1 Introduction

For most countries the development of a safe and effective vaccination for COVID-19 is seen as the long-term solution to the COVID-19 pandemic. A critical step in extinguishing the pandemic will be vaccination of a high proportion of the population in the context of increasing misinformation, vaccine hesitancy and lack of trust in science. In this paper we present evidence from a large nationally representative survey of vaccination intentions to a safe and effective COVID-19 vaccine. We document the demographic, attitudinal, political and social attitudes and COVID-19 health behaviour correlates of vaccine hesitance and resistance to a COVID-19 vaccine. We focus on lower and higher levels of hesitancy and resistance to vaccination, as tailored public health information campaigns may well be more effective for those who are less hesitant.

Herd immunity of populations is a product of several factors, the infectivity of the coronavirus [1], the effectiveness of the vaccine and the percentage of the population vaccinated. Estimates of infectivity of the coronavirus suggest that with a 100 per cent effective vaccine, 67 per cent of the population needs to be vaccinated [2] but that vaccination coverage needed varies by infectivity (55 per cent when R₀ = 2.2 to 82 per cent when R₀ = 5.7 [3]. Simulations suggest that solely relying on a vaccine to extinguish a COVID-19 epidemic would require vaccination coverage of 100 per cent with vaccine effectiveness of 60 per cent [4]. For 80 per cent effectiveness of a vaccine, coverage of 75 per cent of the population would be required [4], a high vaccination rate to ensure eradication or control of the coronavirus in populations.

Research to date suggests that COVID-19 vaccination intentions vary substantially between countries [5]. Vaccine hesitancy (being unsure about getting a vaccine) usually accounts for a more substantial share of the population who will not be vaccinated than vaccine resistance (those who object to vaccines). For instance, in the United States 21 per cent were probably willing and 31 per cent were not willing to have the COVID-19 vaccine [6] while nationally representative surveys in the United Kingdom reported 25–27 per cent were hesitant, and 6–9 per cent resistant [7, 8] and in Canada reported 19 per cent somewhat likely, 9 per cent did not know and 14 per cent unlikely to get the COVID-19 vaccine when available [9]. A cross-national representative survey of over 7,000 participants in seven European countries (Denmark, France, Germany, Italy, Portugal, the Netherlands, and the UK) reported that across these countries 19 per cent were hesitant (not sure) and 7 per cent would not get vaccinated [5]. However, there was substantial variation between countries with vaccine hesitancy 12–28 per cent while resistance ranged from 5–10 per cent [5]. In Australia vaccine hesitancy to a COVID-19 vaccine has been reported at 9 per cent and vaccine resistance 5 per cent however this evidence was from a non-representative online survey [10].

The World Health Organisation’s Strategic Advisory Group of Experts (SAGE) have suggested governments take a proactive response to vaccine hesitancy ‘hotspots’ based on social and behavioural insights [11]. Therefore, nationally representative information is important for an agile response to COVID-19 vaccination. Using a representative longitudinal survey of over 3000 participants from Australia we examine the demographic, attitudinal, political and social attitudes and COVID-19 health behaviour correlates of vaccine hesitance and resistance to a COVID-19 vaccine. We distinguish between those who may get the vaccine but are not sure (hesitant) from those who will definitely get the vaccine because they are usually a large percentage of the population, and unlike vaccine resistant individuals, are likely to be convinced about public health messaging and information about vaccine safety [12]. We also examine those who will not get the vaccine (resistant). Given the Australian government has indicated that the COVID-19 vaccine would be provided free to the population, consistent with previous research on vaccine hesitancy [7, 13] we hypothesise that confidence in government and science, attitudes towards COVID-19 and adherence with public health messages, conservative and authoritarian political attitudes will be more important than demographic characteristics [7, 8, 13]. We also test whether downloading the COVID-Safe app was related to vaccine hesitancy or resistance.

The remainder of the paper is as follows, Section 2 outlines the methodology including the study design and participants, survey questions and statistical analyses. Section 3 shows the results and Section 4 discusses the results in the context of previous research and their implications.

2 Methods

3 Results

3.2 Correlates of vaccine hesitancy and resistance

Descriptive statistics for covariates in the statistical modelling can be found in the S1 Appendix. Table 1 shows the marginal effects from model 1, which included demographic, socioeconomic and geographic variables.

