White Paper on Vaccine Hesitancy in Sub-Saharan Africa

Collaborative research produced at the Scowcroft Institute of International Affairs, Texas A&M University (Bush School of Government & Public Service), 2024. Bernard contributed the Introduction and the Nigeria analysis. Co-authors: Christine Crudo Blackburn, Timothy Callaghan, Brian Colwell, and others.

Introduction

The COVID-19 pandemic caused a global public health crisis, resulting in more than six million deaths worldwide and long-term health, economic, and political consequences for millions of individuals. As the world moves on from the pandemic, health systems globally focused on keeping COVID-19 as a manageable respiratory illness through vaccination and outpatient treatment. Vaccines, in particular, remain a major pillar for both the prevention and amelioration of COVID-19. Despite the importance of vaccines in responding to COVID-19, their development and dissemination brought to the surface an unprecedented level of vaccine hesitancy throughout the globe. The speed and scale of the growth of vaccine hesitancy during COVID-19 threatens our ability to respond to future pandemics and it is therefore necessary to distill lessons learned from this pandemic and apply these lessons in a manner that will increase the preparedness and resilience of health systems moving forward. As the world continues to grapple with the consequences of the COVID-19 pandemic, it is essential to understand the factors that contribute to vaccine hesitancy and how to address them. This will require a comprehensive approach that takes into account the social, economic, and political contexts in which vaccine hesitancy is embedded. By doing so, we can ensure that health systems are better prepared to respond to future pandemics and other public health crises.

Defining Vaccine Hesitancy

Vaccine-hesitant individuals are a heterogeneous group who may accept some vaccines, but not others, and delay or accept vaccines according to the recommended schedule, but be unsure in doing so. This presents a challenge to policy makers when trying to understand attitudes towards vaccination at the population level, as hesitancy is not directly related to uptake. Vaccine hesitancy can be generally defined as the delay in accepting or a refusal of vaccines (Dubé, 2013). This hesitancy lies along a spectrum from total acceptance to total rejection. Additionally, vaccine hesitancy is context-specific and there is no one-size-fits-all answer to the question of what contributes to it. This is because vaccine hesitancy is influenced by a variety of factors, including personal beliefs and experiences, as well as the broader social and environmental context. Some of the most commonly cited factors that contribute to vaccine hesitancy include a lack of trust in the vaccine industry or health authorities, perceptions that vaccines are unsafe or not effective, concerns about the potential side effects of vaccines, a belief that vaccines are used to control or manipulate the population, and misinformation or false information about vaccines.

To further understand the motivations for vaccine hesitancy toward the COVID-19 vaccine, this white paper provides an in-depth analysis of vaccine hesitancy in Kenya, Nigeria, and South Africa, and its implications for biosecurity policies in the United States. Drawing on a mixed-methods study utilizing in-person interviews and a nationally representative survey administered in web and SMS form, this paper seeks to identify the primary drivers of vaccine hesitancy in the above-mentioned countries and provide lessons learned for health and biosecurity policies in the US. These findings are intended to be a valuable resource for national biosecurity agencies, government, and non-government aid agencies as they develop strategies for increasing demand in vaccine intervention initiatives.

Why Vaccine Hesitancy in Africa?

Many countries on the African continent have experience addressing vaccine hesitancy, especially in relation to various childhood vaccination campaigns; however, the motivations and circumstances surrounding hesitancy in these instances were different than those of the COVID-19 vaccine, leading to success stories of eradicating debilitating diseases like polio. Due to underlying differences, these experiences do not provide sufficient knowledge on addressing vaccine hesitancy in the general population. The countries from which we draw empirical evidence for this paper are in the sub-Saharan region of Africa, with 44 countries. The combined population of Kenya, South Africa, and Nigeria represents about 30% of this region and their cumulative disease burden (cases confirmed) of COVID-19 represents 50% of the region (CRC, 2020). Interestingly, South Africa contributes about 90% of this burden. The experiences of African countries in addressing vaccine hesitancy have been varied and complex. While the success stories of eradicating debilitating diseases like polio are encouraging, the motivations and circumstances surrounding hesitancy in these instances were different than those of the COVID-19 vaccine.

The United States Agency for International Development (USAID), as the lead agency for aid and global health for the US, has been working to increase access to and uptake of safe and effective COVID-19 vaccines in Sub-Saharan Africa (SSA), providing over 182.9 million doses to 44 countries in SSA (USAID, 2022). The agency provided support in the form of national-level storage, media messaging, and community outreach, all aimed at engaging in public outreach and direct engagement with communities to dispel misinformation and increase vaccine confidence. According to USAID's FY 2022 report, an estimated $2.3 billion was spent on all aspects of the COVID-19 response in the fiscal year of 2022, with the three countries of study taking up 20% of these funds. Despite hesitancy and supply challenges, USAID states that vaccination rates in SSA have continued to increase. As of September 2022, 20% of the population had completed the primary vaccine series and an additional 5% had received a partial vaccine, with over 450 million doses administered. Implementing evidence-based recommendations, as discussed in this paper, has the potential to increase the return on investment on every dollar spent and improve our global health response.

