Prevalence and predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa: A systematic review and meta-analysis

Eustes Kigongo; Amir Kabunga; Raymond Tumwesigye; Marvin Musinguzi; Ronald Izaruku; Walter Acup

doi:10.1371/journal.pone.0289295

. 2023 Jul 28;18(7):e0289295. doi: 10.1371/journal.pone.0289295

Prevalence and predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa: A systematic review and meta-analysis

Eustes Kigongo ^1,^*, Amir Kabunga ², Raymond Tumwesigye ³, Marvin Musinguzi ⁴, Ronald Izaruku ⁵, Walter Acup ⁴

Editor: Delfina Fernandes Hlashwayo⁶

PMCID: PMC10381063 PMID: 37506132

Abstract

Background

The COVID-19 vaccination is regarded as an effective intervention for controlling the pandemic. However, COVID-19 vaccine hesitancy is hampering efforts geared towards reducing the burden of the pandemic. Therefore, examining COVID-19 hesitancy and its predictors among healthcare workers is essential to improving COVID-19 uptake. In sub-Saharan Africa, the pooled proportion of COVID-19 vaccine hesitancy is yet to be known.

Purpose

The present study was to estimate the pooled proportion of COVID-19 vaccine hesitancy and its predictors among healthcare workers in Sub-Saharan Africa.

Methods

A systematic search of articles was conducted in PubMed, Science Direct, African Journal Online, and Google Scholar. Data was extracted with the help of Excel. Data analysis was conducted using STATA 17. Heterogeneity in the studies was assessed using Cochrane Q and 1² tests. A random effects model was used to examine the pooled estimates to determine if heterogeneity was exhibited.

Results

A total of 15 studies involving 7498 participants were included in the final analysis. The pooled prevalence of COVID-19 vaccination hesitancy among healthcare workers was 46%, 95% CI (0.38–0.54). The predictors of COVID-19 hesitancy were negative beliefs towards vaccine 14.0% (OR = 1.05, 95% CI: 1.04, 1.06), perceived low risk of COVID-19 infection 24.0% (OR = 1.25, 95% CI: 1.23, 1.28), and vaccine side effects 25.0% (OR = 1.23, 95% CI: 1.21, 1.24).

Conclusion

The data revealed generally high hesitancy of COVID-19 vaccine among health workers in Sub-Saharan Africa. Future COVID-19 adoption and uptake should be improved by national and individual level efforts. In Sub-Saharan Africa, it is crucial to address the myths and obstacles preventing healthcare professionals from accepting the COVID-19 vaccination as soon as feasible since their willingness to get the vaccine serves as an important example for the broader public.

Introduction

Since it was initially discovered in Wuhan, China, in late December 2019, coronavirus disease-2019 (COVID-19), a highly contagious illness brought on by the SARS-CoV-2 virus, has become a source of concern for the general public worldwide [1]. On February 12, 2020, the World Health Organization (WHO) formally suggested calling this infectious disease coronavirus disease 2019 (COVID-19), and on March 11, 2020, COVID-19 was determined to have the characteristics of a worldwide pandemic [2]. While vaccination is the best way to prevent the spread of COVID-19, with the introduction of COVID-19 vaccines, the general resistance to and refusal to receive vaccinations appears to have increased, and what is most concerning is that this behavior is being noticed among healthcare workers in the face of a pandemic [3]. For example, in a total sample of 76,471 HCWs from 21 countries, the average prevalence of COVID-19 vaccine hesitancy was 22.51%, ranging from 4.3 to 72% [4].

Similar to other RNA viruses, SARS-CoV-2 is a member of the b-coronavirus subgenus. During host adaptation, SARS-CoV-2 experiences a high level of genomic mutation, which presents a considerable challenge to current therapeutic approaches and preventative measures [5]. Medical professionals and researchers from all around the world have been looking for effective treatment options, such as antiviral medicines, immunotherapy, and vaccines, to better prevent novel coronavirus infections and stop the outbreak [5]. However, due to the lack of treatment for COVID-19, the failure of viral infection and vaccine-induced immunity to stop the spread of the epidemic, and the emergence of antigenically different variations, herd immunity against SARS-COV-2 cannot yet be obtained [6]. A safe and effective vaccine is the most effective and dependable way to build up the population’s immune system (herd immunity) to prevent recurrent infections [5].

SARS-CoV-2 vaccinations are safe and effective in lowering SARS-CoV-2-related deaths, symptomatic cases, severe cases, and infections globally [7]. Healthcare workers have easier access to populations of COVID-19 patients during routine diagnostic and treatment activities and are at much greater risk of contracting COVID-19 than other populations, so the Advisory Committee on Immunization Practices (ACIP) proposed prioritizing healthcare workers’ vaccination in December 2020 [8]. There have been reviews showing a moderate level of healthcare workers’ acceptance of the COVID-19 vaccine [1]. According to Shui and colleagues, it is crucial to implement initiatives to increase healthcare workers’ acceptance of and readiness to get the COVID-19 vaccine to stop the disease from spreading [1].

An increasing body of research indicates that COVID-19 vaccinations are both safe and efficacious [9]. COVID-19 vaccinations lower the risk of infection and serious consequences [9]. COVID-19 vaccinations provide benefits that outweigh the risk of uncommon adverse effects [9]. Many COVID-19 vaccines were approved in different countries in Sub-Saharan Africa, including those from Janssen (Johnson & Johnson), Moderna, Pfizer/BioNTech, Sinovac, and StraZeneca [10]. COVID-19 vaccinations have been recommended many public health organizations, including the WHO [9]. Despite the evident and confirmed benefits of COVID-19 vaccines, there is still vaccine hesitancy among many individuals in the world, including health care personnel. In Africa, the pooled COVID-19 vaccine acceptance rate was predicted to be 46% [11]. Vaccination-specific concerns (safety and effectiveness), a lack of evidence or information, antivaccine attitudes, and a lack of institutional trust are all reasons for vaccine hesitation [12]. Several studies have looked into the elements that contribute to COVID-19 vaccine hesitancy. Low educational attainment, ethnic disparities, rurality, and resistance to other vaccinations (e.g., influenza) are all common variables [12, 13]. However, research on the most important predictors of resistance to COVID-19 immunization is constantly emerging. While the general population’s COVID-19 vaccination hesitancy rates have been well investigated and are reasonably well established, few studies have explicitly investigated COVID-19 vaccine hesitancy among health care personnel [13].

