Abstract
Vaccination is an important strategy in the fight against COVID-19. Although Sudan received vaccines since March 2021, vaccine uptake is very low. This study aimed to determine COVID-19 vaccine uptake and hesitancy in one of the largest Urban settings in Sudan. A survey was done among adults from 15 market places in Wad Medani city. Collected data included; demographic characteristics, vaccination status, type of received vaccine, number of received doses, side effects experienced after vaccination and reasons for refusing or delaying vaccination. In total, 1323 questionnaires were eligible for analysis. Most respondents were male (55.5%), younger than 60 years of age (89.5%) and received some sort of formal education (92.7%). Education level was significantly associated with vaccination uptake (p < 0.001). At the time of the study; 33.2%, 42%, 16.8% and 8% of participants were vaccinated, willing to receive vaccination, rejecting vaccination or haven’t decided to receive a COVID-19 vaccine yet respectively. The most common reason for rejection indicated by participants was safety concerns (79.3%). Reasons for hesitance expressed by 64% of participant who said they were willing to take the vaccine were unavailability and difficult access to vaccines. Participants who expressed willingness to receive COVID-19 vaccine (42%) or were undecided (8%) were invited to a vaccination campaign. Of these, 27.9% attended and received their first shot of COVID-19 vaccine. Education level seems to be the main determinant for vaccination hesitancy. Safety concerns seem to play a major role in rejecting and delaying COVID-19 vaccination. Assuring vaccine's safety seems to be the way forward to reduce concerns about vaccination safety. Hesitancy was also shown to be partially related to difficulty in access to vaccines and a large proportion of the population are expected to receive the vaccine by improving availability and access.
Keywords: Vaccination-uptake, Vaccine hesitancy, COVID-19, Sudan
Introduction
A world health organization goal set in May 2021 was to fully vaccinate 40% of the population in each country by the end of 2021 and to reach 70% by mid-2022 [1]. Sudan was the first country in the Middle East and North Africa to receive COVID-19 vaccines through the COVAX facility in March 2021. The first phase of vaccination was rolled out using the AstraZeneca vaccine targeting health care workers and the elderly with chronic diseases or high risk conditions [1]. Sudan has a population of more than 44 million people, but received just over 800,000 doses of the AstraZeneca vaccine initially. This was followed later on by Sinopharm, Janssen and Pfizer/ BioNTech vaccines. As of November 2022, only 11, 740,000 vaccine doses were administered in Sudan and only 15.43% of the population received a complete initial protocol. Despite the efforts made by the Federal Ministry of Health and international organizations to encourage vaccine uptake, Sudan fell short of reaching the vaccination targets.
Vaccination campaigns are faced by many obstacles including poor access or perceived access to vaccines, misinformation, inconvenient time or place for immunization, poor access to healthcare, high vaccine administration fees, and vaccine hesitancy [2], [3].
Vaccine hesitancy is considered by the World Health Organization as one of the top ten threats to global health [4] and is considered a rate limiting step, in the success of vaccination campaigns [5]. Vaccine hesitancy is described as the ‘‘delay in acceptance or refusal of vaccination despite availability of vaccination services” [6]. Vaccine hesitancy is multifactorial and studies from around the world have demonstrated prevalence estimates of hesitancy towards COVID-19 vaccines ranging from 16.5% to 76.4% [5] and the average global estimate is around 25% [7]. Some of the important factors associated with vaccine hesitancy are related to age, gender, marital status, employment, acceptance of influenza vaccination, beliefs about vaccine safety as well as knowledge and awareness [5], [7], [8], [9].
Prevalence estimates of hesitancy towards COVID-19 vaccines from Sudanese Studies range from 36% to 68.7%. Moreover, clearly stated refusal has been reported among 11.5–27.4 % of studied populations. Some of the most cited barriers facing vaccine uptake include concerns related to short and long term safety, vaccine effectiveness, misinformation and lack of awareness about the importance of vaccination [1], [8], [9].
Methodology
The aim of this study is to explore vaccination uptake and factors leading to vaccination hesitancy towards COVID-19 vaccines in Wad Medani City, Gezira State, Sudan.
