COVID-19 vaccination rates remain low in most countries in Africa. As of July 2022, only 24.4 percent of the population had received at least one dose, compared with the global average of 69.0 percent.1 While vaccine shortages were once the primary barrier to uptake, global dynamics have changed substantially over the past two years. Increasingly, vaccine sentiments and limited access due to delivery challenges are more pressing obstacles to COVID-19 vaccine uptake in many African countries.
According to the Africa Centres for Disease Control and Prevention (Africa CDC), 16 African nations have gone through at least five waves of COVID-19 infection as of June 2022.2 Improving uptake of COVID-19 vaccines is as important as ever, but it will require a deeper understanding of the barriers to, and drivers of, vaccine uptake—an understanding informed by practical, localized research. Public-health stakeholders across Africa—governments, nongovernmental organizations (NGOs), healthcare providers, donors, and international organizations—need better data and insights than are currently available to inform decisions on both short-term and longer-term vaccination priorities. This article summarizes the limited landscape of current research efforts in Africa and describes the attributes of more in-depth research that would be beneficial to increasing vaccine uptake.
Expanded research would yield more actionable insights
Although some research efforts are under way across Africa, they focus primarily on vaccine acceptance or sentiment rather than on a broader set of barriers and drivers influencing uptake that capture the full context of the vaccine delivery environment and citizen decision-making process (see sidebar “Select vaccine sentiment research initiatives in Africa”). These barriers and drivers extend beyond individuals' perceptions and beliefs to social factors such as community influence and behaviors; logistical factors such as vaccine availability, access, or ease of vaccination; health-related factors; and incentives and rewards to motivate vaccination. However, even when we look at research on vaccine sentiment alone, there is much less information available about populations in Africa compared with other regions in the world. For every 100 publicly available studies investigating COVID-19 vaccine sentiment in North America or Europe, there are an estimated 57 available studies covering Africa.3 Without sufficient research, stakeholders in Africa lose out on an opportunity to better understand their own citizens. Despite best intentions, public health institutions and community stakeholders could be deploying valuable resources to the wrong efforts, programs, and campaigns.
Insofar as the available research does provide relevant insights about which strategies and initiatives work (or do not work) to address vaccine sentiment challenges in Africa, it typically is not consolidated and disseminated broadly or quickly enough for relevant stakeholders to coordinate and act upon it in a timely fashion.
Stakeholders can conduct additional, targeted research to develop a fact base that will inform strategies, help set priorities, and make the most of the limited capacity and resources available in the region for COVID-19 (or other) vaccination programs. However, not all research is equally useful, and it is important that this research provides actionable insights to inform decisions. We believe there are four critical elements of an effective approach to this research:
Localized: Rates of vaccination for the adult population as of June 2022 vary widely across the continent, from nearly 72.0 percent reported in Rwanda to less than 0.1 percent reported in neighboring Burundi.4 Vaccine sentiment also varies widely from one country to another and even within countries, depending on factors such as urbanicity, demographics, employment rates, and education levels. For example, according to a study conducted by Africa CDC in late 2020 in the Democratic Republic of the Congo, 85 percent of people in the Kasaï-Occidental region reported a willingness to get vaccinated, in contrast to only 38 percent of people in the Équateur region.5 Stakeholders must avoid extrapolating findings obtained from research in a single region or country and applying them to the whole continent.
It is also important to translate materials to local languages and tailor research to the local context with an understanding of the local institutions and individuals that provide healthcare, transportation and infrastructure systems, and societal and familial norms. Geographies with limited digital penetration and consumer research may require localized approaches to data collection, particularly to engage hard-to-reach populations. These approaches could include face-to-face interviews, SMS, or computer-assisted telephone interviewing (CATI) research.
Actionable: The research conducted will have limited usefulness if it is not specific and actionable. Research on vaccine uptake should strive to illuminate not only individuals’ perspectives and thoughts but also the barriers and drivers that influence vaccine uptake so that policy makers and NGOs might be better able to find tangible interventions and programs to test.
For example, although previous studies (such as those conducted by Africa CDC and various academic researchers)6 have shown a lack of trust in COVID-19 vaccines across communities in Africa, understanding this mistrust on its own does not necessarily inform a specific action. Unpacking the source of mistrust is more helpful: Does mistrust extend to the overall healthcare system and all types of vaccines, or is it specifically related to COVID-19 vaccines? What is the role of access to information or misinformation? Furthermore, gathering research on mechanisms that would address trust challenges can inform strategic action: Who are the stakeholders, and what are the channels or key messages that would be effective in strengthening trust? Addressing these questions may require additional evaluation methods beyond surveys—for example, testing messages or monitoring uptake results based on specific communications campaigns and interventions—but would provide valuable additional data to inform decision making.
