'Vaccine nation' Potential acceptance of a COVID-19 vaccine in South Africa

As South Africa geared up for its national COVID-19 vaccine rollout, concerns were expressed about the extent to which the adult public would voluntarily take it. In response, a recent survey by the University of Johannesburg and the HSRC examined patterns of vaccine acceptance and hesitancy. The results are encouraging in part, but show that we need a large-scale vaccine education campaign to address lingering concerns and call for more scientifically-backed information among a sizable minority. By Narnia Bohler-Muller, Ben Roberts, Carin Runciman, Kate Alexander and Ngqapheli Mchunu

Vaccinations at the Khayelitsha Hospital in Cape Town, South Africa. The Johnson & Johnson vaccine only requires one shot and it can be stored in a normal fridge. Photo: Jeffrey Abrahams/GroundUp

The COVID-19 pandemic continues to inflict appreciable burdens of morbidity and mortality on South African society, while also causing extreme social and economic disruption. In response, ensuring an effective large-scale and equitable rollout of a COVID-19 vaccine(s) has become a pressing issue. It has given rise to significant debate and vaccine activism, but it has also raised concerns about potential public hesitancy to having the COVID-19 vaccine administered.

This issue was examined in Round 3 of the UJ-HSRC COVID-19 Democracy Survey conducted from 29 December 2020 to 6 January 2021. Responses from 10 618 completed questionnaires were weighted by race, age and education, so that findings were broadly representative of South Africa’s adult population.

Two-thirds favour vaccines

The key question asked of survey respondents was: ‘If a COVID-19 vaccine became available to you, would you take it?’ Two-thirds (67%) responded affirmatively, with 52% stating that they would definitely take the vaccine, and a further 14% saying they would probably take it (Figure 1). In contrast, 18% maintained that they would not get vaccinated (12% definitely not, and 6% probably not), with a further 15% voicing uncertainty.

With the Department of Health estimating that at least 67% of South Africa’s population needs to be vaccinated to attain population (or ‘herd’) immunity, these results are encouraging. However, with a third of adults unconvinced, more public education is required to ensure a smooth roll-out of vaccines.

An unequal acceptance: Differences in willingness to take the COVID-19 vaccine

In terms of sociodemographic patterns of acceptance, men were marginally more inclined than women to be willing to accept a COVID-19 vaccine (69% versus 65%). Persons aged 55 and older were more likely to favour vaccination than 18-24-year-olds (74% versus 63%). Attitudes to taking a COVID-19 vaccine also varied by race. White adults tend to be less accepting of vaccines than black African adults (56% versus 69%), as well as Indian (68%) and coloured (63%) adults. Education matters too. Generally, those with less than a matric-level education were more open to receiving a vaccine (72%) than either those who have completed matric (62%) or have tertiary education (59%). Those who self-identified as poor displayed a greater tendency towards vaccination than those regarding themselves as non-poor (74% versus 67%). 

Several other factors beyond demographics were examined, some of which had a substantial bearing on vaccine acceptance. Interestingly, having had a household member infected with COVID-19 did not produce a large increase in willingness to take a vaccine, nor did one’s perceived likelihood of contracting the virus in coming months. Some political variables, however, showed a distinct association with vaccine acceptance (Figure 2). ANC supporters were significantly more likely to demonstrate a willingness to vaccinate (78%) than supporters of the DA (65%), EFF (62%), and other political parties (67%). Among those who said they would not vote, backing for vaccination was only 48%. 

Disillusionment also plays a role. Those expressing discontent with the handling of the country’s COVID-19 crisis by President Cyril Ramaphosa and the national government were less favourable towards vaccination than those offering positive approval ratings. Only 36% of those stating that the president was doing a bad job were willing to take the vaccine, compared to 73% of those stating that he was doing a good job. Similarly, only 45% of those rating the national government’s COVID-19 response poorly were in favour of vaccination. There was also a 21-percentage point difference in vaccine acceptance depending on whether one was satisfied or dissatisfied with the government’s handling of COVID-19-related corruption (76% versus 55%). These results speak to the significance of leadership in shaping attitudes around vaccinations. 

Willingness to sacrifice certain human rights to help prevent the spread of the virus also mattered. Those who were pro-sacrifice were more partial to vaccination than those opposed to temporarily sacrificing rights (73% versus 40%). In addition, those who believed that the pandemic was likely to make South Africans more united and supportive of each other were somewhat more accepting of vaccination than those believing the pandemic would promote suspicion and distrust (76% versus 66%). Such patterns may reflect perceptions regarding the collective societal contribution of vaccination to potentially beating the pandemic and saving lives.

Finally, those fearing that the worst of the pandemic was yet to come were slightly more likely to express acceptance of a COVID-19 vaccine (72%) than those who felt the situation would stay the same (62%) or that we were over the worst (65%). They were considerably more accepting than those voicing uncertainty about the future outlook (55%). 

Self-reported explanations for vaccine acceptance and hesitancy

Respondents were also asked to explain, in their own words, why they would or would not get the vaccine. We coded and analysed a random sub-sample of 1 960 responses taken from the main sample.