Wad Medani is the capital of Gezira State in Sudan where this cross-sectional study was conducted. Clusters of 100 Sudanese citizens 18 years or older were conveniently formed and recruited from 15 randomly selected market places across the city.
The survey was administered face to face in the local Arabic language during December 2021- January 2022. This was done by trained data collectors using a pre tested questionnaire consisting of 20 questions concerning demographic characteristics, vaccination status, type of received vaccine, number of received doses, side effects experienced after vaccination and reasons for refusing or delaying vaccination. Participants who did not receive COVID-19 vaccines were asked to describe themselves as either rejecting vaccination, willing to take vaccines in the future, undecided or other. Their reasons for not taking the vaccine were further explored and transcribed.
Participants who completed the survey who were not vaccinated and did not reject vaccination were invited to get their shots on the coming weekend and were given referral cards to present at the vaccination center for identification. This was arranged with local health authorities and a vaccination campaign was implemented at Aldaraja health center located at the heart of Wad Medani city. The center was conveniently chosen for geographical reasons and ease of access through public transportation.
Sample size was conveniently determined and we anticipated sampling 1500 participants from the 15 randomly selected market places.
Descriptive statistics were done using the SPSS statistical package for social sciences version 25. Frequencies and percentages were used for categorical data and Chi square analysis was used to test the association between groups and the vaccination status.
Multinomial regression analysis was conducted to test the difference between groups with regard to vaccination status. Associated variables with the vaccination status with a p value <0.05 in univariate analysis were entered into the multivariable analysis. Age and gender were forced into the model. Odds ratios with a significance of p < 0.05 and 95% confidence interval were reported.
Thematic analysis was conducted for the qualitative responses regarding reasons for not receiving vaccination among delayers. These were grouped into themes of unavailability/inaccessibility of vaccines, safety concerns, misinformation regarding vaccines, lack of sufficient information about vaccines and inability to make a decision about vaccination. These themes were used to describe responses of participants who were classified as undecided or willing to take the vaccine in the future.
Ethical approval was obtained from the Research and Ethics committee at the Gezira State Ministry of Health. Each participant provided written informed consent prior to participation and data anonymity was maintained throughout the study.
Results
Participant characteristics
In total, 1500 questionnaires were filled (100 per site), 1323 were eligible for analysis and 177 incomplete questionnaires were excluded. Most participants were younger than 60 years (89.5%) and of male gender (55.5%). The vast majority of respondents had received some sort of formal education ranging from primary to postgraduate schools (92.7%). Chronic diseases were present in 23.7% of respondents. See Table 1 for the general characteristics of participants.
Table 1.
Characteristics of participants (n = 1323) and their association with vaccination status.
| Characteristic | Frequency (%) |
Vaccination status |
P value | |||
|---|---|---|---|---|---|---|
| Vaccinated | Rejected | Willing | Undecided | |||
| Age groups | 0.180 | |||||
| 18–39 | 759 (57.4%) | 240(31.7%) | 138(18.3%) | 311(41.1%) | 67(8.9%) | |
| 40–59 | 425 (32.1%) | 155(36.5%) | 61(14.4%) | 181(42.6%) | 28(6.6%) | |
| 60–79 | 130 (9.8%) | 44(33.8%) | 21(16.2%) | 58(44.6%) | 7(5.4%) | |
| 80 and above | 9 (0.7%) | 0(0.0%) | 2(22.2%) | 6(66.7%) | 1(11.1%) | |
| Gender | 0.317 | |||||
| Male | 734 (55.5%) | 239(32.6%) | 114(15.6%) | 324(44.2%) | 56(7.6%) | |
| Female | 589 (44.5%) | 200(34.1%) | 108(18.4%) | 232(39.5%) | 47(8.0%) | |
| Education | 0.000 | |||||
| Uneducated/illiterate | 96 (7.3%) | 21(21.9%) | 26(27.1%) | 38(39.6%) | 11(11.5%) | |
| Technical | 40 (3.1%) | 9(22.5%) | 6(15.0%) | 21(52.5%) | 4(10.0%) | |
| Secondary school or lower | 558 (42.6%) | 155(27.8%) | 93(16.7%) | 275(49.4%) | 34(6.1%) | |
