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Updated: Feb 21

The journey to vaccine acceptance


The World Health Organization (WHO) estimates that 2 – 3 million lives are saved each year from vaccines [1]. The control of vaccine-preventable diseases (VPDs) is one of the greatest public health achievements in human existence. In the 21st century, death and disability from VPD’s are an indictment on global public health systems. Inequitable vaccine access and vaccine hesitancy are amongst the reasons why VPDs are not entirely eradicated as global health crises [2]. Vaccine denialism, anti-vaccination movements and vaccine hesitancy has been in existence since the invention of vaccines itself [3,4]. However, the rise in these movements over the last century has led to the WHO declaring vaccine hesitancy as one of the ‘top 10 threats to global health’ [2].

The COVID-19 pandemic continues to push new frontiers in public health. The universal COVID-19 vaccine program is the first attempt humankind is making at having a coordinated public health intervention for the entire eligible global population. Vaccine hesitancy in the era of the COVID-19 pandemic represents a fundamental threat to global health and must be addressed urgently. In order to do this, we need to unpack why people may be hesitant to vaccinate and evaluate strategies designed to encourage vaccine acceptance.

Vaccine Hesitancy – history and evolution

The WHO SAGE working group on immunizations defines vaccine hesitancy as the “delay in acceptance or refusal of vaccination despite availability of vaccination services” [5]. Its origins can be traced back to 1850 where anti-vaccine movements began in response to state mandated Smallpox vaccinations [3,6]. Sentiments of violations of civil autonomy and general distrust of vaccines on theological views persisted over the course of the 20th century. In 1970, safety concerns were cited as the main objections to vaccination which culminated in the Diphtheria Tetanus and Pertussis (DTP) vaccine acceptance rate plummeting, despite the safety empirically proven after thorough investigations [3,6,7]. Later in 1998, arguably the most notorious study in modern medicine was published by the Lancet, a reputable peer-reviewed medical journal. Dr Andrew Wakefield et al alleged a causal link with the Measles, Mumps and Rubella (MMR) vaccine and Autism [3,6-8]. The General Medical Council in the UK investigated and found that Dr Wakefield produced fictitious study results and committed scientific fraud for his personal financial benefit. In 2010, the Lancet retracted the publication. However, the damage was already done. The falsified study results were widely publicized in the media as fact and Dr Wakefield, the pantomime villain of modern public health, became the poster child for the anti-vaccination movement. The net result was a significant decrease in Measles vaccination and pockets of Measles outbreaks in areas that previously achieved eradication [7,8]. In 2019, the spread of misinformation and rising vaccine hesitancy against Measles contributed to the highest number of global Measles cases reported in 23 years [9].

The rise of social media has further fuelled general public distrust of science and vaccines in particular through the spread of misinformation [10-12]. Wilson and Wissongye found a direct association between misinformation on social media, mobilization of anti-vaccination movements and overall vaccine hesitancy [12].

Why are people Vaccine Hesitant?

The Vaccine Hesitancy model describes how the “three C’s” determine why people may refuse or delay vaccination [5,13].


Individuals perceive that their risk of a disease is minimal and vaccination is deemed unnecessary.


Individuals have a loss of confidence in the safety and/or efficacy of the vaccine, the competency of the health system to deliver them and/or vaccine policy-makers


Individuals develop vaccine hesitancy should they have difficulty accessing the vaccine. Affordability, physical accessibility, quality/efficiency of health services, sociocultural sensitivities may all affect the individuals experience about vaccine access.

In addition to this, there are micro and macro-environmental factors which may influence decision-making about vaccination [5]. [adapted from Working Group on Vaccine Hesitancy Determinants Matrix].

Individual influences

Personal or family member’s knowledge, attitude, beliefs and experience with vaccination.

Community influences

Knowledge, attitude, beliefs and experience with vaccination of their trusted healthcare provider, religious leaders/other influential leaders.

Societal influences

Socio-cultural/religious/political attitudes and beliefs about vaccination.

Socio-economic, historical, geographical factors influences

Vaccine-specific influences: safety, efficacy, cost, delivery, accessibility.

COVID-19 Vaccine Hesitancy

A multinational ISPOS poll shows declining global COVID-19 vaccine acceptance from 74% in August 2020 to 66% in December 2020 [14]. The sentiment in South Africa is lower, however. The current COVID-19 vaccine acceptance rate in South Africa is 61% according to ISPOS and 67% according to a recent UJ/HSRC survey [14,15]. The reasons for COVID-19 vaccine hesitancy in these surveys are due to concerns of side-effects/safety, effectivity of the vaccine, complacency (i.e. respondents felt they are not at risk of COVID-19), general distrust of vaccines and a variety of myths [14,15].