The most common explanations for vaccine acceptance (Figure 3) were the desire to protect oneself (29% mentioned this), as well as to protect others (25%). Among those who indicated they would ‘definitely’ or ‘probably’ take the vaccine, 16% expressed doubts or concerns in the follow-up open-ended question. This highlights that, even among some of those willing to take the vaccine, there are still questions or concerns. The fact that they ultimately favoured vaccine acceptance suggests that the perceived benefits outweigh the reservations for those giving qualified support to the vaccine. Prevention was the fourth most common explanation for vaccine acceptance. Here, people explained themselves using general statements such as ‘prevention is better than cure’. A relatively small share (2%) explained vaccine acceptance in relation to trust in government or science.

The dominant explanation for non-acceptance was concern about possible side-effects (25%). Effectiveness was the second most cited concern (18%), reflecting unease about the extent of medical testing or overall safety of the vaccine. A general lack of trust in the vaccine accounted for 14% of responses. A wider distrust of government, international agencies or ‘Big Pharma’ was referred to in 6% of non-acceptance responses. Needing more information or a general statement of being unsure accounted for 10% of the explanations. This explanation was particularly important among those who said they ‘don’t know’ if they would take the vaccine. A small share (5%) attributed their hesitancy to a view that they were not at risk of the virus. For some, this was because they believed that strict adherence to public health protocols, such as social distancing or mask wearing, was sufficient. Others believed that they were healthy enough to fight infections. Concerns about vaccine affordability were raised by a small minority (4%).

At Khayelitsha Hospital in Cape Town, South Africa, on 17 February 2021, Health Minister Zweli Mkhize receives his vaccination against the virus that causes COVID-19. Photo: Jeffrey Abrahams/GroundUp

Explanations relating to conspiracy theories (responses that either expressed doubt in the existence of COVID-19 or attributed the virus or vaccine to powerful groups or interests) accounted for only a small proportion of non-acceptances (7%). Similarly, only 4% of the explanations provided reasons relating to the occult. Both reasons have received significant media attention. While they are not unimportant, our findings demonstrate that most explanations for vaccine non-acceptance are driven by legitimate concerns about safety and effectiveness.

Sister Zoliswa Gidi-Dyosi, a registered nurse and midwife, was the first recipient of the COVID-19 vaccine at Khayelitsha Hospital in Cape Town, South Africa, on 17 February 2021. Photo: Jeffrey Abrahams/GroundUp

Conclusion

Our survey of attitudes towards COVID-19 vaccination showed that about two-thirds of the population definitely or probably wanted the vaccine. However, despite ample evidence of the safety and efficacy of vaccines, about a third of the population was still sceptical about vaccination, with greater hesitancy among better-educated people and those who were disillusioned with the government and its handling of the pandemic until then. For adults who accepted the need for vaccination, the main justifications were about protecting oneself and others. For those not, as yet, willing to accept the vaccine, including those unsure about whether to get it, the key issues were about side-effects and effectiveness, with some people expressing broader distrust in the vaccine. People wanted more information. Only a small minority were swayed by concerns about conspiracies and the occult.

We are not yet at a point where willingness to take a COVID-19 vaccine would lead to population or ‘herd’ immunity. There is more work to do. Public education in the form of targeted vaccine literacy campaigns will be required to provide factual information where it is presently lacking. The government, civil society, the media, and influential political, faith and cultural leaders can all play a part. Such campaigning will need to take people’s explanations for their hesitancy and opposition seriously. 

Our research shows campaigns should be directed at people with legitimate worries about the possibility of COVID-19 having an adverse impact on their health. With a majority already convinced that vaccines will be good for themselves and for society, there are powerful positive messages that can also be conveyed. Through such efforts, it is hoped that the ill-informed and the reticent will be sufficiently convinced to reconsider their views. 

Authors: Prof Narnia Bohler-Muller is the divisional executive and Dr Benjamin Roberts a research director in the HSRC’s Developmental, Capable and Ethical State (DCES) research division. Prof Kate Alexander is the South African Research Chair in Social Change and Prof Carin Runciman, the director of the Centre for Social Change, both at the University of Johannesburg. Ngqapheli Mchunu is a PhD researcher in the DCES research division.

Data were collected in the online multilingual UJ/HSRC COVID-19 Democracy Lockdown Survey from all willing respondents in South Africa aged 18 or over. The survey was administered using the #datafree Moya Messenger App on the #datafree biNu platform, or alternatively using data via https://hsrc.datafree.co/r/ujhsrc.

This article is a synthesis of these two articles published in Daily Maverick in January 2021:

A hesitant nation? Survey shows potential acceptance of a COVID-19 vaccine in South Africa – 24 January 2021

SA survey sheds some light on what lies behind coronavirus vaccine hesitancy – 27 January 2021

Further reading: Kim Trollip explains the importance of effective and well-targeted science communication in COVID-19, the science communication clarifier HSRC Review, March 2021