| University | 541 (41.3%) | 205(38.0%) | 85(15.8%) | 203(37.7%) | 46(8.5%) | |
| Postgraduate | 76 (5.8%) | 45(59.2%) | 10(13.2%) | 14(18.4%) | 7(9.2%) | |
| Marital status* | 0.197 | |||||
| Single | 477 (36.7%) | 140(29.4%) | 89(18.7%) | 205(43.1%) | 42(8.8%) | |
| Married | 757 (58.2%) | 269(35.6%) | 115(15.2%) | 315(41.7%) | 56(7.4%) | |
| Divorced | 33 (2.5%) | 9(27.3%) | 9(27.3%) | 14(42.4%) | 1(3.0%) | |
| Widow/ widower | 34 (2.6%) | 13(38.2%) | 8(23.5%) | 10(29.4%) | 3(8.8%) | |
| Chronic diseases** | 0.168 | |||||
| Yes | 314 (23.9%) | 119(38%) | 53(16.9%) | 118(37.7%) | 23(7.3%) | |
| No | 998 (76.1%) | 315(31.6%) | 167(16.85%) | 435(43.7%) | 79(7.9%) | |
P value calculated using Chi square test.
In terms of vaccination status at the time of the study; 33.2%, 42%, 16.8% and 8% were vaccinated, willing to receive vaccination, rejecting vaccination or haven’t decided to receive a COVID-19 vaccine yet respectively. Of vaccinated participants, 66.3% received the AstraZeneca vaccine, 28.5% Johnson & Johnson, 2.7% Sinopharm and 1.3% received Pfizer/ BioNTech vaccine. Five participants (1.2%) did not know which type of vaccine they had received. Most vaccinated participants (61%) had received only one dose of vaccine compared to 39% who had received two doses. Side effects after receiving the vaccine were reported by 60.8% of participants. These included; headache, fever, lethargy, pain at site of injection, dizziness, nausea, vomiting and joint pain. A significant association was observed between education level and vaccination uptake (p < 0.001) where uneducated participants were least likely to receive COVID-19 vaccines and most likely to reject them as opposed to participants who had postgraduate, graduate, high school or technical degrees. There was no statistically significant association of vaccination uptake with age, gender, marital status or the presence of chronic diseases.
The proportion of participants that was not vaccinated (66.8%) either rejected vaccination (16.8%), were willing to be vaccinated in the future (42%), or haven’t decided yet (8%). The reasons for rejection indicated by participants were safety concerns (79.3%), having a strong immune system (30.2%), the vaccination being unimportant in their opinion (27.5%), a lack of belief in all vaccines (20.7%), and previous infection with Covid-19 (7.7%). One participant expressed a specific lack of trust in Covid-19 vaccines and another showed disbelief in Covid-19 itself. Table 2 shows the vaccination attributes expressed by the study participants.
Table 2.
Vaccination attributes of study participants (n = 1323).
| Attribute | Frequency (%) |
|---|---|
| Vaccination status | |
| Vaccinated with one dose | 268 (20.3) |
| Vaccinated with two doses | 171 (12.9) |
| Rejects the vaccine | 222 (16.8) |
| Willing to take the vaccine | 556 (42) |
| Hasn’t decided | 106 (8) |
| Type of vaccine received (n = 439) | |
| AstraZeneca | 291 (66.3) |
| Johnson & Johnson | 125 (28.5) |
| Sinopharm | 12 (2.7) |
| Pfizer | 6 (1.3) |
| Don’t know | 5 (1.2) |
| Number of doses received (n = 439) | |
| One dose of Johnson & Johnson | 125 (28.4) |
| One dose of other vaccines | 143 (32.6) |
| Two doses of other vaccines | 171 (39) |
| Side effects after vaccination (n = 439) | |
| Yes | 267 (60.8) |
| No | 172 (39.2) |
| Reasons for rejecting vaccination (n = 222) | |
| Safety concerns | 176 (79.3) |
| I have a strong immune system and don’t need it | 67 (30.2) |
| Vaccination is not important for me | 61 (27.5) |
| Don’t believe in all vaccines | 46 (20.7) |
| Already had Covid-19 | 17 (7.7) |
| Other | |
| Don’t believe in COVID-19 | 1 (0.5) |
| Don’t trust the vaccine | 1 (0.5) |
Participants hesitant towards COVID-19 vaccines expressed different reasons for not receiving the vaccine. The most prominent one was related to unavailability of vaccines or difficulty in accessibility. This was expressed by 64% of participant who said they were willing to take the vaccine and 19.8% of participants who were undecided about taking COVID-19 vaccines (see Table 3). Examples of responses to the question of why haven’t you received the vaccine so far included; “I am busy and the health center is overcrowded” P (17), “I don’t know where to find the vaccine” P (31), “The vaccine is finished in my area” P (39), “The vaccine is not available in my village” P (148).
