COVID-19 vaccine acceptance and hesitancy in low- and middle-income countries

Abstract

Widespread acceptance of COVID-19 vaccines is crucial for achieving sufficient immunization coverage to end the global pandemic, yet few studies have investigated COVID-19 vaccination attitudes in lower-income countries, where large-scale vaccination is just beginning. We analyze COVID-19 vaccine acceptance across 15 survey samples covering 10 low- and middle-income countries (LMICs) in Asia, Africa and South America, Russia (an upper-middle-income country) and the United States, including a total of 44,260 individuals. We find considerably higher willingness to take a COVID-19 vaccine in our LMIC samples (mean 80.3%; median 78%; range 30.1 percentage points) compared with the United States (mean 64.6%) and Russia (mean 30.4%). Vaccine acceptance in LMICs is primarily explained by an interest in personal protection against COVID-19, while concern about side effects is the most common reason for hesitancy. Health workers are the most trusted sources of guidance about COVID-19 vaccines. Evidence from this sample of LMICs suggests that prioritizing vaccine distribution to the Global South should yield high returns in advancing global immunization coverage. Vaccination campaigns should focus on translating the high levels of stated acceptance into actual uptake. Messages highlighting vaccine efficacy and safety, delivered by healthcare workers, could be effective for addressing any remaining hesitancy in the analyzed LMICs.

Fig. 1. Acceptance rates, overall and by respondent characteristics.

Average acceptance of the COVID-19 vaccine across studies and subgroups within studies. For each study, we summarize sampling information in parentheses in the following way: (1) we indicate whether the geographic coverage of the sample is national or subnational. If the coverage is subnational we provide further details; (2) we list the number of observations included in the study. In the plot, points represent the estimated percentage of individuals who would take the vaccine. ‘No’, ‘Don’t know’ and ‘Refuse’ are taken as a single reference category. Bars around each point indicate a 95% confidence interval for the estimate. The ‘All LMICs (national samples)’ row reports averages for just the LMIC samples with national-level geographic coverage. An estimate of average acceptance for all studies in LMICs (excluding the United States and Russia) is also shown in the ‘All LMICs’ row.

Fig. 2. Reasons not to take the vaccine.

The percentage of respondents mentioning reasons why they would not take the COVID-19 vaccine. In the plot, points represent the estimated percentage of individuals that would not take the vaccine or do not know if they would take the vaccine for each possible response option. Bars around each point indicate the 95% CI for the estimate. An estimated average for all studies in LMICs is also shown. The size of the points illustrates the number of observations in each response option. The India and Pakistan survey 2 studies are not included because they either did not include the question or were not properly harmonized with the other studies.

Fig. 3. Trusted sources respondents say they would trust most to help them decide whether to take the COVID-19 vaccine.

Histograms of sources respondents say they would trust most to help them decide whether to take the COVID-19 vaccine. Respondents were only permitted to select one most trusted actor or institution. The India, Mozambique, Pakistan survey 1, Pakistan survey 2 and Uganda survey 1 studies are not included because they either did not include the question or were not properly harmonized with the other studies.

Extended Data Fig. 1. Trusted sources and institutions, broken down by gender.

Figure ED1 shows histograms of sources and institutions that respondents say they would trust most to help them decide whether or not to take the COVID-19 vaccine. Respondents were only permitted to select one most trusted source or institution. Responses are broken down by gender of respondent.

Extended Data Fig. 2. Average vaccine acceptance across all LMIC countries leaving one or two study samples out.

Figure ED2 shows distribution of estimates of average acceptance for all studies in LMICs (excluding USA and Russia) leaving one and two study samples out at a time. Figure also shows distributions of subgroup averages by gender, education and age leaving one and two study samples out at a time. To directly compare the resulting distributions to the estimates reported in Fig. 1, we plot point estimates reported in Fig. 1 for all LMIC studies, Russia and the US.