Overcoming COVID-19 vaccine hesitancy: can Australia reach the last 20 percent?

KEYWORDS:

• COVID-19
• vaccination
• vaccine acceptance
• vaccine hesitancy

Whilemany countries were battling repeated waves of COVID-19, Australia was relatively COVID-19 free by early 2021. From March 2020, swift and decisive public health measures were implemented nationally, including closing Australia’s international borders. Eighteen months into the pandemic, Australia has only recorded 1,245 deaths from a population of 25 million (as of 28 September 2021). However, despite Australia’s strong initial response to COVID-19, the country’s vaccine rollout has been hindered by multiple factors.

Like many countries globally, Australia’s COVID-19 vaccine rollout prioritized adults at highest risk of severe disease first, followed by groups contributing the most to community transmission. In January 2021, the government aimed to vaccinate 80,000 people per week, with 4 million vaccinated by the end of March and the entire adult population vaccinated by October. However, within 3 months, the rollout was falling well short of these targets. Shipment delays, issues coordinating delivery across jurisdictions and other challenges meant it took 45 days to deliver Australia’s first million doses. Vaccine hesitancy also impacted vaccine uptake, particularly after the clotting syndrome (TTS) vaccine safety signal was identified for the COVID-19 ChAdOx1-S viral vector ‘AstraZeneca’ vaccine. In May 2021, approximately 35.5% of people in Australia were either unwilling or refusing to be vaccinated against COVID-19, although this has fluctuated during the pandemic and by jurisdiction [1]. Seven months after the rollout began, only 52.6% of the population over age 16 have received two doses of a COVID-19 vaccine [2].

The National Cabinet has now released a plan to transition Australia’s COVID-19 response from disease suppression to disease containment. Under this four-phase plan, public health restrictions start easing at 70% and 80% two dose adult (over 16 years) vaccination coverage. As we approach these thresholds, what can we learn from the challenging early stages of the vaccine rollout to ensure Australia’s coverage reaches 80% and beyond, and to ensure no groups are left behind?

The WHO Behavioral and Social Drivers of vaccination (BeSD) model provides a framework to consider the measurable and modifiable factors that drive vaccine uptake [3]. These include factors related to vaccine hesitancy – i.e. the thoughts and feelings and social processes that influence an individual’s motivation to vaccinate – as well as the practical issues that mediate the link between motivation and vaccine uptake. Below, we outline some of Australia’s key challenges, as well as potential solutions.

1. Vaccine hesitancy

Motivation to vaccinate is influenced by confidence in vaccine benefits and safety, perceived risk of disease and social norms [3]. Vaccine safety, long term effects and both common and serious side effects are the most frequently cited concerns about COVID-19 vaccines [4]. In Australia, the intense media focus on the safety of the COVID-19 ChAdOx1-S viral vector ‘AstraZeneca’ vaccine has impacted negatively on demand [5], with ongoing low uptake in people over 60 years, for whom it is currently recommended. The Australian government’s public health response measures have also kept COVID-19 disease rates low in most parts of the country, which has decreased people’s perception of disease risk and severity [6]. However, recent outbreaks of the Delta variant have driven demand in New South Wales and Victoria. Other factors driving vaccine hesitancy are lack of trust in the health system or government and exposure to misinformation and conspiracy theories, particularly amongst cultural groups who may have historical mistrust of authorities or receive conflicting information from their country of origin [7]. People less likely to accept a COVID-19 vaccine in Australia are younger, female, living outside capital cities, with a less than year 12 education and/or who speak a language other than English at home [7]. Young women, in particular, report concerns around pregnancy, breastfeeding and fertility related to COVID-19 vaccination, with recent data suggesting that only 48% of pregnant women in Australia intend to be vaccinated (unpublished data).

Addressing vaccine hesitancy generally requires multi-faceted approaches that are tailored for the specific concerns and characteristics of hesitant populations. One strategy for increasing motivation to vaccinate is through community engagement. Empowering community and faith leaders, who come from and speak to their own communities, to act as vaccine champions capitalizes on existing trusted relationships to advocate for vaccination. Vaccine champions can help people find trustworthy sources of information to answer their questions and normalize vaccination by sharing their own experiences. In culturally and linguistically diverse (CALD) communities, community engagement is particularly important to overcome barriers around translation and dissemination [8].

Information provision alone is unlikely to change attitudes, but broad communication campaigns can raise awareness and emphasize shared values and social norms. Communication campaigns to promote COVID-19 vaccination should have a clear call to action, and drawing on humor or emotion may increase engagement [5]. Importantly, campaign communication should represent everyone in the community by featuring the voices and stories from diverse people across the community, rather than actors or politicians [6]. In general, benefits-framed messaging is more effective than using fear [9]. For example, communication could focus on the benefits of vaccination, such as travel, freedom from lockdowns, school closures and free social contact. Due predominantly to concerns around driving demand without adequate vaccine supply, these types of communication campaigns were notably absent for the first several months of the vaccine rollout in Australia, despite widespread calls for promotional messaging. Eventually, some private businesses and non-governmental organizations released evocative advertisements, followed by a broader government campaign.

