--- title: Public Attitudes tags: live-v0.1.2, behaviour, attitudes, culture, social norms permalink: https://c19vax.scibeh.org/pages/publicattitudes --- {%hackmd 5iAEFZ5HRMGXP0SGHjFm-g %} {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} # Public attitudes towards COVID-19 vaccines [TOC] :::success Vaccination programmes are currently being rolled out in many countries. See the [Our World in Data tracker on our main page](https://c19vax.scibeh.org#Vaccination-roll-out-across-the-world) and our [Facts about COVID-19 vaccines page](https://c19vax.scibeh.org/pages/c19vaxfacts#How-many-people-have-received-the-COVID-19-vaccines) for other trackers for the latest data on **vaccine uptake** in various countries. ::: ## Vaccine hesitancy versus anti-vaccine People who are vaccine hesitant can be distinguished from those who are **anti-vaccine** (or 'anti-vaxx'), though both groups may have low levels of vaccine uptake. [Organised anti-vaccine groups tend to promote three key messages](https://science.sciencemag.org/content/371/6536/1289) - that COVID-19 is not dangerous, that COVID-19 vaccines are dangerous and that vaccine advocates cannot be trusted. :::success Our [dedicated page](https://hackmd.io/@scibehC19vax/misinfo_vaxdeniers) provides information about vaccine denial. ::: Those who are **vaccine hesitant** have a more [diverse set of beliefs](https://science.sciencemag.org/content/371/6536/1289) that may include safety fears as well as concerns stemming from previous individual or community experiences. However, they are not necessarily anti-vaccine and may still be convinced of a vaccine's safety, efficacy, and necessity ([Razai et al., 2021](https://www.bmj.com/content/372/bmj.n513)). ## Vaccine hesitancy versus vaccine apathy [Wood and Schulman (2021)](https://jamanetwork.com/journals/jama/fullarticle/2780792?resultClick=1) argue that a sizable proportion of people who report that they are unlikely to get a COVID-19 vaccine may be showing vaccine apathy rather than vaccine hesitancy. Vaccine apathy is characterised by a disinterest in vaccination where a person has spent little time considering it. Unlike vaccine hesitancy, vaccine apathy is associated with weak attitudes towards vaccination. It occurs across socioecomonic groups, for example where a person feels vaccination is not important for them or where they are overwhemlmed by other higher-priority daily stressors. ## Public attitudes towards the COVID-19 vaccine are dynamically changing Studies in several countries have shown that the vast majority of the public recognize the importance of the COVID-19 vaccine and are keen to be vaccinated. <span style="color:green"> A 2021 meta-analysis found that, globally, 66% of the population were willing to be vaccinated ([Nehal et al., 2021](https://www.mdpi.com/2076-393X/9/10/1071)). </span> However, in some countries, current levels of willingness to accept a COVID-19 vaccine may be insufficient for community immunity. [Uneven willingness](https://www.nytimes.com/2021/05/03/health/covid-herd-immunity-vaccine.html) within different parts of the same country could also make it difficult to reach the thresholds needed for herd immunity. In general, the proportion of people worldwide who are willing to take the vaccine (or, increasingly, have already done so) has been on the rise since vaccine roll-outs began. Many resources offer interactive public attitude trackers that depict this (one by [YouGov](https://yougov.co.uk/topics/international/articles-reports/2021/01/12/covid-19-willingness-be-vaccinated) is shown here). [](https://yougov.co.uk/topics/international/articles-reports/2021/01/12/covid-19-willingness-be-vaccinated) _{Source: [YouGov](https://yougov.co.uk/topics/international/articles-reports/2021/01/12/covid-19-willingness-be-vaccinated)_ &nbsp;&nbsp;Click on figure to access interactive tracker.} **Interactive resources:** * **Johns Hopkins University** has a tracker on [vaccine acceptance attitudes](https://public.tableau.com/views/JHUCOVID-19KAPVaccineAcceptance/VaccineAcceptanceStory?:language=en&:embed=y&:embed_code_version=3&:loadOrderID=0&:display_count=y&:origin=viz_share_link). It covers 67 countries over 14 waves (fortnightly) of survey data and visualises the likelihood that people in different regions will accept a vaccine. * [**Imperial College London's** tracker](https://ichpanalytics.imperialcollegehealthpartners.com/t/BDAU/views/YouGovICLCOVID-19BehaviourTracker/4Allbehaviorsovertime?:iid=1&:embed=y&:isGuestRedirectFromVizportal=y&:display_count=n&:origin=viz_share_link&:showVizHome=n) is based on a [survey](https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as) of 13,500 people across 15 countries conducted between November and February 2021. * [**Carnegie Mellon University** has a visualisation tool](https://delphi.cmu.edu/covidcast/?date=20210222&region=42003&sensor=fb-survey-smoothed_accept_covid_vaccine) based on a survey of Facebook users. * The [KFF COVID-19 Vaccine monitor](https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard/) tracks public attitudes and experiences with COVID-19 vaccinations in the USA. :::spoiler Expand this tab for more measures of public attitudes towards vaccines at different time points, including trends over time. * A [YouGov poll](https://today.yougov.com/topics/politics/articles-reports/2021/05/06/one-five-americans-continue-refuse-covid-19-vaccin) in the USA in May 2021 found that 18% of adults claimed they would not get vaccinated whilst 14% were unsure. * [**Imperial College London**]( https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as) conducted a survey of 13,500 people across 15 countries between November and February 2021. It reported that **58% of respondents were willing to get a COVID-19 vaccine if it were available.