Exploratory Study of the Global Intent to Accept COVID-19 Vaccinations

"By understanding why different groups have differing opinions about the COVID-19 vaccine, we may be able to better understand specific concerns and assist healthcare policymakers to design more effective risk-communication strategies."

COVID-19 pandemic exit strategies hinge on widespread acceptance of COVID-19 vaccines. This large-scale global exploratory study examines the levels of COVID-19 vaccine acceptance and explores sociodemographic determinants of acceptance. Such details may yield insights into the specific causes of hesitancy and may suggest and inform targeted communication policies to boost confidence.

The study explores intent to accept a COVID-19 vaccine for 26,759 individuals across 32 countries between October 21 and December 15 2020, using data from the Worldwide Independent Network of Market Research (WIN) World Survey. As of January 25 2021, these countries represent 73% of the total global mortality burden and include those with recent and historic vaccine confidence issues. Bayesian methods are used to estimate COVID-19 vaccination acceptance and detect the sociodemographic determinants of uptake, as well as the link between self-reported health and faith in the government's handling of the pandemic and acceptance.

The overall intent to accept a COVID-19 vaccine is highest in Vietnam (96.8%), India (90.7%), China (90.6%), and Denmark (87.0%), and lowest in Lebanon (44.1%), France (44.0%), Croatia (41.5%), and Serbia (37.8%). Averaged across all countries, being male, being over 65, having a high level of education, and believing that the government is handling the pandemic well are associated with increased stated acceptance, but there are country-specific deviations. For example, females are more likely to report a willingness to accept the vaccine in China (whereas males were more likely to state acceptance in 22 countries), and a belief that the government is handling the pandemic well in Brazil and the United States is associated with lower vaccination intent.

Time-varying trends in intent to accept a COVID-19 vaccine are assessed in the United Kingdom (UK) against previous survey data. The approval and introduction of the Pfizer-BioNTech vaccine in the UK in December 2020 did not appear to have an impact on the UK's vaccine acceptance, though as rollout has continued into 2021, the UK's uptake exceeds stated intent in large-scale surveys conducted before rollout.

In discussing the findings, the researchers point to substantial cross-country variability in vaccine acceptance, with estimates ranging from 69.3% of respondents in Vietnam who would "definitely" accept the vaccine to only 10.3% in Serbia, 13.0% in Croatia, and 13.0% in France, the latter of which consistently has among the lowest vaccine confidence globally.

Providing reflections on the findings from a few of the countries, the researchers note that as high as 42.6% of respondents in Lebanon and 31.8% of respondents in Pakistan state they would "definitely not" accept a COVID-19 vaccine. Confidence in vaccines has fallen in recent years in Pakistan, where a history of vaccine scepticism has posed challenges for polio eradication. Lebanon is only one of five countries surveyed where a belief the government is handling the pandemic well is not found to be associated with an increased likelihood of vaccinating. A round-the-clock curfew implemented in Lebanon on January 14 2021 led to protests against the government over rising rates of unemployment. As trust in government is a key driver of vaccine confidence in many settings, unsupported policies could diminish trust in the COVID-19 vaccination programme; this relationship should be monitored closely, the researchers say.

Intent to accept a COVID-19 vaccine appears to be polarised in Poland and Pakistan. In these two countries, roughly as many respondents state they would "definitely" accept the vaccine (21.0% and 31.8%, respectively) as would "definitely not" accept it (19.6% and 33.7%, respectively). Vaccination confidence appears to be declining in both countries, possibly due to the recent and historic spread of misinformation.

Recommendations include:

• "A robust communication system that engages with the public over issues of distrust and safety can help support acceptance of COVID-19 vaccination and contribute to confidence building around existing routine immunisation programmes, many of which have been disrupted in the context of the COVID-19 pandemic."
• The researchers suggest tailored efforts to listen to and address the concerns of underserved or marginalised groups, noting that losses of trust in one vaccine (i.e., COVID-19) can lead to a drop in uptake of unrelated immunisations.
• Robust monitoring systems for vaccine confidence and misinformation can facilitate early detection of losses in system confidence. Confidence issues can then be addressed via clear communication strategies with messages and types of messengers tailored to specific socioeconomic or cultural groups.

In conclusion: "Identifying factors that may modulate uptake of novel COVID-19 vaccines can inform effective immunisation programmes and policies."