Healthcare workers are still on the front lines of the current pandemic, and countries have prioritized them as the first to be vaccinated [14]. Additionally, healthcare workers serve as a link between healthcare systems and patients. People in the community frequently rely on healthcare workers’ knowledge and behaviors to guide their decisions about whether to accept or refuse the COVID-19 vaccine [15]. However, there has been an increase in reports of vaccination hesitancy [16]. Examining the level of acceptance of the COVID-19 vaccination and predictors of COVID-19 vaccination hesitancy among healthcare workers would thus assist policymakers, researchers, and health authorities in developing appropriate vaccine hesitancy interventions. However, among this group of people in the Sub-Saharan Africa region, there are currently no comprehensive reviews of COVID-19 hesitancy and its predictors among healthcare workers. This review aimed to provide a synthesis of evidence on prevalence and predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa. In this regard, the review attempted to answer the following questions;

What is the proportion of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa?
What are the predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa?

Methods

This systematic review and meta-analysis were conducted in accordance with the guidelines of Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) to ensure a rigorous selection and reporting of studies. The study was registered in the Prospective Register of Systematic Review (PROSPERO) (ID: CRD42022359141).

Search strategy

We searched the following electronic bibliographic databases: Google Scholar, African Journal Online, PubMed, and Science Direct, using a combination of keywords and appropriate thesauri for COVID-19 vaccination hesitancy and healthcare workers. The selected keywords were a vaccine, COVID-19 or SARS, hesitancy, refusal, acceptance, or acceptability. The keywords were conveniently selected based on the study objectives. PubMed was used to create the initial combination of search phrases that were customized for other databases using appropriate thesauri. The literature search was supplemented with materials from institutional repositories as well as studies from reference lists of similar review articles. The detailed strategy has been attached (S1 Table).

Inclusion criteria and exclusion criteria

All studies conducted in English about COVID-19 vaccination hesitancy among health workers in Sub-Saharan Africa since December 2020 were considered. Our inclusion criteria included only studies reporting on predictors of COVID-19 vaccination hesitancy in English, primary studies, all the types of vaccines approved for use by the FAO, and quantitative studies published from December 2020 to October 2022 within sub-Saharan Africa (SSA). We excluded COVID-19 studies reporting animal studies, reviews, commentaries, letters to the editors, studies in which raw data could not be transformed, and studies on hesitancy rates explicitly referring to participants other than healthcare workers in Sub-Saharan Africa.

Study and data management

After searching and collecting articles, duplicate files were removed. The screening was done at two levels: the title and abstracts, and then the full-text screening. This was performed by two independent reviewers to assess their potential relevance for full review using the EndNote software, done against the set inclusion and exclusion criteria. Any discrepancies were resolved by discussion and consulting the third reviewer. Electronic records of the included and excluded studies were kept for audit purposes, specifying reasons for any exclusion.

Data extraction

The data were extracted using a Microsoft Excel template. The form was tested and revised iteratively as needed. The following were included: The first name of the first author, year of publication, study title, country, and study design, period of conducting a survey, study participants, sample size, response rate, and proportion of males, average age, reported hesitancy, and predictors of hesitancy (S2 Table).

Quality assessment for the included papers

The risk of bias was assessed using the validated quality assessment checklist for prevalence studies from Hoy and colleagues [17]. The tool has nine items that generate a total score of 9 (S1 Raw data). These items include the target population, sampling frame, sampling, response rate, data collection, study case definition, study instruments, and parameters for the numerator and denominator. The tools classify studies as low-risk (0–3), moderate-risk (4–6), and high-risk (7–9). Each study was assessed independently, and the majority of the studies were rated as having a low risk of bias. Studies with high risk of bias were not included in the final analysis.

Ethical considerations

The study conducted did not require ethical approval because it utilized secondary data from previously published literature.

Data synthesis and analysis

The data from individual articles was extracted using Microsoft Excel 2013 and exported to STATA (version 17; StataCorp, TX, USA) for all analyses. To determine the pooled prevalence of COVID-19 vaccination hesitancy, analysis was conducted on 15 individual studies, with the main findings described in a table with narratives in texts. Due to the high heterogeneity (I2 = 91.96%, p≤0.001) among the included studies, a meta-analysis using the random effects model was performed to estimate the pooled prevalence of COVID-19 vaccination hesitancy among healthcare workers in sub-Saharan Africa. This was performed at a 95% confidence interval, and the results were presented using a forest plot. The Cochran’s Q test was used to test heterogeneity using the I2 statistics, which were interpreted as low heterogeneity (25%), moderate heterogeneity (25%–50%), and high heterogeneity (>50%) [18]. We also estimated pooled odds ratios for factors associated with vaccine hesitancy, and statistical significance was determined at P<0.05 of the I2. An explanatory variable was eligible for inclusion if there was data from at least two of the included studies. Publication bias was also assessed using visual inspection of funnel plot asymmetry and a weighted Egger’s regression test with P = 0.05 as a cutoff point to declare the presence of publication bias. Subgroup analysis was performed based on the potential sources of heterogeneity. Leave one out sensitivity analysis was also performed to assess the influence of single studies on the overall effect [19].