** Report [here](https://www.imperial.ac.uk/media/imperial-college/institute-of-global-health-innovation/EMBARGOED-0502.-Feb-21-GlobalVaccineInsights_ICL-YouGov-Covid-19-Behaviour-Tracker_20210301.pdf). * [A study of 46,000 people in low- and middle-income countries](https://www.newscientist.com/article/mg24933273-700-covid-19-vaccine-hesitancy-is-declining-as-global-roll-out-ramps-up/?utm_term=Autofeed&utm_campaign=echobox&utm_medium=social&utm_source=Twitter#Echobox=1616643040) found that 80% would have a COVID-19 vaccine when it became available. * In the US, Carnegie Mellon University surveyed Facebook users in January 2021, asking: _If a vaccine to prevent COVID-19 were offered to you today, would you definitely or probably choose to get vaccinated?_ **More than a quarter of the country’s population would not get vaccinated if it were available to them**. * [YouGov data](https://www.politico.eu/article/trust-oxford-astrazeneca-coronavirus-vaccine-wanes-europe-survey/) collected in March 2021 from across the EU and UK show a decline in trust in the AstraZeneca vaccine with more than half of those surveyed in France, Germany and Spain believing the vaccine to be unsafe. In [Germany](https://projekte.uni-erfurt.de/cosmo2020/web/summary/39/), people are less confident in the Oxford/Astra Zeneca vaccine than COVID-19 vaccines in general, with only 39% reporting full confidence in its safety. (Only around a quarter of those polled in the UK believed the vaccine to be unsafe though this figure was still higher compared with the previous month.) * The [KFF COVID-19 Vaccine monitor](https://www.kff.org/coronavirus-covid-19/dashboard/kff-covid-19-vaccine-monitor-dashboard/) reported in May 2021 that although intentions to vaccinate had increased over the previous month, [these were now reaching a plataeu](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/). * In the USA, 30% of **parents of children** aged 12-15 say they will get their child vaccinated as soon as possible, 25% say they will wait, 18% say they will get their child vaccinated if their school requires it, and nearly 25% say they will definitely not get their child vaccinated ([KFF Monitor](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/). * A systematic review in December 2020 of surveys focused on the general public in 33 countries explored **acceptance for COVID-19 vaccines across the world** (which included studies focusing on vaccine hesitancy, vaccine acceptance, and intentions to vaccinate) found varying rates of acceptance across countries ([Sallam, 2021])(https://www.mdpi.com/2076-393X/9/2/160)). The highest acceptance rates for COVID-19 vaccines in this period were reported in Ecuador (97.0%), Malaysia (94.3%), Indonesia (93.3%) and China (91.3%). The lowest COVID-19 vaccine acceptance rates were reported in Kuwait (23.6%), Jordan (28.4%), Italy (53.7%), Russia (54.9%), Poland(56.3%), the US (56.9%), and France (58.9%). <h3>Changes in attitudes to COVID-19 vaccines over time</h3> * <span style = 'color:green'> In the UK, the [Vaccine Confidence Tracker](https://orb-international.com/2021/06/04/vaccine-confidence-tracker-uk/) found that the proportion of people reporting they would definitely take the vaccine increased from 49% in October 2020 to 63% in April 2021.</span> * **[Imperial College London’s survey]( https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as)** found a [general increase in willingness to get a vaccine since November 2020, except in Australia, Japan, South Korea, and Singapore]( https://ichpanalytics.imperialcollegehealthpartners.com/t/BDAU/views/YouGovICLCOVID-19BehaviourTracker/4Allbehaviorsovertime?:iid=1&:embed=y&:isGuestRedirectFromVizportal=y&:display_count=n&:showVizHome=n&:origin=viz_share_link). * **[International data from January 2021 collected by YouGov]( https://yougov.co.uk/topics/international/articles-reports/2021/01/22/europe-becoming-more-pro-vaccine)**, an international research data and analytics group, showed that vaccine acceptance has been increasing in Europe, but decreasing in Asia.  _{_Source: [YouGov]( https://yougov.co.uk/topics/international/articles-reports/2021/01/22/europe-becoming-more-pro-vaccine)._} * A [Kantar survey in January 2021](https://www.theguardian.com/world/2021/feb/04/covid-vaccine-refuse-france-germany-us-quarter?CMP=Share_iOSApp_Other) reported vaccine hesitancy rates of around 25% in France, the US, and Germany, but less hesitancy in Italy (12%), the UK (14%), and the Netherlands (17%). * [Sallam (2021)](https://www.mdpi.com/2076-393X/9/2/160) found that in countries with multiple surveys between March and October, fluctuations in vaccine acceptance rates were observed: * In the UK, the vaccine acceptance rate was 79.0% in April, 86.0% in May, 71.5% in June, 64.0% in July and 71.7% in September/October. * In France, the vaccine acceptance rate ranged from 62.0% to 77.1% in March/April and was 58.9% in June. * In Italy, the vaccine acceptance rate was 77.3% in April, 70.8% in June, and fell to 53.7% in September. * In the US, it was 56.9% in April, ranged from 67.0% to 75.0% in May, and reached 75.4% in June. * **[Pew Research Center](https://www.pewresearch.org/science/2020/12/03/intent-to-get-a-covid-19-vaccine-rises-to-60-as-confidence-in-research-and-development-process-increases/)** surveyed 12,648 U.S. adults in November 2020. Overall, 60% of Americans reported that they would definitely or probably get a COVID-19 vaccine; about 39% reported they definitely or probably would not get the vaccine. This was a slight improvement