An expert’s opinion: An interview with Ayman El-Mohandes on COVID-19 vaccine acceptance and public health messaging

Ayman El-Mohandes, Dean of City University of New York Graduate School of Public Health and Health Policy (CUNY SPH) and co-coordinator of a global survey on potential hesitancy to accept a proven, safe and effective COVID-19 vaccine, speaks to us about the findings and their implications for halting the spread of the virus.

What does the global survey of potential acceptance of a COVID-19 vaccine show?

Ayman El-MohandesAyman El-Mohandes: Our recent study involving over 13,000 people from 19 different countries in Asia, Europe, North and South America and Africa, examines the perception of populations around the world on their government’s response to the pandemic and attitudes towards vaccine acceptance.

We found a very broad range of acceptance, with a high of 88% in China and a low of 55% in Russia. Countries like France and Poland were also quite low on the spectrum of acceptance. There are many factors influencing people’s response. Each country needs to be mindful of these variations and try to improve acceptance rates before the vaccine becomes available.

The overall acceptance of a safe and effective vaccine was 71%, but when participants were asked if they would accept such a vaccine if it were recommended by their employer, the acceptance rates fell to 61%. These results highlight the importance of letting people exercise their own judgement.

In addition, we found that females were more likely to accept the vaccine, as were people over 65 and those with a higher level of education. People with a higher level of trust in their government and in countries with a high incidence and mortality rate were also more likely to accept a COVID-19 vaccine.

What do these findings mean in terms of going back to pre-COVID-19 normality?

Ayman El-Mohandes: We are all in this together and there is a real need to regain the connectivity of global populations, culturally, socially and economically. This divergence in terms of vaccine acceptance doesn’t help.

On the one hand we have 71% of people that are very likely or likely to accept a vaccine, but there are 29% who don’t. Recent reports indicate that the vaccines in development are over 90% effective so if 70% of people take it, we’d end up with around 63% of the population protected.

However, this 63% presumes many things, such as effective distribution, that the cold chain is maintained, that everyone responds in the same way and is compliant with revaccination if multiple doses are required… We also don’t know how long immunity lasts so it may be like the flu shot that has to be taken every year. Will people’s enthusiasm wane over time?

The starting numbers are very hypothetical. For a start they assume similar levels of vaccination across countries and that is not what our study shows. We are also speculating that governments across the world will have the same efficacy in administering the vaccine.

I don’t think that a 71% global acceptance rate is high enough to halt the pandemic and it could lead to a false sense of security. Governments need to be aware of the acceptance rates in their own country. Countries such as Sweden, Nigeria, France, Poland and Russia all have acceptance rates below 65% and the interventions required in each of them will be different since the reasons why their populations are not as enthusiastic about taking the vaccine are not the same.

We are in the process of analysing which sociodemographic factors are most strongly correlated to vaccine acceptance in each country so that public health messaging on vaccines can be tailored appropriately.

How should a COVID-19 vaccine be allocated?

Ayman El-Mohandes: There are many unanswered questions about the most effective way to allocate the vaccine. Two main high priority groups should be defined: those who are at high risk of succumbing to the disease and those that are more likely to be exposed and to disseminate the infection.

A vaccine won’t make much difference to the spread of disease if less advantaged people in overpopulated urban communities, who are more likely to take public transport and less likely to be working from home, are not accepting of it.

We may start with a certain vaccination policy but find that as time goes on changes are required. Maybe children will have to be vaccinated to prevent bringing the disease home from school, the elderly don’t live in a bubble…We face a steep learning curve.

What can be done to improve the acceptance rates?

Ayman El-Mohandes: The content and dissemination of public health messaging on the COVID-19 vaccine needs to be appropriate for the segment of the population that is being targeted.

The least we can hope for is that our political leaders will set a good example by showing that they are willing to take the vaccine; this may help instil some degree of confidence. Seeing a wide array of role models or opinion leaders embracing public-health behaviours can go a long way.

I continue to be amazed at how little people know about what a vaccine is and how it works. The Pfizer and the Moderna vaccine use a completely new technology in vaccine production, they are not starting from the live or an attenuated form of the virus. We need to ensure that people understand what it is. Similarly, the term ‘herd immunity’ is thrown around often without adequate understanding of how it stops the spread of infection.

We need visuals, clear explanations and descriptions…I am not seeing enough of this. We now have the opportunity to issue these messages. Some will be cognitive, but others should be reassuring to reduce people’s fears.

What should we do until a vaccine becomes available?

Ayman El-Mohandes: We need to keep propagating the message of protecting oneself and others by using a mask, social distancing, avoiding crowded places…all of these are very important measures. As we see resurgences in many places, there is a lot of worry about the overlap of symptoms with those of flu. To reduce that confusion and over-testing, people are being encouraged to take the flu vaccine.

We are not accustomed to this level of control over our personal choices and certainly not for this length of time. As months go on, we may see a loosening of self-monitoring as COVID fatigue sets in and manifestations of discomfort with the limitations on our personal freedoms.

We need to maintain vigilance and keep people motivated to remain engaged with the recommendations. We can’t just continue to presume that scaring people into doing the right thing is the only way. We are starting to see more positive messages reminding people that their efforts are appreciated, that we are in this together and that wearing a mask shows good citizenship.

Health communication specialists need to gear up their campaigns to remotivate people because we are in this for the long-haul. If we think about the plague, for example, it lingered for decades and people had to modify behaviours for a very long time to protect themselves and those around them.

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