Correlates of COVID-19 Vaccination Intentions and opinions about mandates among four groups of adults in South Africa with distinct vaccine intentions: Evidence from a large national survey

Introduction: Despite a high number of recorded COVID-19 infections and deaths in South Africa, COVID-19 vaccine coverage remained low in March 2022, ten months into the national vaccine roll-out. This study provides evidence on the correlates of vaccine intentions, attitudes towards vaccination and opinions about mandates. Methods: We used data from the second COVID-19 Vaccine Survey (CVACS), a telephone survey conducted February-March 2022 among 3,608 South African adults who self-reported not being vaccinated against COVID-19. The survey instrument was designed in consultation with government, policymakers, and civil society; and segmented the sample into four distinct groups with different vaccine intentions (synonymous with vaccine hesitancy levels). Kruskal-Wallis and Mann-Whitney tests were used to examine the sociodemographic characteristics, attitudes and behaviours associated with the different vaccination intentions groups. Thematic coding of responses to open-ended questions elicited insights on reasons for not being vaccinated and attitudes towards mandates. Results: Intentions to get vaccinated were greater among individuals with lower socio-economic status (Mann-Whitney Z=-11.3, p<0.001); those believing the vaccine protects against death (Kruskal-Wallis 𝛸 2 =494, p<0.001); and those who perceived themselves at risk of COVID-19-related illness (𝛸 2 =126, p<0.01). Vaccine intentions were lower among individuals who believed that the vaccine causes death (𝛸 2 =163, p<0.001); believed that the vaccine is unsafe for the babies of pregnant/breastfeeding mothers, or the chronically ill (𝛸 2 =123, p<0.01); those not trusting government health information about COVID-19 and the COVID-19 vaccine (Kendall’s 𝜏=-0.41, p<0.01); and those in opposition to mandates (𝜏=0.35, p<0.001). Only 25% supported mandates, despite 48% thinking mandates would work well, with 54% citing individual rights as their main reason for mandate opposition. Conclusion: The profile of individuals not vaccinated against COVID-19 as of March 2022 differed markedly by self-reported vaccination intentions, underscoring the importance of tailored demand-creation efforts. To achieve comprehensive vaccination coverage, interventions to instill trust in government health information, and in the safety and efficacy of vaccines are required early in a vaccination program given the rapid emergence of pervasive vaccine hesitancy. Mandates remain an option to increase coverage but need to be carefully considered given widespread opposition.