from [earlier Pew reports](https://www.pewresearch.org/science/2020/09/17/u-s-public-now-divided-over-whether-to-get-covid-19-vaccine/) showing about 50% of Americans reporting definitely or probably get a COVID-19 vaccine. * **[Daly & Robinson, 2021](https://psyarxiv.com/r28yh/)** analysed survey data in the US from April-October 2020, finding that willingness to be vaccinated declined from 71% to 53.6% in this time. * **[The COVID-19 Consortium for Understanding the Public’s Policy Preferences Across States](https://covidstates.org/reports)** conducted several surveys. A survey of 19,058 individuals across all 50 states plus the District of Columbia in [July 2020](https://www.kateto.net/covid19/COVID19%20CONSORTIUM%20REPORT%209%20VACCINATE%20AUGUST%202020.pdf) showed that 66% of adults would be somewhat or extremely likely to vaccinate themselves; 66% would be somewhat or extremely likely to vaccinate their children. * **[Lazarus et al. (2020)](https://www.nature.com/articles/s41591-020-1124-9)** surveyed 13,426 randomly selected individuals across 19 countries in June. 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. Acceptance rates were also varied across countries. * **[Johns Hopkins Center for Communication Programs’ KAP COVID](https://ccp.jhu.edu/kap-covid/kap-covid-trend-analysis-for-23-countries/)** reported data from a global survey of knowledge, attitudes and practices around COVID-19 between July and December 2020. The data were collected from more than 1.2 million people in 67 countries who chose to participate in a survey promoted on Facebook. One report using data from 23 countries showed that **COVID-19 vaccine acceptance was declining in many countries.** * According to a **[Kantar study](https://www.kantardeutschland.de/zurueckhaltung-gegenuber-covid-19-impfstoff/)** in November 2020 with 1,000 respondents each in the U.S., U.K., France, Germany and Italy showed that reluctance to vaccinate has increased between June and November in all countries surveyed. * A **preprint from December 2020** reporting data on factors influencing willingness to receive the COVID-19 vaccine ([Lindholt et al., 2020]( https://psyarxiv.com/8kn5f)) in 8 Western countries found large variations in vaccine willingness ranging from 38% in Hungary to 79% in Denmark. * **[Murphy et al. (2021)]( https://www.nature.com/articles/s41467-020-20226-9)** surveyed nationally representative adult samples in the UK and Ireland, finding vaccine acceptance rates of 69% in the UK sample and 65% in the Irish sample, with Northern Ireland (one of the four UK nations) showing the lowest acceptance rates of 51%. Longitudinal tracking of these data showed increased resistance towards vaccination during the first wave of the pandemic from March 2020 to August 2020; resistance increased from 9.5% to 18.1% in the Republic of Ireland and from 6.2% to 10% in the UK ([Hyland et al., 2021](https://psyarxiv.com/ry6n4/)). * **A preprint by [Rebitschek et al., 2021](https://psyarxiv.com/f4nqt/)** tracked vaccination intentions in Germany from November 2020 to February 2021. Those reporting they would probably or definitely have the vaccination incraesed from 54% to 65%. * **[Dodd et al. (2021)]( https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30926-9/fulltext)** reported data showing that COVID-19 vaccine acceptance varied in the March-July 2020 time period, with acceptance rates of 86% in Australia (in April; this increased to 90% in July), 58% in the USA, 64% in the UK, and 74% in both New Zealand and France. * **Surveys that included parents and guardians** **showed mostly positive attitudes towards the vaccine**. A recent survey in the UK ([Bell et al., 2020](https://www.sciencedirect.com/science/article/pii/S0264410X20313219?via%3Dihub)) that included 1252 parents and guardians showed that most parents are likely to accept the vaccine for themselves (Definitely 55.8%; Unsure but leaning towards yes 34.3%) and their child/children (Definitely 48.2%; Unsure but leaning towards yes 40.9%). In Australia, the acceptance rate among parents and guardians was 77.3% ([Rhodes et al., 2020](https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30724-6/fulltext)) and in China 72.6% ([Zhang et al., 2020](https://pediatrics.jmir.org/2020/2/e24827/)). * A **December 2020 survey of 16,158 healthcare workers in the US** (reported in a preprint; [Meyer et al., 2020](https://psyarxiv.com/ge6uh/)) highlighted that vaccine hesitancy also exists among healthcare workers: 16.4% reported they would not receive the vaccine if offered, and 28.5% were undecided. ::: <br> Some changes to attitudes towards vaccines can could be due to [external events](https://science.sciencemag.org/content/371/6536/1289) such as increasing infection rates, lockdowns and reported vaccine safety risks. For example: * **[In the UK](https://blogs.bmj.com/bmj/2021/04/16/how-will-the-uks-decision-to-offer-an-alternative-to-the-oxford-astrazeneca-covid-19-vaccine-for-under-30s-following-safety-signals-impact-vaccine-confidence/?utm_source=twitter&utm_medium=social&utm_term=hootsuite&utm_content=sme&utm_campaign=usage)**, the recommendataion that those under the age of 30 should be offered an alternative vaccine to the Oxford/AstraZeneca vaccine was associated with a drop in confidence in its safety, particularly among women (75% to 64%) compared to men (78% to 75%). * **[In the USA](https://www.ipsos.com/en-us/news-polls/axios-ipsos-coronavirus-index)**, intentions to get vaccinated remained stable between January and April of 2021 despite the pause in the roll-out of the Johnson & Johnson vaccine over safety concerns. Overall, 91% of those polled were aware of the pause