Combatting Vaccine Hesitancy

South Africa has faced many obstacles in its vaccination drive, vaccine hesitancy will no doubt further complicate SA’s efforts to ensure maximum distribution. It is futile to procure the vaccine if distribution cannot be effected, or if, for whatever reason, people simply do not wish to be vaccinated. In this brief, we consider the problem and potential effect of vaccine hesitancy, and argue that given the deep-rooted mistrust of the state, the private sector can play a crucial role in combatting vaccine hesitancy, as has been the experience in the US.

At the outset it should be noted that there have always been groups of people who have historically been wholly opposed to the use of vaccines, most commonly known as ‘anti-vaxxers’. This group disputes the scientific evidence given in support of vaccines and is extremely difficult to convince otherwise. It is important not to confuse these individuals with those who fall into the category of ‘vaccine hesitancy’ as these are people who may have ‘limited or inaccurate health information or who have genuine concerns and questions about any given vaccine, its safety, and the extent to which it is being deployed in their interests before accepting it’.[i] This group of people have most likely received many lifesaving vaccines in their life time and are not against vaccines in general, but rather, express concern about the current COVID-19 vaccine and its safety and efficacy. It is this group of people who need to be targeted when thinking about how to combat vaccine hesitancy and build trust in the general population in favour of receiving the COVID-19 vaccine.

Understanding Vaccine Hesitancy

In a study conducted in 2011 by the Strategic Advisory Group of Experts on Immunization (SAGE) working group, vaccine hesitancy was described as the

‘delay in acceptance or refusal of vaccines despite availability of vaccine services. It is complex and context specific, varying across time, place and vaccines’.[ii]

It was noted that vaccine hesitancy becomes a problem when it affects the ‘vaccine uptake rates needed in order to reach herd immunity and program efficiency’.[iii]

Although the term ‘vaccine hesitancy’ itself may not be very complex to understand, there are various factors which may affect a person’s belief or trust in the available current COVID-19 vaccines. The WHO has stated complacency, convenience and confidence as being significant over a person’s decision to get vaccinated. These are the reasons which have long been associated with vaccine hesitancy. However, in the context of COVID-19, and the speed at which the vaccine has been developed, there may be more specific reasons for the hesitancy by some.

Various studies have been conducted in the last few months on the willingness of individuals to take the COVID-19 vaccine. These studies have been conducted in numerous countries and have shown that vaccine hesitancy is a worldwide problem.[iv] According to one South African study, competed by over 10 000 participants, factors such as age, race, education and political affiliation affected ones decision of whether the above mentioned individuals would get vaccinated or not. Some of the findings were as follows:

It was further found that:

‘White adults tend to be least accepting of a Covid-19 vaccine; 55% say they would take the vaccine compared to 69% of Black African adults. Those with less than matric-level education were generally more open to receiving a vaccine (72%) than those who have completed matric (62%) or have a tertiary education (59%). Support for vaccination increases with age. Politics is also important. In terms of voting intention, acceptance was as follows. ANC: 78%, DA: 65%, EFF: 62%, other parties: 67%. Among those who did not intend to vote, acceptance was much lower, only 48%.’[v]

Other factors increasing vaccine hesitancy include, vaccine effectiveness, vaccine side effects, vaccine distrust, affordability and importantly, distrust of the institutions associated with the vaccines such as government, the WHO or pharmaceutical companies.

In order to combat these different factors, the government, specifically the Department of Health, could look to other countries which have successfully partnered with the private sector to do so. In the United States, this partnership has been effective in accelerating the vaccine roll out and fighting vaccine hesitancy by partnering with pharmacies, large retailers and businesses in order to incentivise the general population to get vaccinated.

Private Sector Involvement

The role of the private sector in the United States

Pharmacies have proven to be critical to combating the looming challenge of vaccine hesitancy in the United States. Moreover, beyond the scope of commercialized health care roles in vaccine advocacy, public and private collaboration has provided an additional key to unlocking hesitant populations.

Pharmacies have been described as ‘highly trusted’ community-based health care providers. In its 2015 Health Report, the National Vaccine Advisory Committee identified ‘health-care provider confidence’ as paramount to improving vaccine willingness.[vi] The study uncovered the ability of trusted health care providers to ‘effectively communicate’ the cost-benefit of vaccinations, conversations most impactful in persuading hesitant populations.[vii] In contrast to those working in massive state and federal level operations, pharmacists are specially ‘trained to counsel patients… and provide vaccine education’.[viii] In order to fully engage the capacity of pharmacies to educate and serve the communities, the public sector has continued to support these retailers in any manner that is needed.

While private health care providers, such as pharmacists, have led vaccine confidence campaigns, the public sector’s approach to the challenge has been multifaceted. The private sector’s incentivizing power has also proven to be integral in reaching national vaccination goals as certain groups are likely to be more impacted by commercial incentives.

In the U.S, businesses and large retailers have offered various benefits to encourage vaccine utilization. National stationery supply stores, such as Office Depot and Staples, offered special coupons to customers with vaccination cards.[ix] This precedent was applied in the food services industry as well.[x]

Vaccination discounts could extend even further across a variety of businesses, presenting various new benefits to inoculation. Furthermore, the private sector may also utilize negative incentives to accomplish better public health outcomes. Commercial entities are far less legally constrained in making employment or services contingent upon vaccination in the American context. Talks of universities, sports leagues, and cruise lines mandating vaccination have quickly translated into action.[xi]

The United States has taught us that a successful vaccine rollout has and will continue to rely on contributions from the private sector leading initiatives to vaccinate more Americans. Yet, the federal government will not be able to offload responsibility and expect satisfactory outcomes. Private sector partners will require close oversight and clear deliverables to ensure desired performance. For the potential of the collaborative to be met, the federal government will need to properly identify and fund private sector advantages to tackle the logistical challenge while transitioning more of its responsibility from delivering to managing efforts to increase vaccinations.