Results

The electronic search yielded 13,647 articles, and 11,900 articles remained after the duplicates were deleted. After screening abstracts and titles, 35 articles remained and were subjected to full-text screening. Twenty articles were removed for different reasons: the full outcome of interest was not reported (n = 15) and the full text was not available (n = 5). The results are shown in Fig 1.

Characteristics of the studies

Out of the 15 included studies, 1 was conducted in the Democratic Republic of the Congo (DRC), 1 from Ghana, 3 from Nigeria, 1 from Sierra Leone, 1 from Togo, 1 from Uganda, 7 from Ethiopia, and 1 from Tanzania. The sample size ranged from 108 to 811 participants, giving a total sample size of 7498 participants. The participants included doctors, medical laboratory scientists, allied health professionals, pharmacists, nurses, eye health workers, and medical students. The first survey was conducted between November and December 2020, and the most recent was between September and October 2022. The studies were all cross-sectional and published between 2020 and 2021. The majority of the included studies had a low risk of bias. The findings are summarized in Table 1.

Table 1. Characteristics of included studies.

SN	Author	Year	Country	Participants	Sample	Sampling technique	Period of Study	Males (%)	Average Age (%)	Hesitancy (n)
1	Abay et al [20]	2022	Ethiopia	CP	464	Convenience	Apr-May, 2021	59.2	20-29(51.8)	72
2	Adane et al [21]	2022	Ethiopia	HCW	404	Simple random	May 2021	50.5	20-30(40.1)	141
3	Aemro et al [22]	2021	Ethiopia	HCW	440	Simple random	May-Jun, 2021	62.4	26-30(56.0)	192
4	Amuzie et al [23]	2021	Nigeria	HCW	422	Simple random	Mar, 2021	32.9	30-39(38.6)	231
5	Pharm et al [24]	2022	Ethiopia	HCW	319	Stratified random	Jun-Jul, 2021	53.6	20-29(56.7)	87
6	Nnaemeka et al [25]	2022	Nigeria	HCW	710	Convenience	Sept, 2021-Mar 2022	39.6	15-25(43.4)	287
7	Nzaji et al [26]	2020	DRC	HCW	613	Convenience	Mar-Apr, 2020	50.9	40.3	443
8	Andrew et al [27]	2021	Uganda	MS	600	Convenience	Not reported	62.8	<24(61.2)	184
9	Eveline et al [28]	2022	Tanzania	HCW	811	Convenience	Sept 2021	52.0	35	517
10	Mohammed et al [29]	2021	Ethiopia	HCW	614	Convenience	Mar-Jul, 2021	48.5	<30(57.0)	370
11	Mustapha et al [30]	2021	Nigeria	MS	440	Convenience	Mar-Jun, 2021	49.1	23	264
12	Dufera et al [31]	2021	Ethiopia	HCW	522	Snow ball	Jun 2021	90.2	30-39(77.8)	198
13	Tolossa et al [32]	2022	Ethiopia	HCW	439	Proportionate	Apr 2021	62.18	<30(63.6)	191
14	Yendewa et al [33]	2022	Sierra Leone	HCW	592	Convenience	Jan-Mar, 2022	67.2	29	356
15	Botwe et al [34]	2022	Ghana	HCW	108	Not reported	Feb 2021	67.6	20-29(50.9)	44

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HCW = Healthcare workers; MS = Medical students; CP = Clinical practitioners; HP = Health professionals

Pooled COVID-19 vaccine hesitancy level in Sub-Saharan Africa

The pooled prevalence of COVID-19 vaccination hesitancy rate in Fig 2 among healthcare workers was 46%, 95% CI (0.38–0.54). In this meta-analysis, a random effects model was executed as high heterogeneity (I² = 91.96%, p≤0.001) was detected within the included studies.

Publication bias assessment

Fig 3 indicates funnel plot symmetry. The Eggers test (0.3256) also showed absence of potential publication bias.

Sub-group and sensitivity analysis

Sub-regions were used for sub-group analysis, as indicated in Fig 4 (Central Africa, East Africa, and West Africa). The pooled estimated COVID-19 hesitancy rate in Central Africa was 72% (95% CI: 64%–80%), in West Africa it was 52% (95 CI: 43%–61%), and in East Africa it was 40% (95% CI: 30%–50%). Since we had more than 10 studies, leave one out sensitivity analysis was conducted to assess the impact of independent studies on the overall pooled effect. The results revealed that no single study had a significant impact on the overall prevalence and ranged from 44% (95% CI: 36% - 52%) to 48% (95% CI: 41% to 56%) (S1 Fig).

The predictors of COVID-19 hesitancy among healthcare workers

Results in Table 2 show that the predictors of COVID-19 hesitancy among healthcare workers were negative beliefs towards vaccine 14.0% (OR = 1.05, 95% CI: 1.04, 1.06), perceived low risk of COVID-19 infection 24.0% (OR = 1.25, 95% CI: 1.23, 1.28), and vaccine side effects 25.0% (OR = 1.23, 95% CI: 1.21, 1.24).

Table 2. Predictors of COVID-19 vaccine hesitancy among health workers in Sub-Saharan Africa.