and 88% of these believed the pause was the right course of action. However, the [KFF poll](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/) showed an increase in concerns over potential side effects, especially among women and found that less than half of the public expressed confidence in the Johnson & Johnson vaccine. Hispanic women were particularly likely to report that side-effect concerns had caused them to rethink their vaccination decision. ### Measures of COVID-19 vaccination acceptance The Motors of COVID-19 Vaccination Acceptance Scale (MoVac-COVID19S) is a 9- or 12-item scale that has been developed to measure acceptance of COVID-19 vaccination ([Chen et al., 2021](https://psyarxiv.com/abfp6/)). ## What influences public attitudes towards COVID-19 vaccines? There are various factors that influence people’s attitude towards vaccines, their willingness to accept a vaccine, and intention to get vaccinated. <span style = 'color:green'> A 2021 meta-analysis found that age, gender and education, as well as attitudes and perceptions were all significantly associated with vaccine acceptance or refusal ([Nehal et al., 2021](https://www.mdpi.com/2076-393X/9/10/1071)). An analysis by the World Economic Forum ([WEF, 2021](https://www.weforum.org/agenda/2021/02/disinformation-covid19-vaccine-attitudes/)) of the language used by online communities discussing COVID-19 related topics found that people resistant to vaccines used more emotional language around vaccine-related topics---notably, reflecting high levels of fear. However, they were still open to new ideas; thus **acknowledging people's reasons for hesitancy and addressing their fears is critical for engaging in discussions about COVID-19 vaccines** ([Schoch-Spana et al., 2020](https://www.sciencedirect.com/science/article/pii/S0264410X20313682?via%3Dihub)). As noted above, vaccine hesitancy should not be equated with being 'anti-vax', as people who are hesitant can still be convinced of the vaccines’ safety, efficacy, and necessity ([Razai et al., 2021](https://www.bmj.com/content/372/bmj.n513)). Many of the factors determining attitudes to the COVID-19 vaccine may be interlinked. For instance, sociodemographic factors that predict willingness to be vaccinated may be related to [specific concerns of a particular religious group](https://c19vax.scibeh.org/pages/publicattitudes#Religious-beliefs-and-attitudes-towards-COVID-19-vaccines), or historical precedents in how certain groups in the population have been mistreated when it comes to medical treatments and vaccines, resulting in lower levels of trust. For example, racial disparities in flu immunisation were previously found to be related to trust in institutions ([Jamison et al., 2019]( https://www.sciencedirect.com/science/article/abs/pii/S0277953618306932?via%3Dihub)). African countries that had been exposed to forced medical campaigns (including injections that produced severe side effects) were less trusting of medical treatments for many years following ([Lowes & Montero, 2021]( https://www.aeaweb.org/articles?id=10.1257/aer.20180284&from=f)). ### Perceived health risks * **Concerns over safety** are expressed by some who are vaccine hesitant ([YouGov](https://www.theguardian.com/society/2021/mar/07/10-of-uks-people-of-colour-would-refuse-covid-vaccine-yougov-data?CMP=Share_iOSApp_Other); [KFF, 2021](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/); [Larson et al., 2021](https://orb-international.com/wp-content/uploads/2021/06/The-Vaccine-Confidence-Tracker-UK.pdf)). This was especially the case for the Oxford/AstraZeneca vaccine, for example in Germany, the [COSMOS COVID-19 Snapshot Monitoring project](https://projekte.uni-erfurt.de/cosmo2020/web/summary/39/) found that respondents displayed great uncertainty about the probability of experiencing serious side effects, with 42% considering it a high probability. * **Worries about side effects**, especially long term health effects, are most commonly associated with hesitancy about vaccines ([Dodd et al. 2021]( https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30926-9/fulltext), [Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext), [Razai et al., 2021](https://www.bmj.com/content/372/bmj.n513), [ONS, 2021](https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandvaccinehesitancygreatbritain/13januaryto7february2021#reasons-for-reporting-negative-sentiment-towards-the-vaccine)). * These reasons are consistent across many population groups ([ONS, 2021](https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandvaccinehesitancygreatbritain/13januaryto7february2021#reasons-for-reporting-negative-sentiment-towards-the-vaccine)), and were also observed among healthcare workers ([Meyer et al., 2020](https://psyarxiv.com/ge6uh/)) and students ([Varol et al., 2021 preprint](https://psyarxiv.com/u46bm/)). * Other health-related worries include effects on existing health conditions and pregnancy ([ONS, 2021](https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandwellbeing/bulletins/coronavirusandvaccinehesitancygreatbritain/13januaryto7february2021#reasons-for-reporting-negative-sentiment-towards-the-vaccine)). * People were more hesitant about a vaccine reporting a side effect rate of 1 in 10,000, compared to one reporting a side effect rate of 1 in 100,000 ([Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext)). * These worries sometimes lead individuals to want to wait and see how it went for others first ([Meyer et al., 2020](https://psyarxiv.com/ge6uh/)). (Our page on [freeriding](https://c19vax.scibeh.org/pages/freeriding) explains why this is not a good strategy for COVID-19.) * People will likely be