Introduction

The COVID-19 pandemic has dramatically changed daily life for people across the globe. With more than 303 Million infections globally, and over 7.4 Million in Germany, the toll of the pandemic continues to rise [1]. Finally, at the end of 2020 it seemed that good news was on the horizon: a number of vaccines against the COVID-19 virus had been developed. In November 2020, Pfizer/ BioNTech reported promising results from the clinical trials of their vaccine, with 95% efficacy. These results were remarkably similar to the initial findings released by Moderna regarding their vaccine [2], with at least 58 other vaccine candidates in clinical trials on humans as of December 7, 2020 [3]. Both the UK and the US approved and began vaccine distribution in December of that year. However, to achieve protective population immunity (herd immunity) [4], more than 70% of the population needs to be vaccinated, raising critical questions around trust in governments, just distribution of the vaccine, and a continued societal commitment to preventative measures such as masks, hand hygiene, and physical distancing. It was clear early on that public views on the vaccine would prove critical in vaccine uptake. As the pandemic continues, it remains essential that the public is actively engaged in conversations around the risks and benefits of Covid-19 vaccines [5].

Existing surveys on public perceptions of the COVID-19 vaccine in 2020 suggested that those with an intention to get vaccinated hovered around 70%. A global survey of potential COVID-19 vaccine acceptance rates conducted in June 2020 found that 71.5% of participants across 19 countries reported being very or somewhat likely to get vaccinated, however with differences ranging from almost 90 to 55% [6]. A survey of European countries in April found that 73.9% of participants were willing to be vaccinated [7], however by June that number had dropped to 68% [8]. Similar surveys confirmed these findings, with 77.6% of respondents in France indicating their intention to get vaccinated [9]; 91.3% in China [10]; and 64% of respondents in the UK [11]. Surveys in the US ranged between 57% [12] to 69% [13]. Factors preventing vaccination included concerns about safety and efficacy of the vaccine, side-effects, a lack of trust, social norms surrounding vaccination, mis-information, and ability to access the vaccination [14]. Among European participants who were unsure about getting vaccinated, the most significant concern cited was potential side effects [7].

Drawing on data collected as part of a qualitative, longitudinal study seeking to understand the nature of solidaristic practices during the pandemic, this paper aims to assess the reasons for and against COVID-19 vaccine uptake in Germany and to provide in-depth qualitative data to understand and address concerns surrounding the safety and efficacy of a COVID-19 vaccine. Specifically, we are looking at the period in the pandemic just prior to the approval of the Pfizer/BioNTech and Moderna vaccines in Germany in the latter half of 2020. At that point, Germany had performed relatively well during the COVID-19 pandemic, reporting lower death rates and case numbers than other European countries [1]. Nonetheless, vaccine skepticism has always been relatively high in Germany [15, 16]. Of those who opposed vaccination in the European-wide survey from April 2020, the largest rates were in Germany and France [7]. A number of surveys found that in early summer 2020, only half of the German public would get the COVID-19 vaccine [17]. In another representative survey from November 2020, 42% of the population did not believe that their personal health was endangered by the virus [18]. In Germany, the drop in vaccination readiness was particularly pronounced compared to other European nations, decreasing from 70 to 61% between April and June. Further regional divisions were also apparent: 67% of people in the northern state of Lower Saxony said they would get vaccinated, while only 52% of those in the southern state of Bavaria said they would get vaccinated [8]. A survey reported in Der Tagesspiegel found that the speed of vaccine development led many to question whether vaccination was safe. Taken together, these finding suggest that there is a need for more-in depth understandings of public views of the COVID-19 vaccine and the concert of factors that affect willingness to be vaccinated.

Methods

As part of a qualitative, longitudinal consortium study into “Solidarity in times of pandemics,” we conducted semi-structured interviews in Germany. The consortium, comprised of 9 European countries, was formed at the beginning of the COVID-19 pandemic in order to explore peoples’ experiences during the pandemic, with particular attention to practices relating to solidarity [19].

Participants were recruited through online advertisement on university websites, social media networks, and through snowball sampling in April 2020. All above 18 and living in Germany were eligible to participate. Participants were recruited with attention to a range of different demographics, including age, gender, income, household structure, geographic area, education, and employment (Table 1). The study was approved by the Technical University of Munich’s ethics committee (no. 208/20 S).

