Recommendations for policy and practice.

Covid-19 vaccine hesitancy among young people can be seen as an acute – but not isolated – phenomenon within an alarming longer-term trend of broader vaccine distrust in Africa. Yet there are still considerable knowledge gaps in relation to the scope and drivers of low vaccine acceptability among young people. Moreover, better frameworks and tools are needed to conceptualise and better understand acceptability in this population group. We applied the recently published Accelerate Framework for Young People’s Acceptability to guide qualitative research with young people living in South Africa and Nigeria. We aimed to investigate their overall acceptability of the Covid-19 vaccine, and explore factors shaping this acceptability and willingness to be vaccinated. In collaboration with seven community-based organisation partners, we conducted 12 in-person focus groups and 36 remote interviews with 163 individuals aged 15-24. Through a collaborative, iterative process we conducted thematic analysis, incorporating aspects of both deductive and inductive approaches. Our findings show how vaccine acceptability is shaped by a multiplicity of inter-related factors. They also provide a more in-depth perspective of some of these phenomena, their relative importance and their connections in this group of young people. Limited vaccine understanding, conflicting information and distrust, the influence of others, and fear of side effects were key inter-related drivers of low vaccine acceptability. Factors promoting Covid-19 vaccine acceptability were instead: positive perceptions of vaccine safety and efficacy, protection from disease, protection of others, and a desire to return to normal activity. We discuss implications of these findings for policy and practice, both to increase acceptability of Covid-19 vaccination among young people, and more broadly promote vaccination as a critical component of public health programs. Lastly, we reflect on this first application of theAccelerate Framework, and implications for its use in future studies.