Decolonising vaccine production: Unpacking Ghanaians’ support for made-in-Africa vaccines

Highlights

• •Support for decolonisation of vaccine production in Ghana profiled.
• •Three segments of vaccine ethnocentric consumers identified.
• •Influences vary by vulnerability to infectious diseases.
• •Distrust in capabilities of African scientists decreases vaccine nationalism.
• •Segmented marketing is germane to improving local vaccine support and uptake.

Abstract

Localisation of vaccine production is essential worldwide, but it is particularly crucial for Africa. This continent is more vulnerable to disease burdens and also lags behind other continents regarding access to vaccines. Moreover, many people in Africa have a long-standing apathy towards locally made products and services. This mindset raises the question of whether Africans will support African-made vaccines and what the associated reasons are. Guided by the theories of nationalism and import substitution industrialisation, we formulated and tested eight hypotheses. To answer these, we analysed survey data from 6,731 residents backed by key informant interviews in Ghana. Our findings identified three types of local vaccine consumers: Afrocentric-ethnocentrics, Apathetic-Afrocentrics and Afrocentric-Fence Sitters. Four out of the eight hypothesised factors explain why some individuals have a positive attitude towards locally made vaccines, compared to those who are unsure of their stance. The proposed typology of local vaccine consumers and their defining characteristics can help design public health campaigns to mobilize support for locally produced vaccines.

Background

Localisation has been a central issue in consumer behaviour and consumer sovereignty and has been explored in food and energy production for a long time now [1], [2], [3]. Nonetheless, localisation has not gained much attention in vaccine production and promotion. But the outbreak of the COVID-19 pandamic has reinforced the unequal access to vaccines, with developing countries being the most left-behind. But for international collaboration interventions like the COVAX programme, challenges of equitable access to the COVID-19 vaccine in many developing countries could have been dire. Notwithstanding, disease pandemics could spread faster across borders than vaccines distribution exercises due to institutional as well as transportation and storage arrangements involved in their supply. Local manufacturing of vaccines is thus seen as a means to decolonise vaccine supply, particularly during outbreaks.

The outbreak of COVID-19 has, once again, highlighted the need for import substitution industrialisation and self-reliance for vaccines and other essential pharmaceutical products in developing countries. At the peak of the outbreak, not only did major advanced countries return to the corn laws of yesteryears regarding the production and marketing of vaccines but most developing nations looked to their former colonial masters and /or institutions managed by these countries for assistance. Help came anyway but it was a little too late as the disease ravaged across the populations of the colonised. For instance, the first COVID-19 vaccination in Africa commenced on March 1, 2021 [4]). By this time, 53,400 cases of the disease were confirmed in the human populations of the continent [5], [6]. In addition, not only was the attempt at vaccinating the population against this epidemic on a small scale, as it started in the only few countries with: only two countries, but the doses used for the exercise were part of a facility by COVAX advanced market commitment to provide donor-funded vaccines to lower-income countries. Moreover, while the (laudable) initiative was regarded as a pathway to ending the acute phase of the roaring pandemic, the fact that the doses received were prioritised for essential workers and at-risk groups in the recipient countries signaled deep-seated structural weaknesses and Africa’s ill-readiness to confront pandemics of that magnitude head-on. This underscores the need for understanding the mechanisms through which African countries can break the shackles bounding vaccine production and access among their citizens. Localisation is seen as a solution to timely access to preventive medicine for import-dependent nations by shortening the supply chains. This comes along with significant co-benefits including increased efficiency and reduced environmental footprints. Further, localisation of vaccine production could open doors toward greater diversification of supply chains, stronger partnerships and private investment. It could also tackle the unmet need for discoveries in diagnostics and therapeutics in developing countries [7]. Moreover, it is also demonstrated that the cost of locally produced vaccines could be lower than those imported; guaranteeing affordability as well as protection of foreign exchange reserves [8].

Africa’s dependence on other continents for the supply of vaccines is currently very huge [9], [10]. Cognisant of the high vulnerability associated with the region's overdependence on foreign supplies, the African Union is targeting that the most needed vaccines of the continent should be locally produced by 2040. Leaders pledged to increase the proportion of vaccines made in the continent from 1% to 60% [11]. This ambitious call requires commitment not only from governments of the various countries in the continent but also African citizens. While Africa is left behind in almost all facets regarding vaccine development and uptake, significant evidence of apathy towards homemade products and services abounds. Previous studies have noted increasing vaccine hesitancy across various populations [12], Ognunbajo & Ojikutu, 2022; [13]. This could worsen the global decline in vaccine confidence if citizens' support for locally produced vaccines is not well understood and leveraged.

Despite the rhetoric surrounding the need for locally produced vaccines, research on the subject is dominated by opinion pieces and conceptual studies with minimal empirical evidence. The few available empirical studies focused on profits, intellectual property rights and manufacturing capacity assessments [8], [14]. Citizens' support for African-made vaccines is yet to be explored. Further, Africans have long been noted for negative attitudes towards locally made products and services because of the perceived superiority of foreign substitutes [15], [16]. The consumption of foreign products is considered a symbol of high social status. For instance, people in Ghana have apathy towards locally produced goods and services. A case in point is the poor patronage of medical products made in Ghana compared to foreign ones [17].

As intimated by World Health Organization [5], [6], the biggest impediment is how vaccine markets are structured in Africa. Without intentional commitment and support to buy vaccines manufactured in Africa, it will forever remain a difficult challenge to build a sustainable industry capable of producing vaccine doses at scale. While it is essential to focus on critical issues affecting vaccine production in the continent, including innovative financing, enabling regulatory environment, product development partnerships, infrastructural developments as well as building of technical capacity and technology transfer capabilities, it is equally important to have the end-market in mind, which is the willingness to accept and take African-made vaccines by residents of Africa. Low demand will lead to waste of scarce resources. For example, the African Development Bank Group has dedicated $3 billion to support made-in Africa vaccines over the next decade [18].

