Unpacking vaccine “hesitancy:” the spectrum of vaccine acceptance

Media reports investigating the challenges that lead to relatively low covid-19 vaccine uptake rates in younger age groups highlight a need to consider “vaccine hesitancy” not as a single phenomenon, but as part of a spectrum. It can range from vaccine apathy at one end—driven by lack of interest in a vaccine that mitigates a risk one perceives to be low—to full-blown vaccine conspiracy at the other. Most people are happy to observe vaccine acceptance, driven by a rational desire to mitigate risks from covid-19, by accepting a vaccine that evidence makes clear we should trust. But not everyone trusts healthcare systems to have developed vaccines safely, often because of past historical transgressions or because they are concerned about pharmaceutical companies that have lied in the past. They may be worried about vaccine ingredients or side effects. Some pharmaceutical companies might be trusted more or less simply on the basis of their location, history, and commitment to making profits or not. Some people may just want to see what happens to others first, indicating a vaccine questioning or hesitancy that falls short of vaccine refusal

Not everyone who is not ready to have a vaccine is an “anti-vaxxer” and only by acknowledging this, working with diverse communities and understanding the range of people’s concerns are we likely to win them over to the side of public health interventions.  

Our research—which ranges from the streets of Slough, just a few miles from Royal Holloway’s Egham campus, to Armenia, Uganda, and the digital spaces of redditsuggests that not only are attitudes to vaccines context-specific, but also, as other studies have suggested, acutely heterogeneous: a vaccine may be accepted for one disease, but rejected for another; attitudes may differ between demographic groups within the same population; and may change at different points in time. Rather than seeing vaccine hesitancy as a single challenge, we need to better understand the broad range of reasons why people may be cautious, so that we can best suggest targeted interventions that speak to their specific concerns and circumstances. We need to see attitudes to vaccines as a broad spectrum that ranges from apathy, through acceptance, questioning, hesitancy, refusal and conspiracy, each of which needs to be tackled independently.

Hesitancy to new vaccines that have been developed quickly, rather than to vaccines per se, is not an irrational concern. Communities may be concerned over the ingredients they may contain, as a recent article in Nature recognised. The vaccines themselves, and their delivery, may be infused with a gamut of geopolitical and post-colonial legacies, particularly where old rivals compete in a world where there is, in fact, more than enough space for many victors. If Russia and the USA, for example, were more willing to see one another as allies and collaborators in the fight against covid-19, they might be less likely to sow seeds of distrust about the efficacy of one another’s vaccines. Such an approach does little other than destroy confidence in either’s product in countries such as Armenia and Georgia, caught in the middle of the old East and Western rivalries. The European Union’s relationship to the UK and the Oxford/Astra-Zeneca vaccine has been, at times, fraught with accusations traded about supply and demand, provenance and efficacy. 

Resisting the temptation to frame the vaccine hesitant as either ignorant or susceptible to conspiracy theories would allow us to better understand other factors that may be relevant, such as vaccines containing religiously prohibited ingredients (most don’t, which is easily explained). It could also be the case that vaccination centres are too geographically distant for those who do not own their own car (in which case, community healthcare workers could vaccinate the vulnerable in their own homes). Finally, vaccination progress will be harder to access for those who are not registered, and may not be able to easily register, with a GP surgery. Such concerns—all of which were raised by citizens we surveyed in Sloughhighlight challenges not only with the vaccines themselves, but with the medical-public health systems through which they are delivered and which may need to be reconfigured to meet the needs of the local context. 

In Armenia, hesitancy varied not only from vaccine to vaccine (physicians who readily promote childhood vaccinations for measles, polio, and other diseases, showed hesitancy towards both the recently introduced Gardasil vaccine for HPV, as well as the covid-19 vaccines), but also between different age groups, and at different times. Those who showed concerns about newness—a concern also highlighted in the recent Nature report—may become less hesitant over time, as their fears are not realised. Such concerns can and should be addressed directly by promoting experiences of those who have already received the vaccine safely, as a reddit forum we moderate did, by running a question-and-answer session in which vaccine trial volunteers discussed the relatively mild side-effects they had experienced before the vaccine was rolled out to the wider public. Giving voices to healthcare workers, who tend to be both early recipients of in-country vaccine supplies and also highly trusted by their communities, provides opportunities to bolster community confidence. Evidence shows this is a much more effective response than pushing the vaccine hesitant away. Concerns over the vaccines for covid-19 are no more universal than the reasons behind enduring resistance to polio eradication, a war that may have been won while the world’s attention has been distracted by a different pandemic. 

The policy implications for adopting a more nuanced approach to “vaccine hesitancy” might in itself reveal further potential options for making a difference to vaccination levels. In Israel progress was accelerated by vaccinating the young and healthy in bars, in exchange for a free soft drink, as did offering lottery tickets alongside vaccination in the US). Covid-19 continues to provide a chance to study, unpack, and understand how and why vaccine hesitancy arises and resonates in some individuals and communities. It will help us understand how to frame messages around other urgent policy priorities such as the climate emergency, which is predicted to make such pandemics more common in the future as well as being a challenge in its own right. Lessons identified now may help us to face the challenges to come, if we are willing to consider that we may have as much to learn from the diverse vaccine hesitant communities as they have from us. 

Jennifer Cole, lecturer in Global and Planetary Health, Department of Health Studies, School of Life Sciences and the Environment, Royal Holloway University of London.

Klaus Dodds, professor of Political Geography, Geography Department, School of Life Sciences and the Environment, Royal Holloway University of London.

Hermine Mkrtchyan, professor of Microbiology and Head of Research, School of Biomedical Sciences, University of West London.

Maureen Ayikoru, lecturer in Sustainability and Business Ethics, School of Business and Management, Royal Holloway University of London.

Competing interests: none declared.