.
Through unprecedented collaboration, we’ve already witnessed what many thought was impossible: developing several safe, effective COVID-19 vaccines and delivering more than 6 billion doses of them within a span of year. Now governments across the globe must apply that same steadfastness and spirit of collaboration to ensure that everyone has access to vaccines and that as many people as possible feel confident enough to take them.