Following this, we explore Ghanaians' support for African-made vaccines. Eight hypotheses are formulated and tested based on the theories of nationalism and import substitution industrialisation. The study extends the current knowledge frontier on the subject by providing insightful evidence on the mechanisms of public support for African-made vaccines and related products for guided public health action by governments and public health agencies. Beliefs, perceptions and emotions influence adoption behaviour. Hence it is necessary to know the nature of people's ethnocentric attitudes as this may restrict successful vaccine deployment and coverage. Our findings could provide useful insights on vaccine ethnocentrism and its underlying determinants essential for framing campaign messages to motivate demand for African-made vaccines. Message framing is one of the persuasive tools for influencing desired attitudes and behaviours. The potential predictors of support for localisation of vaccine production investigated are self-reliance, enhanced access, import-substitution, safety and efficacy of vaccines and trust in local expertise. These issues revolve around gains, losses, rationale and emotions; all of which have been noted as the fundamental psychological cues underlying attitudes and behaviours [19].

Hypotheses development

Vaccine hesitancy is one of the world's major public health challenges [20], [21], [22]. Perceived safety and efficacy of vaccines and related conspiracy theories are often the underlying factors to vaccine hesitancy [23], [24]. For instance, the belief that foreign actors often orchestrate infectious diseases and associated vaccines in order to depopulate or render blacks infertile is well documented [25], [26]. This has resulted in many people in Africa either hesitating or boycotting vaccines, including the ongoing COVID-19 vaccination. According to Aroh, Asaolu and Okafor (2021), vaccine mistrust in Africa cannot entirely be overlooked; owing partly to historical unethical practices in medical experimentations and unforeseen side effects. Increasing local capacities for vaccine production could enhance the scientific efficiency and productivity of home-based pharmaceutical units [27], [28]. Localisation of vaccine manufacture in Africa is therefore expected to consolidate expertise in manufacturing safe and efficacious vaccines. African scientists will better understand the vaccine ingredients and formulations suitable for their fellow African populations compared to foreign scientists [29]. But does expected improvement in vaccines due to localisation promote support for African-made vaccines? To provide answers to this question and taking cues from the foregoing discussions, the study formulates and tests the following hypotheses:

• H1: Trust in local expertise has a significant positive effect on support for African-made vaccines.

• H2: Localisation leading to a perceived improvement in the safety of vaccines would significantly and positively lead to support for African-made vaccines.

• H3: Localisation leading to a perceived improvement in the efficacy of vaccines would significantly and positively lead to support for African-made vaccines.

Studies have established significant evidence of Africans’ apathy towards homemade products and services due to perceived low quality [30], [31]. This has contributed to the collapse of industries in Africa. Self-reliance is defined as the social and economic ability of an individual, household or community to meet basic needs, including good health, protection and education in a sustainable manner and with dignity (UNHCR, 2005). Self-reliance implies taking responsibility for one's own needs without relying on others. A number of individuals and institutions have recognised the critical role of self-reliance in addressing weaknesses and inequities in health service delivery, and are thus calling for all continents to be self-sufficient in vaccines and other pharmaceutical products. For example, it has been argued that though international efforts to increase the availability of vaccines to the African population would reduce the suffering and deaths caused by epidemics on the continent, having its own large-scale vaccine production facilities and vaccination programmes is germane to keeping infectious pathogens in check [10].

Localisation in the production of essential medical goods and services is the first critical step toward self-reliance [32]. According to Shuman [33], localisation does not imply walling off the outside world. Rather, it means fostering locally set up businesses that use local resources sustainably, employing local workers at decent wages and serving primarily local consumers. Simply put, localisation refers to becoming self-sufficient and less dependent on imports and external sources for health support in a global age. The quest for self-reliance has encouraged the localisation of industries and the pursuit of more nationalistic policies [34], [35]. It is argued that individuals' consumption of a product is tied to their identity and self-perceptions and that ‘consuming local’ is an expression of a sense of duty to protect one's nation by acknowledging and respecting products that are representative of the country [36]. Hence, localisation of vaccine production in Africa is expected to spark nationalism and the support of African-made vaccines. The study, therefore, hypothesises as follows:

• H4: Localisation of vaccine production leading to perceived self-reliance would significantly affect residents' support for African-made vaccines.

Literature suggests that vaccine acceptance involves trust in the product, the supplier and policy makers [37]. The ability to effectively produce safe, efficacious, and improved products is said to be influenced by research and development [38]. Research and development are, therefore, key in scientific discoveries and application of findings in vaccine production. In recognition of this important role, several international organisations have called for investment in health research and development in Africa [39]. On an annual basis, African countries are expected to commit one percent of their GDP to research and development (African [40]. Sadly, however, Africa's research and development funding stood at 0.42% of GDP compared to the global average of 1.7% as at 2019 [41]. Africa-led research and development has the potential to contribute towards the vaccine development drive and improve health. In recent times, international funders have realised the importance of shifting from internationally-led research efforts to more African-led models [42]. When African scientists lead research, it is expected that more local relevant issues would be targeted and study findings will be communicated in a culturally sensitive manner. Despite the paucity of spending on research and development, Africa has made tremendous advances in technological capabilities in health and medicine [43]. For instance, South Africa has exhibited a great capacity in nanotechnology for the development of vaccines and other therapeutics [44], [45]. This is evidenced in the production of nanoparticle-based antivirals for HIV-positive persons and the successful production of Johnson & Johnson COVID-19 vaccines. Also, other African countries such as Rwanda, Senegal and Egypt have made significant strides towards vaccine manufacture [46]. Against this backdrop, we hypothesised that:

• H5: Trust in local expertise has a significant positive effect on support for African-made vaccines.