Iterative: The research approach—including the format, questionnaire, and deployment method—should be easily replicable so that results can be collected over time. Given the rapidly evolving nature of the pandemic, researchers may consider modular questionnaires with a persistent set of relevant core questions and add-on questions that change based on the latest epidemiological and vaccine delivery status. Continuous monitoring could allow stakeholders to measure the impact of various interventions, identify trends or opportunities for further effort, and then assess the outcomes in a rapid feedback loop.
Agile: Surveys that can be deployed quickly would better support timely interventions that address barriers to COVID-19 vaccine uptake. Agile surveys should be of a reasonable length; include simple, standardized questions; and be conducted by an established research provider in the region. Given the evolving context (for example, new variants and fluctuations in vaccine availability), agile surveys that are targeted and quickly disseminated can help decision makers receive information before it becomes outdated. If researchers are aiming for journal publication, however, there may be instances in which speed of dissemination would be at odds with the academic review process, and stakeholders must consider how to best balance multiple objectives.
COVID-19 vaccine uptake research: Insights from Nigeria
From January to March 2022, McKinsey conducted a rapid survey on vaccine uptake in Nigeria to better understand beliefs about COVID-19 and the factors influencing vaccine uptake. The survey included 30 simple multiple-choice questions that could be repeated over time, thus functioning as a tracking index that can be monitored over extended periods and replicated in other countries for localized insights. It was deployed via SMS in three locally spoken languages: English, Nigerian Pidgin, and Hausa.
In congruence with the existing literature, the survey found that increasing individuals’ trust in information was an essential element of promoting vaccine uptake in Nigeria. More than 50 percent of unvaccinated respondents said they had some, little, or no trust in the information they had received about COVID-19 and the vaccine; 37 percent of unvaccinated respondents cited lack of trust as a barrier to vaccination.1 Thirty-six percent indicated they would be more likely to get vaccinated if they had greater trust in the information received (exhibit). Although health workers were the most trusted source of information (selected by 68 percent of all respondents), personal vaccination decisions were most influenced by family and friends (45 percent) and religious leaders (22 percent). These data imply that initiatives that leverage healthcare professionals to increase trust and vaccinated family and friends to encourage localized community uptake may be most effective in driving vaccine adoption.
Information was a second important theme in promoting COVID-19 vaccine adoption. Conflicting information, selected by about 45 percent of all respondents, was the most cited barrier to vaccination, regardless of vaccination status.2 Insufficient information about the vaccine was also among the top five cited barriers, highlighting a need to combat misinformation at the grassroots level, including from nonofficial or local sources.
Ease of vaccination and rewards are additional levers that may further encourage vaccine uptake. Of unvaccinated respondents who said they might be interested in getting vaccinated, about 30 percent said they would be influenced by easier access (for example, vaccination available at work or during evenings and weekends) or incentives (particularly small cash rewards). Noncash incentives—such as free airtime (cell-phone minutes), food, or drink—were noted to be generally ineffective in driving vaccination.
There is no magic bullet, and these findings suggest that a combination of targeted approaches will likely be needed to encourage vaccine uptake in Nigeria. Depending on regional feasibility, Nigerian stakeholders may consider combating misinformation and barriers to trust by amplifying positive influential voices, improving ease of access to vaccines, and offering small cash rewards. Furthermore, since public-health stakeholders may already be deploying interventions in line with these approaches, additional targeted testing of specific interventions—for example, A/B testing of key messages and channels, locations for vaccination access, or various cash reward amounts where feasible—could help drive greater impact.
Using these four important design principles, McKinsey designed and conducted a vaccine uptake research study in Nigeria (see sidebar “COVID-19 vaccine uptake research: Insights from Nigeria").
Building capacity for the future
As countries in the region begin to ease restrictions, there may be a growing perception that we are nearing the end of COVID-19. However, the ongoing threats of new variants and reinfection—made more likely by lack of compliance with mitigation strategies due to pandemic fatigue—necessitate further investment in a research-led approach to inform public-health policy makers and stakeholders. Given the continent’s low COVID-19 vaccination rates, this investment is particularly relevant in Africa. Research on vaccine uptake—conducted in a manner that is localized, actionable, iterative, and agile—should be widely shared to provide decision makers with relevant information and reduce duplicative efforts.
Moreover, a research-led approach has benefits for African public health systems beyond the immediate COVID-19 response. The COVID-19 pandemic has already adversely affected routine immunization efforts in Africa, and further research is needed to determine the extent to which COVID-19 vaccine hesitancy may be influencing this behavior.7 Additional research on vaccine uptake could also benefit routine immunization programs and non-COVID-19 immunization campaigns, including human papillomavirus (HPV) and measles. By building the capacity and capabilities to quickly gather, understand, and act on citizen sentiment, stakeholders can build healthcare systems that are more citizen-centric and effective in delivering outcomes.
