A Rapid Review of Evidence on the Determinants of and Strategies for COVID-19 Vaccine Acceptance in Low- and Middle-Income Countries

"...the consistency of the findings from the included studies provides an understanding of COVID-19 vaccine acceptance and hesitancy across...LMIC[s]..."

As the COVID-19 pandemic evolved, public concern about the safety of COVID-19 vaccines due to their rapid development, widespread misinformation, and distrust in governments threatened to influence vaccine acceptance and uptake in populations worldwide. This rapid review identifies evidence on the determinants of vaccine acceptance and hesitancy and interventions that can promote vaccine acceptance within low- and middle-income country (LMIC) contexts.

The World Health Organization (WHO)'s Measuring Behavioral and Social Drivers of Vaccination (BeSD) Increasing Vaccination Model was used to identify influencing factors for vaccine acceptance. This model helps distinguish evidence related to: (i) supply-side determinants (practical issues of availability, accessibility, affordability, cost, acceptability, and quality, as well as other vaccination-related factors at the systems level); (ii) demand-side determinants (people's perceptions, such as risk perception, and people's motivation and orientation, such as political affiliation); and (iii) social and health system processes (e.g., provider recommendation, social and gender norms, rumours and misinformation).

Searches of the published and grey literature conducted April 28-29 2021 led to 15 documents based on the inclusion criteria. The records included two systematic reviews, one rapid review, six cross-sectional surveys, five reports, and one opinion piece. Studies were conducted in Bangladesh, Brazil, India, Nigeria, Pakistan, South Africa, Zimbabwe, and Vietnam. Also, a brief summary of findings from ten studies identified from a pre-print server relevant to the LMIC context is provided.

Overall, the results showed that the vaccine acceptance rates differed across LMICs, with vaccine acceptance found to be greater among males, those with higher education, those with elevated socio-economic status, the unmarried, and healthcare workers. The researchers cite a study finding that vaccine hesitancy on the whole in LMICs remains comparatively low as compared to high-income countries (HICs).

A variety of reasons were cited for vaccine hesitancy. For example, in a study in Bangladesh, residents of slum, semi-urban, and rural areas were more vaccine-hesitant than those living in the cities; almost 40% of the slum dwellers were hesitant to vaccinate against COVID-19. A study from Vietnam pointed to the role of information source, noting that receiving information from relatives led to significant misconceptions and fears about vaccine safety. Results from included studies pointed to a strong recommendation from a healthcare provider or an influential community member as a significant motivating factor to get vaccinated. Another study indicated that an individual's political beliefs influence perceptions of the vaccine and its efficacy and safety.

Several studies reported that perceived secrecy and inadequate communication addressing fears and concerns about the COVID-19 response could increase vaccine hesitancy in the population. Suboptimal technical/scientific communication, lack of public engagement, and lack of trust in governments and pharmaceutical companies are other contributing factors. One study suggested that greater understanding of and engagement with localised pockets of unvaccinated or under-vaccinated people within larger communities of vaccinated individuals would be required to allay specific fears or concerns of such groups.

Findings from the included studies indicate there is no "one-size-fits-all" approach to increase vaccine acceptance. However, some of the proposed strategies include: community mobilisation; direct engagement with communities through influencers such as community leaders and faith leaders; clear and transparent communication about COVID-19 vaccines in simple, non-medical terms; mass media campaigns; minimisation of vaccine-associated costs borne by the public; and strong endorsement from healthcare workers. Some specific suggestions include:

• Addressing historic issues breeding distrust and being sensitive to religious and philosophical beliefs;
• Leveraging influential opinion leaders, including celebrities and social media influencers, to promote COVID-19 vaccination acceptance and uptake;
• Designing and running intensive campaigns to address the risk perception of COVID-19 infection and to convey the emotional and immediate economic benefits of the COVID-19 vaccine;
• Developing vaccine communication strategies that consider the level of health and scientific and general literacy in diverse populations (e.g., younger, female, ethnically or linguistically diverse); and
• Using traditional media (e.g., television, radio, newspapers) and social media platforms could be used to raise public awareness of the benefits of the COVID-19 vaccine.

In conclusion: "Decision-makers should consider determinants for reluctance in the relevant context and tailor appropriate and feasible solutions to the target population. Studies suggest high acceptance for the most part; localised strategies to address concerns and misinformation are required to engage the community and are based on broader trust-building and vaccine delivery system-strengthening activities. Further inquiry into best practices for this and adaptation of known strategies and approaches from different LMICs are recommended."