Globalisation has brought about trade openness, thus creating links among countries through various channels, including trade and investment [47]. Consequently, there has been a considerable increase in trade between developed and developing countries [48], [49]). While the significance of this trade cannot be overemphasised, the balance of benefits has largely been in favour of developed countries [50], [51]. In the quest to avert balance of payments difficulties faced by African countries, several strategies are often proposed; one of which is import substitution industrialisation [52], [53]. In fact, import substitution industrialisation is an integral part of the Sustainable Development Goals Nine that favours the consumption of locally produced goods and services [54]. In the view of defendants of the import substitution industrialisation theory, importing vaccines from other nations is not only unpatriotic but also detrimental because it worsens the foreign exchange reserves of fragile economies and dampens domestic employment prospects [55]. Patronising locally produced products and services and, for that matter, vaccines would therefore provide local industries with the needed market and support to produce and expand, thereby creating job opportunities [56]. It would also mean a reduction in imports and a favourable balance of payment, all other things being equal. In the discourse on the localisation of vaccine production in Africa, it is imperative to understand whether perceived job creation and expansion in the local economy would engender support among nationals of African countries for locally made vaccines. With this in mind, we proposed that:

• H6: Localisation leading to import substitution would significantly and positively explain support for African-made vaccines.

• H7: Localisation leading to job creation and expansion of the local economy would significantly and positively explain support for African-made vaccines.

Dependence on medical products from other regions of the world does not only adversely affect Africa’s foreign exchange reserves, it is also inimical to the continent’s real interests in terms of timely access to essential vaccines and other life-saving drugs [57]. This has been revealed in the recent COVID-19 pandemic. According to Amnesty International [58], less than 8% of African people are fully vaccinated due to supply deficiencies in vaccines. Africa, with a population of nearly 1.4 billion, had a total supply of only 134.5 million, while the United States, with a population of about 332 million, had over 375 million vaccine supplies. This disparity exposes Africa's challenges regarding access to the needed vaccines to protect people against infectious diseases. The call for Africa to become self-sufficient in vaccines and other drugs, though long-standing, has been intensified by the upsurge in “medical nationalism.” The rush by most countries to hoard drugs and other medical products during pandemics has exposed the continent's vulnerability to the caprices of global medical supply systems. Although several frameworks, such as the Pharmaceutical Manufacturing Plan for Africa, have been developed to curb over-reliance on imports by promoting local pharmaceutics [59], their effects have been largely limited. Africa still imports over 90% of her drugs and vaccines. The COVID-19 experience, while tragic, has the potential to be the wakeup call for vaccine independence. The issue of timely access to vaccines, mostly during pandemics, directly impacts the lives and livelihoods of people in the vulnerable economies. Thus, it is expedient to understand if the perceived timely access to vaccines due to localisation of production would catalyse public support for African-made vaccines. With this in focus, we test the following hypothesis:

• H8: Localisation leading to timely access to vaccines would significantly and positively lead to support for African-made vaccines.

Methodology

Study design

An embedded sequential exploratory and explanatory mixed methods design was employed in this study to enable us profit from the synergies and complementarities of the qualitative and quantitative approaches to research. Qualitative data was initially collected using in-depth interviews to explore the views of respondents regarding the subject of African made vaccines. The results from this preliminary analysis informed the design of both the interview guide and questionnaire for the concurrent collection of qualitative and quantitative data on the subject matter. The selected design enabled the identification of measures that supported and validated the measurement framework adapted for context-specific measurement and explanation of the survey results, thus reducing attribution bias. Additionally, the survey data addressed the non-representativeness of the interview sample, increasing the generalisability of the study. Overall, the sequential process enhanced the credibility of the study by improving the verification and validation of the findings.

Study setting and data collection procedure

The study commenced with in-depth interviews of 15 key informants conveniently selected respondents from different communities across genders. These individuals were chosen from the exact survey locations. For the survey data collection, respondents were selected using systematic random sampling from the communities chosen, with the sample size proportional to the population of each community. A total of 6,731 adult residents were surveyed. The study was conducted in the Central Region of Ghana. The region is the tourism hub of Ghana, accounting for the majority of international tourists’ arrivals and receipts. Both generating and destination communities of tourism have been noted as epicentres of infectious diseases. The emergence of COVID-19 in Wuhan and its further spread has been attributed to international travellers and tourists. Therefore, given that such communities have a gatekeeping role in disease control and prevention, exploration of new vaccines should begin with those communities. Residents of both tourism-dependent and non-dependent communities were surveyed. Tourism-dependent communities rely on the tourism and hospitality industry as their primary source of income and livelihood. The data used for the study was collected in Cape Coast, the regional capital and six other metropolitan, municipal and districts (Abura Asebu Kwamankese, Assin North, Gomoa West, Mfantsiman, Twifo-Ati Morkwa, and Twifo Hemang Lower Denkyira).

These districts were selected as study sites owing to the fact that the University of Cape Coast School of Medical Sciences (UCCSMS) has adopted them as social laboratories in the training of community oriented medical students through its Community Based Experience and Service (COBES) programme. COBES involves posting medical students annually over four out of the six consecutive years of their medical training into selected communities for a period of three to four weeks. The rationale of COBES is to enable students to build competencies in community engagement by immersing themselves into the everyday life of community folks and empirically studying their social determinants of health.

This set of data helped to explore whether perceived vulnerability potentially influenced support for localisation of vaccine production. Beyond the uneven success of the global roll out of the COVID-19 vaccine illustrating the dying reasons calling for localisation, the need to localise vaccine production to guarantee timely access to immunisation is much needed for tourism-dependent economies, such as Ghana, as they are heavily affected during infectious disease outbreaks and serve as hotspots for the spread of such epidemics to other parts of the world. During outbreaks of vaccine-preventable diseases, not only are people unable to meet their leisure needs due to shutdowns, stay-home orders and border closures but livelihoods are also lost as businesses are forced to shut down [60].