Table 3.
Reasons for not taking vaccination indicated by hesitant study participants n = 662.
| Themes of the reasons for not taking the vaccine |
Willing participants (n = 556) Frequency (%) |
Undecided participants (n = 106) Frequency (%) |
|---|---|---|
| Unavailability/inaccessibility of vaccine | 358 (64.4) | 21 (19.8) |
| Safety concerns | 61 (11) | 16 (15.1) |
| Need for more information | 25 (4.5) | 3 (2.8) |
| Misinformation about vaccine | 22 (3.9) | 5 (4.7) |
| Can’t make up my mind/ undecided | 10 (1.8) | 6 (5.7) |
Safety concerns were the second most common reason for delaying taking the vaccine. This was more common in undecided participants 15.1% compared to willing participants 11% (for details see Table 3). Examples of expressed reasons for not taking the vaccine include; “I am afraid of the vaccine and what it will do to me” P (4), “I don’t know what side effects it will cause” P (70), “I am pregnant and afraid of the effects of the vaccine on my baby” P (105), “I have allergies and want to ask my doctor first” P (11).
There was no significant difference between willing and undecided participants based on gender, age groups or marital status. However, a statistically significant difference (P = 0.01) was observed with education level, where participants with technical, higher secondary or university education where the largest proportions among participants willing to receive vaccine in the future.
In both univariable and multivariable analysis those who were uneducated had the highest odds of rejecting the vaccination and being undecided compared to groups with postgraduate education level (OR 1.92, 95% CI (2.72–16.93)) and (OR 1.58, 95%CI (1.55–15.14)) respectively. Those with technical education had the highest odds for willing to take the vaccine in the future (OR 2.00, 95% CI (2.71–19.96)). No other factors were associated with rejection, decidedness or willingness to take COVID-19 vaccine.
During the survey, the 662 participants classified as delayers were invited to get their COVID-19 vaccine shots on the coming weekend. These were the ones who expressed willingness to receive vaccination in the future (n = 556, 84%) and those who hadn’t decided to take the vaccine yet (n = 106, 16%). In total, 185 study participants were identified at the vaccination center which equates to a response rate of 27.9% of invited participants (Table 4).
Table 4.
Multivariable association of participant characteristics with vaccination status.
