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Reasons not to take the vaccine The percentage of respondents mentioning reasons why they would not take the COVID-19 vaccine. In the plot, points represent the estimated percentage of individuals that would not take the vaccine or do not know if they would take the vaccine for each possible response option. Bars around each point indicate the 95% CI for the estimate. An estimated average for all studies in LMICs is also shown. The size of the points illustrates the number of observations in each response option. The India and Pakistan survey 2 studies are not included because they either did not include the question or were not properly harmonized with the other studies.
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Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low-...
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Citations
... Like this study, COVID-19 hesitancy was reported in several LMICs by other studies. 27 This study demonstrated that age, having a chronic illness, and access to media (ownership of a phone and TV) were significant predictors of vaccine acceptance. Household heads aged 30 years and older were more than two times as likely to accept the vaccine compared with younger individuals (aOR=2.39, ...
Objectives
COVID-19 vaccine was rolled out for the public in August 2021 in Zamfara state, Northen Nigeria. We determined the factors influencing COVID-19 vaccine acceptance.
Settings
We executed a community-based analytical cross-sectional study during the first 4 months of the second phase of the COVID-19 (Oxford/AstraZeneca) mass vaccination campaign in Zamfara state.
Participants
We used multistage sampling to select 910 household heads.
Outcome measures
We used a semistructured electronic questionnaire to collect data on sociodemographic characteristics, uptake and acceptance of COVID-19 vaccine between 12 October and 20 December 2021. We calculated frequencies, proportions, adjusted ORs and 95% CIs for factors influencing COVID-19 vaccine acceptance using logistic regression.
Results
Our respondents had a median age of 48 years (IQR: 37–55), 78.1% (711) were men, a majority more than 30 years, and only 8.9% (81) had received COVID-19 vaccine. Of the 829 unvaccinated respondents, 10.1% (84) accepted to take the vaccine, the current week of the interview while 12.2% (101) rejected the vaccine. Individuals aged 30 years and older (adjusted OR (aOR)=2.39, 95% CI 1.16 to 4.94, p=0.018), who owned a mobile phone (aOR=25.35, 95% CI 11.23 to 57.23, p<0.001) and a television (aOR=3.72, 95% CI 1.09 to 12.69, p=0.036), with medium–high levels of trust (aOR=7.41, 95% CI 3.10 to 17.74, p<0.001), and those with a medium–high (positive) levels of attitude (aOR=1.82, 95% CI 1.06 to 3.11, p=0.029) were more likely to accept the COVID-19 vaccine. Also, those who had been vaccinated with other vaccines (aOR=2.2, 95% CI 1.09 to 4.43, p=0.027) and those previously tested for COVID-19 (aOR=2.0, 95% CI 1.10 to 3.66, p=0.023) were also more likely to accept it.
Conclusion
COVID-19 vaccine had a poor uptake and acceptance. Factors such as age, awareness, trust and previous vaccination experience played a significant role in COVID-19 vaccine acceptance. We recommended targeted public health campaigns, improving community engagement and building trust in community leaders, healthcare providers and public health institutions.
... Healthcare providers, especially physicians, play a significant role in promoting vaccination and strongly influence their patients' decisions to get vaccinated [15][16][17]. Physician recommendations are consistently reported as one of the potent predictors of vaccine uptake in diverse settings [16,17]. Studies support such an association, with a systematic review showing that adults who received a healthcare provider's recommendation had 3.67 times higher odds of getting vaccinated for influenza [17]. ...
... Healthcare providers, especially physicians, play a significant role in promoting vaccination and strongly influence their patients' decisions to get vaccinated [15][16][17]. Physician recommendations are consistently reported as one of the potent predictors of vaccine uptake in diverse settings [16,17]. Studies support such an association, with a systematic review showing that adults who received a healthcare provider's recommendation had 3.67 times higher odds of getting vaccinated for influenza [17]. ...
... For instance, a recent investigation into COVID-19 vaccine hesitancy in Bangladesh found that TPB yielded the highest predictive accuracy (adjusted R 2 = 0.43) compared to other behavioral models [22]. Moreover, TPB has been effectively employed in other LMICs to identify critical factors influencing vaccination behaviors, including physicians' intentions to recommend influenza vaccination [16,23,24]. Within TPB, behavioral intentions are shaped by three key dimensions: individuals' attitudes toward the action, the influence of subjective norms, and their perceived control over the behavior [25,26]. ...