Nigeria: Findings & Discussion

Findings

Misinformation was the most consistent theme noted as a negative driver for COVID-19 vaccination. Most rumors mentioned were vaccine-related, such as people getting malaria from the vaccine; boosters being expired; vaccines killing people; and the vaccine being the anti-Christ. Others included conspiracy theories suggesting the government was trying to get rich in some way. The majority of participants expressed trust in their sources of information, which included a variety of sources from social and traditional media, as well as search engines. Notably, many of the participants expressed confidence in information from government-owned agencies. According to one of the participants: “I trust them because they give you the information you need because they are government-registered organizations and verified on social media.”

The majority of participants believed the COVID-19 vaccine was safe, but they were scared to get vaccinated. Fears were related to side effects such as muscle pain and fatigue. However, despite the fears, most eventually got vaccinated. In the words of one participant who was initially hesitant: “At first when they started taking it I saw some people coming back to complain that their hands were swollen, headache and other mild complaints. So I was actually scared at first to take the first dose but after taking it I felt nothing but later on I saw people coming back to say their hands are swollen because they don’t want to take the second one. So we advise them to take Paracetamol after taking it. So I took the first and second dose and I was okay.”

Worthy of note was the recurring mention of HIV and tuberculosis as the diseases most concerning to most participants. Other diseases of concern included malaria, cancer, and hypertension.

Discussion

Dealing with health-related misinformation is a global health concern, particularly for the United States, as biodefense, public health, and other health issues are often politicized. The emergence of misinfopreneur groups, such as QAnon, aligned to or backed by political establishments, also provides entry points for foreign interference for geopolitical or economic gains. From our study in Nigeria, it is evident that misinformation and conspiracy theories are a major issue surrounding vaccine hesitancy. These rumours are spread through social and traditional media, as well as through word of mouth.

It is important to note that many participants expressed trust in their sources of information, with many expressing confidence in government-owned agencies. This testifies to the effort put into public education and awareness during the pandemic, particularly by the Nigerian Centre for Disease Control and Prevention (NCDC). The institutional transformation of NCDC in the years preceding the pandemic underscores the importance of institutional building and strengthening, especially in a world of rapidly emerging challenges. With support from international donors, NCDC had been undergoing a period of internal restructuring and modernization in the years leading up to the pandemic, with the aim of building a stronger, more effective, and more resilient institution capable of responding to the country’s public health challenges.

Although social media firms have increased their efforts to control anti-vaccination messaging, this does not address the underlying issue that people are looking for answers online. It is therefore pertinent to continue to work with social and traditional media firms to direct users to reliable sources of information. By leveraging the trust in institutions like the NCDC, Nigeria can continually drive messaging regarding the safety and efficacy of vaccines and counter the spread of misinformation.

From the participants’ statements, peer experience contributes greatly to the perception of vaccine safety. People often feel more comfortable when family and friends can give first-hand experiences and insights about the safety of medical interventions. Fear of potentially serious side effects such as swollen hands and headache led many to be hesitant initially, but advice from peers and direct experience eventually encouraged them to take the vaccine despite their fears. This highlights the importance of peer support and proper information sharing about the safety and efficacy of vaccines in order to enhance public confidence. It also demonstrates the effectiveness of providing practical advice on what one should do in the case of minor side effects.

In Nigeria, it appears that the participants generally had a low risk perception of COVID-19 due to the higher perceived risks associated with diseases like HIV, tuberculosis, malaria, cancer, and hypertension. This could be due to comparative morbidity and mortality compared with other countries and the lack of exposure to people who have been infected with the virus. It is also possibly due to the sustained public awareness over the years for other diseases such as HIV and tuberculosis. Furthermore, the limited access to quality healthcare and resources for testing for COVID-19 could have also contributed to the low risk perception. Low risk perception in pandemics has serious consequences, as people fail to adhere to public health protocols such as wearing masks, physical distancing, and frequent hand washing.

In addition to media campaigns, other strategies to increase vaccine uptake include providing financial incentives and increasing access to healthcare services. Improving access to health services, particularly in rural areas of Nigeria, will allow people to receive accurate information about vaccines and develop trust in the healthcare system. Additionally, it is important to ensure that public health messaging is tailored to the local context, taking into account local beliefs and customs. It is equally important to involve community leaders, religious organisations, and other influential stakeholders in the development and implementation of public health campaigns. These stakeholders are often seen as trusted sources of information, and can be used to help spread accurate information about vaccines and increase vaccine uptake.

Full Publication

The complete multi-country study — including Kenya and South Africa chapters, cross-national findings, and policy recommendations — was published by the Scowcroft Institute of International Affairs at Texas A&M University (Bush School), 2024. Authors: Christine Crudo Blackburn, Timothy Callaghan, Brian Colwell, Bernard Fatoyẹ, et al.