Dr Nirvana Pillay and Dr Nancy Coulson (Sarraounia Public Health Trust) are Principal Investigators on the VaxScenes Project. VaxScenes is funded by the Human Sciences Research Council, in partnership with the Sarraounia Public Health Trust and the South African Medical and Research Council (SAMRC).

The past weeks have seen the debate on mandatory vaccination increasing in frequency and intensity. Currently vaccination is not mandatory in South Africa except for a few sectors. Notwithstanding this, debates in the public space rage on and are increasingly seeping into private spaces, too. 

Many are considering how they feel about family, friends and employees who do not vaccinate – including how to ask or enquire about vaccination, and what to do when people in personal spaces refuse to vaccinate. 

The path ahead is potentially conflict ridden and litigious. As a country, there are some important considerations before we decide which route to go with regard to mandatory vaccination.

Like many medical and health-related choices, the decision to take the vaccine is far more complicated for people than public health decision-making considers. Failure to understand this can have the unintended consequences of creating a society of blame and shame. 

People who are vaccine hesitant or unsure are not the same as “anti-vaxxers”. We need to carefully consider why people are hesitant at this time and what can be done efficiently, effectively and empathetically to address these concerns. This is crucially important when one considers that the steps to educate the population about vaccines and vaccine safety lagged significantly BEHIND the EVDS registration and vaccination drive.

The term “vaccine hesitancy” is now part of everyday language in South Africa, and the many factors of vaccine hesitancy are increasingly being discussed and debated. Many studies have provided evidence on the reasons for, and solutions to, vaccine hesitancy.

Case study research in four wards in South Africa that explored the impact of Covid-19 as well as barriers to vaccine uptake recommended that some solutions to vaccine hesitancy include improving vaccine literacy by increasing knowledge of the basic medical facts about vaccination and vaccine safety; addressing the practical barriers to vaccination (registration, transport, access); as well as communicating more effectively to dispel myths circulating on social media. This research was presented by VaxScenes to the Ministerial Advisory Committees on Vaccines and Science as Building a comprehensive ward-based response to Covid-19 in South Africa, on 7 and 8 July 2021. 

The past few weeks have seen a notable increase in interventions that address all of these. 

Vaccine literacy, however, encompasses far more than just improved knowledge of vaccination and forms a part of a wider literature on health literacy. 

Health literacy is an important element of health promotion; literacy does not simply mean understanding health information, but more comprehensively the ability “to obtain, process and understand basic health information and services needed to make appropriate health decisions” to maintain good health across the life course in a way that’s relevant in different health contexts. 

Thus health literacy must be context sensitive and consider the full range of the human experience of health and ill-health. It is addressed not simply through the provision of health information, but in understanding the breadth of the experience of health and wellbeing, the right to bodily integrity and human dignity and the ability to access information and services. 

The rapid generation of Covid-19 scientific evidence in the past 18 months has meant that public health information, communication and interventions have had to rapidly keep pace with recent scientific evidence as it emerges. This poses a challenge for health messaging and communication, and often leaves people confused as they are required to assess and appraise information on an ongoing basis. 

For example, messages about the importance of mask wearing have changed over the course of the pandemic; moving from uncertainty about the value of masks at the beginning of the pandemic to being one of the most important measures to fight Covid-19. 

People have therefore been required to absorb and digest complex scientific information to keep pace with a rapidly emerging evidence base. The enduring nature of Covid-19 and the still expanding generation of knowledge means that even though there is solid evidence that vaccines are safe and effective, there are still some uncertainties: such as how long they will last, whether we will need boosters annually or biannually, and whether they will work against future variants. 

Communicating uncertainty with integrity is essential to win the faith and trust of the wider population. 

In a context where Covid-19 has caused insurmountable suffering, and the lack of faith and trust in the government is at an all-time low, people must be taken along the journey of information and communication in a way that is sensitive to their concerns and fears, and provided with the health literacy skills to increase their agency to navigate the future of Covid-19. 

Furthermore, we need to acknowledge that information and communication will not be the panacea to managing Covid-19, and that structural barriers to accessing health services, in this case vaccination services, must be removed to ensure that all South Africans are armed with the right information to make this choice. 

With only one-quarter of the population now vaccinated, the question remains how we address this gap in a way that keeps pace with the vaccination drive to reach the remaining unvaccinated as quickly as possible; making sure that everyone has the necessary vaccine (health) literacy skills to make a considered and well-informed decision. The question of mandatory vaccination should only be addressed once we are certain that this has been achieved. DM/MC

Dr Nirvana Pillay and Dr Nancy Coulson (Sarraounia Public Health Trust) are Principal Investigators on the VaxScenes Project. VaxScenes is funded by the Human Sciences Research Council, in partnership with the Sarraounia Public Health Trust and the South African Medical and Research Council (SAMRC).