Several studies identified low disease risk perception as a barrier to COVID vaccine acceptance. We hypothesise that this barrier may be relevant in countries where COVID has been politicised, for example the US, or in countries like Australia where the pandemic was well contained for an extended period of time.
In contrast, several studies found that high perceived risk of developing COVID disease facilitated COVID vaccine acceptance.
Similarly, perception of disease risk has been shown to play a role in motivating people to vaccinate against influenza [ 38 ]. Several studies reported trust—in health authorities, in governments, in scientists and the vaccine development process—as a facilitator of COVID vaccine acceptance.
Some studies found that healthcare provider recommendations were a facilitator of COVID vaccine acceptance; trust may in part explain this finding. In studies of acceptance of routine vaccinations, trust in healthcare providers has been found to support vaccine confidence and acceptance, while primary healthcare providers are consistently found to be the most trusted source of information on routine vaccinations including influenza [ 39 ].
Findings indicate that, at the time of this review, COVID vaccines had not elicited any new types of concerns around vaccine acceptance, with barriers and facilitators presenting in a similar way as for other already established vaccines [ 40 , 41 ].
This is an important observation because there are several known effective strategies that can be operationalized in response to COVID vaccine concerns, including communication strategies. We note that strategies beyond communication could also be operationalized to improve uptake of COVID vaccines beyond vaccine acceptance, if there are known access barriers to vaccination [ 41 ].
The purpose of this review was to explore themes describing factors influencing COVID vaccine acceptance, and to reflect on how this evidence can inform health authority responses, especially communications.
This is in keeping with risk communication literature, which recommends using formative research to inform communication efforts [ 42 , 43 ].
Communications may also mitigate potential threats to vaccine confidence and support acceptance of COVID vaccines throughout the life of a vaccination program. One factor identified in this narrative review—that safety and effectiveness of new vaccines as well as perceived scientific uncertainty may concern some individuals—suggests that health authorities and other vaccine stakeholders could benefit from adopting approaches aligned with risk communication principles.
First, they could be open and forthcoming with information about COVID or other new vaccines and vaccine rollouts. Being transparent with information and providing it in a timely manner can build trust with communities [ 42 , 43 ]. Second, health authorities and other vaccine stakeholders, such as government and vaccine regulatory authorities, could engage with specific questions and concerns to help reassure communities about vaccine safety and effectiveness.
The accelerated trials of COVID vaccines, coupled with a perception that they were rushed, may have heightened safety and effectiveness concerns about COVID vaccines [ 44 ]. Research with other vaccines suggests that beliefs about low safety and effectiveness can result in low confidence and acceptance [ 40 , 45 ].
In terms of approaches, concerns about safety and unanticipated long-term side effects could be addressed by sharing details about the processes in place for ongoing safety monitoring, and emphasizing numbers of people already vaccinated globally and associated safety data.
This information could be delivered by credible sources, such as well-known scientists or medical professionals, who are trusted sources of vaccine information [ 36 ], including about COVID vaccines specifically [ 46 ].
Third, any information should be complemented with opportunities for two-way communication, where individuals can easily ask questions about COVID vaccination, for example via online or public forums, telephone hotlines, or social media. Fourth, any information should be easy to digest, for example using visuals e.
Individuals may not have the time, capacity or desire to digest lengthy research findings on COVID vaccines. Tools that assess readability e. Any messaging should be pre-tested with target audiences, as individuals can respond unpredictably to messages about vaccination [ 47 , 48 ].
Another finding of this review—that low perceived risk of developing severe COVID disease and doubts about the seriousness of the pandemic can be a barrier to vaccine acceptance—suggests that individuals should be supported to understand their personal risk of COVID disease, as well as the risks to the broader community.
In general, individuals who perceive themselves at low risk of disease may be less willing to vaccinate [ 49 ]. This information could be framed in terms of anticipated regret; such messages emphasizing anticipated regret of infection have been associated with positive intentions for other vaccines [ 52 — 54 ].