Variable	Studies	Proportion	OR (95% CI)	I², P-value
Negative beliefs towards vaccine	6	14.0	1.05(1.04, 1.06)	98.7%, <0.001
Perceived low risk of COVID-19 infection	4	24.0	1.25(1.23, 1.28)	98.2%, <0.001
Vaccine side effects	8	25.0	1.23(1.21, 1.24)	99.2%, <0.001

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Discussion

This review investigated healthcare workers’ pooled level of hesitation over the COVID-19 vaccine and related factors. Acceptance of the COVID-19 vaccination is a serious global concern. The results of the study showed that the pooled prevalence of COVID-19 vaccination hesitancy among healthcare workers in sub-Saharan Africa was 46%. In this meta-analysis, a random effects model was performed as high heterogeneity (I² = 91.96%, p≤0.001) was detected within the included studies. In particular, despite availability and accessibility, a significant proportion of the healthcare workers in our study refused vaccination, demonstrating that healthcare workers are not immune to vaccine hesitancy. Indeed, the WHO has identified vaccination hesitancy as one of the ten most serious threats to world health [35]. Healthcare workers must be vaccinated against COVID-19 because they give care to COVID-19 patients, and a high infection rate among HCWs could result in a major loss in this critical workforce. Furthermore, healthcare workers who have been vaccinated and are well-informed are a valuable source of COVID-19 vaccine knowledge and are more likely to advocate COVID-19 vaccination to their families, colleagues, and patients [36]. Healthcare workers are respected experts who can act as role models for healthy behavior in the wider public, hence increasing vaccination coverage [37]. This result was within the range of 12 to 91.4% observed in the United States of America [38]. The result was however, higher than the 26.7% reported by a systematic review conducted in the United States and the United Kingdom [39] and 27.8% in Europe [40] and 12.06% and19.15% hesitancy rate in three national studies in China with more than 2,000 participants [41, 42]. This difference may be attributed to differences in sample size.

Sub-group analysis was performed utilizing African areas in this systematic review and meta-analysis because of the presence of significant heterogeneity in the included papers, which may expose the findings to publication bias. The pooled estimated COVID-19 hesitancy rate in Central Africa was 72% (95% CI: 64%–80%), in West Africa it was 52% (CI: 43%–61%), and in East Africa it was 40% (95% CI: 30%–50%). The presence of variability may be attributed to study sample size, study design characteristics, and study settings.

In this systematic and meta-analytical analysis, the most common factors that predicted vaccine hesitancy were negative beliefs towards vaccines, a perceived low risk of COVID-19 infection, and vaccine side effects. It’s significant to note that these predictors were also named as pertinent variables in two earlier, related systematic reviews and meta-analyses [43, 44]. Results indicate that healthcare workers who thought that COVID-19 vaccines had side effects were 1.23 times more likely to be hesitant as compared to their counterparts who thought otherwise. Our finding confirms findings from studies done in the United States, [45] China [46] and DRC [26] that participants’ main worries and vaccine hesitancy were long- and short-term side effects. Therefore, to increase vaccine uptake and acceptance, the ministry of health should develop strategies such as organizing intercultural health advocacy sessions for healthcare workers and the community, improving health advocates’ knowledge and interpersonal communication skills, involving influential community leaders in the dissemination of information, and involving vaccine users in providing agreed vaccination in a variety of cultural contexts [29].

Another important predictor of vaccine hesitancy among healthcare professionals in Sub-Saharan Africa in our study was a lower perceived risk of getting infected. Results also show that healthcare workers perceiving a low risk of contracting COVID-19 were 1.25 times more likely to hesitate the COVID-19 vaccine compared to their counterparts perceiving a high risk of infection. It is significant to note that this predictor was also recognized as a pertinent component in earlier related systematic reviews and meta-analyses [43, 44]. Therefore, this study suggests that improved enactment is required to address issues of confidence, acceptance, benefit, and worry regarding the side effects of the COVID-19 vaccine.

Our results indicated that healthcare workers who reported negative attitudes and beliefs about the vaccine had a 5% increased likelihood of hesitating vaccination compared to those who did not report negative beliefs. The participants’ erroneous beliefs, discomfort, and skepticism may cause hesitation in receiving the COVID-19 vaccine. There is evidence to show that acceptance of the COVID-19 vaccination is significantly influenced by a positive attitude toward the vaccine [47]. Participants who had a positive attitude toward the COVID-19 vaccine were more likely to accept it than those who had a negative attitude [47]. This suggests that having a good attitude about getting vaccinated against COVID-19 is essential. This indicator of COVID-19 vaccination hesitancy discovered here is likely explained by widespread COVID-19 disinformation, such as fake news or the dissemination of inaccurate or false information regarding COVID-19 on social media, such as Facebook or other networks [48, 49].

This review seems to be the first of its kind to synthesize evidence on the prevalence and predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa. However, it has the following limitations: Only English-language articles were included in the review. Only quantitative studies were included. Also, we included only primary studies. The systematic review also reports publication bias from small study differences. This might have resulted in omissions or restricted the applicability of our findings.

Conclusion

The data revealed generally high hesitancy of COVID-19 vaccine among health workers in Sub-Saharan Africa. The following were the most common predictors of COVID-19 vaccine hesitancy: negative beliefs towards vaccines, perceived low risk of COVID-19 infection, and vaccine side effects. Future COVID-19 adoption and uptake should be improved by national and individual-level efforts. In Sub-Saharan Africa, it is crucial to address the myths and obstacles preventing healthcare professionals from accepting the COVID-19 vaccination as soon as feasible since their willingness to get the vaccine serves as an important example for the broader public.

Supporting information

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

Click here for additional data file.^{(30.4KB, docx)}

S1 Table. Search strategy for the databases.

(DOCX)

Click here for additional data file.^{(14.1KB, docx)}

S2 Table. Quality assessment checklist.

(DOCX)

Click here for additional data file.^{(25.6KB, docx)}

S1 Raw data

(XLSX)

Click here for additional data file.^{(14.2KB, xlsx)}

S1 Fig. Leave one out sensitivity analysis.

(DOCX)

Click here for additional data file.^{(19.2KB, docx)}

Acknowledgments

The authors acknowledge the authors of the different study articles that were used in the present systematic review and meta-analysis.

