Addressing COVID-19 vaccine hesitancy in South Africa- moving beyond a reliance on information-based responses

ABSTRACT

It has been over a year since South Africa officially began its national COVID-19 vaccination programme. Yet, currently only half of the adult population is fully vaccinated. While supply-related challenges continue to contribute to suboptimal vaccination coverage, so too does vaccine hesitancy. Drawing on research conducted over the last year, we highlight some overarching insights around the nature and drivers of COVID-19 vaccine hesitancy in South Africa and how this complex phenomenon might be addressed. We have found multiple socio-economic and political root causes of COVID-19 vaccine hesitancy, many of which are not knowledge-related. These include inter alia fear and uncertainty, practical challenges around access, experiences of poverty and marginalization, and the ongoing geopolitics surrounding the pandemic. Intervention strategies therefore need to form part of broader development and trust-building measures that focus on relationships, transparency, inclusion, equity and justice. This is essential if we hope to bolster acceptance of and demand for vaccines during and beyond the COVID-19 pandemic.

KEYWORDS:

• COVID-19
• vaccine hesitancy
• nature and drivers
• intervention strategies
• South Africa

It has been over a year since South Africa officially began its national COVID-19 vaccination programme. As of 6 July 2022, only half (50.66%) of the adult population (18 years and older) was fully vaccinated, well-below the target to vaccinate 67% of the population by the end of 2021.¹ While access and supply-related challenges continue to contribute to suboptimal vaccination coverage, so too does vaccine hesitancy.² One year ago, we suggested that COVID-19 vaccine hesitancy in South Africa is a complex social phenomenon.³ Since then, we and others have undertaken several additional studies exploring the nature and drivers of COVID-19 vaccine hesitancy in South Africa.^4–12 The findings from this research have shed further light on this complex phenomenon and how it might be addressed.

One of the most consistent findings across this research has been the ongoing fear and uncertainty people have about the safety and effectiveness of COVID-19 vaccines. These sentiments are, arguably, entirely reasonable. Since the beginning, the pandemic has been characterized by much uncertainty as a result of rapidly changing and evolving evidence, new and emergent strains of the virus, and an ever-shifting landscape of travel bans and lockdowns.¹³ Still today, our understandings continue to emerge – about the virus and how it is spread, about the vaccines and what they can (and cannot prevent), about the duration of vaccine immunity, amongst other uncertainties.¹⁴ Over the past two years, people’s trust in authorities has also been undermined significantly, due at times to ill-conceived and inequitable bans,¹⁵ as well as horrendous corruption scandals.¹⁶ And all of this has been accompanied by an explosion of information, with the pandemic and COVID-19 vaccines being drawn into a whirlpool of confusing and often contradictory messages (or what is now referred to as an “infodemic”).¹⁷

There is thus a dire need for meaningful communication strategies to address people’s ongoing concerns, at the level of both the community and the individual within patient-healthcare worker encounters.^18,19 However, what is arguably equally (if not more) important than the what of communication, is the how, and the necessity of building trust. Here identifying and using trusted messengers and communication mediums to deliver vaccine messages in people’s local languages is important.² So too is honesty about uncertainties.^20,21 This means providing balanced and transparent information about COVID-19 vaccines, including about adverse events, benefit-risk considerations, evidence gaps and legitimate uncertainties surrounding the vaccines.² Empathy is also paramount, particularly when interacting with those who may be vaccine hesitant or skeptical.²² Various patient-centered techniques have been found to be effective in this regard, such as motivational interviewing (MI), which requires that the messenger adopts a collaborative, non-judgmental and empathic attitude.²³ The role of community engagement and ownership in building trust cannot be overstated. Community organizations, such as non-government and civil society organizations and local leadership (e.g. chiefs, village heads, religious leaders, traditional healers, councilors) are close to their communities, know how to tailor messages to them and are trusted leaders who can be effective vaccine champions, motivating communities toward trust in and acceptance of COVID-19 vaccination.¹⁸ South Africa has a rich history of community engagement and mobilization through years of HIV advocacy and treatment literacy that could be drawn upon for COVID-19 vaccination communication.²⁴