Measures and data collection

The current study was, thus, conceptualised and tailored into the research component of the 2022 COBES posting for 5th year students of UCCSMS from 9th to 30th January 2022. Two communities were selected in each district. Given that a district is typically composed of an urban capital and several rural villages, the capital city and one other rural community were randomly selected in each district as a study site. The data collection in Cape Coast was conducted by Level 300 students of the Department of Hospitality and Tourism Management based on a similar approach and instrument described earlier. The students were put into groups of maximum 17 and assigned to an enumeration community. To measure attitudes and behaviour of people toward local products and services, researchers often rely on the multi-dimensional consumer ethnocentrism tendencies scale (CETSCALE) by Shimp and Sharma [61]. We adapted this scale by incorporating items on safety, efficacy and scientific capability which are at core of vaccine production. The CETSCALE is heavy on nationalism and economic benefits. We drew the measurement items used as the predictors of residents' support for locally made vaccines from the existing literature on support for locally made products and services. The adapted measures were validated and complemented with views from the 15 key informants mentioned earlier. To minimise the weakness of this measurement approach, we asked open-ended questions before exposing respondents to the Likert scale closed-ended questions. They were first asked about their support for African-made vaccines. The “yes” or “no” response was accompanied by an open-ended question asking for reasons or further details. This form of questioning enabled the gathering of representative qualitative data as every respondent was mandated to provide a non-restricted response. A questionnaire programmed in KoBoToolbox was used to collect the survey data. It works in both offline and online modes; which allows for automatic updating of questionnaires. Both tablets and android powered mobile phones were used as the medium for data collection.

The questionnaire was divided into three primary sections. The first section (Section A) focused on gathering information about the demographic and community profile of the respondents. The second section (Section B) captured their preference for made-in-Africa vaccines and the corresponding qualitative reasons. The last section contained closed-ended questions on CETSCALE. To ensure the validity of the data, several measures were implemented. In addition to using computer-assisted data capture, the team regularly reviewed the data to detect potential errors in data entry. Any identified errors were reported through a WhatsApp group for prompt correction before the data collectors left the communities. Anyway, these errors were very minimal because of the robust programming logic and validation checks used for the data collection. Back check calls were also implemented at regular intervals using the phone numbers provided by the respondents to verify the responses provided.

Preliminary analysis revealed acceptable results regarding two widely used internal consistency measures and validity measures: Cronbach's alpha, the corrected total-item correlation (homogeneity indexes). All Cronbach's alpha values exceeded the recommended threshold of 0.70 by Hair et al., (2019), indicating strong internal consistency of the items in measuring vaccine ethnocentrism (Table 1). Additionally, the total-item correlation coefficients were higher than the recommended threshold of 0.5, reinforcing the measure's validity. We intended to identify individual granular measures reliably measuring vaccine consumption ethnocentrism for onward clustering of respondents, not high-level factors. As such, we did not perform exploratory factor analysis or confirmatory factor analysis. More importantly, the adapted measurement items used in this study were few. Factor analysis often leads to losing significant marker variables (Dolnicar et al., 2012; Leisch et al., 2018).

Table 1.

Measures and their corresponding reliability indicators.

	Mean	SD	Cronbach alpha if item deleted	Corrected Item-Total Correlation
Self-reliance: African-made vaccines will promote self-reliance of Africans	7.61	2.83	0.778	0.715
Enhance access to vaccines: Made-in Africa vaccines will enable us (Africans) to get timely access to vaccines against diseases	7.79	2.69	0.773	0.772
Enhance efficacy of vaccines: Made-in Africa vaccines will be efficacious because African scientist understand Africans better	7.72	2.77	0.775	0.752
Enhance safety of vaccines: Made-in Africa vaccines will be safer to take	7.70	2.76	0.773	0.763
Create employment opportunities: Made-in vaccines will lead to creation of more jobs for us.	8.00	2.65	0.700	0.700
Reduce revenue leakages: By producing made-in Africa vaccines, Africa can save money from importing vaccines	7.84	2.89	0.789	0.629
Trustworthy: The production of vaccines in Africa would lead to increased trust in locally produced vaccines	7.61	2.83	0.777	0.728
Capability of African scientist: African scientists are capable of making safe/efficacious vaccines	3.77	3.63	0.866	0.7263
Overall reliability measure			0.855

Rating scale of means: 0–10.

As regards the interviews, they were conducted at locations convenient to the participants and averagely lasted for 30–45 min and in the language of choice of the participant. Participants were approached and the intent of the study and objectives shared with them. Notes were also taken alongside to document the non-verbal expressions. To further ensure the accuracy of the qualitative data, the researcher conducted member checks of both transcripts and themes, and employed peer debriefs to validate the findings and perspectives presented in the data.

Prior to the actual data collection, a two-day training was organised for the students. They were taken through field protocols, administration of consent form, the content of the questionnaire and how to use the computer-assisted personal interview mask to administer the survey. The training also involved breakout sessions where the students role-played and did mock trials with the instrument to enhance their knowledge and capability of administering the survey in Twi and Fante, the most spoken local languages in the study setting. Members of the research team facilitated the training sessions. However, other faculty members assisted because the vaccine module was part of a comprehensive survey containing other community health modules that needed the attention and input of these faculties. The same team took responsibility for supervising, coordinating and backstopping the field activities.

Data analysis

We employed both quantitative and qualitative techniques for the data analysis. The qualitative data was manually transcribed and analysed by the research team followed the framework approach (familiarisation, identifying a thematic framework, indexing, charting and mapping and interpretation) to qualitative data analysis proposed by Ritchie and Spencer [62]. At the first stage, two qualitative experts in the research team project repeatedly read the transcripts to familiarise themselves with the data. The second stage involved the development of analytic frameworks by identifying recurrent issues and themes. In the next phase, they refined themes and summarised them into concise and coherent forms. At the final stage they compared themes and subthemes with transcripts, field notes and tape recordings where needed to ensure that adequate consistency was achieved. The study primarily used a deductive approach to thematic analysis, employing the refined CETSCALE themes and measures as a pre-existing coding framework to categorise the data into predetermined themes. This approach is consistent with an explanatory sequential design, which aims to complement and provide further explanation to the quantitative data by including qualitative data that captures the perspectives and experiences of the participants. However, the researchers also allowed for emerging themes from the data to be captured through an iterative process of reading and re-reading the data.