Data Availability

All data are fully available without restriction and have been attached as Supplementary 3.

Funding Statement

The authors received no specific funding for this work.

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PLoS One. doi: 10.1371/journal.pone.0289295.r001

Decision Letter 0

Delfina Fernandes Hlashwayo

25 Apr 2023

PONE-D-22-29316Prevalence and Predictors of COVID-19 vaccination hesitance among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysisPLOS ONE

Dear Dr. Kigongo,

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Consider assessing the impact of heterogeneity and bias on the reported results.
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**********

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Reviewer #1: No

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**********

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

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Reviewer #2: Yes

Reviewer #3: Yes

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Reviewer #1: Topic : Prevalence and Predictors of COVID-19 vaccination hesitance among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysis

Manuscript ID: PONE-D-22-29316

The systematic review and meta-analysis done by Kigongo etin prevalence and predictors of COVID-19 vaccination hesitance has a public health significance and a timely topic; however there are a lot of issues and must be corrected before publication.

Minor comments

1. In abstract correct this sentence. Data were extracted using was extracted using excel.

2. Topographical errors like grammar and spelling correct it.

Major comments

1. Only cross sectional studies included what about case control, and cohort studies?

2. What about studies written other than English language?

3. All the studies regardless of the level of risk were included. So what is the significance of quality assessment, if you included all studies without assessing risk of bias. It is better to avoid those studies high risk of bias or weak studies and reanalyze?

4. In result part in Figure 1, you have excluded 11 studies from 35, you should included 24 studies but you have included only 22 studies ? Correct and reanalyze

5. Under characteristics of studies you have mentioned 23 studies but you have included 22studies? Please correct it.

6. There is a table in page ten without any table name 2 or 3 ?

7. The pooled prevalence of vaccine hesitance was 36% and I2 =99.58% , this shows heterogeneity is very high. If heterogeneity is high, it is difficult to pool. If you want to pool the findings you should do other heterogeneity assessment methods like sub group analysis or using meta regression, but I did not see such methods here?

8. In this manuscript there is no strength and limitation of this systematic and meta-analysis?

Reviewer #2: Abstract

The abstract speaks to the systematic review. The problem is stated with relevant support the systematic review. The methods shows summary of the articles used but were limited to cross-sectional studies of a period of 2 years (2020-2022). This is reasonable period since the COVID-19 pandemic started in 2019 achieving appropriate results. The abstract concludes with summary of the findings relevant to the subject. The results are pertinent to the local region

Background

1. The review was not of randomized trials. The review included the description of the approaches used to identify all the literature in the subject. The question the paper wants to answer should be stated clearly. Moreover, it is surprising that the review could not capture the study below which was conducted in a West African country among a specific healthcare professionals about COVID -19 hesitancy in vaccine uptake to give more credence to the systematic study. It is advised the authors include this paper in the review unless they found it in the eleven articles removed as stated in the results.

Botwe BO, Antwi WK, Adusei JA, Mayeden RN, Akudjedu TN, Sule SD. COVID-19 vaccine hesitancy concerns: Findings from a Ghana clinical radiography workforce survey. Radiography (Lond). 2022 May;28(2):537-544. Doi: 10.1016/j.radi.2021.09.015. Epub 2021 Oct 8. PMID: 34654631; PMCID: PMC8498685.

2. The context of the systematic review including why it’s important are stated.

3. The statement in page (8-9) “COVID-19 vaccine hesitance and acceptance among Healthcare workers in Sub-Saharan Africa have been investigated through observational research [4]” cannot be totally true as the study quoted above was not an observational study.

Why Methods and methods?

Looking at the period of the unset of the pandemic the participants identified in the 22 articles and the aggregate data used is large enough for the systematic review.

Search Engine

Appropriate but would be good to include SCOPUS articles if possible.

Eligibility criteria

Inclusion

The review included only studies reporting on predictors of COVID-19 vaccination hesitance. However, Botwe et al study indicated above reported similar findings

Results

Data was synthesized.

1. The writers offer a high-quality, well-protected setting for assessing significant research works that advance understanding of the subject matter and a specific geographic area.

2. The study’s characteristics are displayed clearly in the results and supported with Forest plot of the pooled proportion of COVID-19 vaccine hesitance.

3. However, the Table with the heading “Predictors of COVID-19 vaccine hesitance among Health workers in Sub-Saharan Africa” is supposed to come with a label (i.e Table 2)

4. Overall the results will help local health policies

Discussion.

The discussion was tailored to the results and in relation to previous studies used for the systematic review.

Reviewer #3: Please find my specific review comments below:

Background:

(1) The pooled COVID-19 vaccine hesitancy in Africa was 54%[4]. It is difficult to

comprehend vaccination hesitancy since it is influenced by complicated and context-specific elements that change

across time, place, and vaccines. Complacency, convenience, confidence, as well as sociodemographic and cultural

factors also have an impact on the outcome[3].

Here, are the context specific elements and sociodemographic and cultural factors different? How?

(2) A safe and effective vaccine is the most effective and dependable way to build up the population's immune system to prevent recurrent infections[5].

Here, is population's immune system refering to herd immunity? please clarify

(3) The efficiency of a vaccine and the extent to which it is used determines its success[9]

Please elaborate the 'extent' and please make more logical connection with the next sentences.

(4) However, among this group of people in the region, there are currently no thorough reviews.

Please strengthen the justification part. Now this is not much stronger.

(5) any reviews and experimental studies were excluded.

Please provide justification

(6) qualitative studies were excluded

Please provide reasons.

(7) After screening abstracts and titles, 35 articles remained and were subjected to full-text screening.

Please elaborate the screening process here.

(8) the wrong publication type (n=3)

What is meant by wrong publication type?

