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The underlying factors of vaccine hesitancy are complex and context-specific, varying across time and socio-demographic variables. Vaccine hesitancy can also be influenced by other factors such as health inequalities, socioeconomic disadvantages, systemic racism, and level of exposure to misinformation online, with some factors being more dominant in certain countries than others. Therefore, strategies tailored to cultures and socio-psychological factors need to be developed to reduce vaccine hesitancy and aid informed decision-making.
- hesitancy
- acceptance
- vaccine efficacy
- vaccine safety
1. Introduction
Due to the coronavirus infection, the current pandemic is the topmost public health concern. With COVID-19 vaccines approved by the World Health Organization (WHO), the hope of overcoming the pandemic soon has increased. However, vaccines must be more widely accepted and used to end the pandemic [1]. The spread of the virus can also be mitigated by reaching herd immunity, but that takes more time [2]. Therefore, public awareness and well-designed campaigns promoting vaccination are essential to decrease the progression of COVID-19.
The WHO has already approved several vaccines and suggested getting the vaccine by majority of the population of a country as soon as possible to obtain herd immunity [2]. Despite evidence of the safety and effectiveness of vaccines, misperceptions about vaccines persist. Some people think that getting vaccinated can lead to temporary health impairments or long-term damage. Vaccine hesitancy is a complex phenomenon that affects people’s willingness to be vaccinated. Studies have shown that there is no single set of factors responsible for vaccine hesitancy. Instead, there is a wide range of contextual (i.e., communication and media, historical influence, religion, culture, gender, politics, geographic barriers), individual and group (i.e., personal, family experience with vaccination, beliefs, knowledge), and vaccine-specific factors (i.e., risk and benefit, costs) that can affect vaccine acceptance [1,3,4]. The cost of the vaccine may also affect willingness to be vaccinated because, in some countries, the cost is related to a person’s monthly income [5,6]. The factors affecting vaccination intention vary across countries, socioeconomic groups, demographic variables (i.e., ethnicity, gender), and types of infectious diseases [7].
Conspiracy theories and fake news propagating across social media have flourished during the COVID-19 pandemic [8]. In February 2020, when the pandemic rapidly grew worldwide, the WHO warned of an infodemic, a wave of fake news and misinformation on social media regarding COVID-19 [8]. After the approval of COVID-19 vaccines, misinformation about the vaccinations also started to disseminate quickly. The conspiracies frequently seen on social media include claims that COVID-19 vaccines change the human genome, that a microchip is implanted in the human body through the syringe, that the vaccination causes COVID-19 infections [9]. YouTube, Facebook, and Twitter announced working together to combat the problem. This misleading information may have affected the acceptance of COVID-19 vaccinations. Studies have also shown that rumors can have a negative effect on willingness to accept COVID-19 vaccines [5,10,11].
2. SARS-CoV-2 Vaccine Hesitancy
2.1. Worldwide COVID-19 Vaccine Acceptance and Hesitancy Rate
Several studies [3,20,21,45,46,47,48,49] measured potential COVID-19 vaccine acceptance and hesitancy rates for people in Italy. The latest study [3] found that 15% of the general population in Italy would most likely refuse the vaccine, whereas 26% would be hesitant. Willingness to vaccinate was measured to be 83.2% among the HCWs in Italy [47], and students’ willingness to vaccinate was measured to be 86.1% [21]. Vaccine acceptance among people at-risk because of critical health conditions was measured at 86% [46].
Studies [6,22,50,51,52,53,54,55] measuring public attitudes towards COVID-19 vaccination in China showed that general population hesitancy was reported to be 25% in March 2020 [50]. Afterwards, vaccine hesitancy among the general population reduced to 10.9% [6], and, in September 2020 unwillingness to vaccinate was measured at 8.2% [22]. A total of 76.4% of the HCWs in China were willing to vaccinate [50].
Among the included studies [4,23,56,57,58,59,60] measuring the willingness to vaccinate in France, intention to refuse the COVID-19 vaccine increased over time. During the first coronavirus wave in May 2020, vaccine hesitancy was measured 28.5% among general population [56]. Over time, vaccine hesitancy increased to 32.8% in July 2020, 39.0% in August 2020, and 47.9% in September 2020 [56]. The willingness of HCWs in France to vaccinate was measured to be 48.6% [59] and for patients suffering from cancer diseases, willingness to vaccinate was measured to be 53.7% [23].
In Canada, 20% of the general population was unwilling to get the COVID-19 vaccine [73]. In comparison, 65% of caregivers intended to get vaccinated [74]. In Turkey, 31% of people were hesitant, and 54% were willing to vaccinate when the COVID-19 vaccine became available [62]. Another study reported that 43% of the healthcare personnel in Turkey were hesitant to get the COVID-19 vaccine [75]. On the other hand, a total of 65% of the general population in Ireland was willing to vaccinate [61]. Meanwhile, 73.9% of people in Denmark and Portugal were willing to accept the COVID-19 vaccine, 18.9% were unsure, and 7.2% refused to get vaccinated [76].
During the COVID-19 pandemic, general population willingness to vaccinate was reported as: 74% in Scotland [77], 37% in Poland [78], 78.3% in Indonesia [79,80], and 57.7% in Greece [81]. Several studies were conducted in the Gulf Cooperation Council (GCC) countries. Vaccine hesitancy among the general population in Qatar was measured at 19.8%, and vaccine refusal was measured at 20.2% [82]. A total of 35% of the general population in Saudi Arabia was hesitant about the COVID-19 vaccine [83]. Studies [84,85] reported that 53.1% of the general population in Kuwait was willing to vaccinate. Two studies were performed in Jordan [85,86], where the latest study [86] showed that 29.1% of the general population was willing to accept the vaccine when it became available. The survey in [87] included 19 countries worldwide, and the survey in [63] included 26 countries from Europe. In these studies, the authors measured public willingness to vaccinate in each country. Lower vaccine intention was reported in Congo, where 28% of HCWs were willing to vaccinate [10].
