To date, we have had good uptake of Covid-19 vaccines. Healthcare workers, the elderly and the vulnerable have been quick to take a vaccine. As time runs on, it would seem that registration for vaccination is not quite as enthusiastic as early signs might have had us believe.

Last week, we heard 220,000 people aged 60-69 chose not to register on the vaccine portal. The latest Amárach poll does not auger well. Approximately 70 per cent of respondents report they will definitely take the vaccine. Due to the high proportion of children in Ireland who cannot be vaccinated, we need almost all adults to be vaccinated to prevent another wave of infection. The need to understand people’s concerns about the Covid-19 vaccination is imperative.

Low trust is associated with low vaccine uptake and can lead to persistent disease outbreaks and clusters

Hospital Report

A significant proportion of our population, one in five respondents, are non-committal or at best lukewarm about their plan to take the vaccine. Looking at the international literature, we can see this same pattern emerging elsewhere. Hesitancy becomes an increasing problem as the vaccine rollout continues and those who feel less threatened by Covid-19 – the healthy, younger cohorts – are offered vaccination. In cross-national studies, trust is strongly associated with vaccine acceptance and a stronger predictor of intention to get vaccinated than knowledge.

Trust can be both built and broken. For some, most often women, the young, the poor and the less-educated, trust in science, medicine and pharma is comparatively weaker. The Amárach polls bear this out. Overall these groups are less willing to be vaccinated. This dearth of trust is not without justification. Take the younger generation for example. They have grown up watching the increasingly questionable behaviour of medicine and big pharma. Their mistrust of medicine and pharmaceutical companies is grounded in a reality of many false claims and cover-ups over the last 30 years. Similarly, young people’s trust in government has been violated in big and small ways before, including during this pandemic. They have not been protected from a housing crisis and the intersection between poor housing and infection risk has been clear throughout the pandemic.

Historical crimes in Northern Ireland

---

Scotland and the UK

---

Charges and environmental targets

---

Dublin city centre is in a sorry state

---

Confidence and scepticism

Of course, a key barrier to vaccination uptake is safety concern. Over the last two months, Amárach polling indicates that these concerns have increased week on week. Almost 40 per cent of our population are now concerned about vaccine side-effects. Some vaccines have a higher risk of side-effects in young people. Whether or not the AstraZeneca vaccine is suitable for younger people is back in the news. Germany is again allowing its use, having previously banned it before allowing it in the first instance. This just doesn’t inspire confidence for those who might be already sceptical.

A cornerstone of trust is being consistent and aligning decisions with the available knowledge. As I listened to an immunologist on the radio criticising the decision to give the less efficacious but available AstraZeneca vaccine to older cohorts, I was very struck by his statement that he had lost trust in the Government’s method of vaccine allocation. It seems his trust had been compromised by the misalignment of the knowledge that the best protection for older people, who are at the greatest risk of severe Covid-19 disease, is with the mRNA vaccines, Pfizer and Moderna.

It is perhaps then not surprising that the latest Amárach vaccine polling suggests that, as things stand, only one in two people appear to trust Health Service Executive and Department of Health advice on vaccines. And trust has been on a downwards trajectory over the last number of weeks.

The vaccine rollout needs to be nuanced to the concerns of those who by virtue of their gender, age and educational position are least likely to trust

There is clear evidence measures that constrain choice – in an attempt to force people’s hand – with regard to vaccination are counterproductive. People try to subvert or game the system where trust is low. Requiring people to take one vaccine over another is likely part of the reason for the reduced uptake in the over-60s. My guess is that it will be the same for the over-50s. Trust and mistrust matters. Low trust is associated with low vaccine uptake and can lead to persistent disease outbreaks and clusters.

Dividends and freedoms

In this context, a vaccination “dividend” for individuals – in terms of additional “freedoms” – seems particularly ill-advised even if all of the vaccines were equivalent in terms of efficacy and safety. The fact that there are different “dividends” depending on which vaccine you take beggars belief. Aside from any safety concerns, this decision alters the perceived attractiveness of the jabs on offer and is enough to alter people’s preferences. We have made a difficult situation worse.

Herd immunity is the aim. Until children can be vaccinated we need all adults on board to achieve this. Vaccine dividends for individuals would be difficult to sell in the absence of corruption. And our programme has been beset by issues of queue-jumping and corruption. Age-based rollout seems to be an aspiration rather than a reality. And vaccine access seems to be terminally affected by geography. Vaccination offers shared immunity and so we should all share in its dividends – those at the front and the back of the queue, those who jumped and those who still wait.

Even in this small nation, there is much diversity. We need to build rather than break trust. The vaccine rollout needs to be nuanced to the concerns of those who by virtue of their gender, age and educational position are least likely to trust. And it needs to honour those who trust science and the system by making decisions that make sense. Trust is built with reliable friends and allies. Many groups and communities in Ireland have a strong sense of the collective, a value on relationships and reciprocity. Key and credible stakeholders within these groups who emphasise the value of the vaccine to “us all” are likely to be far more potent than Government advice, regulation or restriction.