Background
Human behaviour is a key determinant of the effectiveness of vaccines in controlling the COVID-19 pandemic. For vaccines to control the spread of COVID-19, a high percentage of the population must be vaccinated [
1,
2]. However, studies from many countries worldwide find that a large proportion of individuals report COVID-19 vaccine hesitancy, or concerns or reluctance about the vaccines that affect intention to seek or accept a vaccine once available [
3]. Vaccine hesitancy itself is a complex phenomenon, influenced by a range of cognitive, psychological, socioeconomic, cultural, social, and environmental factors [
3,
4]. Large regional differences in vaccine hesitancy underscore both the complexity of the problem and the importance of detailed country-level analyses. Within each setting, it is important to understand the degree of vaccine hesitancy, its drivers, and its evolution over time.
The concern about COVID-19 vaccine hesitancy in South Africa is motivated by the pandemic’s severe impact on the country. In June and July 2021, in the midst of a third wave of infections, South Africa was one of twenty countries worldwide most impacted by the COVID-19 pandemic, ranking sixth among this group for case fatality ratio [
5,
6]. This study examines COVID-19 vaccine hesitancy in South Africa amidst the heightened uncertainty, anxiety, and distrust due to the pandemic, as well as the slow emergence of a feasible strategy to vaccinate the country’s adult population. Data collection took place between February 2 and May 11, 2021, in the early phase of vaccine rollout. At this time, only health workers were eligible to receive a vaccine. Registration for Phase II (elderly individuals and essential workers) opened on April 16, but vaccinations for these groups had not yet started. As in many other middle-income countries, the government in South Africa initially struggled to procure enough vaccines and only managed to resolve this supply shortage by mid-August. Against this backdrop, this study assesses the stability and predictors of vaccination intent, with the aim of providing insights that can guide interventions to increase vaccine demand. The lessons learned from this study are relevant for low- and middle-income countries that may experience similar challenges to their vaccination rollout programmes.
Discussion
Our analysis of COVID-19 vaccination intent among adults in South Africa showed that 76% of those surveyed agreed with the statement that they would get a vaccine if one became available to them in April/May 2021, a statistically significant increase from 71% in February/March 2021. These estimates are consistent with results from other recent surveys conducted in South Africa [
15]. The April/May survey’s interviews overlapped with the introduction of a large-scale rollout of vaccines to health workers, and we would expect that the overwhelmingly positive real-life vaccine experiences of health workers would prompt their friends, families and neighbours to reappraise fears based on hear-say rumours and conspiracies. On the other hand, the April/May survey also overlapped with the pause in vaccinations due to blood clotting concerns, which was expected to amplify worries about the safety of the vaccine. Encouragingly, the rise in vaccine acceptance shows that any negative influence of this pause in the vaccine rollout has not dominated attitudes towards vaccines. The greatest change between the two waves was in the proportion of respondents who indicated strong willingness to get a vaccine, at a 9 percentage point increase. Our findings on individual-level changes in vaccination intent between waves indicated that willingness to get a vaccine was more stable than reluctance to get a vaccine.
Our study has important limitations to note. Our use of a telephonic survey may have introduced sampling and non-response biases, though we attempted to mitigate them by having access to several phone numbers, including those of friends and family, for each respondent. We adjusted for systematic non-response through survey weights that drew on the 2017 NIDS survey, but factors that increased during the pandemic such as migration and challenges to mental health may have contributed to further non-response. Reporting bias due to social desirability bias may have affected our findings, though the degree of willingness to get a COVID-19 vaccine would likely have been overstated in this case. We are aware that our survey questions on vaccine hesitancy reflect stated intentions, and the literature has shown substantial gaps between stated intentions and realised decisions. We also acknowledge that slight methodological differences between the survey waves may limit their ability to be directly compared, though this is minimised with regards to the primary vaccine hesitancy outcome.
The implications of having one quarter of the adult population in South Africa expressing vaccine hesitancy require further attention. The community immunity threshold for SARS-CoV-2 is likely to be considerably higher in South Africa than the 60–70% that was previously estimated, due to the growing dominance of the highly transmissible Delta variant [
16]. The main concern with the interpretation of an individual’s stated vaccine willingness is that intentions and attitudes do not always translate into behaviour [
17]. This suggests that our finding of 76% willingness to get a vaccine may be an upper bound for the proportion that eventually accept it. Data on vaccine registrations support this perspective. We note that while 78% of those 60 years and over were willing to accept vaccines in April/May 2021, just over half of this age group had registered for vaccinations by July 4, two and a half months after registrations opened for this group [
11]. This is consistent with international evidence that highlights that stated vaccine willingness is not always reflected in vaccine uptake [
18,
19]. Proposed solutions to address barriers to registration and vaccination include offering these services at more convenient locations and times [
19,
20]. For instance, the under-resourced province of Limpopo has partnered with community healthcare workers to conduct smartphone-enabled door-to-door registrations, and increased vaccination rates by administering doses on weekends [
21].
Vaccination promotion campaigns should continue to frame vaccine acceptance as the norm. While it is important to address rumors and misinformation, frequently discussing vaccine scepticism can perversely give credence to myths by creating the impression that these beliefs are widespread and valid [
22]. Our results indicate that people who are entrenched in opposition to the vaccine make up a significant minority of the population of South Africa. We also demonstrate that many strongly hesitant individuals change their minds over a short period of time. Aligned with what has been previously reported, [
23] our study finds a significant association between trust in social media as a source of COVID-19 information and vaccine hesitancy.
Campaigns that promote vaccine acceptance should emphasize how many previously hesitant individuals have since become willing to get a vaccine. Our results add to the evidence emerging from other countries that younger adults are more reluctant to get vaccinated [
15], but we also find that they are more likely to quickly change their mind. Approaches to reduce the tendency to rationalise vaccine refusal among this demographic may include framing decisions in terms of the prosocial impact of getting the vaccine, harnessing the desire to “return to normal” as a motivator, or emphasizing personal health benefits such as the lower likelihood of severe illness and hospitalisation [
24,
25]. Finally, our results are consistent with prior findings that concerns about the vaccine’s safety, including those related to the roll-out timeline and possible side effects, are common reasons for hesitancy [
15]. Vaccination campaigns should be consistent and transparent in communicating possible side effects, and can reframe beliefs by emphasising that minor side effects are a sign of the vaccine working [
26].
Conclusions
This study highlighted that the proportion of adults in South Africa willing to receive a COVID-19 vaccine increased between February/March and April/May 2021. This rise in vaccine acceptance suggests that setbacks in the vaccine rollout process, such as pauses due to safety concerns, have not dominated attitudes towards vaccines. We analysed a wide variety of information available in this dataset on respondents’ demographics, socioeconomic status, health status, and health beliefs. While most of these covariates did not significantly predict vaccination intent, we found that younger adults, those in formal housing, and those who trusted social media as a source of COVID-19 information were more likely to be hesitant about the vaccine. Though approximately one-quarter of the population were hesitant, a significant minority were entrenched in their reluctance between the two survey waves. Concerns about the vaccine’s development timeline and side effects were prevalent reasons for hesitancy. Vaccination promotion campaigns should emphasize that vaccine acceptance is the norm and employ strategies that account for the perceptions and attitudes of different demographic groups.
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