The importance of addressing social inequalities and targeting the undecided to promote vaccination against COVID-19.

Abstract

As vaccines against COVID-19 are distributed across the Western Pacific, it is vital to investigate the barriers and enablers of vaccine acceptance in countries across the region. A paper in the latest issue of The Lancet Regional Health - Western Pacific presents the first multivariate analysis of attitudinal and sociodemographic predictors of vaccine intentions against COVID-19 in New Zealand ([1]Prickett KC Habibi H Carr PA. COVID-19 Vaccine Hesitancy and Acceptance in a Cohort of Diverse New Zealanders.The Lancet Regional Health- Western Pacific. 2021; (Pre-print)https://doi.org/10.1016/j.lanwpc.2021.100241Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar). Among the surveyed sample of 1,284 New Zealanders, 71% indicated they would likely accept the vaccine; 15% were unsure, 5% were somewhat unlikely, and 10% were very unlikely to do so. Vaccine acceptance was commonly motivated by a combination of several reasons. The most important reasons were avoiding COVID-19 illness, protecting others from infection, returning to ‘normal’ and promoting herd immunity. Older respondents were more likely to be motivated by protecting themselves against catching COVID-19 than were younger respondents. Younger respondents and those with lower educational attainment were less willing to vaccinate, while women and lower-income households were more likely to be unsure. Non-acceptors (i.e., unsure or unlikely to vaccinate) tended to have concerns about unknown future adverse effects and vaccine side effects. Women were more concerned about vaccine impacts on their health, while men were more likely to distrust vaccines or believed that the threat of COVID-19 was overstated. Younger respondents were more likely to have concerns about unknown future vaccine effects relative to older respondents. Unlike in descriptive findings, regression analyses showed that ethnicity was not associated with vaccine acceptance when socioeconomic measures were included in the model. This study adds to previous research to underscore the importance of prioritising undecided people in COVID-19 vaccine promotion. Hesitancy towards COVID-19 vaccines is common across the world ([2]Sallam M. COVID-19 Vaccine Hesitancy Worldwide: A Concise Systematic Review of Vaccine Acceptance Rates.Vaccines (Basel). 2021; 9Google Scholar), and many New Zealanders have some doubts about whether they will vaccinate, with 35% indicating they were ‘unsure’ or only somewhat likely/unlikely to vaccinate. Concerns about unknown longer-term effects of the Pfizer/BioNTech vaccine are particularly prevalent ([1]Prickett KC Habibi H Carr PA. COVID-19 Vaccine Hesitancy and Acceptance in a Cohort of Diverse New Zealanders.The Lancet Regional Health- Western Pacific. 2021; (Pre-print)https://doi.org/10.1016/j.lanwpc.2021.100241Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar). Similarly, in Australia ([3]Attwell K Lake J Sneddon J Gerrans P Blyth C Lee J. Converting the maybes: Crucial for a successful COVID-19 vaccination strategy.PLoS One. 2021; 16e0245907Crossref PubMed Scopus (48) Google Scholar) and the United Kingdom ([4]Sherman SM Smith LE Sim J Amlôt R Cutts M Dasch H et al.COVID-19 vaccination intention in the UK: results from the COVID-19 vaccination acceptability study (CoVAccS), a nationally representative cross-sectional survey.Hum Vaccin Immunother. 2021; 17: 1612-1621Crossref PubMed Scopus (332) Google Scholar), ‘maybes’ comprise most non-acceptors. Strong opposition to COVID-19 vaccines appears to be less common in all three countries, with fewer than 10% very unlikely/unwilling to vaccinate. It has been argued long before the COVID-19 pandemic that vaccine promotion targeting undecided people is key to increasing uptake ([5]Leask J. Target the fence-sitters.Nature. 2011; 473: 443-445Crossref PubMed Scopus (132) Google Scholar). But it may be particularly salient now. The rapidity of development and novelty of vaccines against COVID-19, intense public scrutiny, polarisation, misinformation ([6]Gabarron E Oyeyemi SO Wynn R. COVID-19-related misinformation on social media: a systematic review.Bull World Health Organ. 2021; 99 (455–63A)Crossref PubMed Scopus (61) Google Scholar), as well as vaccine policy changes and other factors, may undermine confidence among members of the public who may otherwise trust vaccines. In this context, some vaccine hesitancy is understandable; most hesitant people are unlikely to be ‘anti-vax’, and strategies to expedite vaccination against COVID-19 should reflect that. Communications to alleviate vaccine concerns should be prioritised, and vaccine promotion strategies should be tested with undecided people to check that they are having the desired impact on this group. Understanding the reasons why people want vaccines against COVID-19 aids vaccine promotion. Prickett et al. provide valuable insights about this in New Zealand. For example, their findings suggest that community factors, such as protecting others and striving towards herd immunity, may motivate younger New Zealanders to vaccinate. New Zealand is rolling out its vaccinations in four prioritised waves, ([1]Prickett KC Habibi H Carr PA. COVID-19 Vaccine Hesitancy and Acceptance in a Cohort of Diverse New Zealanders.The Lancet Regional Health- Western Pacific. 