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Table 1. Demographic distribution of participants in Germany.

https://doi.org/10.1371/journal.pone.0266659.t001

Interviewers explained the design and intent of the SolPan project to all participants, who then gave consent to participate orally. Interviews ranged from 30 to 45 minutes in length, and were conducted in German with the exception of one interview which was held in English. Interviews were recorded on a digital recorder or using a GDPR-compliant video chat recorder. Only audio material was stored. The interviews were transcribed and subsequently pseudonymized; due to the size of the SolPan project, interview transcripts were not returned to participants for comment.

The interviews were conducted in two periods (T1 and T2) approximately 6 months apart, the first covering the “lock down” period in Germany in April 2020 (6 April-6 May 2020), and the second in October 2020 (2–28 October). 46 individuals participated in T1, and 42 participated in T2. Four individuals elected not to participate in T2, or were not reachable for interviews at the time. Demographic information was collected at the conclusion of the first interview (T1), and interviewing for T1 concluded once the authors collectively agreed that different demographic categories were reasonably represented. Most interviewers interviewed the same individuals in T1 as in T2. Some interviewers took notes during the interviews, which were subsequently destroyed in accordance with data protection. The interviewers had no prior relationship with participants.

The interview guides used in this study for T1 and T2 were generated by a group of researchers in the SolPan consortium, and iteratively edited across the nine country teams in order to generate a final guide [20, 21]. Country teams were encouraged to follow the guide, but free to add in some country-specific questions. The interview guides were pilot tested prior to implementation. All individuals in T2 were asked a series of questions about vaccines (Table 2). Although there was no specific question regarding vaccines during the T1 interviews, nearly half of the respondents [21] spontaneously brought it up. The T1 data on vaccines is reported in the “Differences in hopes for the vaccine over the course of the pandemic” section; the rest of the results are drawn from T2 data.

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Table 2. Interview questions asked in T2 about vaccines.

https://doi.org/10.1371/journal.pone.0266659.t002

All authors conducted the interviews as part of the SolPan project, and most of the authors completed interviews in Germany [AF; FS; BZ; NH; AS; AB]. Interviewers were trained in qualitative interview techniques; the majority of the authors have advanced degrees in social science disciplines and specialize in qualitative research and design. The majority of the interviewers identify as female, and all were employed by the Institute for History and Ethics in Medicine at the Technical University of Munich at the time interviews were conducted.

The interviews were coded using an inductively generated coding scheme created using a grounded theory approach [22] as part of the SolPan consortium. Eight members of the SolPan research team coded the T1 and T2 data using Atlas.ti software (including five of the authors); all authors have access to this dataset [21]. Coding was checked by a second researcher for consistency. Relevant text passages were extracted via the Atlas.ti query function and analyzed inductively. Responses were also analyzed with respect to demographic information in order to ascertain if different positions in relation to vaccination tended to be associated with age, gender, household composition, geographic location, employment status, education level, and income level. No notable differences emerged in this regard, and as such we do not address demographic characteristics in the results section.

Results

Discussion

While many participants had concerns regarding the safety of the vaccine due to the rapid timeframe in which it was developed, these doubts were significantly buffered by widespread trust in German health authorities. This maps well against existing findings that suggest that trust in authorities is comparatively high in Germany [23]. However, attitudes towards the COVID-19 vaccine were clearly shifting with the nearly 10% drop in willingness to be vaccinated between April and June 2020. Further, significant regional differences in willingness to be vaccinated suggest that some parts of Germany had levels of public acceptance as low as 50% [8], possibly resulting in uneven vaccination progress across the country. Reading the national survey results together with the concerns raised in our qualitative interviews indicates that it is important that the apparent trust in health authorities not be taken for granted. Trust in authorities does not necessarily translate to voluntarily getting vaccinated in a timely fashion. Reflecting back on these findings prior to the availability of vaccines, clear, transparent discussions between experts and the public emerge as critical in answering outstanding questions about the vaccine, potential side-effects, and in particular, the process that went into developing, testing, and certifying the vaccine. This remains true today, as questions arise with the need for booster shots, mix-and-match boosters, and encouraging vaccine uptake among the unvaccinated. This is especially true in light of the confusion regarding the safety and recommended age requirements in the case of the AstraZeneca and Jansen vaccines in Germany [24, 25].

