13 December 2021 | Story Prof Michelle Engelbrecht, Dr Gladys Kigozi, Prof Christo Heunis | Photo Pixabay

Research article by Prof Michelle Engelbrecht, Dr Gladys Kigozi and Prof Christo Heunis from the Centre for Health Systems Research & Development, University of the Free State.


The emergence of Omicron, the new COVID-19 variant, emphasises how unpredictable and resilient the novel coronavirus can be. Variants tend to emerge when vaccination rates are low. Approximately 43% of the adult population in South Africa are vaccinated against COVID-19. For various reasons, many people are “vaccine hesitant”, opting not to vaccinate despite free access to this service. This highlights the importance of vaccine literacy, particularly within the context of widespread contradictory information about COVID-19 vaccines. Health literate individuals understand the reasons behind medical recommendations, take cognisance of the possible outcomes of their actions, and may better understand the risks of taking or not taking vaccines. 

With this in mind, the Centre for Health Systems Research & Development undertook a study to determine people’s abilities to collect and understand information about vaccinations in order to make an informed choice when opting whether or not to have the COVID-19 vaccine. We conducted an online survey among the adult population in South Africa in September 2021. The survey, which was available on a data-free platform, was advertised on social media and via the Moya App. Participants could choose to complete the survey in Zulu, Xhosa, Afrikaans, English, Sepedi, Setswana and Sesotho. A total of 10 466 completed questionnaires were included in the analysis. 

Key findings

Approximately 60% of respondents were not vaccinated. A geographic distribution of unvaccinated people revealed that approximately two thirds of people residing in North West (70%), Mpumalanga (68%), and Northern Cape (64%) had not been vaccinated, while the Free State had the lowest percentage of unvaccinated persons (46.1%). An overall profile of unvaccinated people indicates the following groups: 

• More women: 67% of women compared to 56% of men were not vaccinated.
• Younger people: 75% of persons 18-34 years were not vaccinated compared to 35% of people 35 years and older. 
• Less educated people: 70-75% of persons with no formal education, primary or secondary education had not vaccinated compared to 44% of people with tertiary education.
• Unemployed, part-time employed and students: 74% of unemployed people, 55% of students and part-time employees were not vaccinated compared to 35% of full-time employees and 18.9% of retirees. 
• Vaccine illiterate people: There was a significant association between higher scores on the vaccine literacy scale and being vaccinated. More people with higher vaccine literacy scores were vaccinated compared to those with lower scores.

Approximately 30% of unvaccinated people were unsure if they would vaccinate in the future and 16% said that they would definitely not do so. The main reasons for not vaccinating or being unsure whether to vaccinate included: concerns about the side effects (26%); perceptions that vaccines had been developed too rapidly (12%); desire to obtain natural immunity (10%); fear of needles (10%); questioning whether vaccines are effective (8%); and being against vaccines in general (7%).

Most people had heard about COVID-19 vaccines via social media (21%), television (21%) or radio (18%), with 12% indicating that they had heard from healthcare workers. Research has found that the spread of misinformation on social media and other channels can influence COVID-19 vaccine confidence. 


These findings highlight the importance of vaccine literacy when making a decision whether or not to vaccinate. They also suggest that when advertising COVID-19 vaccines there should be a concerted focus on the following groups: women, younger people, less educated people; the unemployed, part-time employees and students. People need access to accurate information from reputable sources that address issues such as concerns about the side effects of COVID-19 vaccines; how the vaccines were developed and why it was possible to develop vaccines so quickly; as well as the effectiveness of the vaccines. Vaccine literate people should be able to identify misinformation about vaccines and assist in spreading accurate information that can assist their family, friends and colleagues in making decisions about the vaccines. 

A limitation of this study is that only people with access to a smartphone, tablet or computer could complete the online questionnaire. Furthermore, the survey was open during September, which was when people 18 years and older had just become eligible for COVID-19 vaccines. This may partially account for the low number of vaccinated people in the 18-34 year age group. 

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