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Table 1. Demographic correlates of vaccine resistance and hesitancy, marginal effects.

https://doi.org/10.1371/journal.pone.0248892.t001

Females were less likely than males to intend to get the vaccine, and more likely to be hesitant and resistant. Those who were older (55–64, 65–74 and those over 75 years) were less likely to be resistant or hesitant and more likely to intend to get vaccinated when it became available than those aged 35–44 years old. Compared to those had Year 12 only, those with an undergraduate or postgraduate university degree were less likely to be resistant or hesitant and more likely to intend to be vaccinated.

There were neighbourhood differences, those living in the 4^th most disadvantaged quintile of disadvantage were less likely to intend to get vaccinated when compared to those living in the 3^rd quintile. Individuals living in households with more household income were less likely to be resistant or hesitant and more likely to intend to get vaccinated. All other demographic variables were not statistically significant.

Health and disability status were not associated with vaccine intentions (model 2, see S1 Appendix).

In model 3 COVID-related variables were included as well as demographic variables (see S1 Appendix). Contrary to other research on the likelihood of getting vaccinated to COVID-19 [13] individual concerns or concerns about relatives or friends contracting COVID-19 were not related to vaccination intentions. Being tested for coronavirus was also not related to vaccination intentions.

People who reported greater levels of social distancing behaviour were less likely to be resistant and more likely to intend to get vaccinated. Similarly, those that had downloaded the COVID-Safe App were less likely to be resistant (-3.0 percentage points lower) or hesitant (high: -2.7 percentage points and low: -5.1 percentage points) and more likely to intend to get vaccinated (+10.8 percentage points). Those who thought too much fuss had been made about COVID-19 were more likely to be resistant (8.1 percentage points) or have high levels of hesitancy (4.2 percentage points) and less likely to intend to get vaccinated (-14.9 percentage points less likely).

In Model 4 we added political and social attitudes to demographic characteristics (see S1 Appendix). There were no statistically significant differences by levels of social trust, altruism or support for authoritarianism. Compared to those who voted for the Coalition, those who voted for Labor were less likely to be resistant (-1.6%, p<0.10), hesitant (high: -1.5%; low: -3.2%) and more likely to intend to get vaccinated (6.3%, p = 0.05).

Those who had confidence in their state or territory government or in their hospitals and health system were less likely to be resistant (-3.4 and -4.4 percentage points respectively) or have high levels of hesitancy (-2.8 and -3.4 percentage points respectively) or have low levels of hesitancy (-4.8 and -5.2 percentage points respectively) and more likely to intend to get vaccinated (11.1% and 13.0% respectively).

Those who were more religious were less likely to intend to get vaccinated. People who had more populist views were more likely to be resistant or hesitant (at high or low levels) and less likely to intend to get vaccinated. Finally, those who were more likely to support migration were less likely to be resistant and more likely to intend to get vaccinated.

The final model included statistically significant variables from models 2 to 4 and demographic variables (Table 2). Females were less likely to intend to get vaccinated while those aged 55 and over were more likely to intend get vaccinated. Those with higher household income were less likely to be resistant and more likely to intend to get vaccinated. Differences by levels of education observed in model 1 were explained by other variables. Neighbourhood differences by socio-economic index for areas were evident with those living in the most disadvantaged area more likely to be resistant or hesitant (at high levels) and less likely to intend to get vaccinated.

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Table 2. Correlates of vaccine resistance and hesitancy–final model, marginal effects.

https://doi.org/10.1371/journal.pone.0248892.t002

People exercising greater levels of social distancing were less likely to be resistant and more likely to be vaccinated. Those who downloaded the COVID-Safe App were less likely to be resistant or hesitant and more likely to intend to get vaccinated. Those who reported too much fuss had been made about COVID-19 were still more likely to be resistant or hesitant and less likely to intend to get vaccinated.

Those who had confidence in their state or territory government or confident in their hospitals and health system were less likely to be resistant or hesitant (at high or low levels) and more likely to intend to get vaccinated. People who were more supportive of migration were more likely to get vaccinated.

Those who reported more populist views were more likely to be resistant or hesitant (at high or low levels) and less likely to intend to get vaccinated. This pattern of results was also evident in terms of level of religiosity although this finding should be treated with caution as there was a higher level of uncertainty around the estimates (statistical significance was only at the 90% level). Similarly, those living in Victoria, with by far the highest numbers of COVID-19 infections in Australia in August 2020, were significantly less likely than Australians from other states to get vaccinated but this was not evident in other statistical modelling, bivariate analyses and should not be considered a robust finding.