For the survey data, both descriptive and inferential statistics were computed in STATA 14.0. A multinomial probit regression was estimated to determine the predictors of support for locally made vaccines. Two different but comparative regression models were estimated. The first model included only the scale constructs while the second controlled for socio-demographic characteristics. However, both models used respondents who said they were uncertain as the point of reference for the estimation. The regression estimation technique was employed after the absence of multicollinearity and normality of the data were met.

Results

Of the 6,731 respondents surveyed, about 60% of them were women and the remaining men. The majority had formal education, with those attaining Middle/Secondary level education dominating the sample. They constituted 68% of the surveyed respondents. As is often the case, people who professed Christianity were more than those who professed Islam (5.29%) or traditional African religion (1.39%). The remaining said they were atheists. The average age of the respondents was 38 years and the minimum age was 18 years and the maximum 100 years. The majority (73.39%) of the respondents affirmed their support for African-made vaccines while 10.14% reported otherwise (Fig. 1). Of those who supported African-made vaccines, over half (58%) of them prefer vaccines made in Ghana by Ghanaian Scientists. Those who prefer vaccines made in Ghana by foreign scientists (16%) placed second while those who prefer vaccines produced in other Africa countries but by Ghanaian scientists were the least (8%).

Fig. 1.

Preferences for made-in- Africa vaccines.

Out of the seven explanatory variables used to explain support for African-made vaccines, perceived economic benefits were the most rated of which perceived creation of employment opportunities was the most rated (mean = 8.010). Reduction in revenue leakages placed second (Mean = 7.704) followed by enhanced access to vaccines (Mean = 7.607) whereas the least rated factor was capability of African scientists. However, there were significant variations in ratings across all the factors when disaggregated by support type. Higher rating of the factors was provided by those who expressed support for African-made vaccines compared to their counterparts (Table 2). Table 3 shows the results of the predictors of support for locally made vaccines across the segments of the identified consumers.

Table 2.

Marker variables by Clusters.

	Overall	Afrocentric-ethnocentrics (n = 3679)	Apathetic-Afrocentrics (n = 560)	Afrocentric-Fence Sitters (n = 717)	F Stat.
Self-reliance	7.462	8.320	4.733	5.193	830.46*
Capability of African scientist	4.513	4.521	4.859	4.190	4.86*
Trustworthy	7.437	8.365	4.169	5.227	1042.31*
Reduce revenue leakages	7.704	8.379	5.628	5.860	434.45*
Enhance access to vaccines	7.607	8.424	4.919	5.510	824.42*
Create employment opportunities	8.010	8.630	6.018	6.142	460.36*
Enhance safety of vaccines	7.526	8.421	4.396	5.375	1020.53*
Enhance efficacy of vaccines	7.586	8.477	4.596	5.351	1018.70*

Note: *indicates statistical significance at 1%.

Table 3.

One-way analysis of differences in the ratings of the factors by the socio-demographic characteristics of the respondents.

	Self-reliance	Capability of African Scientist	Trustworthy of made-in Africa vaccines	Reduce revenue leakages	Enhance access to vaccines	Create employment opportunities	Enhance safety of vaccines	Enhance efficacy of vaccines
Sex
Female	7.63	4.324	7.592	7.880	7.804	8.127	7.699	7.763
Male	7.49	5.105	7.429	7.737	7.578	8.063	7.476	7.572
t	2.29	41.71*	3.16	2.38	6.76*	0.63	6.25**	4.68**
Age
Below 24 years	7.37	4.17	7.30	7.57	7.56	8.08	7.48	7.54
25–34	7.41	4.33	7.48	7.67	7.62	8.04	7.58	7.58
35–44	7.63	4.31	7.52	7.80	7.74	8.05	7.59	7.68
45 and above years	7.45	5.02	7.44	7.76	7.54	7.90	7.47	7.55
t	1.50	14.69*	1.19	1.44	1.17	1.18	0.60	0.53
Religion
Christian	7.46	4.51	7.46	7.72	7.61	8.01	7.54	7.592
Muslim	7.48	4.73	7.16	7.54	7.54	8.03	7.33	7.657
Traditional	7.01	3.60	6.67	7.19	7.01	7.69	6.91	7.029
t	0.82	2.41	3.53**	1.44	1.63	0.38	2.26	1.41
Education
No formal education	7.77	5.36	7.72	7.31	7.55	8.16	7.82	8.24
Middle	7.61	3.68	7.63	7.76	7.82	8.15	7.76	7.67
Primary	7.44	3.57	7.35	7.57	7.50	7.96	7.52	7.56
Secondary	7.40	4.03	7.34	7.86	7.66	8.06	7.51	7.63
Tertiary	7.36	4.08	7.21	7.54	7.51	7.96	7.44	7.66
t	1.31	6.30*	2.68**	1.66	1.97	0.70	1.91	1.22

Note: * indicates statistical significance at 1%, ** indicates statistical significance at 5%.

A one-way test of differences in the rating of the factors across the socio-demographic characteristics of the respondents also revealed pockets of variations. Perceived improvement in the safety and efficacy of vaccines as well as timely access due to localisation received significantly higher ratings among women than men. For example, while the average rating of enhanced access of vaccines for females is 7.804, that for males is 7.578 (Table 2). Generally, while there was low trust in the capability of African scientists to make vaccines, young people, especially those who are formally educated, were less trusting than other respondents.