(9) Table 1: One collumn for sampling techniques can be added

(10) The result implies that a considerable proportion of healthcare workers in Sub-Saharan Africa were hesitant towards the COVID-19 vaccine, implying a direct negative impact on the mitigation of COVID-19.

Hesitant towards receiving? Please make it clear here.

(11) the concerned bodies like ministries of health should develop strategies such as ........

what about other concerned bodies? who are they? please mention

**********

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Reviewer #1: No

Reviewer #2: Yes: DR. WILLIAM KWADWO ANTWI

Reviewer #3: Yes: Shafayat Sultan

**********

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PLoS One. 2023 Jul 28;18(7):e0289295. doi: 10.1371/journal.pone.0289295.r002

Author response to Decision Letter 0

15 Jun 2023

Eustes Kigongo

Department of Environmental Health and Disease Control, Lira University

Uganda

May 2, 2023

Dear Editor,

Re: Response to reviewers’ comments

First all, I wish to thank the reviewers and editors for the positive feedback that will help to improve the quality of our manuscript.

This letter serves to re-submit our manuscript titled “Prevalence and Predictors of COVID-19 vaccination hesitance among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysis”.

Please see the responses in the table below;

Sn Comments Response Page, Lines

Editor

1 Carefully review the manuscript for language errors and correct them as needed. Thanks for this

The manuscript has been reviewed All pages

2 Use the PRISMA 2020 flow diagram and cite PRISMA (http://www.prisma-statement.org/PRISMAStatement/CitingAndUsingPRISMA.aspx)

Thank you,

This has been used Pg 6,

Lines 166-200

3 Improve the introduction by providing more justification for the research questions Thanks for this advice

The introduction has been improved by providing more justification for the research questions Pg 3,

Lines 76-87

4 Consider assessing the impact of heterogeneity and bias on the reported results Thank you for the insight,

Heterogeneity and bias has been assessed using Egger’s test and a funnel plot inserted as supplementary 1 Pg 5,

Lines 143-150

5 Ensure consistency among calculations, text, figures, and tables in the results section Thank you, these have been updated throughout the entire manuscript All pages

6 To improve reproducibility, ensure that supporting data are available in the manuscript’s supplementary files or public repositories. This can include a detailed search strategy used for each database and a detailed assessment of risk of bias for each included study Thank you for the comment,

The detailed search strategy has been included as a supplementary 2

The risk of bias for each included study was assessed and the tool used has been cited. Pg 4,

Lines 103-104

Pg 4,

Lines 126-127

7 Include a discussion of study limitations in the manuscript We have included the limitations in the manuscript Pg 13,

Lines 288-292

Reviewer one

1 In abstract correct this sentence. Data were extracted using was extracted using excel Thanks for this

This has been rectified Pg 1,

Lines 13

2 Topographical errors like grammar and spelling correct it Thanks for this

The manuscript has been reviewed All pages

3 Only cross sectional studies included what about case control, and cohort studies? Thank you,

This was a typo and has been rectified. Pg 4,

Lines 107-110

4 What about studies written other than English language? Thanks for this observation, ‘

We included on studies in English. However, we have acknowledged this in the limitations of the study. Pg 13,

Lines 288-292

5 All the studies regardless of the level of risk were included. So what is the significance of quality assessment, if you included all studies without assessing risk of bias. It is better to avoid those studies high risk of bias or weak studies and reanalyze? Thank you for the observation,

This was a typological error, only studies with low and moderate risk were included. Pg 5,

Lines 130-131

6 In result part in Figure 1, you have excluded 11 studies from 35, you should included 24 studies but you have included only 22 studies? Correct and reanalyze Thank you,

This has been rectified Pg 5,

Lines 153-155

7 Under characteristics of studies you have mentioned 23 studies but you have included 22studies? Please correct it. Thank you,

This has been rectified Pg 7,

Lines 203-206

Reviewer Two

1 The abstract speaks to the systematic review. The problem is stated with relevant support the systematic review. The methods shows summary of the articles used but were limited to cross-sectional studies of a period of 2 years (2020-2022). This is reasonable period since the COVID-19 pandemic started in 2019 achieving appropriate results. The abstract concludes with summary of the findings relevant to the subject. The results are pertinent to the local region Thanks for the complement NA

2 The review was not of randomized trials. The review included the description of the approaches used to identify all the literature in the subject. The question the paper wants to answer should be stated clearly. Thank you for the great suggestion,

The questions have been clearly stated Pg 3,

Lines 88-91

Moreover, it is surprising that the review could not capture the study below which was conducted in a West African country among a specific healthcare professionals about COVID -19 hesitancy in vaccine uptake to give more credence to the systematic study. It is advised the authors include this paper in the review unless they found it in the eleven articles removed as stated in the results Thank you,

This study has been considered Pg 8,

Lines 212-213

4 The context of the systematic review including why it’s important are stated Thanks for the complement NA

5 The statement in page (8-9) “COVID-19 vaccine hesitance and acceptance among Healthcare workers in Sub-Saharan Africa have been investigated through observational research [4]” cannot be totally true as the study quoted above was not an observational study Thanks for this observation

This statement has been modified Pg 3,

Lines 76-87

6 Looking at the period of the unset of the pandemic the participants identified in the number of articles and the aggregate data used is large enough for the systematic review. Thank you for the compliment NA

7 The review included only studies reporting on predictors of COVID-19 vaccination hesitance. However, Botwe et al study indicated above reported similar findings Thank you,

This study has been incorporated Pg 8,

Lines 212-213

8 Data was synthesized.

The writers offer a high-quality, well-protected setting for assessing significant research works that advance understanding of the subject matter and a specific geographic area Thanks for this complement NA

9 The study’s characteristics are displayed clearly in the results and supported with Forest plot of the pooled proportion of COVID-19 vaccine hesitance Thanks for this complement NA

