The importance of addressing social inequalities and targeting the undecided to promote vaccination against COVID-19

As vaccines against COVID-19 are distributed across the Western Pacific, it is vital to investigate the barriers and enablers of vaccine acceptance in countries across the region. A paper in the latest issue of The Lancet Regional Health - Western Pacific presents the first multivariate analysis of attitudinal and sociodemographic predictors of vaccine intentions against COVID-19 in New Zealand (1).

Among the surveyed sample of 1,284 New Zealanders, 71% indicated they would likely accept the vaccine; 15% were unsure, 5% were somewhat unlikely, and 10% were very unlikely to do so. Vaccine acceptance was commonly motivated by a combination of several reasons. The most important reasons were avoiding COVID-19 illness, protecting others from infection, returning to ‘normal’ and promoting herd immunity. Older respondents were more likely to be motivated by protecting themselves against catching COVID-19 than were younger respondents. Younger respondents and those with lower educational attainment were less willing to vaccinate, while women and lower-income households were more likely to be unsure. Non-acceptors (i.e., unsure or unlikely to vaccinate) tended to have concerns about unknown future adverse effects and vaccine side effects. Women were more concerned about vaccine impacts on their health, while men were more likely to distrust vaccines or believed that the threat of COVID-19 was overstated. Younger respondents were more likely to have concerns about unknown future vaccine effects relative to older respondents. Unlike in descriptive findings, regression analyses showed that ethnicity was not associated with vaccine acceptance when socioeconomic measures were included in the model.

This study adds to previous research to underscore the importance of prioritising undecided people in COVID-19 vaccine promotion. Hesitancy towards COVID-19 vaccines is common across the world (2), and many New Zealanders have some doubts about whether they will vaccinate, with 35% indicating they were ‘unsure’ or only somewhat likely/unlikely to vaccinate. Concerns about unknown longer-term effects of the Pfizer/BioNTech vaccine are particularly prevalent (1). Similarly, in Australia (3) and the United Kingdom (4), ‘maybes’ comprise most non-acceptors. Strong opposition to COVID-19 vaccines appears to be less common in all three countries, with fewer than 10% very unlikely/unwilling to vaccinate. It has been argued long before the COVID-19 pandemic that vaccine promotion targeting undecided people is key to increasing uptake (5). But it may be particularly salient now. The rapidity of development and novelty of vaccines against COVID-19, intense public scrutiny, polarisation, misinformation (6), as well as vaccine policy changes and other factors, may undermine confidence among members of the public who may otherwise trust vaccines. In this context, some vaccine hesitancy is understandable; most hesitant people are unlikely to be ‘anti-vax’, and strategies to expedite vaccination against COVID-19 should reflect that. Communications to alleviate vaccine concerns should be prioritised, and vaccine promotion strategies should be tested with undecided people to check that they are having the desired impact on this group.

Understanding the reasons why people want vaccines against COVID-19 aids vaccine promotion. Prickett et al. provide valuable insights about this in New Zealand. For example, their findings suggest that community factors, such as protecting others and striving towards herd immunity, may motivate younger New Zealanders to vaccinate. New Zealand is rolling out its vaccinations in four prioritised waves, (1), which correlate with different age profiles. Prickett et al.’s. findings of the associations between sociodemographic variables and vaccine intentions can inform the tailoring of vaccine promotion associated with each wave. They may also inform targeted vaccine promotion for particular sociodemographic subgroups who remain under-vaccinated despite having access to vaccines.

Growing evidence highlights the importance of structural factors in vaccine acceptance during the COVID-19 pandemic. Prickett et al. advocated for interventions to address social inequalities in order to increase the acceptance of COVID vaccines in New Zealand. This conclusion reflected their finding that being Māori did not predict COVID-19 vaccine acceptance, but lower age, less education and lower-income- all more common among Māori people- did. In Australia, living in disadvantaged areas also predicts COVID-19 vaccine hesitancy (3), and access issues have long been known to account for significant under-vaccination (7). COVID-19 vaccine hesitancy is associated with lower health literacy and lower education (8), and a range of cultural and political factors, such as degree of trust in government (9). It is important to reduce financial and practical barriers to getting vaccinated against COVID-19, such as the inability to take time off work. As the COVID-19 pandemic further widens social inequalities (10), research about COVID-19 vaccine acceptance yet again underscores the importance of addressing the social determinants of health for pandemic preparedness.

Conflict of interest

Both authors have no funding sources to declare.

There was no original data for this short commentary article. As the corresponding author, TR had final responsibility for the decision to submit for publication.

Author contributions

Both authors conceived the article, collated materials and contributed to writing the manuscript.

Declaration of Competing Interest

The authors declare no conflict of interest.