Communication strategies are, however, not enough. We as a public health community need to move beyond our reliance on information-based responses when people do not take-up healthcare technologies and innovations. COVID-19 vaccine hesitancy has numerous possible demographic and socio-psychological root causes, many of which are not knowledge-related.¹³ For example, we have found that practical challenges around access and logistical issues pertaining to vaccination services are major contributors to COVID-19 vaccine hesitancy in the country.^6,7 Specifically, questions of geography, transport and other (opportunity) costs associated with accessing vaccination services, long queues and waiting times at vaccination services, and difficulties around navigating the online registration system all impacted on people’s unwillingness to get vaccinated. There is therefore a need for ongoing and enhanced strategies which target the structural and service-level factors that hinder access and convenience around COVID-19 vaccination. Here initiatives such as the ‘Vooma vouchers’²⁵ and ‘Taxi Vaxi’²⁶ are excellent examples that could be drawn upon and expanded.

We have also found that experiences of poverty and marginalization may provide a fertile ground for COVID-19 vaccine hesitancy in South Africa.⁶ The pandemic has had dire economic consequences, including generating or exacerbating poverty, food insecurity, a lack of social support, unemployment and a real sense of hopelessness for so many individuals and communities.²⁷ Context matters. What happens at this level influences acceptance, use and uptake of COVID-19 vaccines. Some people feel resentful being asked to vaccinate when so many of their other needs and concerns are being neglected. Others feel mistrustful of initiatives supposedly offered for their benefit, such as the COVID-19 vaccination, when they are disadvantaged in so many other aspects of their lives. Acceptance of COVID-19 vaccination in certain cases may therefore depend on people’s other health and livelihood priorities being met. Here it could be beneficial to avoid an exclusionary focus on COVID-19 vaccination by integrating or aligning it with other primary health care and social development programmes (e.g. social grant initiatives, food distribution channels).¹⁹

Our and others’ research has also highlighted how the ongoing geopolitics surrounding COVID-19 and COVID-19 vaccines – persistent vaccine nationalism, vaccine diplomacy, donor dependency, patent laws – are an additional driver of vaccine hesitancy in South Africa.^6,28 Such geopolitics have produced outrageous inequities in COVID-19 vaccine access between the Global North and Global South, including South Africa.²⁹ They are also stark reminders of a painful history of (medical) colonialism and more recent incidences of patent laws and commercial interests denying communities access to the very drug treatments which were tested on them as research participants (antiretroviral treatment for HIV is a case in point in this regard).²⁴ This context is contributing to resistance to and distrust in COVID-19 vaccines and those delivering them. There is thus a need for advocacy and social mobilization around the geopolitics of COVID-19 vaccines.³⁰ Initiatives such as the COVID-19 Vaccines Global Access (COVAX) are important here, and we need more of these, particularly continental collective efforts. Advocacy for increased COVID-19 vaccines procurement and manufacturing in South Africa is also essential. So too is the need for more local and bottom-up COVID-19 vaccine research and testing approaches that are led by South African scientists and institutions and anchored in local views, realities and priorities. These kinds of initiatives are essential to promote equitable and widespread access to COVID-19 vaccines, but also to foster community trust and reduce resistance.

Clearly, there is a lot to be done. Confidence in COVID-19 vaccines and vaccination programmes depend on the work they do for the community – socially, politically, morally and biologically – as Harrison and Wu so poignantly demonstrate. These scholars suggest that “Once this particular epidemic has fallen into historical memory, the development of a vaccine for COVID-19 should not be the indicator of a successful response, nor should it indicate the achievement of an improved public health system. Vaccine confidence may be the better indicator.”³¹ Ultimately, if this is anything to go by, we believe that investing in initiatives to reduce hesitancy and build confidence in COVID-19 vaccines are essential and urgent.

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Funding

The author(s) reported there is no funding associated with the work featured in this article.