However, individuals may respond unpredictably to appeals to negative emotions and may decrease their intention to vaccinate [ 5 ]. Such strategies should therefore be used with caution, and always pre-tested with target groups including both confident and hesitant individuals.
Strategies to address population level risk could include explaining visually if possible the concept of exponential growth, i. the ability for low numbers of COVID cases to increase quickly to unmanageable levels. This strategy has been shown to encourage support for COVID public health measures [ 55 ], and may extend to support for vaccination.
Debunking misinformation may have a role in supporting vaccine acceptance. Health authorities could identify misinformation that is getting considerable attention, and debunk it by emphasizing factual information, exposing flawed arguments, and providing alternative explanations [ 58 ]. The articles and reports included in this review were from high income countries with well-established health systems only.
Caution should to be taken when interpreting findings and extrapolating to other contexts, particularly low-income countries. Findings from individual studies offer a snapshot at a particular time and in a particular context.
Given rapidly evolving knowledge and circumstances surrounding COVID vaccines, factors influencing COVID vaccine acceptance may fluctuate and change over time. Our analysis was intended to be primarily descriptive in nature. We did not perform quality assessment of included studies. Studies that were more representative or of higher quality were not given more weight in the analysis.
Given the scope of the included studies, we were not able to tease out barriers and facilitators specific to particular vaccines and vaccine technologies, such as mRNA versus viral vector vaccines.
Most studies included in this review report from cross sectional, quantitative surveys. While rapid data collection has been necessary during the COVID pandemic to readily inform the responses of health authorities and other vaccine stakeholders such as regulatory authorities, qualitative interview- or focus group-based research may offer a deeper understanding of COVID vaccine acceptance.
Socio-demographic characteristics associated with vaccine acceptance need to be interpreted with caution.
This approach may also lead to profiling individuals and groups as more or less accepting of COVID vaccines, which may lead to stigma and discrimination.
A more nuanced approach is needed, underpinned by an understanding of the broader social, economic, and cultural determinants of COVID vaccine acceptance. There are inherent limitations with the use of preprint articles and grey literature as these have not been peer-reviewed.
This should be borne in mind when interpreting findings. Preprint articles and grey literature used in this review are clearly differentiated from peer-reviewed articles in Table 1.
Given the dynamic nature of the pandemic, knowledge on the safety and effectiveness of COVID vaccines, and changing policies and public health recommendations, both qualitative and quantitative data on factors influencing COVID vaccine acceptance should be iteratively collected over time.
This should include in countries not covered by this review. Analysis of how factors influencing acceptance over time would also be beneficial to inform future efforts to support acceptance of novel pandemic vaccines.
We propose potential communication strategies for consideration by health authorities. These include being open and forthcoming with information about COVID vaccines; engaging with specific questions and concerns; and ensuring that information is straightforward and easy to digest.
Individuals must also be supported to understand their personal risk of COVID disease, as well as the risks to the broader community.
Emerging misinformation about COVID vaccines receiving considerable attention should be addressed. Mixed-methods and longitudinal approaches are needed to gather more nuanced evidence on COVID vaccine acceptance as the pandemic evolves and vaccination programs expand to include COVID booster vaccines, a range of vaccine choices, the next generation of COVID vaccines, and vaccination of groups previously ineligible to receive COVID vaccines, for example children.
Findings and recommendations presented here can inform the public health and communication responses aimed at supporting acceptance of COVID vaccines, with a potential beneficial flow-on effect for other routine and seasonal immunisation programs, and future novel pandemic vaccines.
MS, BB, and CK designed and conducted the literature review. MS and BB screened and reviewed the literature. MS, BB, and KB performed the analysis. All authors contributed to the interpretation and discussed implications. MS developed the first draft of the manuscript.
All authors contributed to subsequent drafts and approved the final manuscript. This study received funding from NSW Health COVID Research Grants Program. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.
