In February 2021, as the first COVID-19 vaccinations were rolled out to healthcare workers in South Africa, there was a renewed sense of hope in the fight against SARS-CoV-2. At the time there were concerns around vaccine procurement and inequity in vaccine distribution. But in the latter part of the year the major obstacle was a slow uptake of the vaccine among the South African public.

Just over 17 million South African adults are fully vaccinated, out of an adult population of about 40 million.

Meanwhile, the emergence of new variants and waves of COVID-19 pose a massive cost to society in terms of lives lost, resources occupied and economic diminution.

The emergence of new variants of concern may lead to a perception that vaccines are futile as the virus continues to mutate. But the best chance of decreasing mutations and preserving vaccine efficacy is to increase the proportion of the population who are vaccinated.

Vaccines are our best chance of overcoming this pandemic.

Efforts to improve vaccine uptake must be tailored to the needs and concerns of the individuals and families who make up society, rather than just mass-campaigning to the public as a whole.

In every country there is a spectrum of stances on vaccination. There are the so-called “anti-vaxxers” who actively campaign against vaccines. There are vaccine refusers who have decided they will not take the vaccine and are unlikely to be convinced otherwise. And then there are those who have vaccine hesitancy – they do not refuse vaccination altogether, but have reservations, unanswered questions and fears around the COVID-19 vaccines.

This latter group is the most likely to be open to honest, transparent and good-quality data sharing.

South Africa’s vaccination uptake shows that vaccine hesitancy is a major problem. The country has enough vaccine supply for the entire adult population. As we race against the development of more resistant and transmissible variants it is important to consider what can be done to address such hesitancy.

Barriers to vaccination

Vaccines are one of the greatest accomplishments in the history of public health. They have indisputably contributed to a decline in sickness and death from numerous infectious diseases. But their success is completely dependent on high uptake by the public. In South Africa, the COVID-19 vaccination programme has been driven mainly by health professionals’ recommendations and public health policies. Perhaps we need to pay more attention to the socio-political factors that may influence the individual’s decision-making process when it comes to vaccination.

Information: The first factor that influences an individual’s perception is their knowledge and the quality of information that is available to them. Healthcare professionals and regulatory bodies have a responsibility to provide quality information to the public, as well as platforms where data can be interpreted and discussed. The National Institute for Communicable Diseases has an information-sharing platform, which provides accurate information. But it may not be accessible to all.

It would be useful to have virtual spaces where people can ask questions. Past experiences and the experiences of others can influence a person’s perception of the risk of vaccination and contribute to vaccine hesitancy.

One of the recurrent themes of concern, for instance, is the rapid rate at which the COVID-19 vaccines were developed. Fears around insufficient testing and studying of the vaccine can be put to rest if people understand that:

• the technology and manufacturing facilities to develop the vaccines were already in place at the start of the pandemic
• there was unprecedented global funding and information sharing
• studies could be rapidly conducted due to the contagious nature of the virus.

Trust: Individual discussions with trusted healthcare workers can unpack misconceptions and address concerns. A survey performed in 2021 showed that most people consider their personal physician to be the most trusted source of vaccine information.

Healthcare workers should be transparent about what they don’t know and realistic about potential side effects and limitations of the vaccines. Ignoring these is likely to damage vaccination efforts.

It is critical to understand that the aim of the vaccine is not to prevent infection with SARS-CoV-2, but to prevent severe disease and death from it. A perception that the vaccine is meant to prevent all disease can lead to mistrust in its efficacy.

Religion: Misinformation and misconceptions may lead to a perception that the vaccine is in opposition to religious standards. Rather than being viewed as a “problem” when it comes to COVID-19 and vaccination, religion should be considered as an important part of society’s world view. Religious leaders can demystify COVID-19 related policies as they act as a “gatekeeper” to their communities and exert influence on behaviour.

Culture: Cultures influence how vaccines are perceived and taken up. Mistrust in conventional medicine is more widespread in certain communities than in others. If we are to increase the uptake of vaccines in South Africa, we have to engage on the issues relevant specifically to such cultures. In our multifaceted society something as simple as ensuring information is available in all official languages can go a long way to improve understanding. Appealing to South Africans’ sense of “ubuntu” (the concept that “I am because you are”) can foster a sense that the vaccine is taken to protect others as well as oneself.

Media: Responsible media coverage, without sensationalism, is essential. The use of social media has been shown to increase during periods of crisis. Deliberate anti-vaccine campaigns have proliferated and necessitated active intervention from social media companies to curb disinformation. The scientific community should understand the workings of social media and harness its power to provide quality information that the public can understand.

Mandates: One of the more controversial means to increase vaccine coverage is mandatory vaccination. The debate in South Africa rages on, but various institutions have initiated mandatory vaccination policies. First prize remains voluntary vaccination.

Going forward

Emphasising the benefits of vaccines beyond just preventing death may help communities understand the urgency of increasing the number of vaccinated individuals in South Africa. Such benefits include:

• protecting the most vulnerable among us, such as children and immune suppressed individuals
• the ability to resume economic activity and provide for loved ones
• the freeing up of healthcare resources to address chronic diseases that have been overshadowed by the pandemic.

Sharing positive stories, together with good quality data around vaccine effectiveness, will encourage vaccination. Presenting vaccines as a way to regain some control over our own lives may be effective.

Interventions need to take multiple factors into account. They should aim to increase knowledge, awareness and confidence in the safety and efficacy of COVID-19 vaccines. Engagement of community leaders, religious leaders and healthcare professionals who have the trust of community members is more likely to increase vaccination than policies and campaigns by government institutions would be. Efforts to improve awareness should be accompanied by efforts to improve access and convenience of vaccination sites in all communities.

Vaccines are our best chance of overcoming this pandemic. They are safe and well-studied. They offer protection against severe disease and death. And they are the way we can protect not just ourselves but each other.

Professor Veronica Ueckermann is Adjunct Professor in the Department of Internal Medicine at the University of Pretoria.

This article first appeared in The Conversation on 7 December 2021.