resistant to a vaccine if fear of the vaccine (namely potential unknown side effects) outweighs fear about the virus ([WEF, 2021](https://www.weforum.org/agenda/2021/02/disinformation-covid19-vaccine-attitudes/)). (See also our page on [COVID-19 risk perceptions](https://c19vax.scibeh.org/pages/riskperception).) * In [Imperial College London’s survey]( https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as), 47% of respondents reported [worries about vaccine side effects]( https://ichpanalytics.imperialcollegehealthpartners.com/t/BDAU/views/YouGovICLCOVID-19BehaviourTracker/4Allbehaviorsovertime?:iid=1&:embed=y&:isGuestRedirectFromVizportal=y&:display_count=n&:showVizHome=n&:origin=viz_share_link) (see our dedicated page for information about [side effects of the COVID-19 vaccine](https://c19vax.scibeh.org/pages/sideeffects)). Worries about side effects increased in Singapore, but stayed constant or decreased in other countries surveyed. * Concerns over a **lack of information** have been expressed by some who are vaccine hesitant ([Rebitschek et al., 2020, preprint](https://psyarxiv.com/f4nqt/); [YouGov](https://www.theguardian.com/society/2021/mar/07/10-of-uks-people-of-colour-would-refuse-covid-vaccine-yougov-data?CMP=Share_iOSApp_Other); [KFF, 2021](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/)). * Research by [Rebitschek et al., 2021](https://psyarxiv.com/f4nqt/) (preprint) suggests that simple fact boxes summarising the benefits and risks of vaccination can lead to more accurate risk perception as well as promote more positive attitudes towards vaccination among those who are vaccine hesitant. :::success Our [dedicated page](https://c19vax.scibeh.org/pages/sideeffects) provides information about potential side effects of the COVID-19 vaccine. ::: ### Perceived benefits * **Protecting oneself and one’s family** is a common motivator to get vaccinated ([Dodd et al., 2021]( https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30926-9/fulltext)). * Explaining the benefits of herd immunity to people reduced hesitancy about getting a vaccine ([Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext)). * However, **mistrust in the benefits** of vaccination lower willingness to be vaccinated ([Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext), [Hornik et al., 2020](https://psyarxiv.com/t3kyx/)). * People who were **less concerned about COVID-19** showed less willingness---and in some cases, outright refusal---to get a vaccine ([Lindholdt et al., 2020](https://psyarxiv.com/8kn5f), [Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext), [Lindholt et al., 2020](https://psyarxiv.com/8kn5f)). * In [Imperial College London’s survey]( https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as), trust in the vaccine’s benefits was strong or moderate for 66% of respondents. Trust was lowest in Japan (less than 50%) and highest in Italy (82%). ### Previous experience with other vaccines and exposure to diseases * Those who had **previously been vaccinated** showed more willingness to receive the COVID-19 vaccine than those who had not ([Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext), [Garcia and Cerda, 2020]( https://www.sciencedirect.com/science/article/pii/S0264410X20313207?via%3Dihub), [Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext)). * Lower willingness to be vaccinated is associated with **poor adherence to COVID-19 government guidelines** ([Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext)). * People with **experience of COVID-19** (e.g., had symptoms or knew someone who had) were more willing to receive a COVID-19 vaccine ([Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext)). ### Encouragement from others * **Endorsements from public figures** may also help to increase confidence in a vaccine, as suggested in a preprint that studied the politicisation of vaccines and how it affects vaccine hesitancy ([Bokemper et al., 2020]( https://www.researchsquare.com/article/rs-95823/v1)). * Among healthcare workers, endorsement from regulatory authorities improved intentions to vaccinate—with 79% of respondents willing to receive a vaccine after endorsement from the US Food and Drug Administration (compared to 55% on average) ([Meyer et al., 2020](https://psyarxiv.com/ge6uh/)). * If vaccination is seen as a **social norm**, it may increase willingness to receive a vaccine ([Moehring et al., 2021 preprint](https://psyarxiv.com/srv6t/)). * **Recommendations from family and friends** may outweigh recommendations from government officials or other spokespeople ([Schoch-Spana et al., 2020](https://www.sciencedirect.com/science/article/pii/S0264410X20313682?via%3Dihub))---especially for those who are worried and want to 'wait and see' ([KFF Vaccine Monitor](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-wait-and-see/)). Peer networks may also be very influential among young adults; those who say at least half their close friends are vaccinated are more enthusiastic about getting vaccinated compared to those who report that just a few or none of their friends have been vaccinated ([KFF Vaccine Monitor](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/). * In [Imperial College London’s survey]( https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as), peer support (from family and friends) to be vaccinated was reported for 60% of respondents, and in most countries (except France and Japan) over 50% of respondents felt [their family and friends would like them to get a vaccine]( https://ichpanalytics.imperialcollegehealthpartners.com/t/BDAU/views/YouGovICLCOVID-19BehaviourTracker/4Allbehaviorsovertime?:iid=1&:embed=y&:isGuestRedirectFromVizportal=y&:display_count=n&:showVizHome=n&:origin=viz_share_link). * In