The multinomial regression results reported in Table 4 indicate that the second model resulted with the highest variance explained, which is 31% compared with 29% in the first model. In all, five factors significantly explained Ghanaians' support for African-made vaccines. Perceived self-reliance (Coef = 0.124); the belief that locally made vaccines will be more efficacious (Coef = 0.160), and safer (Coef = 0.078) and trusting (Coef = 0.124) emerged as the top four positive and significant predictors. However, the less trust of residents in the capability of African scientists to make vaccines resulted in a lack of support for African-made vaccines (Coef = −0.049). Of the controlled variables, only the level of education had an effect on support such that those with tertiary education had a higher chance of being supportive compared to those with no formal education.

Table 4.

Predictors of support for locally made vaccines (reference group = Afrocentric fence sitters).

	Model I (Apathetic-Afrocentrics)			Model II (Afrocentric-ethnocentrics)
Explanatory variables	Coef (SE)	[95% Conf. Interval]		Coef (SE)	[95% Conf. Interval]
Self-reliance	0.043(0.0383)	−0.032	0.118	0.125*(0.032)	0.063	0.187
Capability of African scientist	0.064* (0.024)	0.018	0.112	0.049** (0.019)	−0.088	−0.011
Trustworthy	−0.018(0.040)	−0.097	0.061	0.124(0.034)	0.057	0.191
Reduce revenue leakages	0.003(0.034)	−0.062	0.069	−0.009(0.029)	−0.068	0.048
Enhance access to vaccines	−0.092** (0.045)	−0.180	−0.005	0.029(0.039)	−0.846	0.106
Create employment opportunities	0.057 (0.037)	−0.016	0.129	−0.009 (0.035)	−0.078	0.059
Enhance safety of vaccines	−0.091** (0.044)	−0.177	−0.005	0.078** (0.039)	0.002	0.154
Enhance efficacy of vaccines	−0.021*(0.042)	−0.103	0.061	0.160*(0.037)	0.088	0.232
Age (years)	−0.009 (0.005)	−0.016	0.005	−0.009** (0.085)	−0.018	−0.001
Sex (ref. female)
Male	0.321 (0.1165)	−0.002	0.644	0.167(0.139)	−0.107	0.440
Education (ref. No formal education)
Middle	0.472 (0.0.481)	−0.470	1.416	0.672 (0.361)	−0.035	1.379
Primary	0.351 (0.505)	−0.638	1.339	0.592 (0.380)	−0.153	1.338
Secondary	0.569 (0.491)	−0.393	1.532	0.487 (0.372)	−0.752	1.216
Tertiary	0.819 (0.518)	−0.196	1.835	0.997**(0.407)	0.208	1.786
Religion (ref. Traditionalist)
Christian	0.506 (0.659)	−0.786	1.799	0.146 (0.604)	−1.037	1.166
Muslim	0.421(0.736)	−1.022	1.864	0.038 (0.665)	−1.264	1.127
Constant	−0558 (0.865)	−2.253	1.136	−2.009* (0.746)	−3.472	−0.547
R2	0.312			0.291
F Stat.	113.41*			325.71*

Note: * indicates statistical significance at 1%, ** indicates statistical significance at 5%.

We further explored whether vulnerability to infectious diseases could influence residents' support for localisation of vaccine production. This analysis was critical for identifying the existence of vaccine ethnocentric attitudes. Overall, Table 5 reveals that the perceived vulnerability of the community to infectious diseases, proxied by tourism-dependent and non-dependent status, did not cause significant variation in the influence of these factors on residents' support for made-in-Africa vaccines. But it shows statistically significant effects on the perceived enhanced access to vaccines and employment opportunities due to the localisation of vaccine production on support for made-in-Africa vaccines. The belief that localisation of vaccine production would enhance residents' access to vaccines significantly influenced residents in tourism-dependent communities to support the localisation of vaccine production. However, they were less likely to perceive any job opportunities associated with localisation of production. Consequently, they are less likely to support localisation due to job opportunities.

Table 5.

Predictors of support for Africa-made vaccines based on tourism dependence status.

	Model I (Tourism-Dependent Communities)			Model II (Non-Tourism Dependent Communities)
Explanatory variables	Coef (SE)	[95% Conf. Interval]		Coef (SE)	[95% Conf. Interval]
Self-reliance	0.133*(0.049)	0.036	0.231	0.091*(0.029)	0.033	0.148
Capability of African scientist	−0.132*(0.037)	−0.206	−0.058	0.067*(0.015)	0.038	0.097
Trustworthy	0.102**(0.049)	0.005	0.198	0.154*(0.027)	0.099	0.208
Reduce revenue leakages	0.013(0.034)	−0.054	0.081	0.0169(0.023)	−0.029	0.063
Enhance access to vaccines	0.141*(0.053)	0.035	0.246	0.039(0.034)	−0.027	0.106
Create employment opportunities	−0.125**(0.050)	−0.234	−0.016	0.0168 (0.026)	−0.035	0.069
Enhance safety of vaccines	0.155*(0.051)	0.054	0.257	0.1046* (0.032)	0.041	0.167
Enhance efficacy of vaccines	0.119**(0.053)	0.015	0.223	0.178*(0.029)	0.121	0.236
Sex (ref. female)
Male	0.159(0.244)	−0.319	0.638	−0.074(0.129)	−0.328	0.179
Age	−0.010(0.001)	−0.028	0.008	−0.001(0.003)	−0.014	0.001
Religion (ref. Traditionalist)
Christian	0.590(0.860)	−1.095	2.276	−0.410 (0.804)	−1.987	1.166
Muslim	0.821(0.942)	−1.025	2.668	−0.529(0.845)	−2.187	1.127
Education (ref. No formal education)
Middle	0.887(0.545)	−0.180	1.955	0.336(0.392)	−0.433	1.105
Primary	1.484(0.634)	0.240	2.727	0.190 (0.409)	−0.612	0.994
Secondary	0.944(0.531)	−0.097	1.986	0.036 (0.402)	−0.752	0.824
Tertiary	1.368(0.536)	0.316	2.420	0.329 (0.444)	−0.540	1.200
Constant	−3.605(1.084)	−5.730	−1.480	−3.500*(0.910)	−5.285	−1.715
R2	0.3204			0.312
F Stat.	11*			445.77*

Note: * indicates statistical significance at 1%, ** indicates statistical significance at 5%.

