The COVID-19 pandemic continues apace, with high- and lower-income settings struggling to contain outbreaks. The vaccine rollout is relatively speedy in some countries such as the UK. However, vaccine demand is much greater than supply. This, combined with the hoarding of surplus doses from high-income countries, means that the continent of Africa is left with very few doses to protect its countries’ populations.

As of 13 July 2021, Our World in Data report that only 2.95% of the African population had received one dose of a COVID-19 vaccine. In Ghana, this figure is just 2.8%.

West Africa has handled the pandemic response relatively well thus far, with lessons learned from the 2014/15 Ebola outbreak. However, with the highly transmissible Delta variant now known to be present in Ghana, the vaccine rollout is arguably more important than ever. The Ghanaian population has very little immunity to this novel coronavirus and is thus almost entirely susceptible to infection. It is essential that people accept vaccines when doses arrive in the country.

As we know from existing international guidance, vaccine acceptance requires time, laborious engagement, planning and monitoring to be successful. In 2019, before the pandemic, the World Health Organisation described vaccine hesitancy as one of the top ten greatest threats to global health.

Much of the existing literature and knowledge focuses on the richer countries, but the scenarios faced in Ghana may be very different. Previous research has suggested there are differences in types of misinformation across countries and continents.

Also, a false sense of confidence may emerge because Ghana has a long history of successful mass vaccination campaigns, for example, pneumococcal and rotavirus vaccines. COVID-19 is different in that it is driven by a novel emerging pathogen, and the knowledge base is rapidly evolving. The general public know the impact on the quality of life of existing vaccine-preventable diseases like polio. But the strength of Ghana’s infrastructure and health workforce is up against widespread misinformation about this novel pathogen.

Our multi-disciplinary team from Ghana, Togo and the UK has conducted surveys in Ghana repeatedly over time. We focused on COVID-19 and assessed trends between August 2020 and June 2021, key drivers of willingness to vaccinate, and vaccine hesitancy.

The key findings

The first survey was conducted in August 2020 before any COVID-19 vaccines had been approved. The second round was in March 2021 at a time when the Oxford AstraZeneca vaccines had arrived in the country. Hesitancy significantly decreased between those two-time points – from 36.8% to 17.2%.

Our new report includes findings from the latest survey, which took place in June 2021, and includes 1,295 Ghanaian respondents. We saw a significant decrease in willingness, and therefore an increase in hesitancy – from 17.2% to 28.5%. Within this 28.5% subgroup, 15.1% reported that they were undecided, and 13.4% indicated they would not accept the vaccine if offered. Both of these proportions had increased since the previous survey in March.

Around one-third of respondents had read stories (for example on CNN) about the indecision surrounding the Oxford AstraZeneca vaccine in Europe and North America on social media. Worryingly, a high proportion of respondents suggested that these stories made them feel concerned about accepting a COVID-19 vaccine in the future. COVID-19 will always be a global problem that requires international collaborations and solutions. Thus, the actions of a few countries can easily have an impact beyond their borders, and this may be what we are witnessing here with observed hesitancy in Ghana.

We found the groups more likely to be hesitant were women, Christians, opposition party supporters and people with higher education.

Research in higher-income settings often shows that more years of education correlates with stronger vaccine confidence. But in other research covering African nations, there is a mixed set of findings regarding education status. It may be that younger urban populations are more likely to be educated and also have access to the internet, and thus be exposed to a mixture of good and bad information about vaccines. There may also be different voting patterns in younger education groups that affect level of trust in government messaging.

In Togo, we carried out one survey in January 2021. Hesitancy was higher than in Ghana – at 32.3%. The two main reasons provided were that the vaccines were dangerous (stated by 90% of the hesitant respondents) and that they did not trust the current government (40% of the hesitant respondents).

Considering the results across Ghana and Togo, there is a clear need for strong health promotion ahead of any future arrivals of vaccine doses. It is difficult to push good public health messages through the noise of uncertainty, misinformation, and outright conspiracy theories. For maximum impact, the information must come from trusted sources, and this may differ depending upon the receiving demographic.

Approaches to health messaging

Our results show that, generally, the Ghana health service is a highly trusted source. Many respondents obtain their vaccine-related information directly or indirectly via social media – particularly Facebook. Therefore, Ghana health service messaging via electronic platforms such as Facebook and Whatsapp can potentially be effective, but the use of multiple methods and sources will be vital.

Our research required use of the internet and access to a device. Thus, there will be an additional need to assess vaccine confidence in rural and hard-to-reach areas where access to information will be different to urban areas.

Vaccine confidence is essential if the pandemic is to be brought under control. Vaccinating a population is the endpoint, and there must be proactive approaches to health promotion and community preparedness. The Ghana health service may be the best organisation to take the lead on this, but the government, opposition political parties and employers can all contribute positive messaging ahead of the next delivery of COVID-19 vaccines.

Michael Head, Senior Research Fellow in Global Health, University of Southampton; Ken Brackstone, Research Fellow in Health Psychology, University of Southampton, and Laud Boateng, Post Doctoral Researcher, University of Southampton