The authors receive funding from the NSW Health COVID Research Grants Program. The authors declare no other conflicts of interest. Public Statement for Collaboration on COVID Vaccine Development [Internet] Google Scholar.
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Although the prevailing vaccine resistance factors may vary widely depending on the geographic location, it is clear from the results reported in this review that global COVID vaccine acceptance is dependent on several common psychological, societal, and vaccine related factors.
Investigating the key influential factors of COVID vaccine hesitancy is a fundamental task that must be undertaken to ensure an effective COVID immunization plan worldwide.
A major challenge to the successful implementation of COVID vaccination programs is the unpredictable nature of the pandemic. The adequate manufacture of vaccines and proper distribution, vaccine safety confirmation, uncertainty regarding long-term efficacy, and the acquisition of optimal immunity are other challenges that must be overcome.
Public trust in health systems and in the vaccine information provided by government agencies regarding vaccine safety, efficacy, and side effects as well as the communicative roles of the media and public health experts will also be essential in improving vaccine confidence among rural and disadvantaged groups in low-income countries.
Useful communication channels and public trust in vaccinations will remove anti-vaccine beliefs, fear, anxiety, and rumors, thereby enabling rapid vaccine uptake.
Regular, follow-up and timely communication during the pandemic could be important drivers of vaccine confidence and in maintaining peak trust among population groups. Effective messages clarifying the safety, effectiveness, and side effects of COVID vaccines will increase public trust and promote vaccine confidence among less-educated and doubtful individuals in rural places.
In summary, the policy makers should focus on the effects of psychological, societal, and vaccine-related factors, which may be associated with the uptake intention and lead to vaccine hesitancy in a particular territory. To ensure the prompt achievement of herd immunity, the scientific community and health authorities should pay attention to and validate potential common and individual factors, and the potency with which they may influence COVID vaccine acceptance and hesitancy in a given geographical location.
All authors greatly acknowledge the graduate students of Jashore University of Science and Technology, who were sincerely assisted in literature search process. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field.
Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures. Abstract Background and aims Although vaccines are considered the most effective and fundamental therapeutic tools for consistently preventing the COVID disease, worldwide vaccine hesitancy has become a widespread public health issue for successful immunization.
Methods A systematic search of the peer-reviewed literature articles indexed in reputable databases, mainly Pub Med MEDLINE , Elsevier, Science Direct, and Scopus, was performed between21stJune and10th July Conclusions The prevailing factors responsible for COVID vaccine acceptance and hesitancy varied globally; however, the global COVID vaccine acceptance relies on several common factors related to psychological and, societal aspect, and the vaccine itself.
Funding: No external fund was available Competing interests: There is no competing interests to declare. Introduction The corona virus disease COVID has been an unprecedented disease burden around the world that has drastically impacted diverse areas of human societies, from public health systems to, education, economic growth, and personal well-being.
Materials and methods In this review the relevant factors and themes associated with the COVID vaccine acceptance or hesitancy concerns were examined. Download: PPT.
Fig 1. PRISMA-based flow diagram of study selection process for new systematic reviews. Table 1. Potential factors associated with COVID vaccine acceptance and hesitancy. Table 2. Distribution of potential factors across different continents.
Discussion Public acceptance of a new vaccine is not an old concept; rather, it is a dynamic phenomenon that is regulated sharply by psychological behavior, societal issues, and vaccine-derived factors related to a particular vaccine candidate.
Limitations The current study had some limitations; the foremost of which was article sample size. Implications The practical implications of this systematic review in terms of vaccination policy and future research include the following aspect: a This review acts as scientific evidence for initiating further predictive studies of COVID vaccine acceptance and for examining the association between hesitancy and explanatory variables.
Conclusions The reluctance towards and refusal of COVID vaccines is currently a global concern. Supporting information. S1 Checklist. PRISMA checklist. s DOCX. S1 Dataset. Acknowledgments All authors greatly acknowledge the graduate students of Jashore University of Science and Technology, who were sincerely assisted in literature search process.
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