Background: Influenza remains a significant public health challenge in low- and middle-income countries (LMICs) like Bangladesh, where vaccine uptake remains low despite the substantial disease burden. Physicians play a vital role in promoting vaccination, yet their intentions and influencing factors are not well understood. Methods: We conducted a cross-sectional study from June to October 2022 across four tertiary-level hospitals in Bangladesh using a questionnaire grounded in the Theory of Planned Behavior (TPB). Hierarchical logistic regression was employed to identify factors associated with vaccine recommendation intentions. Results: Among 972 physicians with an average age of 32.1 years, 40.1% intended to recommend and administer the influenza vaccine. Most (85.3%) agreed vaccination reduces risk, 65.5% desired vaccination for self-protection, 63.5% would vaccinate if available at work, and 85.3% anticipated Ministry of Health support. Male (OR = 1.9, 95% CI: 1.5–2.3) and married (OR = 1.5, 95% CI: 1.1–1.9) physicians were more likely to recommend vaccination. Each unit increase in attitude score doubled the likelihood of recommending the vaccine (OR = 2.0, 95% CI: 1.4–3.0). Conclusions: Physicians’ influenza vaccine recommendations in Bangladesh are suboptimal, influenced by gender, marital status, and attitudes. Targeted educational interventions addressing attitudinal barriers and leveraging institutional support could improve recommendation practices.
... Willingness to receive a COVID-19 vaccine was generally higher in lowand middle-income countries in Asia, Africa, and South America compared with the United States (mean 80.3% vs. 64.6%, respectively); in these countries, desire for personal protection and apprehension over vaccine side effects were the major factors in vaccine acceptance and hesitancy, respectively [180]. In Latin America, individual/group influences have been identified as the primary barrier to vaccination, with low socioeconomic status, lower education, and age contributing to low vaccine uptake, and education and trust in healthcare professionals enhancing vaccine acceptance [174]. ...
Vaccination represents a core preventive strategy for public health, with interrelated and multifaceted effects across health and socioeconomic domains. Beyond immediate disease prevention, immunization positively influences downstream health outcomes by mitigating complications of preexisting comorbidities and promoting healthy aging. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza virus, and respiratory syncytial virus (RSV) are common respiratory viruses responsible for broad societal cost and substantial morbidity and mortality, particularly among at-risk individuals, including older adults and people with frailty or certain comorbid conditions. In this narrative review, we summarize the overall impact of vaccination for these 3 viruses, focusing on mRNA vaccines, each of which exhibits unique patterns of infection, risk, and transmission dynamics, but collectively represent a target for preventive strategies. Vaccines for COVID-19 (caused by SARS-CoV-2) and influenza are effective against the most severe outcomes, such as hospitalization and death; these vaccines represent the most potent and cost-effective interventions for the protection of population and individual health against COVID-19 and influenza, particularly for older adults and those with comorbid conditions. Based on promising results of efficacy for the prevention of RSV-associated lower respiratory tract disease, the first RSV vaccines were approved in 2023. Immunization strategies should account for various factors leading to poor uptake, including vaccine hesitancy, socioeconomic barriers to access, cultural beliefs, and lack of knowledge of vaccines and disease states. Coadministration of vaccines and combination vaccines, such as multicomponent mRNA vaccines, offer potential advantages in logistics and delivery, thus improving uptake and reducing barriers to adoption of new vaccines. The success of the mRNA vaccine platform was powerfully demonstrated during the COVID-19 pandemic; these and other new approaches show promise as a means to overcome existing challenges in vaccine development and to sustain protection against viral changes over time.
A graphical abstract and video abstract is available with this article.
