CPHA Canvax

How Government Policies and Political Ideologies Impact Vaccine Acceptance: COVID-19 and Beyond

Noni E MacDonald, Eve Dube, Janice Graham

Noni E MacDonald1, Ève Dubé2, Janice Graham1 

  1. Department of Pediatrics, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia
  2. Institut National de Santé Publique du Québec and Université Laval, Québec, Québec 

In 2019, the World Health Organization (WHO) highlighted the importance of addressing vaccine hesitancy, listing it as one of the top ten global threats to health.1 The April 2021 policy briefing, Enhancing COVID-19 Vaccine Acceptance in Canada, published by the Royal Society of Canada, posited pivoting away from the largely individual-focused concept of “hesitancy” to a more encompassing community-based term of “acceptance.” “Acceptance” recognizes the wider context of government policies and programs, and political ideologies that may present barriers to or enable vaccine access and influence individual and community beliefs, attitudes and behaviours towards immunization.2 

The complexity of a wide range of social, political and biomedical issues in interaction with government policies and political ideologies influences decisions about vaccine acceptance, marking it as a “wicked problem.”3 Over the past decade, several frameworks and models have been proposed to bundle these factors, to help in understanding the concept of vaccine acceptance and align potential strategies to address this wicked problem. The initial 3 “Cs” model in 2014 – confidence, complacency, and convenience4 – evolved into the 5 “Cs” model in 2018 with the replacement of the word convenience with the word constraints and the addition of collective response and calculation.5 In contrast, the 5 “As” model in 2016 broadened the scope of influences on uptake by focusing on access, affordability, awareness, acceptance, and activation.6  The more recent WHO Working Group on Behavioural and Social Drivers of Vaccination honed in on the drivers of vaccine acceptance in four areas: what people think, social processes, motivation, and practical issues.7 

Two contentious aspects neither highlighted nor specified in these frameworks are the jurisdictional-specific policies (e.g., government laws, regulations and policies) and the ideologies of government and partisan politics at the national, provincial, and municipal levels (e.g., influence on policies and actions and inactions on problems) that might influence vaccine access and the vaccination beliefs and choices of citizens. The 2021 Royal Society of Canada’s Vaccine Acceptance Framework explicitly highlights these aspects of federal, provincial, territorial and Indigenous policies, programs, practices and politics in the Healthcare System domain as being integrative factors in influencing vaccine acceptance (see Figure 1).8

Figure 1: The Royal Society of Canada Vaccine Acceptance Framework of factors influencing vaccine acceptance

Politics and Vaccine Acceptance Image_EN

The COVID-19 pandemic has raised attention on the role both government policies and political ideologies have been playing in the shaping of domestic and supranational vaccination policy, including vaccine availability9, program implementation, and policies’ influence on individual/community acceptance and uptake.

At the community level, lived experiences of government legacy policies influence vaccine acceptance amongst equity-deserving groups, such as Indigenous, LGBTQ2S+, racialized, pregnant, immunocompromised, and persons with disabilities.10 Politicians responded in various ways to communities reluctant to accept COVID-19 immunization, ranging from ignoring them11,12 to providing structural (e.g., financial, policy, legislative) support in developing specific programs adjusted to meet their particular needs.13  Some communities carried out specific programs themselves in the absence of political or governmental assistance.14 

While many programs were successful, challenges still remained for increasing vaccine acceptance in some communities. In Quebec, for example, more than 70% of adolescents12 years and older had received their first dose of the COVID-19 vaccine by June 2021, but adolescents is some communities remained unvaccinated.15 Among the Nunavik Inuit in the province, government distrust persisted, despite intense community outreach.16 In instances similar to this example, low uptake needed to be understood not only as a matter of individual values, attitudes and knowledge, but as a consequence of centuries of systemic racism and unequal power relationships with colonial governments.17 These intersectional positionings (historical and current policies and practices, laws and politics) must be considered in developing public health strategies to address reluctance to accept vaccines. Therefore, co-creation of programs with communities is crucial in order to build equitable relationships and trust.

In addition to government policies and programs, political ideologies also impact vaccine acceptance. Ideological influences are most apparent in the United States, where partisan politics has markedly influenced vaccine uptake.18 With just over 50% of Americans having received one dose,19 after peaking at 3.4 million per day in April 2021, vaccine acceptance had fallen to less than a million per day by early June 2021, and rates varied in states from over 70% immunized to under 35% immunized.20 For example, states such as Vermont offered potential insights into the importance of a common public health goal, with well over 70% vaccine uptake and strong support for COVID-19 vaccines across the political spectrum.21 On the other hand, vaccination had less uptake and support in states such as Mississippi, with less than 35% of the population vaccinated; this was well linked to voting patterns.22 Similar to the Nunavik example, lower vaccine acceptance rates occurred in some ethnic and racialized communities in the U.S., which could be related to underlying issues of historical and systemic inequity and distrust.23 

Recognizing the impact of historical and present government policies and political ideologies on current vaccine (both COVID-19 and routine) access, delivery and acceptance is crucial to developing programs tailored to communities across Canada. Addressing structural challenges is difficult, as provincial/territorial governments fund public health through federal transfer agreements, and public health officials have little power to directly influence policy or “do-nothing” policy decisions. Therefore, change to proactively and pre-emptively address vaccine acceptance and uptake requires acknowledging how government policies and political ideologies impact vaccine confidence and trust, and requires a concerted effort from a broad spectrum to address the challenges and barriers these factors create. For instance, public health, academics, nongovernmental organizations, civil society, and specific public/private interest groups need to highlight the evidence on strategies to improve vaccine acceptance for equity-deserving communities and the general population. The media needs to be a conduit for best evidence and aggressively expose non-evidence-based policies and non-action. Finally, community activists and civil society leaders must demand programs that fit their communities’ needs and push them forward.24

Lessons learned from government policy and political ideological experiences during the COVID-19 pandemic and the COVID-19 vaccine rollout will, it is hoped, help Canada and other countries deliver better routine health care and routine immunization programs. While Canadian governments have made strides in addressing inequities and removing systemic barriers to vaccines through programs and legislation, these need to be more multipronged and multifaceted, with stronger community co-creation. Minimum wage levels above the poverty line, sick days for those in part-time and low-wage positions, and dismantling culturally biased roadblocks to health care and vaccine access are but a few issues that must be addressed now. COVID-19 is not yet under control, and higher vaccine acceptance in all groups is necessary in Canada and globally. Using oversimplified models can and did lead to a focus on overly simplistic strategies. The complexity emphasized by the Royal Society of Canada’s Vaccine Acceptance Framework must be borne in mind with COVID-19 and routine vaccine program development to encourage and support vaccine acceptance across Canada and throughout the life course. Politics and government policies do influence vaccine acceptance and can no longer be ignored.


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