2.2. Determinants of COVID-19 Vaccine Hesitancy
There are three main types of factors that influence vaccine hesitancy or acceptance: (i) demographic factors (i.e., education, income, ethnicity), (ii) environmental factors (i.e., policies, media), and (iii) vaccine-specific factors (i.e., vaccine efficacy, safety) [74]. Determinants of vaccine hesitancy are specific to the context and are presented separately. Therefore, it is important to understand and acknowledge the interrelatedness of the factors [88].
The most common factors that influence vaccination intention are described in Table 4. In Table 4, determinants affecting vaccine hesitancy, the papers the determinants were found in, the places the studies were conducted, the education levels of the population, and the occupations of the population are described.
Vaccine safety and efficacy were found to be major concerns among people of all occupations. Vaccine safety determines the risk associated with vaccine benefit-risk profile changes and can anticipate coincidental events [89,90]. Vaccine efficacy determines the percentage of vaccine effectiveness against COVID-19 [41]. Public concerns regarding vaccine safety and efficacy were found in several studies [2,3,5,20,29,32,43,46,54,55,60,65,69,71,83].
Another finding is that some people were unwilling to vaccinate due to the side effects of vaccines, as reported in [11,19,25,29,40,42,53,54,68,77,79]. The COVID-19 vaccine is new, and it takes time to determine the vaccine’s short-term and long-term side effects [55].
Willingness to vaccinate was found to be associated with the perceived risk of being infected with the COVID-19. Younger people were more confident about being at less risk of being infected by the COVID-19 [20,27,40,43,53,54,59,64,91]. The perception of young people is also correlated with the concept of herd immunity of the body and knowledge about SARS-COV2 [22,46].
The conflict between vaccination science and religious people exists due to conspiracy theories about morality. Because of this, some religious people reject or delay vaccination [11,56,76,92]. This report predicted that religiosity strongly predicts anti-vaccine beliefs [56,76].
Due to a lack of health insurance or financial resources that might be necessary to have access to the vaccination, people were unwilling to vaccinate [5,6,39,55,80]. Moreover, the ability to spend money on health was often dependent on monthly income, creating health inequalities and increasing the vaccine hesitancy rate in certain countries [5,6].
Inconsistent messages from health organizations lead to hesitation in making decisions about vaccination. Throughout the coronavirus pandemic, mistrust in healthcare systems has increased [20,25,26,37,39,66,93]. Because of this, a vast number of people intend to postpone getting vaccinated.
Moreover, due to mistrust of the government, the general population was concerned about the vaccination information provided by government organizations, resulting in vaccine refusal [4,30,40,41,87].
Healthcare workers and the general population assumed that the vaccines were developed rapidly, might not pass a reasonable trial period, and were created without considering vaccine safety issues. Thus, they wanted to delay their vaccination to ensure effectiveness [35,40,69,79,84].
Many people use social media rather than traditional sources (newspaper, TV news) to find vaccine-related information. Anti-vaccine groups are active on social media and spread misinformation, which also influences willingness to vaccinate [32,61,63,69,81,85,93].
Past experiences with vaccine side effects were also associated with COVID-19 vaccine hesitancy [60,69,89]. People who have had other vaccines such as Influenza, Hepatitis-B, or Polio might have suffered from short-term side effects, making them unwilling to get vaccinated.
Demographic factors such as duration of the survey, population size, level of education, occupation, place of study, language, and religion are interrelated with each other and they influence the decision to vaccinate [34,42,45,62]. In addition, vaccine approval due to political pressure without proof of vaccine safety and efficacy was also reported as an issue that led to people refusing the COVID-19 vaccine [22,28,88].
Throughout history, ethnic groups (i.e., Black) have been the victims of systemic and institutional racism and discrimination. They have been used as a target population for vaccine trials [94]. This scenario undermines the trust level upon vaccination. From several studies [27,42,44], it has been observed that Blacks are unlikely to get the COVID-19 vaccine.
Trust in vaccination is also associated with the vaccine manufacturer [54,58,72,75,95]. However, a low percentage of people have confidence in the manufacturing companies developing safe and effective vaccines. The source of the COVID-19 vaccine might affect the perceived safety and effectiveness. It was assumed that vaccines manufactured in Europe or America were safer than those made in other countries [75].
Lockdowns and other precautionary measures, such as face masks, have reduced the number of infections [46]. Because of this, studies have found that some people became less interested in getting vaccinated [54]. It has also been found [27,36,38,43,91] that the inconsistent risk messages regarding COVID-19 reduced the intention of vaccine uptake. Moreover, the anti-vaccination movement on social media [31,39,64,79,91,92] has made a significant impact on people’s perception about vaccination.
Another reason for hesitancy is that some people prefer natural immunity [73]. This preference can stem from not trusting the scientific enterprise of medicine or not believing in it entirely [37]. In addition, some people want to know about the components and manufacturing process of the COVID-19 vaccine, which is not often revealed to the public. The lack of information provided by the manufacturers was also a reason for some people to be hesitant to get the vaccine [74,86,87,91].
This entry is adapted from the peer-reviewed paper 10.3390/vaccines9111243
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