2021; (Pre-print)https://doi.org/10.1016/j.lanwpc.2021.100241Summary Full Text Full Text PDF PubMed Scopus (25) Google Scholar), which correlate with different age profiles. Prickett et al.’s. findings of the associations between sociodemographic variables and vaccine intentions can inform the tailoring of vaccine promotion associated with each wave. They may also inform targeted vaccine promotion for particular sociodemographic subgroups who remain under-vaccinated despite having access to vaccines. Growing evidence highlights the importance of structural factors in vaccine acceptance during the COVID-19 pandemic. Prickett et al. advocated for interventions to address social inequalities in order to increase the acceptance of COVID vaccines in New Zealand. This conclusion reflected their finding that being Māori did not predict COVID-19 vaccine acceptance, but lower age, less education and lower-income- all more common among Māori people- did. In Australia, living in disadvantaged areas also predicts COVID-19 vaccine hesitancy ([3]Attwell K Lake J Sneddon J Gerrans P Blyth C Lee J. Converting the maybes: Crucial for a successful COVID-19 vaccination strategy.PLoS One. 2021; 16e0245907Crossref PubMed Scopus (48) Google Scholar), and access issues have long been known to account for significant under-vaccination ([7]Lawrence GL Hull BP MacIntyre CR McIntyre PB. Reasons for incomplete immunisation among Australian children. A national survey of parents.Aust Fam Physician. 2004; 33: 568-571PubMed Google Scholar). COVID-19 vaccine hesitancy is associated with lower health literacy and lower education ([8]Pickles K Cvejic E Nickel B Copp T Bonner C Leask J et al.COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey.J Med Internet Res. 2021; 23 (e): e23805Crossref PubMed Scopus (52) Google Scholar), and a range of cultural and political factors, such as degree of trust in government ([9]Trent M Seale H Chughtai AA Salmon D MacIntyre CR. Trust in government, intention to vaccinate and COVID-19 vaccine hesitancy: A comparative survey of five large cities in the United States.United Kingdom, and Australia. Vaccine. 2021; Google Scholar). It is important to reduce financial and practical barriers to getting vaccinated against COVID-19, such as the inability to take time off work. As the COVID-19 pandemic further widens social inequalities ([10]Paremoer L Nandi S Serag H Baum F. Covid-19 pandemic and the social determinants of health.BMJ. 2021; 372: n129Crossref PubMed Scopus (251) Google Scholar), research about COVID-19 vaccine acceptance yet again underscores the importance of addressing the social determinants of health for pandemic preparedness. Both authors have no funding sources to declare. There was no original data for this short commentary article. As the corresponding author, TR had final responsibility for the decision to submit for publication. Both authors conceived the article, collated materials and contributed to writing the manuscript. The authors declare no conflict of interest. COVID-19 Vaccine Hesitancy and Acceptance in a Cohort of Diverse New ZealandersAlthough a majority intend to take the COVID-19 vaccine once available, a sizeable minority who were more likely to be young, female, and less educated, were unsure about or unlikely to get the vaccine, primarily due to perceptions of unknown future side effects. Ethnicity was not statistically associated with vaccine hesitancy, suggesting that public health efforts aimed at increasing vaccine acceptance among Māori and Pacific peoples—subgroups most at-risk of COVID-19 infection and morbidity—should focus on inequities in health care access to increase uptake. Full-Text PDF Open AccessShifting COVID-19 Vaccine Intentions in New Zealand: Next Steps in the Vaccination CampaignFew studies inform us about the New Zealand public intentions to get a COVID-19 vaccine, even as the vaccine rollout has been slow—a pattern similar to Australia, unlike several other developed countries [1]. Such low vaccination rates pose an increasing threat from the new COVID-19 variants to New Zealand, which has been able to evade the pandemic so far [2]. Given the brittle health care system in New Zealand—with second-fewest intensive care beds per capita among developed countries—health experts say it is important to vaccinate a very large proportion, about 80-90%, of the population to safely open the borders [2]. Full-Text PDF Open Access