Germany, the [COSMOS monitoring project](https://projekte.uni-erfurt.de/cosmo2020/web/) found that willingness to vaccinate and confidence in vaccine safety was higher if it was **recommended by the family doctor** (particularly for the Oxford/AstraZeneca vaccine). In contrast, if family doctors were doubtful, this lowered patients' willingness to vaccinate. ### Trust in scientists, healthcare systems, and the government * People are more likely to accept a vaccine when they **trust in scientists** ([Murphy et al., 2021](https://www.nature.com/articles/s41467-020-20226-9), [Kossowska et al., 2021]( https://psyarxiv.com/hcbmw/)). (See also our page on [trust in scientists](https://c19vax.scibeh.org/pages/trust_scientists)). * Greater **trust in healthcare systems and governments/the state** also increases vaccine acceptance ([Murphy et al., 2021](https://www.nature.com/articles/s41467-020-20226-9), [Hornik et al., 2020](https://psyarxiv.com/t3kyx/), [Lindholt et al., 2020](https://psyarxiv.com/8kn5f), [Kossowska et al., 2021](https://psyarxiv.com/hcbmw/); [Varol et al., 2021 preprint](https://psyarxiv.com/u46bm/)). * Often this is related to [previous experiences with the healthcare system and/or government](https://www.nature.com/articles/d41586-021-00769-7?utm_source=twt_nnc&utm_medium=social&utm_campaign=naturenews), and how it has historically treated certain groups of people: when people [**do not believe governments are acting in their interest**](https://www.washingtonpost.com/outlook/nursing-home-skip-vaccine/2021/02/12/4d31d17a-6bfa-11eb-9f80-3d7646ce1bc0_story.html), they are likely to be sceptical when they are offered a vaccine. * Relatedly, a study in France found that people's attitudes were more positive for **vaccines manufactured in Europe** vs. China ([Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext)). * A pre-print reporting on a UK study suggested that COVID-19 vaccine hesitancy was particularly low among those who expressed both low trust in political institutions and low concern over the consequences of the pandemic ([Lalot et al., 2021](https://psyarxiv.com/y9amb/)). ### Sociodemographic factors * **Income:** groups earning < £16,000, a year were more likely to be uncertain about or to refuse a vaccine ([Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext); [Daly & Robinson, 2021](https://psyarxiv.com/r28yh/)). In a French study, people who were not working were more hesitant about a vaccine than people who were working ([Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext); [Daly & Robinson, 2021](https://psyarxiv.com/r28yh/)). * **Education:** People with lower **education levels** were more likely to be hesitant or outright refuse a vaccine ([Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext)). * **Gender**: Females were more likely than males to be uncertain about or to refuse a vaccine ([Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext), [Garcia & Cerda, 2020;]( https://www.sciencedirect.com/science/article/pii/S0264410X20313207?via%3Dihub) [Schwarzinger et al., 2021](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext); [Daly & Robinson, 2021](https://psyarxiv.com/r28yh/); [Nehal et al., 2021](https://www.mdpi.com/2076-393X/9/10/1071)). <span style = 'color:green'>This may be related to unfounded concerns about effects of vaccination on fertility ([Nehal et al., 2021](https://www.mdpi.com/2076-393X/9/10/1071)). </span> * **Age**: [Daly & Robinson, 2021](https://psyarxiv.com/r28yh/) found that **younger adults** were less willing than older adults to get a vaccine, while [Schwarzinger et al. (2021)](https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00012-8/fulltext) found an inverted U-shape relationship between **age** and vaccine hesitancy and refusal, with older and younger age groups both more hesistant/resistant. In the USA, the [KFF poll](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/) also found higher levels of hesitancy among younger adults. * [Murphy et al. (2021)](https://www.nature.com/articles/s41467-020-20226-9) distinguished between **vaccine hesitancy** and **vaccine resistance**. They found that vaccine hesitancy tended to be found among older age categories (≥ 65 years) while vaccine resistance tended to be found among younger age groups. * Those **living with children** were more likely to be uncertain about/refuse a vaccine ([Paul et al., 2020]( https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(20)30012-0/fulltext)). * Those from **ethnic minority communities** show less willingness to be vaccinated ([Daly & Robinson, 2021](https://psyarxiv.com/r28yh/); [YouGov](https://www.theguardian.com/society/2021/mar/07/10-of-uks-people-of-colour-would-refuse-covid-vaccine-yougov-data?CMP=Share_iOSApp_Other); [KFF, 2021](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/); this is also seen in [vaccination uptake rates]() among these groups, and could be linked to factors such as [discriminatory practices in healthcare](https://c19vax.scibeh.org/pages/vaxculture#Discriminatory-practices-in-healthcare) ([Khan et al., 2021)](https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00938-7/fulltext?utm_campaign=comment21&utm_content=163297654&utm_medium=social&utm_source=twitter&hss_channel=tw-27013292) or to a belief that the vaccine has not been sufficiently tested among ethnic minority populations ([Lacobucci, 2021](https://bmj.com/content/372/bmj.n460)). * **Religious groups** may also be less likely to accept vaccines (see our section below on [religious beliefs]( https://c19vax.scibeh.org/pages/publicattitudes#Religious-beliefs-and-attitudes-towards-COVID-19-vaccines)) ([Murphy