Funded by the Bill & Melinda Gates Foundation, the CVACS project officially began in SALDRU at the beginning of October 2021. CVACS collects information on facilitators and barriers to COVID-19 vaccine uptake in South Africa, and provides rapid answers to the most pressing policy-relevant questions to support vaccine demand-creation strategies. The telephonic survey provides insights from samples of unvaccinated individuals, and from a sample of respondents who were vaccinated between CVACS Survey 1 and Survey 2. In mid-April, the CVACS team shared key findings from Survey 2 in a webinar (webinar recording and slides), and accompanying policy brief. In this article we share some of these key findings.
The CVACS sample and survey rounds
The Survey 1 sample was drawn from a large credit bureau database, which includes individuals who had applied for credit, regardless of the outcome, and individuals who have had a credit check. The sample was stratified on several characteristics to ensure representation across provinces, area types, age groups (based on the age categories used for the national vaccine roll-out), gender, and income groups. Survey 1 interviewed 3,510 individuals who were unvaccinated against COVID-19, between 15 November–15 December 2021 (vaccination status was self-reported, and being unvaccinated was an eligibility criterion for inclusion into the study).
Survey 2 attempted to re-interview the original Survey 1 sample of 3,510 individuals: 1,772 were successfully re-interviewed, with 386 individuals who were vaccinated between the surveys (self-reported), and 1,386 remaining unvaccinated. A new top-up sample of 2,222 unvaccinated individuals was also interviewed, to achieve a total sample of 3,608 unvaccinated individuals. Survey 2 interviews were conducted between 23 February-25 March 2022.
It is important to note that CVACS is not a prevalence survey and that the results are not nationally representative. Nevertheless, CVACS provides insights into the opinions and experiences of unvaccinated and recently vaccinated individuals in South Africa. For the key findings that follow, design weights were used to account for sample selection and non-response for cross-sectional analysis; and panel weights were used to account for potential attrition bias between Survey 1 and Survey 2 in longitudinal analysis.
The majority of the unvaccinated individuals in Survey 2 do not want to get vaccinated – a significant change since Survey 1
The majority of the unvaccinated respondents in Survey 2 do not intend to get vaccinated. When asked about their intentions to vaccinate against COVID-19, 36% said “definitely not” and 24% said “only if required”. This is a significant shift in intentions among the unvaccinated subpopulation as compared to CVACS Survey 1, when the majority said either “as soon as possible” or “wait and see”.
Furthermore, in Survey 2 only 29% of the unvaccinated sample thought they would be vaccinated by May 2022, which is significantly lower than the future intentions stated in Survey 1.
Only one in five unvaccinated people think that they will get very sick if they catch COVID-19, with most stating that there is no need for the vaccine
Most unvaccinated respondents do not believe that they need a vaccine. Less than 20% of the unvaccinated respondents believe that they will get very sick if they get COVID-19. Half or more than half of the vaccine hesitant individuals (i.e. excluding the “as soon as possible” group) believe that their body is strong enough to fight COVID-19 (60%), that God or the ancestors will protect them (50%), and that their infection risk is low (approximately 50%).
Few unvaccinated people believe that the vaccine is effective and a majority think that it harms people rather than keeps them healthy
Belief in vaccine efficacy is low and strongly correlated with vaccination intentions among the unvaccinated sample. 2 in 3 of all respondents either do not believe that the vaccine will help prevent them from dying of COVID-19 (61%) or don’t know (7%). Approximately 70% of those who want to get vaccinated “as soon as possible” believe that the vaccine helps prevent death from COVID-19, while only 10% of the most hesitant group do.
There are high levels of concern about the safety of vaccines among the unvaccinated sample, including high levels of mistrust in the safety of the vaccine for the babies of pregnant or breastfeeding mothers. These beliefs are more prevalent among the more vaccine hesitant. Similar beliefs are present regarding vaccine safety for people with chronic illnesses, with approximately 80% of unvaccinated respondents either not knowing if the vaccine was safe for those with chronic illnesses, or believing that it was not safe. The more reluctant to vaccinate are more certain in these beliefs. Similar patterns were found when unvaccinated respondents were asked the degree to which they believed that the vaccine could kill someone; and whether the vaccine is more likely to keep a person healthy or harm them. The majority of the unvaccinated sample believed that the vaccine was more likely to harm people than to keep them healthy.
High risk groups such as those with chronic illnesses do not intend to get vaccinated
Unvaccinated respondents with chronic conditions are no more likely to want to be vaccinated than other unvaccinated respondents, and are only slightly less hesitant. Only 19% of unvaccinated respondents who also have a chronic illness intend to get vaccinated as soon as possible, and nearly 1 in 3 definitely do not intend to be vaccinated. This is only slightly lower than respondents with no chronic illnesses (37%).
Mandates may be the most effective strategy remaining to increase vaccination coverage
Despite almost 1 in 2 unvaccinated respondents believing that mandates would work fairly or very well to increase vaccine coverage, there is strong opposition to mandates among the vaccine hesitant. Opposition is driven mainly by the belief that it is an individual’s right to decide to get vaccinated or not (cited by more than 1 in 2 of those in opposition).
Vaccinated individuals are happy with their decision, and likely to recommend vaccination to others
9 in 10 of the people who got vaccinated between Survey 1 and Survey 2 were happy with their decision. 75% had recommended the vaccine to someone else and 4 in 5 felt the same or better than expected after getting vaccinated. Vaccinated respondents were also asked whether they intend to get their follow-up doses of vaccines and 84% said that they intended to get their second dose (Pfizer) or booster shot (J&J).
Policy implications
Findings indicate that longer-term, more intensive demand creation measures will be needed to encourage vaccination among the last group of older and more hesitant to vaccinate individuals, with limited scope left for ‘quick win’ demand creation strategies.
Overall, the combined findings from the CVACS Survey 2 vaccinated and unvaccinated respondents point towards mandates or other vaccine requirements being the most effective strategy remaining to increase vaccination coverage. In the absence of mandates it will be difficult to convince people to get vaccinated because the unvaccinated respondents, in general, don’t think that the vaccine is effective, don’t think it is safe, and don’t think that they need it. In addition, the most common reason why respondents got vaccinated was because it was a requirement for work, for looking for a job, or for doing other normal activities. However, findings indicate that such strategies will be met with resistance and will need to be designed with sensitivity to opposition. Careful framing will be required. The role of the government may be to support and facilitate NGO and private institutions’ mandates/requirements, while maintaining government mandates where feasible and effective.
The results also indicate that improving beliefs about the efficacy of the vaccine, and dissemination of the correct information about the safety of the vaccine for key groups, such as pregnant/breastfeeding mothers or those with chronic illnesses, is needed. Creating awareness of others getting vaccinated could still influence decisions through social norms and by convincing people that the vaccine is safe (social proof).
CVACS materials and data
The Survey 2 webinar recording is available to watch on the CVACS YouTube Channel here. The slides that we shared during the webinar are available here, and the policy brief sharing results from CVACS Survey 2 is available here.
The Survey 2 data will be available at the end of April via DataFirst’s online open data portal. The Survey 1 data is available here.
For more information, comments or questions contact the CVACS co-PIs: Brendan Maughan-Brown (Brendan.maughan-brown@uct.ac.za) and Katherine Eyal (Katherine.Eyal@uct.ac.za).