What Can Be Done To Combat Or Deal With Vaccine Hesitancy In South Africa?

Although private sector involvement in the form of commercial incentives is helpful in enticing individuals to get vaccinated, it won’t entirely get to the root of vaccine hesitancy as it relates to the COVID-19 vaccine.

According to Professor Narnia Bohler-Muller from the Human Sciences Research Council (HSRC):

‘vaccine hesitancy comes down to a range of legitimate concerns about a vaccine developed and rolled-out in record time, as well as some distrust in the government and corporations. We need a vaccine literacy campaign that provides factual information that will sway the waverers.’ (emphasis added)

Therefore it is important that the government deals with the legitimate concerns referred to above and ensures that those receiving the vaccine trust in the process and the institution rolling it out.

Since the majority of the population are still set to receive their vaccinations, the government and private sector must work on the above mentioned methods in order to increase general trust in the vaccine roll out and the vaccine itself. Part of this response will be to ‘ensure effective community engagement, build local vaccine acceptability and confidence, and overcome cultural, socioeconomic, and political barriers that lead to mistrust and hinder uptake of vaccines’.

Vaccine Distrust - Safety And Efficacy

The government, medical experts, broadcasting and media must play a role in countering false information and must be a reliable and easily accessible source of truth.

In the digital age in which we live, fake news and misinformation play a vital role in forming the concerns expressed by society about the safety and efficacy of the vaccine. Therefore, it is understandable that vaccine hesitancy tends to increase when news reports surface about different side effects of the vaccines. Although the side effects are rare and affect less than 0.1% of those vaccinated, they still affect public confidence.

‘Some people are genuinely worried and concerned that a vaccine may harm them. To allay such fears we need accurate information, clear messaging, and excellent science. Lies and misinformation can only be countered by facts, data and solid evidence. Baseless claims and conspiracy theories about the Covid-19 vaccine should be met by these means’.[xii]

The type of information disseminated will also be important. For example, as stated above, the majority of South Africans (67%) would accept a vaccine if it were available to them. This type of data should be shared in order to assure the general population that the vaccine is viewed as being safe by a large segment of the country and may influence them in the same direction.

Distrust Of The Institutions Associated With The Vaccine Roll Out, Especially Government.

During the course of 2020, many South Africans who were already vulnerable and marginalised were pushed further into poverty and starvation. As a result many lost confidence in the government and no longer believe that the institutions associated with the vaccine roll out will act in their best interests.

An article published in the Lancet journal aptly describes the present situation:

‘Globally, the COVID-19 pandemic has further marginalised historically oppressed and excluded groups, including people with disabilities and growing numbers living in precarity. These groups have suffered disproportionate economic and health consequences, and have been largely excluded from social protection and resources needed to minimise their contracting the virus. The widespread impacts of the pandemic have illuminated the structural violence embedded in society. Now these communities are being asked to trust the same structures that have contributed to their experiences of discrimination, abuse, trauma, and marginalisation in order to access vaccines and to benefit the wider population’.[xiii]

‘Trust is a key component of making the decision to take the vaccine’.[xiv] One of the ways in which the government has worked to gain this ‘trust’ has been by leading by example. President Cyril Ramaphosa made sure that he was one of the first in the country to receive the jab. This was also done in order to counter the narrative that the Johnson & Johnson trial had used health care workers as guinea pigs. However, because of the factor of mistrust in the institution of government as the sole procurer and distributer of the vaccine, it will be imperative that people who hold positions in power outside of government also publically declare their support for the vaccine. Individuals such as religious leaders, traditional healers and social media influencers may have the largest reach when advocating for herd immunity and a trust in the ‘national effort to vaccinate the public’.[xv]

A similar situation can be seen in Russia - the country which registered the first Covid-19 vaccine. Currently Russia’s vaccination rate is ‘one of the lowest in countries where vaccines are widely available’ with only 12 per cent of the population having received at least one dose of a vaccine.[xvi] In contrast to studies conducted in South Africa, surveys done in Russia indicate that ‘over 60 per cent of respondents do not intend to be vaccinated’ (emphasis added). Sociologists believe the main reason for this resistance to be a ‘breakdown in trust between Russians and the authorities after decades of Kremlin propaganda’.[xvii] The above information further shows the role that trust plays in the vaccine roll out and the danger of a breakdown of this trust between government authorities and the general population.

Conclusion

Although vaccine hesitancy has not emerged as a major problem in South Africa when compared to the issues of distribution and procurement, it is still an obstacle which needs to be understood in order to be overcome. Strangely, phase two of the roll out which sought to vaccinate 5.5 million individuals, including those over the age of 60 has to date, vaccinated less than two million people. It is currently unknown what percentage of this can be attributed to hesitancy and whether a lack of access to registration is the real underlying issue.

As seen above, the private sector can play a major role in increasing public confidence in the safety and efficacy of the vaccine as well as the institutions behind the roll out. With 67% of South African’s being willing to take the jab, vaccine hesitancy does not seem to threaten herd immunity at this point. Phase two has seen the private and public sector joining forces in the fight against the pandemic and has shown an increase in the rate of distribution, which has been a welcomed development.

Sophie Smit
Legal Researcher
sophie@hsg.org.za

Josh Zients
Intern
A second-year student at Brown University studying International and Public Affairs. Josh holds both American and South African citizenship.
joshua_zients@brown.edu

[i] RA Burgess, RH Osborne, KA Yongabi et al. ‘the COVID-19 vaccine rush: participatory community engagement matters more than ever’ Lancet. (2021); 397: 8-10 available here.