et al., 2021](https://www.nature.com/articles/s41467-020-20226-9)). Though there does not seem to be an association between religion and vaccine hesitancy in the UK ([Larson et al., 2021](https://orb-international.com/wp-content/uploads/2021/06/The-Vaccine-Confidence-Tracker-UK.pdf)). * A **[podcast by the Guardian newspaper]( https://www.theguardian.com/news/audio/2021/jan/26/vaccine-hesitancy-what-is-behind-the-fears-circulating-in-bame-communities-podcast)** discusses why people from ethnic minority groups may experience more hesitancy towards the COVID-19 vaccine than people in majority (e.g., White) groups. * **Political affiliation**: [Survey data from the USA](https://www.axios.com/republicans-coronavirus-vaccine-hesitancy-023bf32f-3d68-4206-b906-4f701b87c39f.html) in February 2021 showed that 56% of White Republicans expressed vaccine hesitancy compared to 7% of White Democrats; hesitancy among White Republicans was higher than hesitancy among Blacks (31%) or Hispanics (30%). [Polls conducted by KFF](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/) and by [YouGov](https://today.yougov.com/topics/politics/articles-reports/2021/05/06/one-five-americans-continue-refuse-covid-19-vaccin) have shown similar differences in attitudes between Republicans and Democrats.In the UK there is no significant association between vaccine hesitancy political affiliation ([Larson et al., 2021](https://orb-international.com/wp-content/uploads/2021/06/The-Vaccine-Confidence-Tracker-UK.pdf)). :::success Our page on **[cultural differences in vaccine accceptance](https://c19vax.scibeh.org/pages/vaxculture)** covers some of the reasons why certain communities may be hesitant about a vaccine and how to engage with them respectfully. ::: ### Psychological characteristics * A [survey of 17,907 US adults](https://precisionforcovid.org/vaccinebarriers.html) grouped people into one of five types according to their **barriers and beliefs**; Enthusiasts (those wanting to get the vaccine as soon as possible), Watchful (people who need to see friends and peers having positive experiences before they will commit), Cost-Anxious (those worried about time and cost), System Distrusters (those who believe people of their own race are not treated fairly by the system) and COVID Skeptics (people who believe in COVID conspiracy theories). 39% of US adults were described as Enthusiasts, 20% as Watchful, 14% as Cost-Anxious, 9% as Distrusters and 17% as COVID skeptics, with proportions varying from state to state. * **Traits** like altruism, social dominance, cognitive reflection, and internal locus of control are associated with acceptance for COVID-19 vaccines ([Murphy et al., 2021](https://www.nature.com/articles/s41467-020-20226-9)). * People with negative **attitudes towards others in society** (e.g., migrants) are also less willing to be vaccinated ([Murphy et al., 2021](https://www.nature.com/articles/s41467-020-20226-9)). * **Conspiracy beliefs** can reduce willingness to get vaccinated ([Lindholdt et al., 2020](https://psyarxiv.com/8kn5f)). * A preference for 'natural immunnity' may also be associated with vaccine hesitancy ([Williams et al., 2021 preprint](https://psyarxiv.com/h87s3/)). * A [survey of over 21,733 US adults](https://osf.io/cgfzt/) in April 2021 found that people with depression were less likely to be vaccinated but also less likely to be vaccine resistant. * Research carried out in the USA with 846 unvaccinated adults found that greater perceived moral reproach was associated with stronger vaccine hesitancy ([Rosenfeld & Tomiyama, 2021 preprint](https://psyarxiv.com/ycbrd/)). ### Misinformation about COVID-19 vaccines :::success See our [**myths about COVID-19 vaccines**](https://c19vax.scibeh.org/pages/misinfo_myths) for common myths and how to debunk them. ::: * **Online misinformation** around COVID-19 vaccines can affect the intent to vaccinate to protect oneself or others, especially when the misinformation sounds scientific ([Loomba et al., 2021](https://www.nature.com/articles/s41562-021-01056-1)). * [Singh et al. (2021 preprint)](https://arxiv.org/abs/2104.10864) surveyed over 18,400 individuals from 40 countries and found a strong association between perceived **believability of misinformation** and vaccination hesitancy. * Some sociodemographic groups are differentially impacted by exposure to misinformation ([Loomba et al., 2021](https://www.nature.com/articles/s41562-021-01056-1)). [Singh et al. (2021 preprint)](https://arxiv.org/abs/2104.10864) also found that poorer regions of the world are more susceptible to encountering and believing COVID-19 misinformation. * In the past, anti-vaccination groups have also [targeted minority communities](https://www.statnews.com/2017/05/08/measles-vaccines-somali/) and other [individuals](https://www.texasmonthly.com/news-politics/anti-vax-influencer-covid-19-vaccine-hesitancy/?fbclid=IwAR0FT39Q7XGKhKWOvFPYUuJhSP9s0cPl3dVpqW3a3D8NUWzBCOAKlQVSN6Q) **with misinformation** about other types of vaccines. * [In Malawi,](https://www.theguardian.com/global-development/2021/apr/16/malawi-to-bin-16000-astrazeneca-doses-amid-fears-of-rise-in-vaccine-hesitancy?CMP=Share_iOSApp_Other) false rumours that people would receive an expired vaccine reportedly reduced uptake. Indiana University's Observatory on Social Media has a **[new tool](https://osome.iu.edu/tools/covaxxy)** that can be used to visualise relationships between COVID-19 vaccine hesitancy and online (mis)information. ## Logistical factors * **Availability** of an effective vaccine and **access to vaccines** can affect decisions to get vaccinated ([Garcia and