10 However, the Table with the heading “Predictors of COVID-19 vaccine hesitance among Health workers in Sub-Saharan Africa” is supposed to come with a label (i.e Table 2) Thank you,

This has been done Pg 11,

Lines 232

11 Overall the results will help local health policies Thanks NA

12 Discussion.

The discussion was tailored to the results and in relation to previous studies used for the systematic review. Thanks for this complement NA

Reviewer Three

1 The pooled COVID-19 vaccine hesitancy in Africa was 54%[4]. It is difficult to comprehend vaccination hesitancy since it is influenced by complicated and context-specific elements that change across time, place, and vaccines. Complacency, convenience, confidence, as well as sociodemographic and cultural factors also have an impact on the outcome[3]. Thank you for the observation,

The statement is rectified Pg 1 & 2,

Lines 39-41

3 A safe and effective vaccine is the most effective and dependable way to build up the population's immune system to prevent recurrent infections [5].

Here, is population's immune system referring to herd immunity? please clarify Thanks for this

We clarified this in the text;

'population immunity is the same as herd immunity' is Pg 3,

Lines 76-87

4 The efficiency of a vaccine and the extent to which it is used determines its success[9]

Please elaborate the 'extent' and please make more logical connection with the next sentences. Thanks for this information

The statement has been modified Pg 3,

Lines 76-87

5 However, among this group of people in the region, there are currently no thorough reviews.

Please strengthen the justification part. Now this is not much stronger. the introduction has been improved by providing more justification for the research questions Pg 3,

Lines 76-87

6 Any reviews and experimental studies were excluded.

Please provide justification It's true, we only included only primary studies. However, we have acknowledged this in the limitations of the study.

Secondly at the time of the review experimental studies seemed minimal or non-existent Pg 13,

Lines 288-292

7 Qualitative studies were excluded

Please provide reasons. Thank you,

This has been acknowledged as a limitation Pg 13,

Lines 288-292

8 After screening abstracts and titles, 35 articles remained and were subjected to full-text screening.

Please elaborate the screening process here. Thank you for the insight,

The screening process is elaborated in the study and data management section Pg 4,

Lines 113-119

9 The wrong publication type (n=3)

What is meant by wrong publication type? Thank you for the good observation,

This has been re-written Pg 5,

Lines 153-155

10 Table 1: One column for sampling techniques can be added Thank you for the advice,

This has been added Pg 8,

Lines 211-213

11 The result implies that a considerable proportion of healthcare workers in Sub-Saharan Africa were hesitant towards the COVID-19 vaccine, implying a direct negative impact on the mitigation of COVID-19.

Hesitant towards receiving? Please make it clear here. Thanks for this advice

We have modified the sentences Pg 11,

Lines 283-241

12 The concerned bodies like ministries of health should develop strategies such as ........

What about other concerned bodies? who are they? please mention Thanks for this

We have modified the sentence Pg 12,

Lines 265

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(15.7KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0289295.r003

Decision Letter 1

Delfina Fernandes Hlashwayo

11 Jul 2023

PONE-D-22-29316R1Prevalence and Predictors of COVID-19 vaccination hesitance among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysisPLOS ONE

Dear Dr. Kigongo,

The reviewers have provided feedback on the manuscript to enhance its quality. The authors are advised to consider the following key points for any subsequent revisions:

Abstract: Please ensure that the results are not repeated in the conclusion. The conclusion should provide a concise summary of the findings and highlight their implications and significance.
Please review the order of keywords to ensure consistency and alignment with relevant concepts in the manuscript.
Ensure consistent use of terms related to vaccine hesitancy throughout the manuscript to maintain clarity and coherence.
Please provide a comprehensive and well-defined set of exclusion criteria that clearly outline the criteria for excluding studies from the systematic review.
Please clarify if the tool adapted from Hoy et al. has been validated. If any item was removed, provide a justification for its exclusion. In addition, please include the questions and scoring criteria for the risk of bias assessment in the supplementary file, as requested previously.
Please use the correct symbol (p<0.05) to indicate statistical significance, rather than using "P=0.05."
Include the search strategies for Google Scholar, African Journal Online, and Science Direct in the supplementary file, along with the date and results in numbers. Currently, the supplementary file only includes the search strategy for PubMed.
Please provide full names for the abbreviations used in the Supplementary File 2 and ensure that the citations contain the corresponding references.
Please revise the first sentence of the conclusion to accurately reflect the quantitative data and align it with the findings of the study.
Please carefully review the comments provided by Reviewer 4 in the attached PDF and address them accordingly.

Please submit your revised manuscript by Aug 25 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Delfina Fernandes Hlashwayo, M.Sc.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

Reviewer #4: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

Reviewer #4: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: N/A

Reviewer #4: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: (No Response)

Reviewer #4: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #4: Yes

**********

6. Review Comments to the Author

Reviewer #2: Issues raised in the previous review have been addressed. What I cannot find per the manuscript sent to me is the data availability. It only contains the response to reviewer comments. Have you made all data underlying the findings in the manuscript fully available?

Reviewer #4: (No Response)

**********

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Reviewer #2: Yes: Dr William Kwadwo Antwi

Reviewer #4: Yes: Chinedu Anthony Iwu

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Submitted filename: PONE-D-22-29316_R1_REVIEWER COMMENT.pdf

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PLoS One. 2023 Jul 28;18(7):e0289295. doi: 10.1371/journal.pone.0289295.r004

Author response to Decision Letter 1

14 Jul 2023

Eustes Kigongo

Department of Environmental Health and Disease Control, Lira University

Uganda

July 14, 2023

Dear Editor,

Re: Response to reviewers’ comments

First all, I wish to thank the reviewers and editors for the positive feedback that will help to improve the quality of our manuscript.