The elusive target of herd immunity from COVID-19 is not fully understood yet, but is estimated to require around 67% of a population to be immune from the virus [16-18]. Vaccination represents the only effective strategy to obtaining herd immunity rapidly [19]. Therefore these survey findings of COVID-19 vaccine sentiment globally, and particularly in South Africa, are deeply concerning. It may undermine public health efforts to rapidly achieve herd immunity and minimize severe illness and death.

Moving to COVID-19 Vaccine Acceptance

Any complex public health issue requires multi-level approaches and multi-stakeholder engagements. Therefore, the best strategy to address COVID-19 Vaccine Hesitancy is to implement an integrated approach using several evidence-based and locally relevant methods simultaneously [20].


In order to combat misinformation, strategies need to be designed to provide direct and accurate information on COVID-19 in general, and vaccines in particular, to the individual in a language of their choice [20,21]. The information needs to be succinct and use multiple platforms, including social media [22,23]. Story-telling is a powerful medium to bring about behaviour change. In an era where anecdote appeals more to the lay-person than empiric evidence, the anti-vaccination campaigns have utilized this tool more effectively to sway public opinion [24]. However, this should be seen as an opportunity to use the same “first-hand account” methodology to bring about COVID-19 vaccine acceptance [24]. Personal success stories of flawless vaccinations and stories about the hardships endured by those who suffered from COVID-19 who were not vaccinated yet, can be distributed in common channels.


Data has shown that engaged societal leaders can improve vaccine acceptance [20]. Healthcare providers, religious/community leaders and celebrities/influential people occupy integral societal leadership positions. Their role in determining vaccine acceptance cannot be underestimated. Their beliefs and attitude towards vaccination may unwittingly determine other people’s vaccination views as well [20,21,25,26]. Their leadership position thus represents both a risk and opportunity for COVID-19 vaccine acceptance. It’s therefore incumbent on these influential individuals to equip themselves with facts, recognize their power and provide responsible leadership. Strategies to address vaccine acceptance must engage with these leaders on multiple levels in order to leverage their influence.

Healthcare providers have an additional unique opportunity during a health consultation to directly engage with people about their vaccination knowledge, beliefs and attitudes.

Public Health Policy

COVID-19 vaccination needs to have minimal accessibility challenges in order to improve acceptance. Any costs and/or inconvenience to the user may significantly impair acceptance [20]. Most of the current COVID-19 vaccinations use a 2-dose schedule. This inconvenience may represent a significant factor in determining acceptance and institutions may opt to utilize vaccines on a single-dose schedule to combat this. Special considerations are needed for rural and impoverished communities.

Policies to mandate vaccination or sanction against non-vaccination are commonplace for childhood vaccinations and have proven effective in improving vaccine acceptance [20]. However, mandatory vaccination of adults raises both ethical and legal considerations about autonomy and civil liberties respectively [27]. A preferred approach is for institutions to encourage voluntary acceptance [27].

Policies incorporating non-financial incentives have shown efficacy in improving vaccine acceptance[20]. Examples of these are food and care packages distributed at vaccination centres. These are of particular importance in impoverished communities.

Infodemic response

In a joint statement with several international bodies, the WHO recognizes how COVID-19 responses are undermined by a parallel “infodemic” of misinformation [28]. They call on countries to develop action plans and appeal to individuals to equip themselves with accurate information and develop skills to identify falsehoods [28]. “Infodemic” resilience building is an integral component of a comprehensive strategy to improve vaccine acceptance. However, the role that social media companies occupy has come under scrutiny in recent times. Their failure to censor deliberate misinformation (i.e. disinformation) has significantly impacted the rise of COVID-19 vaccine hesitancy [28,29]. A coordinated vaccine acceptance strategy needs to lobby more ownership and regulation of disinformation from social media companies.

Engaging with Anti-vaxxers

Engaging with people that have strong anti-COVID-19-vaccination views with hostility is counter-productive. Taking an adversarial approach will only cause further polarization [30]. Channels to engage with people of opposing views must be created in a manner that is constructive and geared to appreciating and addressing underlying concerns [30].


COVID-19 vaccine hesitancy is a threat to global health. A multilayered, coordinated, evidence-based and dialogue-based approach is needed to address it. Understanding the causes and drivers is key to developing an integrated and locally-relevant strategy. There is no room for ambivalence. We need our leaders to take an unequivocal position to support science, support public health approaches and encourage collaborative discourse to transition public sentiment from COVID-19 vaccine hesitancy to acceptance.


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