Discussions

This study examined an important but neglected issue in the vaccine literature. Using a mixed-methods research design, we found evidence that vaccine uptake ethnocentrism exists among Ghanaians. Three attitudinal types emerged concerning support for localisation of vaccine production. This is partly revealed by the preferences and willingness to take locally produced vaccines. We labelled those who indicated support for made-in-Africa vaccines as Afrocentric-ethnocentrics, those unsupportive of these vaccines as Apathetic-Afrocentrics and those who were uncertain as Afrocentric-Fence Sitters.

Four out of the eight hypothesised factors explain those with positive attitudes towards locally made vaccines relative to those who are uncertain of their position. Supporters of locally made vaccines believe that their attitude will lead to the conferment of some benefits on them. The functional theory by Katz [63] terms these benefits as utilitarian function of attitude. The anticipated benefits include the promotion of self-reliance, enhancement of the safety and efficacy of vaccines. The significant influence of these factors on the support for localisation of vaccine production confirms the arguments of the theories of nationalism and import substitution industrialisation. Consequently, the study accepted the presupposition that residents who perceive that localisation of vaccine production would lead to self-reliance would be more likely to support African-made vaccines. This is an indication of a mind-set change towards valuing home-made products and services (ethno-localism) as many people in Africa have long been socialised to consider their own as inferior when compared to those from the global north. This observation confirms the view that patriotic, nationalistic and ethnocentric consumption practices demonstrated through the consumption of local goods and services are on the rise [36]. Recently, there has been a renaissance among developing countries and their populations to reduce their dependence on donor support, dubbed normatively in Ghana as ‘Ghana beyond aid’ [64]. Respondents regarded support for African-made vaccines as a pathway for undoing the colonial mentality of vaccine aid and dependency and the old tradition of master-servant relationships forged for self-reliance, independence and autonomy from the global north. Reflecting deeply on Africa’s recent relationship with other countries of the globe as well as its past colonial experiences, it is easily noticed that the continent had relied on the global north for far too long for almost every essential good or service, including lifesaving medicines. Respondents opined that Africans can also manufacture vaccines just like their counterparts in the north, which will help reduce the continent’s high foreign dependence. The dependence of developing countries on rich nations with pharmaceutical acumen for vaccines is unbeneficial, unsustainable and perpetuates health and economic inequality. As a result, some of our survey participants opined that they would support African-made vaccines as a sign of their patriotism towards liberating the continent from the shackles of neo-colonialism. In their view, such moves are crucial for democratising vaccination. The quotes below summarise this view:

We must not import everything from foreign countries but support our own. It is about time we Africans stood up because we have the knowledge required to produce drugs that will liberate us from the apron strings of our colonial masters and past experiences, said Kwesi, a 27-year-old who noted that he is yet to marry and have his children.

Sixty (60) year old Kojo noted that we have to support our own continent including its decision to make vaccines locally. Health inequalities in this world abound and these can only be resolved if we all make efforts by our leaders to promote local vaccine manufacturing in the continent. Local manufacturing of vaccines will enable us to be self-reliant.

We postulated that if residents perceive that localisation promises safe and efficacious vaccines, both reasons will significantly explain support for African-made vaccines. The data confirmed these hypotheses. Afrocentric ethnocentrics explained that localisation of vaccine production processes will improve safety and efficacy of vaccines due to easy access to ingredients for vaccine production. Safety and efficacy of vaccines have been widely identified as the most significant determinants of vaccine acceptance by previous studies [24], [37], Adongo et al., 2021). Our respondents noted that Africa is endowed with enough fauna and flora products suitable for pharmaceutical formulations and that local scientists who best understand the genetic and physiological makeup of fellow Africans could formulate vaccines that would effectively grant immunity. Our study’s participants equally justified their perceived enhancement in vaccines if produced locally to Africa being one of the best sources of herbs for pharmaceutical formulations and that the continent has always made superior drugs. To them, the only problem is that the continent does not have the systems for formalisation and large-scale production obtained elsewhere. They further noted that weather conditions and immune systems vary from region to another which can easily be understood by local scientists in the formulation of pharmaceutical products and services. For instance, one of the respondents intimated as follows:

Africa has intelligent scientists and health experts who better understand their fellow Africans and the continent’s health challenges. Our physiology is different from that of people of other continents. Thus, we need to make vaccines for ourselves to do what is good for us as well as our cultural sensitivities. They know what will work for us better than scientists from other parts of the world do. If the vaccines are produced here, our people can monitor and ensure its safety right from the production stage. More so, we have the primary ingredients (herbs) that can help in formulating better preventive medicines. Personally, I believe in local medicines. Especially, when I'm not feeling well and I take them, I feel much better. So, I believe that Africans should take charge of our vaccine production (Mawuko, male, 38 years old, married, and has 2 children).

