This six-country study on COVID-19 vaccine acceptance revealed a very high association (strong evidence, estimated relative risk or its reciprocal [ERR or 1/ERR] of 8.0 or greater) between responses regarding eight behavioural determinants and vaccine acceptance in Bangladesh, Kenya, Tanzania, and DRC: perceived social norms, perceived positive consequences, perceived negative consequences, perceived risk of getting COVID-19, perceived severity of COVID-19, trust in COVID-19 vaccines, expected access to vaccines, and safety of COVID-19 vaccines. A high level of association (ERR or its reciprocal = 4.0–7.9) on responses regarding eleven of the behavioural determinants studied was found in the six study countries: perceived self-efficacy, perceived social norms, trust in COVID-19 vaccines, trust in leaders’ COVID-19 information, expected access to COVID-19 vaccines, perceived divine will, perceived action efficacy, perceived positive consequences, perceived negative consequences, perceived severity, and culture (e.g. cultural and religious reasons people plan to not get vaccinated). Findings are presented below, organized under each behavioural determinant.
Regarding perceived social norms, the study showed that close family members, friends, religious leaders, political and social leaders are key in influencing people’s decision to get a COVID-19 vaccine. A strong majority of Acceptors believed that most of their close family and friends would get a COVID-19 vaccine in Bangladesh (100%), Myanmar (100%), Kenya (91%), Tanzania (62%), India (62%) whereas Non-acceptors were much less likely to believe that, and in some places strikingly less likely to believe that (38%, 84%, 36%, 0%, 22%, respectively). Acceptors were also more likely to say that most of their community leaders and religious leaders want them (or would want them) to get a COVID-19 vaccine in four of the five countries (all but DRC) where it was assessed. Acceptors were also more likely to say that they would get a COVID-19 vaccine if a health worker recommended it in four of the five countries where it was assessed. (India chose to omit these close-ended questions on perceived social norms, and only used the open-ended questions “who approves?” and “who disapproves?” instead. Kenya chose to omit the closed-ended questions on health workers approval.)
Related to social norms, in all four countries where this was assessed, Acceptors were more likely to say that they were very or somewhat likely to get a COVID-19 vaccine if a doctor or nurse recommended it. Conversely, Non-acceptors in these four countries were more likely to say that they are not likely to get the vaccine if a doctor or nurse recommends it. (This question was not asked in Kenya or India.)
When asked whether they trust the COVID-19 vaccines, Acceptors were more likely (than Non-acceptors) to say that they “trust it a lot” or “trust it a moderate amount” in all four of the countries where it was assessed. (India choose to not assess this question.) Non-acceptors were more likely to say that they “they have no trust at all” or only “trust them a little” in all five countries that assessed this. (India chose not to assess this.) The correlation between lack of trust in the vaccine and being a Non-acceptor was very high, especially in Kenya (ERR = 17.9) and Tanzania (ERR > 12).
To assess perceived action efficacy, respondents were asked how likely it would be that they would get COVID-19 disease after getting the COVID-19 (i.e., do they think the vaccine will work as intended to protect them from COVID-19). Acceptors were more likely to say that they would not be likely at all get COVID-19 after vaccination in Bangladesh, Kenya, and Tanzania. Conversely, Non-acceptors were more likely to say that they would be somewhat or very likely to get COVID-19 even after they were vaccinated in Bangladesh and the DRC. Despite being a vaccine acceptor, Acceptors in the DRC were more likely to say that they were still “somewhat likely” get COVID-19 after being vaccinated (than Non-acceptors). There were no statistically significant differences between the percentage of Acceptors and Non-acceptors responses for this question in India or Myanmar.
Respondents were asked how safe it would be for them to get a COVID-19 vaccine. Acceptors in all five of the countries where this was assessed (all but India) were more likely (than Non-acceptors) to say that it is “very safe” or “mostly safe.” Conversely, Non-acceptors in all five countries where this was assessed were more likely to say that COVID-19 vaccines are “not safe at all.”
In the DRC, respondents were also asked if they have previously received the Ebola vaccine. Acceptors were 1.6 times more likely to say that they have received it.
Acceptors in five of the six countries were more likely to say that they would have a very or somewhat high level of trust in the information that government representatives and politicians provide on the safety and effectiveness of COVID-19 vaccines. In India, paradoxically, Acceptors were more likely to say that they had a very low level of trust in the COVID-19 vaccine info provided by these officials. Non-acceptors in Bangladesh, Myanmar, and DRC were more likely to have a very or somewhat low level of trust in COVID-19 vaccine information provided by the government or politicians than Non-acceptors. Similarly, Non-acceptors from India, Myanmar, and Tanzania are more likely to say that they have a “very low” or “somewhat low” level of trust in COVID-19 information provided by government representatives or politicians.
Acceptors in five of the six countries (all but India) were more likely to say that they would have a very or somewhat high level of trust in the information that religious leaders provide on the safety and effectiveness of COVID-19 vaccines. Conversely, Non-acceptors from five of the six countries (all but Kenya) said that they had a somewhat or very low trust in this information from religious leaders.
When asked about advantages of vaccination with a COVID-19 vaccine, Acceptors were more likely to say prevention from COVID-19 in five of the six countries. (There were no statistically-significant differences between the percentage of Acceptors and Non-acceptors giving particular advantages and disadvantages of COVID-19 vaccination in Kenya.) Acceptors in Bangladesh and Myanmar were more likely to say, “won’t transmit COVID-19 to others.” In Myanmar, Acceptors were also more likely to mention lifting of travel restrictions, and in Tanzania, Acceptors were more likely to mention being able to work and earn and income and to reduce the COVID-19 death rate, as well. Non-acceptors were more likely to say that there were no advantages in four of the six countries, as well (all but Kenya and Myanmar).