Cerda, 2020](https://www.sciencedirect.com/science/article/pii/S0264410X20313207?via%3Dihub); [KFF, 2021](https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-april-2021/); [Surgo, 2021](https://static1.squarespace.com/static/5f7671d12c27e40b67ce4400/t/60a3d8ab329fba4e0e46d229/1621350573725/FINAL+for+posting-Surgo+Ventures+Facebook+Survey+Press+Release+%281%29.pdf)). * Making vaccines available in **safe, familiar, and convenient places**, and **not imposing a cost** on people to receive it, are critical factors in encouraging people to get vaccinated ([Schoch-Spana et al., 2020](https://www.sciencedirect.com/science/article/pii/S0264410X20313682?via%3Dihub); [Surgo, 2021](https://static1.squarespace.com/static/5f7671d12c27e40b67ce4400/t/60a3d8ab329fba4e0e46d229/1621350573725/FINAL+for+posting-Surgo+Ventures+Facebook+Survey+Press+Release+%281%29.pdf)). * Having **time** to get vaccinated has also been reported as a barrier ([Surgo, 2021](https://static1.squarespace.com/static/5f7671d12c27e40b67ce4400/t/60a3d8ab329fba4e0e46d229/1621350573725/FINAL+for+posting-Surgo+Ventures+Facebook+Survey+Press+Release+%281%29.pdf)). * [A report from the UK](https://www.theguardian.com/politics/2021/mar/22/tuc-says-covid-vaccine-efforts-hindered-by-lack-of-paid-time-off-for-jab?CMP=Share_iOSApp_Other) suggests some private sector employers may not be giving their staff **paid time off work** to get vaccinated. * A [survey of 15 countries]( https://imperialcollegelondon.app.box.com/s/j83207ufjosqr1vn4kz5qpcosmhsv7as) between November 2020 and January 2021 showed that **accessibility** was an issue, as many respondents reported difficulties in obtaining a COVID-19 vaccine, especially in South Korea and Japan. * Research carried out with German participants suggested that financial incentives could increase vaccination intentions, though large amounts of money would be required to bring about significant change ([Sprengholz et al., 2021 preprint](https://psyarxiv.com/hfm43/)). ## Attitudes towards vaccine allocation Vaccines for COVID-19 are still scarce, so most countries have prioritisation strategies for offering people vaccines. However, **public attitudes about who should be offered a vaccine may not match government strategies**. * A study (in preprint) reported misalignment between government strategies and public preferences for vaccine allocation in Germany: while the government had prioritised vulnerable people (being of high age or accommodated in nursing homes for the elderly), participants deprioritised these groups and preferred exclusive allocation of the first available vaccines to medical staff and personnel caring for the elderly ([Sprengholz et al., 2021](https://psyarxiv.com/6na7t/)). * In [Japan](https://www.theguardian.com/sport/2021/apr/08/japan-considering-vaccinating-tokyo-olympic-athletes-before-rest-of-population?CMP=Share_iOSApp_Other) the government has been criticised for reportedly considering vaccinating Olympic atheletes before completing roll out to other groups, such as the elderly. [Shimizu (2021)](https://www.bmj.com/content/373/bmj.n962) argues that a scheme to vaccinate athletes could promote vaccine nationalism and undermine solidarity in global vaccinational efforts. ## Religious beliefs and attitudes towards COVID-19 vaccines Members of religious communities may be hesitant towards vaccines because they have concerns about whether the vaccines are compatible with their religious beliefs, for example dietary restrictions (e.g., whether a vaccine contains pork products). They may also be susceptible to misinformation that taps on these concerns ([Ahmed et al., 2017]( https://pubmed.ncbi.nlm.nih.gov/28988775/)). It is important to acknowledge religious concerns and point to guidance from faith leaders. * Islamic associations have released consensus statements recommending that **the vaccine is permissible for Muslim use**: British Islamic Medical Association statement on [Pfizer/BioNTech vaccine](https://britishima.org/pfizer-biontech-covid19-vaccine/) and [Oxford-AstraZeneca vaccine]( https://britishima.org/covid19-vaccine-az/); [Islamic Religious Council of Singapore’s religious position COVID-19 vaccines]( https://www.muis.gov.sg/Media/Media-Releases/13-Dec-20-Religious-Position-on-COVID-19-Vaccine). * An [open letter from **Jewish medical doctors in the UK**]( https://docs.google.com/document/d/1ldvpDSrzJommeevkjt6ynFaEG0FkIdlSGfRlFz9Smm8/edit) explains common concerns about the Pfizer/BioNTech vaccine. * The Holy See Press Office issued [guidance that it is **morally acceptable to receive COVID-19 vaccines**]( https://press.vatican.va/content/salastampa/en/bollettino/pubblico/2020/12/21/201221c.html). * **[Immunize.org](https://www.immunize.org/talking-about-vaccines/religious-concerns.asp)** provides resources for people with religious concerns about vaccinations. :::success Would you like to find out more about public attitudes towards COVID-19 vaccines? We created a search query specifically for this page, which links you to other interesting resources like Twitter threads, blogposts, websites, videos and more. Check out the search query that we generated specifically for this page [here](https://hypothes.is/groups/Jk8bYJdN/behsci?q=hesitancy). Would you like to know more about how we generated the search queries and how our underlying knowledge base works? Click [here](https://hackmd.io/B3R70tuNTiGy6wi9HObuSQ) to learn more. ::: ---- _{**Page manager:** Katy Tapper <br>**Expert reviewers:** Panayiota Kendeou, Stephan Lewandowsky <br>**Other contributors:** Dawn Holford} {%hackmd GHtBRFZdTV-X1g8ex-NMQg %} {%hackmd TLvrFXK3QuCTATgnMJ2rng %} {%hackmd oTcI4lFnS12N2biKAaBP6w %}