Please see the responses in the table below;

SN Reviewers’ comments Response Page/lines

1 Abstract: Please ensure that the results are not repeated in the conclusion. The conclusion should provide a concise summary of the findings and highlight their implications and significance Thank you,

We have removed the results from the conclusion. Pg 1,

Lines 35-36

2 Please review the order of keywords to ensure consistency and alignment with relevant concepts in the manuscript. Thank you,

The key words have been reorganized as advised. Pg 1,

Lines 40

3 Ensure consistent use of terms related to vaccine hesitancy throughout the manuscript to maintain clarity and coherence. For consistency, we have used “Hesitancy” throughout the entire manuscript. All pages

4 Please provide a comprehensive and well-defined set of exclusion criteria that clearly outline the criteria for excluding studies from the systematic review. Thank you,

We have provided the exclusion criteria. Pg 4,

Lines 123-125

5 Please clarify if the tool adapted from Hoy et al. has been validated. If any item was removed, provide a justification for its exclusion. In addition, please include the questions and scoring criteria for the risk of bias assessment in the supplementary file, as requested previously. This has been clarified, we used the validated tool and we did not modify.

The tool has been attached as supplementary file 3. Pg 5,

Lines 139-140

6 Please use the correct symbol (p<0.05) to indicate statistical significance, rather than using "P=0.05." Thank you,

This has been rectified. Pg 5,

Lines 158

7 Include the search strategies for Google Scholar, African Journal Online, and Science Direct in the supplementary file, along with the date and results in numbers. Currently, the supplementary file only includes the search strategy for PubMed. Thank you,

This has been addressed accordingly. Attached as Supplementary file 1 NA

8 Please provide full names for the abbreviations used in the Supplementary File 2 and ensure that the citations contain the corresponding references. Thank you,

This has been done. NA

9 Please revise the first sentence of the conclusion to accurately reflect the quantitative data and align it with the findings of the study. Thank you,

This has been revised. Pg 14,

Lines 311-312

10 Please carefully review the comments provided by Reviewer 4 in the attached PDF and address them accordingly. Thank you for the comments,

Comments in the attached document (manuscript) have been reviewed. All document

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(15KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0289295.r005

Decision Letter 2

Delfina Fernandes Hlashwayo

17 Jul 2023

Prevalence and Predictors of COVID-19 vaccination hesitance among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysis

PONE-D-22-29316R2

Dear Dr. Kigongo,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Delfina Fernandes Hlashwayo, M.Sc.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

PLoS One. doi: 10.1371/journal.pone.0289295.r006

Acceptance letter

Delfina Fernandes Hlashwayo

20 Jul 2023

PONE-D-22-29316R2

Prevalence and Predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa: a systematic review and meta-analysis

Dear Dr. Kigongo:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Ms. Delfina Fernandes Hlashwayo

Academic Editor

PLOS ONE

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

S1 Checklist. PRISMA 2020 checklist.

(DOCX)

Click here for additional data file.^{(30.4KB, docx)}

S1 Table. Search strategy for the databases.

(DOCX)

Click here for additional data file.^{(14.1KB, docx)}

S2 Table. Quality assessment checklist.

(DOCX)

Click here for additional data file.^{(25.6KB, docx)}

S1 Raw data

(XLSX)

Click here for additional data file.^{(14.2KB, xlsx)}

S1 Fig. Leave one out sensitivity analysis.

(DOCX)

Click here for additional data file.^{(19.2KB, docx)}

Attachment

Submitted filename: Prevalence and Predictors of COVID.docx

Click here for additional data file.^{(13.1KB, docx)}

Attachment

Submitted filename: PLOS ONE SYTEMATIC REVIEW.docx

Click here for additional data file.^{(14.4KB, docx)}

Attachment

Submitted filename: Response to reviewers.docx

Click here for additional data file.^{(15.7KB, docx)}

Attachment

Submitted filename: PONE-D-22-29316_R1_REVIEWER COMMENT.pdf

Click here for additional data file.^{(928.5KB, pdf)}

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(15KB, docx)}

Data Availability Statement

All data are fully available without restriction and have been attached as Supplementary 3.

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Prevalence and predictors of COVID-19 vaccination hesitancy among healthcare workers in Sub-Saharan Africa: A systematic review and meta-analysis

Eustes Kigongo

Amir Kabunga

Raymond Tumwesigye

Marvin Musinguzi

Ronald Izaruku

Walter Acup

Roles

Abstract

Background

Purpose

Methods

Results

Conclusion

Introduction

Methods

Search strategy

Inclusion criteria and exclusion criteria

Study and data management

Data extraction

Quality assessment for the included papers

Ethical considerations

Data synthesis and analysis

Results

Fig 1. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) flow diagram of the study selection process.

Characteristics of the studies

Table 1. Characteristics of included studies.

Pooled COVID-19 vaccine hesitancy level in Sub-Saharan Africa

Fig 2. Forest plot of the pooled proportion of COVID-19 vaccine hesitancy in Sub-Saharan Africa, 2022.

Publication bias assessment

Fig 3. Assessment of publication bias.

Sub-group and sensitivity analysis

Fig 4. Forest plot of the pooled proportion of COVID-19 vaccine hesitancy by regions of Sub-Saharan Africa, 2022.

The predictors of COVID-19 hesitancy among healthcare workers

Table 2. Predictors of COVID-19 vaccine hesitancy among health workers in Sub-Saharan Africa.

Discussion

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Delfina Fernandes Hlashwayo

Roles

Author response to Decision Letter 0

Decision Letter 1

Delfina Fernandes Hlashwayo

Roles

Author response to Decision Letter 1

Decision Letter 2

Delfina Fernandes Hlashwayo

Roles

Acceptance letter

Delfina Fernandes Hlashwayo

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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