... According to other international data, only 29.9% of low-income people had received at least one dose of the vaccine as of May 2023. 2 By 2022, the percentages of vaccinated people were 88.95% in China, 88.67% in Cuba, 86.48% in Portugal, 80.96% in Italy, 76.02% in Germany, 75.13% in the United Kingdom, 62.67% in Türkiye, and 67.18% in the USA. 3 However, vaccination problems continue to occur in low-and middleincome countries. 4 According to data from Cyprus in general, 50.2% of the population were fully vaccinated, whereas 64.6% had received at least the first dose in 2021. 5 Vaccine hesitancy should be monitored in all countries by relevant measures according to WHO. 6,7 Vaccine hesitancy was previously defined as "the delay in acceptance or refusal of vaccination services despite their availability" which was modified in May 2022 by the WHO as "a motivational state of being conflicted about, or opposed to getting vaccinated". ...
... A survey of 15 studies in 2020-2021 compared lowincome, lower-middle-income, and upper-middle-income countries with Russia and the USA. 4 Similar to the 93% vaccine uptake rate in our study, the average acceptance rate in all studies in low and middle income countries was 80.3%, higher than samples from the United States (64.6%) and Russia (30.4%). 4 Another study covering 15 African countries found that the majority of the respondents (79%) were willing to receive a COVID-19 vaccine. ...
... A survey of 15 studies in 2020-2021 compared lowincome, lower-middle-income, and upper-middle-income countries with Russia and the USA. 4 Similar to the 93% vaccine uptake rate in our study, the average acceptance rate in all studies in low and middle income countries was 80.3%, higher than samples from the United States (64.6%) and Russia (30.4%). 4 Another study covering 15 African countries found that the majority of the respondents (79%) were willing to receive a COVID-19 vaccine. 13 The highest acceptance rates were found in Malaysia (94.3%), ...
... Results are concerning considering the association of low perceptions of disease severity with higher levels of vaccine hesitancy [41]. in longitudinal analysis, we also found that respondents' perceptions of the severity of cOViD-19 disease and an individual's risk for infection remained consistent over time. Research has shown vaccine acceptance is associated with establishing trusting relationships with healthcare providers who are well versed with an individual's health history and risk factors [30,42]. therefore, healthcare providers may support cOViD-19 vaccine uptake by consolidating or clarifying information for those who remain undecided. ...
Background
Despite high COVID-19 vaccine coverage in Canada, vaccine acceptance and preferred delivery among newcomers, racialized persons, and those who primarily speak minority languages are not well understood. This national study explores COVID-19 vaccine acceptance, access to vaccines, and delivery preferences among ethnoculturally diverse population groups.
Methods
We conducted two national cross-sectional surveys during the pandemic (Dec 2020 and Oct-Nov 2021). Binary logistic regression analysis investigated the association between newcomer, language, and racialized minority respondents’ perceptions and acceptance of COVID-19 vaccines, experiences of discrimination when accessing health services, and sociodemographic characteristics. McNemar-Bowker tests were used to assess changes in responses collected at two time points.
Results
Among 1630 respondents, 30.8% arrived in Canada within the last five years, 87.4% self-identified as a racialized minority, and 37.2% primarily spoke languages other than English or French. Although single dose COVID-19 vaccine uptake was at 92.7% among respondents, 14.8% experienced difficulty accessing vaccines, citing a need for translated resources or multi-lingual personnel. In longitudinal analysis, respondents were increasingly motivated over time to overcome barriers to accessing vaccines (61.4% to 69.6%, p = <.001). Fifty-nine percent (59.9%) of respondents would accept annual vaccination and over half would accept co-administration with routine (56.2%) or influenza (52.3%) vaccines. Experiences of racism/discrimination upon health service access were reported by 12.3% of respondents, who recommended increasing culturally safe practices and community involvement at vaccination sites.
Conclusions
Understanding how newcomers, racialized peoples, and minority language speakers perceive and access COVID-19 vaccines will support vaccination campaigns to optimize equitable access.
... High rates of COVID-19 vaccination are required for the achievement of sufficient immunization coverage to end the pandemic evolution (Cascini et al. 2021;Tregoning et al. 2021). Vaccine hesitancy and anti-vaccination are major barriers to this (Arce et al. 2021). By early December 2021, governments in more than 40 countries have implemented various forms of COVID-19 vaccination mandates (VMs) with the purpose of overcoming vaccine hesitancy and ultimately increasing vaccination rates (Reuters 2021). ...
