A global survey of potential acceptance of a COVID-19 vaccine

We conducted a study of potential acceptance of a COVID-19 vaccine in 13,426 randomly selected individuals across 19 countries, most with a high COVID-19 burden. Of these, 71.5% responded that they would take a vaccine if it were proven safe and effective, and 61.4% said that they would get vaccinated if their employer recommended it (Table 1). However, we observed high heterogeneity in responses between countries. Furthermore, reporting one’s willingness to get vaccinated might not be necessarily a good predictor of acceptance, as vaccine decisions are multifactorial and can change over time.

The far-from-universal willingness to accept a COVID-19 vaccine is a cause for concern. Countries where acceptance exceeded 80% tended to be Asian nations with strong trust in central governments (China, South Korea and Singapore). A relatively high tendency toward acceptance in middle-income countries, such as Brazil, India and South Africa, was also observed. Unless and until the origins of such wide variation in willingness to accept a COVID-19 vaccine is better understood and addressed, differences in vaccine coverage between countries could potentially delay global control of the pandemic and the ensuing societal and economic recovery.

Univariate variation among demographically defined groups was least among those with lower education and income levels. Future vaccine communication strategies should consider the level of health, scientific and general literacy in subpopulations, identify locally trusted sources of information10 and go beyond simply pronouncing that vaccines are safe and effective. Strategies to build vaccine literacy and acceptance should directly address community-specific concerns or misconceptions, address historic issues breeding distrust and be sensitive to religious or philosophical beliefs11. Researchers have identified promising interventions for building confidence and reducing vaccine hesitancy in different contexts12,13, but translating this evidence into large-scale vaccination campaigns will require particular awareness of and attention to existing public perceptions and felt needs. Engaging formal and informal opinion leaders within these communities will be key.

Additionally, we observed age-related associations with vaccine acceptance. Older people were more likely to report that they would take a vaccine, whereas younger respondents were more likely to accept an employer’s vaccine recommendation. This finding might reflect who was actually employed or employable at the time of the survey—an issue we did not investigate. Men in this study were less likely than women to accept vaccines in general or their employer’s recommendation to get vaccinated; however, this association was not strong. Those with a higher income were most likely to accept a vaccine than those with a lower income. These data could help governments, policymakers, health professionals and international organizations to more effectively target messaging around COVID-19 vaccination programs.

The other source of concern was a discrepancy between reported acceptance of a COVID-19 vaccine and acceptance if vaccination was mandated by one’s employer. All respondents, regardless of nationality, reported that they would be less likely to accept a COVID-19 vaccine if it were mandated by employers. This finding across all countries with both high and low reported vaccine acceptance proportions suggests that promoting voluntary acceptance is a better option for employers. It might seem easier to monitor compliance among adults in the working age group if employers required it, but this could fail if it is perceived as limiting employees’ freedom of choice or a manifestation of employers’ self-interest14.

A careful balance is required between educating the public about the necessity for universal vaccine coverage and avoiding any suggestion of coercion. Respected community-based groups and non-governmental organizations, such as the Red Cross, which is considered to be impartial, are essential to help build trust in a future COVID-19 vaccine.

Arguably, trust is an intrinsic and potentially modifiable component of successful uptake of a COVID-19 vaccine. Our findings show that trust in government is strongly associated with vaccine acceptance and can contribute to public compliance with recommended actions15. Lessons learned from previous infectious disease outbreaks and public health emergencies, including HIV, H1N1, SARS, MERS and Ebola, remind us that trusted sources of information and guidance are fundamental to disease control16. However, addressing vaccine hesitancy requires more than building trust. It is a multifactorial, complex and context-dependent endeavor that must be addressed simultaneously at global, national and sub-national levels.

Clear and consistent communication by government officials is crucial to building public confidence in vaccine progams. This includes explaining how vaccines work, as well as how they are developed, from recruitment to regulatory approval based on safety and efficacy. Effective campaigns should also aim to carefully explain a vaccine’s level of effectiveness, the time needed for protection (with multiple doses, if required) and the importance of population-wide coverage to achieve community immunity. Instilling public confidence in regulatory agency reviews of vaccine safety and effectiveness will be important. Credible and culturally informed health communication is vital in influencing positive health behaviors17,18, as has been observed with respect to encouraging people to cooperate with COVID-19 control measures. This includes preparing the public and leaders of civic, religious and fraternal organizations that are respected within various sectors of society and local communities, as well as the private sector, for a mass vaccination program with credible spokespeople, local engagement, accurate information and technological support.

This study had limitations. It must be kept in mind that all public surveys of the type reported here are snapshots taken at a point in time. This particular survey was conducted in the context of a highly dynamic and changing landscape, with daily variations in perceived disease threat and COVID-19 vaccine development itself.

In the 3 months since this survey was conducted, several highly visible events have affected COVID-19 vaccine development. A phase III trial of one of the most visible vaccine candidates was put on hold due to the report of a serious adverse event, although that hold was later lifted19. The Russian government, on the other hand, has made a vaccine available for general use on the basis of extremely limited data20. A group of former US Food and Drug Adminstration commissioners and several companies developing COVID-19 vaccines and biomedical advisory bodies have urged the US federal government to base any pending vaccine approvals on clinical data and not bend to political pressure from the incumbent US president to approve a vaccine before the US elections (https://www.washingtonpost.com/opinions/2020/09/29/former-fda-commissioners-coronavirus-vaccine-trump/).

In the context of these developments that post-date our survey, subsequent national surveys in the United States and elsewhere have suggested strongly that public hesitancy to a COVID-19 vaccine is now greater than that which we report here (https://www.kff.org/coronavirus-covid-19/press-release/poll-most-americans-worry-political-pressure-will-lead-to-premature-approval-of-a-covid-19-vaccine-half-say-they-would-not-get-a-free-vaccine-approved-before-election-day/). This can only intensify the vaccine communications challenges discussed above.

In most of the 19 countries surveyed in our study, current levels of willingness to accept a COVID-19 vaccine are insufficient to meet the requirements for community immunity. To build increased trust among the general population, the elements that define and build trust must be understood and interventions crafted accordingly. It is increasingly clear that transparent, evidence-informed policy and clear, accurate communication will be required of all relevant stakeholders. The ongoing pandemic provides the public health community with an important opportunity to build vaccine literacy and confidence to support the uptake of a potential COVID-19 vaccine, as well as to bolster overall immunization programs for all vaccine-preventable diseases.