The responses from the interviews illustrate that a vaccine never operates in a vacuum. No vaccine is 100% effective, and there will always be some members of a population that cannot be vaccinated because of medical reasons [26]. As Thomas Mertens of the STIKO indicated, both infrastructure and a high public acceptance of vaccination are key for rolling out a new vaccine and reaching a high enough level of immunity to significantly change the course of the pandemic [27]. Thus, any conception of ‘success’ in relation to vaccination needs to include strong public health infrastructure, widespread public trust in the structural conditions guiding vaccine development, and clear communication between health authorities and the public surrounding the necessity and function of the vaccine, the plans for distribution, and any potential side effects. Our findings point to the crucial role that general practice doctors and other local professionals that individuals may turn to for vaccine advice may play in this vaccination infrastructure. This is particularly important given a recent study by the COSMO project that found that vaccination readiness was lowest in the health worker group, with levels lower than the general population, those with chronic diseases and the elderly [28]. By contrast, a separate survey found that medical professional willingness to be vaccinated against COVID-19 was quite high, at 91%, and was higher than medical professional readiness for the annual flu vaccine [29]. Despite these contradictory survey results, our results show that health professionals are trusted sources of information in their communities and their perceptions may affect public readiness towards vaccination. It is clear the embedding of individuals within networks of support that allow them to evaluate expert information is critical. One of the most resounding findings that emerges from this study is that vaccination is a societal effort; this suggests that the goal is not only achieving ‘herd immunity,’ but also a social endorsement of the collaborative effort that is required for a vaccine to be successful.

Among those who expressed significant doubts or skepticism about the vaccine, the reasons given usually related to the speed of the development process and the uncertainty of the evidence. However, it is important to note that the interviews were conducted before the initial release of the clinical trial data at 95% efficacy [2]. In some cases, individual responses suggested misconceptions, indicating that a clear communication campaign on the function and testing of the vaccine is always necessary. In many cases, the concerns were more general than specific. Some respondents seemed to be unsettled by the news of vaccines testing in Russia or the US, with the suggestion that due process was not being followed. Building public confidence in COVID-19 vaccination, and in particular the German and European process that led up to the vaccination campaign, is central to addressing fears around vaccination. This seems to have been additionally important given the novel mechanism of the major vaccines.

Individual positions on vaccination are wide-ranging. Significant variation within the category of ‘vaccine hesitancy’ may be glossed over in national surveys [30]. It is clear in our results that it is not productive to think of distinct ‘camps’ of those who are strictly for or against the COVID-19 vaccine. Further, there are significant differences among those who may be labelled as “vaccine-hesitant,’ and it is important to understand this hesitancy as complex and context specific, and subject to change based on time, place, and the vaccine in question [31]. Our results suggest that for many individuals it is important to feel that they have the information needed in order to evaluate the vaccine for themselves. Some individuals who had doubts about the safety of the COVID-19 vaccine went on to clarify that they were not “anti-vax.” Likewise, some who endorsed the vaccine went on to suggest that were not blindly following the vaccine “bandwagon.” In comparisons to the annual flu vaccine, many noted they had elected to get the annual flu vaccine due to the pandemic despite normally not getting it. This suggests that vaccine hesitancy in relation to the COVID-19 vaccine is a nuanced territory and will continue to shift as more evidence regarding the safety and efficacy of the vaccine emerges, in particular as the vaccine is distributed. However, it is important that COVID-19 vaccine hesitancy not be simply dismissed as across-the-board rejection of vaccination, and should be met with nuanced information combined with multiple levels of public and expert support. There will be no single solution to vaccine hesitancy in relation to COVID-19 [26].

Responses to the question on prioritization quickly reached a ‘saturation’ point, suggesting a broad sense of consensus surrounding vaccination prioritization based on individual risk and profession (e.g. for health professionals). These responses are largely consistent with the prioritization recommendations of the STIKO, which designated the first group to be vaccinated as those who have an increased risk of poor health outcomes due to underlying medical conditions, and the second group to as those who work in medical or long-term care facilities [32]. The significant overlap between interview responses and the Joint Position Paper guidelines point to widespread acceptance of this tiered proposal for distribution. Similarly, a national survey found that 93% of those surveyed agreed with the prioritization scheme for the vaccine [18]. Particularly interesting is that no one, including those who were over 70 years of age, self-identified as being in a risk group. This may mean that there was a disconnect between individual’s perceptions of their own personal risk in relation to COVID-19 and the prioritization guidelines’ understanding of risk. It is important moving forward that clear communication continues surrounding the specific risks posed by age, employment, or other forms of vulnerability in relation to COVID-19 and the need for vaccination.