... Historically, vaccines have been the most effective way to combat disease outbreaks (Dhama et al. 2021). As of 8 December 2021, a total of nearly 8 billion vaccine doses have been administered globally, of which 4.28 billion persons vaccinated with at least one dose and nearly 3.37 billion persons fully vaccinated. 1 However, a growing number of studies show that sustained high level of hesitancy against COVID-19 vaccines poses a challenging barrier to the achievement of high vaccination rates, which are required for the achievement of sufficient immunization coverage, especially herd immunity, to end the COVID-19 pandemic evolution (Cascini et al. 2021;Arce et al. 2021). ...
... Within the USA, Arce et al. (2021) and Uslu et al. (2021) observe that most survey studies report a decreasing trend in willingness to vaccinate or an increasing trend in vaccine resistance over time, even in recent months of 2021. For example, in June 2020, 12% of 22,470 respondents indicated "extremely unlikely" responses if a vaccine was available to them. ...
Mandatory vaccination for COVID‐19 has received intense political and ethical debates, while the literature on the causal effects of vaccination mandates on vaccination outcomes is very limited. In this study, we examine the effects of the announcement of vaccine mandates (VMs) for workers working in three sectors, including health, education, and state governments, on the uptake of first‐dose and second‐dose vaccination across 50 states in the United States of America. We show that VM announcements have heterogeneous effects; hence, standard two‐way fixed effects and difference‐in‐differences estimators are biased. We present evidence for the heterogeneous treatment effects in single and two‐treatment settings. In the setting of a single treatment, when treating all VM announcements equally, our results show that VM announcement was associated with an increase of 20.6% first‐dose uptake from 1 July to 31 August 2021. In two‐treatment settings, our results suggest that VM announcements for workers in health or state government sectors have significant causal effects on first‐dose vaccination. Additionally, VM announcements do not have significant causal effects on second‐dose uptake. Our results are robust to the choice of differing outcome variables and periods after controlling for state‐level covariates, including COVID‐19 death, unemployment, and cumulative two‐dose vaccination.
... Vaccine hesitancy, recognized by the World Health Organization as one of the top ten global health threats, has been particularly prominent in rural communities [6]. This hesitancy often stems from various factors, including misinformation, cultural beliefs, and concerns about vaccine safety and efficacy [7]. Understanding these barriers is essential for developing targeted interventions to improve vaccine acceptance and completion rates. ...
The COVID-19 vaccination program in India demonstrated rapid deployment, yet rural populations exhibited lower vaccination rates compared to urban centers. A cross-sectional survey was conducted in rural areas of Surampalem of Andhra Pradesh state in India to evaluate vaccination status, assess public perception, and identify barriers to vaccine uptake. The study included 312 participants (151 males, 161 females) through a door-to-door survey using a structured questionnaire. Results indicated that Covaxin was administered to 168 participants while 144 received Covishield. It is found that 67% of the surveyed population required their second dose, indicating a substantial gap in complete vaccination coverage. Common misconceptions identified among participants included concerns about adverse effects, doubts regarding vaccine efficacy, belief in natural immunity superiority, and fears about vaccine interactions with comorbidities. Statistical analyses using one-way ANOVA and Student's t-tests showed no significant differences between groups regarding vaccine doses, age versus gender, and age versus vaccine type (p > 0.005). Educational interventions were implemented through awareness camps and distribution of informational brochures to address identified misconceptions. Data was shared with local health authorities to facilitate targeted vaccination drives. The study results show the need for continued education and awareness programs in rural communities to improve COVID-19 vaccine acceptance and completion rates.
... Additionally, the present study found that participants with a probability of having a previous COVID-19 infection had lower confidence in the COVID-19 vaccine than those who had not been previously infected. After studying many low-and middle-income countries, Solís Arce et al. [34] revealed that the main cause of vaccine acceptance was the hope of people to protect themselves from COVID-19 infection. In contrast, the fear of side effects of vaccines was the major cause of vaccine rejection. ...
Background
The World Health Organization (WHO) stresses the importance of worldwide vaccine coverage of coronavirus-19 (COVID-19) vaccination. This study fills a critical gap in the literature by providing empirical evidence on the factors influencing COVID-19 vaccine hesitancy and inequity in the Middle East and North Africa (MENA) region. This study investigated the determinants of psychological antecedents and other factors behind COVID-19 vaccination and their role in vaccine coverage in MENA.