4 Discussion

In August 2020 36 per cent of Australians are hesitant and 6 per cent resistant to being vaccinated with a safe and effective vaccine for COVID-19 if one was available. Given previous research suggests that the factors associated with vaccine resistance might be different to vaccine hesitancy, we examined demographic, health, COVID-19 related health behaviour and attitudes, and political and social attitudinal correlates.

Many factors were associated with vaccine resistance and hesitancy. Consistent with previous research, females, those with lower levels of household income and living in disadvantaged areas were associated with increased likelihood of vaccine resistance or hesitancy [7, 13]. However, in contrast to previous research, younger people were not less likely to intend to get vaccinated than those aged 35–44 years.

Less adherence to COVID-19 health behaviours was consistently associated with lower likelihood of being vaccine resistant or hesitant (social distancing and downloading the COVID-Safe app) and these were strongly related to vaccine intentions [13]. For example, downloading the COVID-Safe app was associated with an increase of 11 percentage points in the likelihood of being vaccinated. Similarly, there was a seven-percentage point increase in the likelihood of intending to be vaccinated for COVID-19 if an individual moved from the 16^th percentile in terms of social distancing to the 50^th percentile (a one standard deviation increase). Given that many governments have tracking surveys about social distancing, this information could be used to support targeted campaigns to encourage vaccination in areas of low social distancing.

Consistent with other studies of COVID-19 several variables that could be considered associated with broader societal dissatisfaction and anti-establishment sentiments were also associated with vaccine resistance or hesitancy. Specifically in this study, attitudes about too much fuss being made about COVID-19, lack of confidence in state or territory government, and having more populist sentiments [7, 16]. Other studies have also independently reported that religious beliefs associated with declining a COVID-19 vaccine [13].

For many with low levels of hesitancy, providing information about the safety and efficacy of the COVID-19 vaccine will be critical as other studies have highlight this as important hesitancy [13, 17]. Our analyses suggest that those with resistance or hesitancy are likely to lack trust in those providing health services (e.g. state governments or health systems) and therefore the misinformation about the COVID-19 vaccine that will occur may be even more effective for these groups. Pre-emptively using cognitive inoculation techniques and pre-bunking techniques [18] to actively work against the likely misinformation that will be generated in the development and preparation phase of a vaccine for COVID-19 will be important but probably requires more targeted and nuanced public health messages by trusted members of the community including doctors, journalists and politicians. Other strategies to engender trust among the population could include enlisting community and cultural leaders to assist in the development and spread of information [19].

Those with higher vaccine resistance or hesitancy are more likely to have a set of strongly held beliefs, a lack of trust in those responsible for health (state or territory government and hospitals or health systems) and lower levels of compliance with public health advice for COVID-19 (e.g. lower levels of social distancing, not downloading the COVID-Safe App). If large scale surveys collect information on the extent of compliance with health advice, further nuanced targeting could be employed. Beyond more sophisticated and nuanced public health messaging, it should be noted that a systematic review of research on compulsory vaccination policies suggests that the majority of the population supports these programs [18]. However, none of the studies in the systematic review were conducted during a pandemic where civil liberties were restricted due to lockdowns [19] and a staged approach may well be more proportional [20].

While we used a rich set of variables to predict vaccine intentions some factors were not collected in our surveys. In particular, we did not collect information about concerns about vaccine safety which may be important determinant of vaccine hesitancy and may also explain why females were more likely to be hesitant or resistant than males. Another robust correlate in other studies of vaccine intentions is previous vaccination such as for influenza [13]. Vaccine safety and public discourse will likely be particularly important as media and public scrutiny of vaccine trials is unprecedented for COVID-19 vaccines and further monitoring of public sentiment [7].

Another issue that we did not address in this paper is if there are initial shortages of a vaccine how would these be distributed? A survey experiment using these participants suggests that essential health workers, those with a health condition, those in areas with high levels of COVID-19 and with caring responsibilities should get priority [21]. Moreover, vaccine intentions of respondents did not change these priorities.

5 Conclusion

Given that over 75 per cent of the population are likely to need to be vaccinated with a highly effective vaccine to extinguish the epidemic [4] our findings that only 59 per cent of Australians will definitely get vaccinated is sobering and suggests that as noted by WHO [11], proactive measures need to be adopted by countries to encourage vaccination in the community. Our findings suggest that vaccine hesitancy, which accounts for a further significant proportion of the population, and can be addressed by public health messaging. However, for a significant minority of the population with strongly held beliefs that are the likely drivers of vaccination intentions, alternative policy measures may well be needed to achieve sufficient vaccination coverage.

Supporting information