| vaccination status | Adjusted OR | P value | 95% Confidence interval | |
|---|---|---|---|---|
| I reject taking the vaccine | Age | −0.02 | 0.005 | 0.97–0.1.00 |
| Chronic disease(Yes) | 0.13 | 0.548 | 0.75–1.72 | |
| Chronic disease(No) | 1 | – | – | |
| Uneducated/illiterate | 1.92 | 0.000 | 2.72–16.93 | |
| Technical | 1.23 | 0.056 | 0.97–12.02 | |
| Secondary school or lower | 1.02 | 0.007 | 1.33–5.82 | |
| University | 0.48 | 0.204 | 0.77–3.37 | |
| Postgraduate | 1 | – | – | |
| Male | −0.08 | 0.655 | 0.66–1.30 | |
| Female | 1 | – | – | |
| I will take the vaccine in the future | Age | −0.01 | 0.057 | 0.98–1.00 |
| Chronic disease(Yes) | 0.30 | 0.067 | 0.98–1.88 | |
| Chronic disease(No) | 1 | – | – | |
| Uneducated/illiterate | 1.94 | 0.000 | 3.06–15.73 | |
| Technical | 2.00 | 0.000 | 2.71–19.96 | |
| Secondary school or lower | 1.75 | 0.000 | 3.04–10.85 | |
| University | 1.05 | 0.001 | 1.52–5.42 | |
| Postgraduate | 1 | – | – | |
| Male | 0.11 | 0.429 | 0.85–1.46 | |
| Female | 1 | – | – | |
| I haven’t decided yet | Age | −0.02 | 0.047 | 0.97–1.00 |
| Chronic disease(Yes) | 0.11 | 0.697 | 0.64–1.95 | |
| Chronic disease(No) | 1 | – | – | |
| Uneducated/illiterate | 1.58 | 0.007 | 1.55–15.14 | |
| Technical | 1.26 | 0.095 | 0.80–15.14 | |
| Secondary school or lower | 0.54 | 0.261 | 0.67–4.35 | |
| University | 0.39 | 0.407 | 0.59–370 | |
| Postgraduate | 1 | – | – | |
| Male | 0.07 | 0.765 | 0.68–1.68 | |
| Female | 1 | – | – | |
Discussion
This study revealed low vaccination uptake and a significant association between vaccine acceptance and education level. Also, problems related to availability and ease of access to vaccines were clearly evident. Fear of long-term and short-term side effects seemed to be the most common deterrent for vaccination among those who reject COVID-19 vaccines and the second most common reason among those who are delaying the decision of vaccination. The study was able to demonstrate that improving access and availability can greatly increase uptake of COVID-19 vaccines.
This study found that 33.2% of participants were vaccinated, 42% were willing to take the vaccine, 16.8% refused, and 8% did not decide yet. In comparison with the data published in “Our world in data, 2022” [4] that only 15.43% of the population in Sudan received a complete initial protocol, 33% in Gezira state seems high, bearing in mind that the vaccination was restricted to healthcare providers, elderlies and chronic disease patients at the beginning of the COVID-19 vaccination program. The results are consistent with the global ranges in which vaccine uptake ranges from 28 % to 86.1%, vaccine hesitancy ranges from 10% to 57.8%, and vaccine refusal ranges from 0% to 24.0% [10]. The levels of uptake and hesitancy vary between countries, but hesitancy is highest in Arab countries [11]. The earlier studies carried out before the vaccine rollout evaluated acceptance and willingness rather than uptakes, such as the global review performed by Sallam that showed greater acceptance in Ecuador (97.0%) and Malaysia (94.3%), but lower rates in Jordan (28.4%) and Kuwait (23.6%) [5]. Following the start of vaccination campaigns, a study conducted in Kuwait between March and April 2021 revealed that 59.8% of the population was vaccinated. A study conducted in Iraq found that only 16.5% of 926 participants received the vaccine and 51.4% were unwilling to receive the vaccine [12]. Furthermore, an online survey carried out among healthcare workers across 10 countries in the Eastern Mediterranean Region showed that 58% of participants agreed to take the COVID-19 vaccine, while 42% were unwilling to take the vaccine or were undecided [13]. Furthermore, in a study conducted in Khartoum among healthcare workers, 36.2% refused to take the vaccine, 63.8% accepted it, but only 22.7% were vaccinated [1]. The vaccination uptake of 33.2% found in our study falls well below WHO targets for herd immunity.
This study showed a significant association between education level and vaccination hesitancy. The evidence of this association was found in several studies such as those conducted in Jordan and Kuwait [14], Iraq [12], Saudi Arabia [15], Italy [16], and the USA [17]. In general, inadequate and low health literacy is associated with difficulties in obtaining reliable information and believing in misinformation, respectively [18]. Additionally, lower education levels were associated with higher conspiracy beliefs [19] and acceptance of misinformation [20] and this misinformation may influence the level of acceptance [21]. It is possible that all of these factors together contribute to an increase in hesitancy. Providing reliable information in an easy-to-understand manner to citizens of all educational levels will help in overcoming health literacy and will enable the population to make informed decisions about their health [22].
