The pandemic is testing our societal structures like never before. To deal with it successfully, we need to think and act collectively, led by our key institutions. But at a time when unity is critical, are we about to see the effects of a long-standing and corrosive drip feed of mistrust?
The rapid development and testing of COVID-19 vaccines has been an extraordinary scientific undertaking. What happens now is arguably even more important: to ensure the vaccines are an effective intervention, people will need to take them. The practical challenges of manufacturing and dispensing millions of doses worldwide are of course immense, but societies also have to deal with the issue of vaccine hesitancy: the belief that a vaccine may be unnecessary, ineffective, or unsafe (and perhaps all three). Unsurprisingly, people who have these concerns may be reluctant to take a vaccine; they may even refuse it outright.
The pandemic has created the ideal conditions for mistrust of a COVID-19 vaccine to thrive. Part of the problem is the complexity and variability of transmission and infection.
Vaccine hesitancy isn’t new. However, the pandemic has created the ideal conditions for mistrust of a COVID-19 vaccine to thrive. Part of the problem is the complexity and variability of transmission and infection. The fact that you may not catch the virus if you break social distancing guidelines and that the illness may be mild if you do get it, has led some to conclude that there isn’t a real problem. The unprecedented speed with which the vaccines have been developed has also provoked worry: there are concerns that safety has been compromised or that the vaccine will be rolled out before we understand the extent and nature of possible side effects. Moreover, the Internet is awash with misinformation -- including conspiracy theories – about the virus, lockdown, and vaccinations.
Finally, it’s worth bearing in mind that this is all taking place after a long period in which trust in science, medicine, and key institutions has been steadily eroded. We can’t overcome the virus if health experts aren’t trusted; yet that’s exactly how many people have been primed to react.
In the Oxford Coronavirus Explanations, Attitudes, and Narratives Survey (OCEANS), we aimed to gauge the extent of COVID-19 vaccine hesitancy: how many people are sceptical about vaccination; whether particular sections of the population are especially reluctant; and, most importantly, why people are hesitant. 5,114 adults took part, representative of the UK population for age, gender, ethnicity, income, and region.
First, the good news: we found a substantial majority in favour of a COVID-19 vaccine, with 72% willing to be vaccinated. But this isn’t enough to be truly considered a consensus. 16% of the population are very unsure about receiving a COVID-19 vaccine, and another 12% are likely to delay or avoid getting the vaccine. One in twenty people describe themselves as anti-vaccination for COVID-19.
Vaccine hesitancy has implications for us all. The fewer the people who are vaccinated, the greater the number of people who will get seriously ill.
The signs are concerning: we may be close to a tipping point, when suspicion of vaccination becomes mainstream. Already we’ve seen conspiracy theories about the virus achieve significant traction. Is COVID-19 vaccine hesitancy about to follow in their wake?
In our survey, one in five people thought vaccine data are fabricated and another one in four people did not know whether such fraud is occurring. Why does this matter? Vaccine hesitancy has implications for us all. The fewer the people who are vaccinated, the greater the number of people who will get seriously ill. Also, we don’t yet know how many people will need to be vaccinated to achieve full herd immunity, but an estimate of 80% has been suggested. As things stand, our survey suggests that figure may not be easy to achieve.
The fear that vaccine hesitancy may be going mainstream is borne out by the fact that, in our survey, mistrust wasn’t confined to particular groups; on the contrary, it was evident across the population. Hesitancy was slightly higher in young people, women, those on lower income, and people of Black ethnicity, but the size of the associations was very small. So we can’t explain COVID-19 vaccine hesitancy by reference to socio-demographic factors.
What, then, lies behind these beliefs? Our survey suggests that what matters most is the way people think about a number of key issues relating to a COVID-19 vaccine, specifically:
• the potential collective benefit
• the likelihood of COVID-19 infection
• the effectiveness of a vaccine
• its side-effects
• the speed of vaccine development
So those who are hesitant about a COVID-19 vaccine tend to be people who may not be so aware of the public health aspects of a vaccine, don’t consider themselves at significant risk of illness, doubt the efficacy of a vaccine, worry about potential side effects, or fear that it’s been developed too quickly.
When I speak to people who are enthusiastic about vaccination the first thing they say is that it helps everyone. In contrast, people wary of a vaccine often focus on their own situation: they’ll tell me that they’re unlikely to fall ill, for example, or worry about what may go wrong if they were to take a vaccine. But this perspective can change: when I’ve asked vaccine-hesitant individuals to imagine that someone close to them is especially vulnerable to COVID-19 they say that they’re more likely to get vaccinated.
Our survey shows people want reassurance that safety hasn’t been sacrificed for speed. They want accurate and comprehensible guidance on effectiveness, potential risks, and how long protection will last. And they’re not scared of detail: messaging should provide us with the full picture.
Vaccine scepticism, it would seem, is linked to a wider crisis of trust. Our data suggest that people who are vaccine hesitant are more likely to be mistrustful of doctors, are more likely to hold conspiracy beliefs, and to have little or no faith in institutions. They can also feel like they are of lower social status compared to others. What we see here is a combination of vulnerability and distrust of those in authority. That manifests itself in defensiveness. Unwilling to be experimented upon by people who don’t care about their well-being, they avoid vaccination.
The next few months are vital. Messaging must be strong and clear: for the benefit of everyone, each of us has a duty to get vaccinated when possible. Most people can see vaccination as the light at the end of the tunnel, but they are also looking – perfectly reasonably – for information they can trust. Our survey shows they want reassurance that safety hasn’t been sacrificed for speed. They want accurate and comprehensible guidance on effectiveness, potential risks, and how long protection will last. And they’re not scared of detail: rather than slogans, soundbites, and selective emphases, messaging should provide us with the full picture.
It must also be energetic, proactive, and open-minded. Make no mistake: people who are vaccine hesitant are thinking long and hard about whether to take a COVID-19 vaccine. Public health professionals need to be out and about across the country, listening to concerns and responding transparently. Presenting accurate information as powerfully as possible is obviously essential, but we also need to counter, and limit the spread of, vaccine misinformation.
Over the longer term, we need to rebuild trust in public institutions and experts – a task that will require society to address the sense of marginalisation that has led many people to question the value and veracity of science and other forms of expert knowledge. As crises like the current pandemic make clear, trust is the foundation stone of our community. Without it, even the most significant medical breakthroughs can seem like cause for suspicion.
Daniel Freeman is Professor of Clinical Psychology in the Department of Psychiatry, University of Oxford.
Read: ‘COVID-19 vaccine hesitancy in the UK: The Oxford Coronavirus Explanations, Attitudes, and Narratives Survey (OCEAN) II’ in Psychological Medicine.