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Health promotion and public health
Implementation of public policies as a strategy to increase adherence to immunisation against COVID-19
  1. Regina Ruivo Bertrand1,
  2. Renata Pereira2
  1. 1 Health Information Center, Sabara Children's Hospital, Sao Paulo, Brazil
  2. 2 Continuous Education, Pensi Institute, Sabara Children's Hospital, Sao Paulo, Brazil
  1. Correspondence to Regina Ruivo Bertrand, health information center, Sabara Children's Hospital, Sao Paulo, Brazil; r.ruivobertrand{at}

Statistics from

Commentary on: Daly M, Robinson E. Willingness to vaccinate against COVID-19 in the US: Longitudinal evidence from a nationally representative sample of adults from April- October 2020. medRxiv [Preprint]. 2020 Nov 30:2020.11.27.20239970. doi: 10.1101/2020.11.27.20239970.

Implications for practice and research

  • Studies targeting the reasons that discourage vaccination are relevant.

  • The knowledge of these reasons gives support to the improvement of public policies of education and incentive to immunisation of the population.


In February 2020, the WHO named COVID-19 the newly emerging viral infection caused by a new coronavirus nominated SARS-CoV-2. This infection resulted in a pandemic.1

Currently, vaccines that prevent severe infection by SARS-CoV-2, developed in unprecedented time frames, are identified as the most promising approach to contain the pandemic and are being widely adopted.

On the other hand, there is a concern about receiving the immunising agent and questions regarding its safety, since there are no in-depth studies on its effectiveness and efficiency, as well as on its long-term adverse effects.2


Daly and Robinson described a longitudinal study of a relevant sample of the US population from the Understanding America Study composed of adults ≥18 years old. This sample was based on probability, which allows generalisations to be made.

A total of 8547 participants were eligible and 7547 responded in the 13 waves of evaluations carried out biweekly through online interviews, from 1 April to 31 October 2020. After the exclusions of deviations from the survey, 78 453 observations were obtained. Weights were assigned for population adjustments.3

Longitudinal data as demographic variables were analysed by multinomial logistic regression: age, sex, race/ethnicity, family income, university degree and the presence/absence of chronic disease.3

Another factor studied through the application of the Likert scale was the level of agreement, with nine items evaluating their attitudes towards the existence of a vaccine against COVID-19.3


The willingness to vaccinate fell from 71% in April to 53.6% in October 2020 due to the increase in undecided and those who did not want to be vaccinated.3

The incidence of undecided or unwilling to receive the vaccine is higher in participants without a college degree, those of black ethnicity and in women, compared with those ≥65 years old, those with high family income and those of other races/ethnicities.

The analysis of attitudes found that most considered the vaccine beneficial, a good form of protection and effective if approved by regulatory bodies.

In general, concerns about the vaccine, its serious side effects and the possibility of causing long-term health problems were common.3


Several studies have shown the importance of immunity through vaccination in order to control the spread of a pandemic disease.2 4 However, for the development of vaccines, an extensive, detailed and costly process is necessary. The investment is high and it usually takes several research participants and many years of studies to produce a vaccine that is safe, effective and authorised by regulatory agencies. The accelerated development of an immuniser requires a new pandemic study paradigm, with a quick start and several steps carried out simultaneously before even confirming a successful result from another step.4

The need to accelerate this process generates a feeling of insecurity about its related adverse events and also about its benefits, making people reluctant to receive the vaccine and, consequently, compromising the response to the pandemic, as explained by Daly and Robinson.3 At the time of the study, vaccines were still restricted to clinical studies, but insecurity was obtained after approval for use, which indicates that the findings of the study were to have been better used.3

Thus, a structured, comprehensive and effective vaccination programme is essential to reduce the spread of the disease. For this purpose, the information provided in several studies in which the socioeconomic profile, education and race are directly related to the willingness or not to receive the vaccine from COVID-19 is fundamental.3 5

The disadvantaged groups face difficulties in accessing health services, which suggests that measures related to reducing social inequalities would provide greater availability of health information and possibly greater adherence to vaccination campaigns.3 5

Well-defined strategies and public policies are important to encourage large-scale immunisation. In addition, it is necessary to ensure scientifically proven information is disseminated in a clear, accurate and accessible way, in order to promote confidence in the decision making of those eligible to receive the vaccine.



  • Competing interests None declared.

  • Provenance and peer review Commissioned; internally peer reviewed.

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