Fears over the side effects of COVID-19 jabs, which led to initial vaccine hesitancy, mostly gave way to acceptance in the course of the pandemic, with only a small minority remaining unvaccinated due to deep-seated mistrust, a new major study published in The Lancet finds.

For the first time, the study “Profiling vaccine attitudes and subsequent uptake in 1.1 million people in England” compared attitudes towards vaccinations with actual vaccination behaviour on a large scale. Based on the findings, health policy experts call for evidence-based, group-specific and long-term communicative approaches to counter vaccine hesitancy.

Many of the initially hesitant individuals chose a wait-and-see approach. They were driven by concerns over side effects and efficacy, but eventually opted for the jab as real-world evidence of safety and efficacy grew.

The benefit of vaccination was recognised by the majority of those initially hesitant, mainly due to public health communication, community outreach and vaccine rollout itself.

“Our findings suggest that most COVID-19 vaccine hesitancy was rooted in concrete concerns that can be addressed and successfully overcome with time and increasing availability of information,” according to the principal authors, Paul Elliott, who is Chair in Epidemiology and Public Health Medicine at the Imperial College in London, and Marc Chadeau-Hyam, Professor of Computational Epidemiology and Biostatistics.

Vaccine hesitancy plummeted once information was available

According to the data, vaccine hesitancy decreased for the vast majority of initially hesitant individuals in the course of the COVID-19 pandemic.

Over time, 3.3% of all participants were categorised as hesitant towards the COVID-19 vaccine. Individuals were classified as “vaccine-hesitant” if they stated they would refuse the vaccine, had already refused it, or had not yet decided.

Their number fluctuated, plummeting from 8% in January 2021 to 1.1% at the start of 2022, before rising again to 2.2% in February 2022. This slight rise might be the result of “pandemic fatigue” or a shift in “personal risk perception” in the course of the Omicron wave.

The study data is based on the Real-time Assessment of Community Transmission (REACT) studies, which monitored the prevalence of SARS-CoV-2 in England during the COVID-19 pandemic from 1 May 1, 2020, to 31 March, 2022, in random samples of the population.

The researchers linked consecutive survey data from 1.1 million adults in England to official National Health Service (NHS) health records. The participant questionnaires included queries about vaccination status and attitudes toward vaccines, significantly enabling a comparison. However, the results may under-represent the most radical critics, who often avoid scientific surveys.

Concrete health concerns caused vaccine hesitancy

Vaccine hesitancy was mainly grounded in concrete concerns about effectiveness and side effects, perception of low risk from COVID-19, mistrust of vaccine developers, and fear of vaccines – sometimes as a result of misinformation, the researchers found.

The most prevalent categories of hesitancy, related to effectiveness and health concerns, declined substantially over time as  65% of hesitant participants received one or more vaccinations by May 2024.

The reasons for initial vaccine hesitancy varied by demographic. Men were more likely to perceive themselves as not being at risk (17.9% versus 10.2% of women), while women more frequently cited concerns regarding fertility (21.2% versus 8.4% of men). Younger participants more frequently cited a fear of needles.

Socio-economic deprivation and institutional mistrust are primary drivers of the reluctance to get a jab. Notably, Black participants were three times more likely to express hesitation than White participants.

Experts interpreting the study also suggest this mistrust is frequently rooted in negative healthcare experiences or historically unequal treatment. Significantly, non-White participants were ultimately no less likely to be vaccinated at a later date.

Communicative approaches key to successful campaigns

Although the researchers did not test the success of specific communication efforts or interventions to shift attitudes toward vaccinations, the findings can be used in public health policy and future vaccination campaigns, according to Sarah Eitze, deputy director of the WHO Collaborating Centre for Behavioural Research in Global Health.

Transparent, continuous, and evidence-based information provision has proven to be effective, explained Eitze, who is a researcher at the Institute for Planetary Health Behaviour (IPB) at the University of Erfurt (Germany).

“Optimal communication about vaccination is most successful when we take a more evidence-based, target group-specific and long-term approach,” said Eitze.

“The study shows that not every form of vaccine scepticism works in the same way. While uncertainty about information can often be addressed effectively, deeply rooted attitudes of rejection based on mistrust of institutions or science are much more difficult to overcome.”

Image Credits: European Union/Martin Matev, Felix Sassmannshausen, European Union/Martin Matev, Lisa Wollenschläger/University of Erfurt.