Methods
An anonymous online cross-sectional survey was conducted in 11 MENA countries (Egypt, Sudan, Kuwait, Saudi Arabia, Morocco, Iraq, Yemen, Lebanon, Libya, Afghanistan, and Pakistan). The minimum required sample size from each country was 307, which was increased to 330 to accommodate a non-response rate of 7%. A multilevel logistic regression model was used to capture the clustering of observations in each country and estimate the explanatory variables’ effects on each item of the 5C components of the psychological antecedents scale namely (confidence, constraints, complacency, calculation, and collective responsibility).
Results
The total number of respondents was 3630, 40.5% of them were between the ages of 18 and 25 years, 61.1% were females, 54.0% completed university education, 55.8% were unmarried, 19.5% had chronic diseases, 43.7% reported a previous COVID-19 and 42.4% had relatives who died from COVID-19. Much of the variation in the log of the odds in each item of the 5Cs was due to heterogeneity between different countries (intraclass correlation > 0.05). Therefore, this variability confirms the various effects of psychological antecedents on vaccination coverage, stimulating vaccination inequity among them. Increasing confidence in vaccines and collective responsibility towards relatives and the community is related to increasing acceptance of the COVID-19 vaccine. The reduction in complacency, calculations, and constraints was found to be associated with acceptance of the COVID-19 vaccine.
Conclusions
This study is novel in shedding light on the importance of psychological determinants as hidden causes of vaccine inequities by using a multilevel logistic regression model for COVID-19 vaccination intention. The findings suggest that targeted interventions addressing socio-demographic factors, psychological antecedents, and accessibility barriers are essential to mitigate vaccine inequity and improve vaccination rates.
... Instead, the intention is to understand some of the mechanisms behind vaccine inequities beyond availability and access. Furthermore, quantitative data indicates that, during the COVID-19 pandemic, vaccine acceptancy was higher in 10 LMICs (80.3 %) than in the USA (64.6 %) and Russia (30.4 %) [14], and recent studies have revealed that feelings about vaccine safety are particularly negative in Europe [15]. This same study showed that countries with high levels of schooling and good access to health services show lower rates of positive feelings towards vaccination, pointing to an emerging inverse relationship between vaccination sentiment and socioeconomic status. ...
... Previous COVID-19 global surveys have shown large variation in vaccine acceptance across countries ranging from 47.9% in South Africa to 98.3% in India (6). Despite the disproportionate challenges in vaccine availability and distribution faced by low-and middle-income countries (LMICs), these countries tend to exhibit lower levels of vaccine hesitancy and higher acceptance rates than higherincome countries (7). Previous research shows that perceived susceptibility to COVID-19 infection, severity of complications, and believed benefit are associated with a higher intention to vaccinate (8). ...
Introduction
The COVID-19 pandemic has greatly impacted the way that the world views vaccines. While safe and effective, COVID-19 vaccines were, and continue to be met with hesitancy and misinformation. We aimed to understand public perceptions and trust in COVID-19 vaccinations and how the pandemic has impacted perceptions of non-COVID-19 vaccines.
Methods
Survey data were collected between August 7, 2023–August 16, 2023, from 7,000 respondents aged 18 years and older from the United States (n = 1,000); Nigeria (n = 1,000); United Kingdom (n = 1,000); France (n = 1,000); Canada (n = 1,000); Brazil (n = 1,000); and India (n = 1,000).
Results
Trust in COVID-19 vaccines was highest in Brazil (84.6%) and India (80.4%) and lowest in the United States (63.5%) and France (55.0%). 47.5% of respondents agreed that they trust traditional protein-based vaccines more than mRNA vaccines, 13.5% disagree and 39.0% are neutral about their trust in protein-based versus mRNA vaccines. Overall, 53.9% of respondents reported that the COVID-19 pandemic impacted their perceptions of vaccines with half of these respondents (51.7%) reporting that the pandemic made them think that other vaccines are more important as they understand how critical vaccines can be at preventing serious illnesses.
Discussion
These data can be used by health system decision makers, public health and researchers to understand how vaccine trust impacts perceptions of COVID-19 and influenza vaccines globally and develop tailored interventions that address local concerns.