The overlap between the Joint Commission’s position paper and our results shows that there was a shared understanding of stratified ‘social need’ in relation to the effects of the pandemic, and a willingness to wait so that those in need can have the vaccine first. However, we were unable to assess if people’s willingness to be vaccinated was tempered by the assumption that they would not be first in line, and therefore would be receiving the vaccine after it had already been administered to many others. One striking contrast was the doubts raised by some respondents regarding whether risk groups should receive the vaccine first, given the perception that the vaccine would be the ‘riskiest’ earlier in its distribution. Further, even those who doubted the safety of the vaccine still suggested similar priorities for distribution. No respondent–including those who said they would not get vaccinated–said that the vaccine should not be given at all. This suggests that there may be an important difference between individual risk assessment and societal risk assessment in relation to the COVID-19 vaccine. This is in line with results from a recent study on voluntary and mandatory vaccination, where four attitudes regarding the vaccination were identified, including those who would not voluntarily get vaccinated, but were in favor of mandatory vaccination [33]. That is to say, some may try to benefit from the decisions made by others and the same time would refrain from contributing themselves.

On the whole, hope in the vaccine was measured. In comparing responses across the six-month period between the T1 and T2 interviews, as a vaccine became more of a reality, more questions regarding efficacy, safety, and how long it would take to effect widespread change emerged. This suggests that there was a shared understanding that the vaccination campaign would take a significant amount of time and would not simply ‘resolve’ the pandemic overnight. It also means that public perceptions of the vaccine are malleable; concerns can be clearly addressed through transparent communication, and likewise, doubt about the safety and effectiveness of the vaccine could grow if left unanswered.

Limitations

This was a qualitative study conducted with a relatively limited number of individuals in Germany, and thus the responses and conclusions are not representative. No differences in relation to demographic characteristics were discernible in the data analysis; it is possible that this is in part due to the limited number of participants in the study. Interviews were conducted in October 2020 before first results from COVID-19 vaccine trials were released, so the views presented are prior to the release of clinical trial data.

Conclusions

Much of the existing public skepticism in Germany is related to the accelerated timeframe in which the COVID-19 vaccines was developed [34]. The findings from our research illustrate that many people did not have many specific concerns in relation to the vaccine’s safety, efficacy, and delivery, but rather held more generalized concerns about safety in relation to speed of development. Key steps were taken to assuage public concerns on this front, including the establishment of a monitoring and surveillance system at the RKI to follow the administration of the vaccine. In addition, we would advocate for continued, clear communication to explain the process of vaccination approval in Europe across national and local levels. More generalized concerns can be tackled with clear, transparent information that is readily accessible to the public, available in multiple languages, and tailored to specific demographic groups such as health professionals, high-risk patients, and young people. Specifically, our results suggest that a public explanation of how the standard safety procedures were enacted within the accelerated timeline of vaccine development is necessary in order to assuage fears of expediency being favored over safety.

Particular conditions emerged in the interviews that are important for health authorities to pay attention to, including the need for the independence of the German and European vaccine approval process. A second condition is that while trust is high in national institutions, people turn to local experts such as general practice physicians in order to assess if the vaccine is right for them. This means that vaccination efforts also depend significantly on this kind of ‘second-tier’ or informal support. These conversations, while out of view of the official vaccination program, may be particularly fruitful in answering questions and encouraging people to follow-through with an initial vaccination series or booster shots in the German context, as physicians may have an amplified effect on public readiness. As such it may be productive to have a national campaign that reaches out to health professionals and local leaders to provide them with clear information about the COVID-19 vaccine and strategies for discussing vaccine concerns with their patients or constituents. Finally, public health messaging should emphasize the relationship between individual vaccinations and the broader public good. This could be particularly helpful to support the overall solidaristic readiness we found to give those at greater risk priority.

Our findings provide a more in-depth understanding of how some individuals are both hesitant about the specifics of the vaccine but also supportive of those most in need receiving it first. This suggests the need for a nuanced approach to vaccine communication, and in particular, a differentiated response to vaccine hesitancy that addresses not only concerns surrounding safety and efficacy, but also the particular necessity of the vaccine in relation to the threat of the COVID-19 pandemic. Given that many respondents’ willingness to be vaccinated was explained in relation to their own perception of the threat that COVID-19 posed for their health, it continues to be necessary for health officials to emphasize that vaccination is not only about an individual benefit. Efforts need to be made to expand the individual risk calculus of catching COVID-19 versus vaccination to include the many societal benefits afforded by vaccination. Ultimately, we find that further reassurance from both national and local health professionals that any vaccine made available in Germany is safe and effective will continue to be needed, lest the public trust in COVID-19 vaccination wane to such an extent that vaccination efforts could be significantly compromised [7].

Supporting information

Acknowledgments

This study is part of the qualitative, longitudinal, and multinational SolPan study and has been made possible by the joint work of the members of the SolPan research commons. We thank the consortium members for conceptualization and design of the study, including the interview guide. We are grateful to Eric Paul, Paul Stephan and Magnus Tibbe for their assistance with the data coding in this project.