Broad campaigns are important to normalize vaccination, but targeted communication that aligns with the underlying values and worldview of specific hesitant groups and individuals is key to increasing motivation to vaccinate. Using mixed methods approaches such as those outlined in the WHO Tailoring Immunization Programmes (TIP) enables exploration and assessment of the drivers and barriers to vaccine uptake to inform tailored communication strategies [10]. Once supply and access issues have been addressed, receiving a recommendation to vaccinate from a trusted healthcare provider is the strongest predictor of vaccine receipt [11]. In Australia, individuals can obtain a COVID-19 vaccine from state-based vaccination hubs, pharmacies or in primary care from their individual health care provider. However, many healthcare providers have found it challenging to stay across the tsunami of information on vaccine safety, effectiveness and recommendations, which has impacted their confidence to discuss COVID-19 vaccines with patients [6]. Healthcare providers have requested clear, simple resources to support complex and timely risk and benefit discussions [5] around the COVID-19 vaccines. These discussions and resources ideally address people’s individual medical histories and eligibility, taking into account changing disease rates and Australian Technical Advisory Group on Immunization (ATAGI) vaccine recommendations.

Incentives and nudges have also shown promising results with other vaccinations, such as influenza [12], though evidence for COVID-19 vaccines is mixed. Reminder systems are needed, especially where advice around second dose timing may change due to supply constraints or changing COVID-19 disease rates. Mandatory vaccination is now also being broadly considered and implemented, particularly for those at higher risk of infecting others, such as healthcare and education workers [13]. However, certain criteria should be satisfied before mandates are introduced, including ensuring vaccines are equitably accessible, sufficiently safe and effective, and that less restrictive measures are tried first.

2. Practical issues

Most of Australia’s initial challenges were related to vaccine supply and access. In April 2021, the serious safety signal of thrombosis with thrombocytopenia (TTS) was linked to the AstraZeneca vaccine, which comprised the bulk of Australia’s vaccine stock. ATAGI initially advised that the COVID-19 BNT162b2 ‘Pfizer-BioNTech’ vaccine was preferred for all adults under age 50, raising the age threshold to 60 in June 2021 when this age group was also assessed to be at higher risk from TTS. Due to insufficient Pfizer supply, healthy younger adults under age 40 were not eligible for Pfizer vaccines until late August 2021 in most jurisdictions. Supply remains a key rate limiting factor, with long wait times for appointments and extended 6-week spacing between Pfizer doses advised to maximize first dose coverage in some facilities. However, additional vaccines have now been secured by the Commonwealth government, including Moderna and Novavax, which should stimulate uptake.

Practical issues are faced more frequently by certain groups, including Aboriginal and Torres Strait Islander peoples, those with underlying medical conditions and disabilities, and people from CALD communities, and require a tailored approach. Aboriginal and Torres Strait Islander communities across Australia are at increased risk from COVID-19, but their vaccination rates are more than 20% lower than the national average [2]. The future success of the vaccination program depends on investing in culturally appropriate community-led immunization services that establish vaccination as the social norm [14]. Challenges for people with disabilities include difficulties navigating complex booking systems or booking vaccination in accessible venues, with some jurisdictions utilizing disability liaison officers, mobile vaccination services and other in-reach strategies. Many CALD communities have reported difficulties with poorly translated information materials and culturally insensitive practices [8]. Community engagement, including local pop-up vaccination clinics, vaccine champions and resources to support appropriate translation and dissemination of information, are key to reaching CALD groups.

Critical to the vaccine rollout, and to any efforts to boost coverage, is accurate measurement and reporting of data. The national four-phase plan relies on reaching coverage targets, but information on the number of vaccines delivered according to broad demographics, including at-risk medical conditions, pregnancy and cultural groups has not been uniformly collected or made publicly available. General population vaccine uptake figures alone are not sufficient to develop targeted strategies – it is critical to understand the scope and nature of the problem for key groups and to differentiate between barriers to access and acceptance. There is currently no validated measurement instrument to accurately make this distinction, though one is in development for Australia and New Zealand, called the Vaccine Barriers Assessment Tool (VBAT) [15].

3. Conclusion

As we endeavor to reach the last 20% and attain very high COVID-19 vaccine coverage in Australia, the use of social and behavioral science will be critical. A robust and transparent measurement and monitoring system needs to be established, with repeated measures of not only vaccine uptake but also of the other social and behavioral drivers, including attitudes and values. Researchers, government, and public health officials must work together to develop evidence based and theory driven solutions to address these key challenges, as we navigate a path out of the pandemic.

Author contribution statement

All authors were involved in the conceptualisation, design and drafting of the review perspective and revised it for intellectual content. JK an JT are equal joint first authors.

Declaration of interest

The institution of all three authors, Murdoch Children’s Research Institute, receives funding from the Commonwealth and Victorian Department of Health for COVID-19 vaccine social research. Jane Tuckerman is an investigator on a project grant sponsored by Industry. Her institution has received funding from Industry (GlaxoSmithKline) for investigator-led research. She does not receive any personal payments from Industry. Margie Danchin receives funding from the National Health and Medical Research Council (GNT 1164200) and the Victorian Department of Health. She is a member of the Australian Technical Advisory Group on Immunisation and is a Specialist Advisor to the Vaccine Safety Investigation Group of the Therapeutic Goods Administration. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Funding

This paper was not funded.