When asked about disadvantages of vaccination with a COVID-19 vaccine, Non-acceptors were more likely to say there were no advantages (or they did not know any) in four of the six countries (all but Kenya and Myanmar). Negative or serious side effects were mentioned more often by Non-acceptors in Myanmar. Interestingly, negative or serious side effects were mentioned more by Acceptors – who intended to get a vaccine nonetheless – in both India and DRC. In the DRC, Non-acceptors were more likely to mention both death and other serious diseases as a disadvantage of the getting a COVID-19 vaccine, and in Tanzania, Non-acceptors were more likely to mention impotence, cancer, dizziness, and reduced life expectancy. In Tanzania, Acceptors were more likely to mention a relative mild side effect, fever.
When assessing perceived severity, Acceptors were found to be more likely to believe that more people have had COVID-19 in Bangladesh, India and DRC. Interestingly, in Tanzania, Acceptors were more likely to say that no one has had COVID-19 in their community, while Non-acceptors were much more likely to say that “very few people” have had COVID-19. When asked if about the likelihood of someone in their household getting COVID-19 over the next three months, Acceptors in four of the six countries (Bangladesh, India, DRC and Tanzania) were all more likely to say that the likelihood was very or somewhat likely. Conversely, Non-acceptors in Bangladesh, DRC, and Tanzania were more likely (than Non-acceptors) to say that it was not likely at all that they or someone in their household would get COVID-19 in the next three months. Acceptors were also found to be more likely to say that that were moderately or very concerned about getting COVID-19 in the next three months in DRC, Bangladesh, and Myanmar. (There were no statistically significant differences between the percentage of Acceptors and Non-acceptors who believed COVID-19 was serious or very serious in Myanmar.)
When assessing perceived severity, and in line with the Health Belief Model, Acceptors were more likely to believe that it would be very serious if they or someone in their household contracted COVID-19 in four of the six countries (Bangladesh, Kenya, DRC, and Tanzania), and conversely, Non-acceptors in India were more likely to believe that COVID-19 was not serious at all.
Respondents were asked two questions regarding perceived access to COVID-19 vaccines: (1) “If a vaccine for COVID − 19 were available in the country in the coming month free of charge, do you think that it would be available within 30 minutes’ walk from your home?” and (2) “If a vaccine for COVID − 19 were available in the country in the coming month free of charge, how much time in minutes or hours do you think people would need to wait in queue, on average, to receive the vaccine?” (In the DRC, respondents were asked to rate the degree of difficulty in getting to the clinic where vaccines are normally offered instead.)
Acceptors were more likely to say that they believe it would be available 30 minutes from their home in Bangladesh, India, Myanmar, and Tanzania. In DRC, the question was modified to ask how difficult it would be to get to the site where vaccines are normally provided. There, Acceptors were more likely to say that it would not be difficult at all, and Non-acceptors were more likely to say that it would be very difficult. Regarding the question on expected queue time, results varied. In Bangladesh, Acceptors were more likely to say 60–90 minutes (from categories of 0–30 mins, 31–60 mins, 60–90 mins, 1.5 to 2 hours, or 2–3 hours) than Non-acceptors. In Tanzania, Acceptors were more likely to say 1.5 hours or more, and Non-acceptors expected queue times of 31–60 mins. (There were no statistically significantly differences between Acceptors and Non-acceptors on the first question, and the second question was not asked in Kenya.)
Respondents were asked, “If a vaccine for COVID − 19 were available to you in the coming month free of charge, what might make it easier for you to get that vaccine?” Acceptors were more likely to mention providing the vaccine close to their homes (India), providing it through satellite clinics, PHC sub-centres, and health facilities, and avoiding stock-outs (Bangladesh, India and Myanmar, and Kenya respectively), using convincing and clear information on the vaccines and their effects (DRC), and knowing that COVID-19 is dangerous and offering it free of charge (Tanzania).
Respondents were also asked what might make it difficult for them to get a COVID-19 vaccine. Non-acceptors were more likely than Acceptors to say lack of information or documentation, being too time consuming (India), cost of transportation and having a prolonged illness (Myanmar), uncertainty about COVID-19 being real (DRC), and not trusting COVID-19 vaccination or not having COVID-19 cases in their community (Tanzania) might make it difficult to get a COVID-19 vaccination.
When assessing perceived divine will, Acceptors from five of the six countries (all but India) were more likely to believe that God, Allah, or the gods approves (or approve) of getting a COVID-19 vaccine. (In India, Acceptors were more likely to say that a deity does not approve.)
Respondents were also asked whether or not they agreed with the statement, “Whether I get COVID-19 or not is purely a matter of God’s will or chance – the actions I take will have little bearing on whether or not I get COVID-19.” Non-acceptors were more with this statement in Bangladesh where Non-acceptors were more likely to say they agree a lot, and Acceptors more likely to say they agree a little. Unexpectedly, in Tanzania Acceptors were more likely to agree a little with the statement and Non-acceptors were more likely to disagree a lot.
However, their response to whether it is God’s will for them to get COVID-19 or not, varied. Non-acceptors from Bangladesh believe (“Agree a lot”) it is God’s will, and Non-acceptors from Tanzania “disagree a lot” that it is God’s will for them to get COVID-19 or not. Surprisingly, Acceptors in Bangladesh (80% of Acceptors vs. 27% of Non-acceptors) and in Tanzania (38% of Acceptors vs. 13% of Non –acceptors) believe (“agree a little”) that it is God’s will or chance whether they get COVID-19 or not.