Others added that Africa remains a dumping ground for fake products and services including vaccines. Therefore, making our own vaccines could be a magical bullet against dumping activities by foreign pharmaceutical companies and their financiers. Similar to food miles that can compromise the quality and safety of food, those in support of localisation pitched their argument on vaccine miles. We conceptualise vaccine miles as the distance that vaccines are transported from the time of its making until it reaches the vaccines end-users. It has been widely reported that inability to store and handle vaccines properly undermines vaccine potency and cumulates in low confidence in vaccination programmes [65], [66], [67]. Moreover, social scientists have recognised the role of trust in consumption spaces, especially in health contexts where the stakes are high with patients in a dilemma of whom and what to trust [37], [68]. The fourth factor which explained the attitudes of Afrocentric ethnocentrics borders on locally produced vaccines being more trustworthy than foreign ones. Some Africans have long nursed the fear that the West uses vaccines as a channel to perpetrate harm and evil against them. Unlike foreign manufacturers, Afrocentric pro-vaccinists are confident that African scientists would not seek to harm their compatriots. African scientists and pharmaceuticals are unlikely to nurture and implement any hidden negative agenda such as the idea of depopulation, which is one of the widely known conspiracies surrounding vaccination. Vaccines made by local scientists are more likely to signal trust compared to other vaccines because in-group members are more empathetic and concerned with each other (in-group collectivism) than out-group members. In-group collectivism refers to the care of those close to oneself while institutional collectivism refers to the broader consideration of society. In-group collectivism is a duty-bound, relational approach to care, expected in many cultures, mainly when the state does not provide such care [69].

I do not trust foreign vaccines. Foreigners have no good intentions for Africans, so we need to produce our own vaccines. Now African countries make cars and other machines, so we can also make a vaccine and stop depending on others for it, said Adjoa, a 32-year-old married woman.

Kwame, a young and unmarried adolescent added that it is better we also make our own vaccines because we don’t know the intentions of the people we are taking the vaccine from. From time past, we know that a stranger can’t be trusted as much as your own people. They have dark minds and they want us to die but our own fellow scientists will aim at making their citizens healthy.

Finally, we established that lack of trust in the scientific capability of African scientists on vaccine production dampens support for African-made vaccines and arguably acceptance of vaccines produced in Africa by African scientists. They perceived risk as lack of expertise could result in vaccines that are not safe and efficacious. Larson et al. [37] denote confidence as a performance-based facet of trust in which the expertise and ability of the trusted party is assessed. Generally, our study participants showed low confidence in the scientific capability of African scientists to produce vaccines. A similar observation has been made by Cadeddu et al. [70] in their survey in Italy where the majority of the subjects expressed lack of trust in the scientific community regarding vaccines.

Kojo, a 24-year male Afro-vaccine apathetic in the current study, noted that: African scientists are not yet there to produce effective vaccines. They do not have the needed knowledge and skills to prepare vaccines. The technology and know-how are currently weak.

For Adjoa, a 38-year-old woman, she argued that she is not sure African scientists can produce quality vaccines; and even if they do these vaccines may not be fit-for-purpose or very effective.

Sentiments seeding doubt and distrust in the capability of African scientists was linked to the claim that they are inexperienced in formulating vaccines and lack equipment and systems necessary for such scientific activities. This implies an awareness of the systemic challenges faced by African scientists including pharmaceutical research, innovation and development and helping tackle them is extremely important in motivating support for home-made vaccines. Despite having positive coefficients, we failed to generally obtain evidence in support of the fact that perceived potential employment opportunities, alleviation of revenue leakages and enhanced access to vaccines as outcomes of localisation of vaccine production would significantly influence positive attitude towards African-made vaccines. The effects of these variables on support for African-made vaccines were dampened by the perception that the continent lacks scientists with the capability to formulate safe and effective vaccines. This is suggestive that localisation leading to improved access of vaccines, creation of employment opportunities and favourable balance of trade alone are not enough to yield significant support for African-made vaccines.

But perceived enhanced access to vaccines showed a positive effect on support for African-made vaccines among tourism-dependent communities due to their perceived vulnerability to infectious diseases (Adongo et al.,2021; Gursoy et al., 2021). For example, most of the people interviewed from such communities indicated that the biggest constraint in getting people to voluntarily and fully vaccinate in Africa is vaccine hesitancy but not access as is often narrated. Though the general availability of vaccines is a big problem in resource poor settings including Africa, getting people to take up the available ones is sometimes a problem, even with convenience. Albeit positive, the view that localisation could ease access to vaccines did not significantly explain support for African-made vaccines at the general sample level. In fact, some participants pointed out that while localisation of vaccine production can guarantee reliable and timely access than relying on foreign manufactures, there are equally important constraints including cold chain storage and handling conditions which needs to be addressed before any discussion on localisation of vaccine production can be had.

Conclusions and recommendations

The findings reported in this study highlight an important gap in knowledge regarding citizens' support for African-made vaccines and the need to understand this to address vaccine hesitancy. The study concludes that vaccine ethnocentric tendencies are prevalent among the majority of Ghanaians, and they have a strong preference for African-made vaccines, particularly made-in-Ghana vaccines by Ghanaian scientists. The study recommends that public health practitioners and ministries of health in Africa should use these factors as the basis for campaigns promoting home-made vaccines to alter how Africans accept vaccines and minimise hesitancy.

Trustworthiness of made-in-Africa vaccines positively influences support for vaccine localisation, while lack of trust in African scientists to produce vaccines decreases support. However, perceived employment opportunities, revenue leakages, and enhanced access to vaccines do not significantly influence support for made-in-Africa vaccines at the general population level. Nevertheless, perceived enhanced access to vaccines influence support for vaccine localisation in tourism-dependent communities, and therefore, it is recommended that health campaigns and nudges targeting these communities should include factors that enhance access to vaccines. The study also recommends building the capacity of African scientists and empowering them with state-of-the-art equipment and technology required for vaccine production to compensate for low trust. Greater transparency and publicity in these processes and their outcomes are required to engender trust among citizens.

Though we do not have and consequently did not provide all the answers to vaccine location decisions, this study represents a major leap forward. To begin with, data from the Central Region of Ghana were used for the analysis. This may, obviously, not reflect the national situation. As such, the results should only be considered exploratory cross-sectional baseline data that should be relied on with caution. Moreover, the study did not analyse the role of culture in moderating certain beliefs about vaccines made in Africa, which could have been an important insight. Future research should consider the role of culture and other issues not explored in this study. Finally, there is a need for further research that utilises data from many African countries to ascertain a broader understanding of how residents in these countries perceive home-made vaccines.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Data availability

Data will be made available on request.