Abstract
Declared as one of the ten most pressing threats to global health in 2019, the complexity around vaccine acceptance and hesitancy has once again gained great momentum following the COVID-19 pandemic. Lack of vaccine acceptance may endanger the mission of improving vaccine uptake globally to tackle pandemics, reduce morbidity and mortality of preventable diseases and to prevent antibiotic resistance worldwide. Countries of the global south, including South Asian Association for Regional Cooperation (SAARC) countries are especially affected by the dangers of low vaccination uptake and continue to show decreases in coverage in recent years. This paper examines factors contributing to vaccine hesitancy in south Asia and the extent to which they are context and disease specific, guided by a modified version of the WHO SAGE 5 C model by Razai et al. Three databases were searched for peer-reviewed articles by using a comprehensive search strategy. Results from 44 quantitative, qualitative and mixed-method studies were included in the systematic review and appraised for quality, thematically analyzed and mapped onto the 5 C model. findings from India, Pakistan, Bangladesh, Nepal and Afghanistan showed vaccine hesitancy to be context and vaccine-specific within different settings of the countries. The main factors contributing to vaccine hesitancy can be identified as narrow confidence in vaccines, miscommunication, and lack of knowledge embedded into overarching constraints and contexts. To tackle vaccine hesitancy in SAARC countries, interventions need to be co-created by communities and mutual trust needs to be ensured, for instance through increased equity in knowledge distribution.