Safety concerns were the main reason behind rejecting and delaying COVID-19 vaccination. This concern has been reported in several studies [1], [10], [12], [13], [15], [23], [24], [25], [26], [27], [28], [29], [30], [31]. Participants who questioned vaccine safety are more likely to believe myths about vaccines and express hesitancy. This is consistent with studies suggesting that concerns about vaccine safety have a negative impact on the vaccination program [22]. In two surveys in China aimed to track changes on acceptance of COVID-19 vaccines, 44.2% accepted the vaccine in the first survey, and the main reason for hesitation was doubts about its effectiveness. In the second survey, the acceptance rate dropped to 34.8%, and vaccine safety was the main concern [29]. Increased safety concerns and spread of misinformation about vaccines contributed to lowering the acceptance level [29], even if the disease is considered to be severe [32].
Well-planned campaigns that build on evidence-based information regarding the vaccine's safety seem to be an important and needed strategy to reduce the negative concerns about vaccination safety. This could be done by establishing an expert group to disseminate information through both traditional and online media, engage the scientific community, celebrities, and politicians to support vaccination campaigns [33]. Complicated scientific language has been highlighted as one of the reasons for not using the official websites by the public [22]. Therefore, different strategies should be adopted [31] and vaccination programs should consider using simple language in communicating information about safety and efficacy of the vaccines to the public [34].
Despite a relatively high percentage of participants willing to receive vaccination (42%) in this study, the literature indicates that it is not necessary that all willingness to take the vaccine will turn into actual uptake [35]. A study analyzing data from 10 Low and Middle-Income Countries found that willingness to take the vaccine is higher than Russia and the United States [27]. The willingness to be vaccinated could be considered as an opportunity for vaccination programs to increase the vaccine uptake by increasing access, educating the public about the safety and efficacy of vaccines, and collaborating with the vaccinated community to spread the pro-vaccination norm [27]. Thus, determining reasons for not taking the vaccine among willing and undecided groups is crucial to enable policymakers to develop strategies to overcome hesitancy. In our study, the primary reason for not taking the vaccine among the delayer group was unavailability/ inaccessibility of the vaccine. This finding suggests that the level of hesitancy may not be a real hesitation, but rather related to barriers to vaccination accessibility [1], [8], [26], [36], [37]. A qualitative study was conducted in seven Arab countries to identify barriers and enablers to vaccination. Access and availability of the vaccine were among the main enablers [28]. Moreover, making the vaccine available was one of the strategies that increased uptake by more than 25% [38].
A cross sectional house-hold survey would’ve provided a more representative sample in this study. However, stigma around the disease, difficult access to households during the study period and logistic limitations led to the selection of these study sites instead. The selection was based on that previous educational campaigns about COVID-19 were done in 24 market places in Wad Medani city earlier in 2021 from which the 15 study sites were randomly selected.
It is worth noting that 27.9% (185) of delayers who participated in this study opted to receive their vaccinations after being invited. This outcome sheds light on the importance of effective communication between the general public and the healthcare providers, educators, or vaccination promoters. It also highlights the importance of increasing awareness about the vaccination centers, vaccine availability, safety, and importance. It is therefore highly recommended that further studies assess the impact of vaccination supportive strategies in increasing COVID-19 vaccine uptake especially those that address the issues of vaccine availability and accessibility.
Authors’ contribution
Elmustafa M. designed the project, supervised data collection and data analysis, and wrote the first draft of the manuscript.
Wedaa A. participated in the interpretation of the data, writing and critically reviewing the manuscript.
Babiker Hanaa A. participated in the interpretation of the data, writing and critically reviewing the manuscript.
Elmajzoup Ammar A.E. participated in the study design, supervised data collection and critically reviewed the manuscript.
Ali Halima I.M. participated in the study design, supervised data collection and critically reviewed the manuscript.
Rana Ahmed participated in the study design, data analysis and interpretation, wrote and critically reviewed the manuscript.
All authors approved the final manuscript of the article
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data will be made available on request.