Willingness to Embrace COVID-19 Vaccination Amongst Residents in a Low-Income Nation: Insights From a Cross-Sectional Study on a Limited Cohort

Abstract

The global pandemic had a significant impact on countries around the world, both politically and socioeconomically. It is crucial that swift decisions and actions need to be taken to prevent negative outcomes. The development of vaccines has emerged as a potential necessity for countries worldwide. Ethiopia began vaccinating health professionals and high-risk individuals in March 2021, according to a report from the World Health Organization citing the Ethiopian Federal Ministry of Health. This study aimed to assess the determinants of willingness to receive the COVID-19 vaccine among Debre Markos city administration residents. A community-based cross-sectional study design was employed to recruit 845 individuals as a sample. Descriptive statistics and logistic regression were used as statistical analysis techniques. Among the total 845 samples, the overall response rate was 98.34%. Two hundred forty-two participants showed their willingness to receive vaccines. Age (AOR = 2.56; 95%CI = [1.87-3.23]), sex (Female) (AOR = 3.45; 95% CI = [2.07-5.26]), having children (AOR = 1.21; 95% CI = [1.02-1.90]), and Chronic Disease (AOR = 2.98; 95% CI = [1.67-3.50]) were significantly and positively associated with willingness to receive COVID 19 vaccines at 95% CI. Although most of the participants were aware of the possibility of COVID-19 to cause fever; and its transmission, only a small percentage of the total participants showed their willingness to receive the vaccine if it was available to them. Elderly and individuals with chronic diseases need to get a priority of taking those vaccinations.

• What do we already know about this topic?

• There are disparities observed in the willingness and attitude of vaccine uptake in different countries.

• How does your research contribute to the field?

• By assessing the community’s WTR COVID-19 vaccines and their determinants it can be used as one input to see the disparities across countries.

• What are your research’s implications for theory, practice, or policy?

• It requires a strong advocacy campaign to increase people’s awareness about covid 19 vaccines.

Introduction

On December 1, 2019, officials in Wuhan, China reported the first case of a new disease caused by a novel coronavirus, which is now known as COVID-19. ¹ The global pandemic had a significant impact on countries around the world, both politically and socioeconomically. ² Due to the global nature of the COVID-19 pandemic, swift decisions and actions must be taken to prevent negative outcomes. The development of vaccines has emerged as a potential necessity for countries worldwide, in addition to the availability of various techniques used to combat this pandemic. ³ At the beginning of the COVID-19 pandemic, Africa began vaccinating its population to achieve herd immunity by vaccinating at least two-thirds of the continent’s population. The African Union acquired a billion doses of COVID-19 vaccines by February 2021, totaling nearly 1.27 billion. Following this, 5 countries began vaccinating their healthcare workers. ⁴ Ethiopia began vaccinating health professionals and high-risk individuals in March 2021, according to a report from the World Health Organization (WHO) citing the Ethiopian Federal Ministry of Health. ⁵

As global vaccine demand rises, it is critical to address the challenges associated with vaccine utilization. ⁶ The promotion of vaccines and educating the public about the importance of universal coverage should be balanced by giving attention to unnecessary promotions. ⁷ Coverage of vaccine usage is largely reliant on community willingness. The use of vaccines can be severely hampered by mistrust against them. As a result of low community vaccination coverage, the population may find it difficult to develop the necessary immunity. ⁸ The degree to which the public has developed faith in the various options is a major determinant of their willingness to receive (WTR) vaccine. Examining this from several angles and taking into account multiple factors makes it an extremely complex topic. ⁷ This implies that when vaccines are made available to nations, vaccination rates may vary depending on the situation. ³ Due to the intricate nature of vaccine uptake intentions, it is imperative to address the issue on a global scale, national level, and with diverse ethnicities. ⁷ To develop effective strategies for vaccine uptake, it is crucial to consider various determinants that influence people’s decision-making toward vaccine uptake. For instance, a study conducted in the USA revealed that the majority of respondents (74.1%) agreed to take the COVID-19 vaccine. However, the study also found that participants aged between 45 and 54 were less likely to take the vaccine. ⁹ Vaccine hesitancy has been reported among ethnic minorities and low-income citizens in various studies. It is crucial to address the reasons behind this hesitancy to develop effective strategies for vaccine uptake. ⁸

In addition to the limited number of studies conducted globally, there are differences in the willingness and attitude toward vaccine uptake across various countries.^4,8,10,11 To the best of researchers’ knowledge, there have been few studies conducted in Ethiopia on the community’s attitude toward COVID-19 vaccine uptake.^{12 -16} Thus, the objective of this study was to evaluate the community’s WTR COVID-19 vaccines and the factors that influence their decision-making among the inhabitants of Debre Markos city administration.

Research Questions

1. What is the level of WTR COVID-19 vaccinations among inhabitants of Debre Markos city administration?

2. What are the factors that influence WTR COVID-19 vaccinations among inhabitants of the Debre-Markos city administration?

Methods and Materials

Study Area, Design, Period, Source Population, and Study Population

A community-based cross-sectional study was conducted from December 15, 2021, to January 25, 2022, in Debre Markos City, which is located 299 km away from Addis Ababa, the capital of Ethiopia. Debre Markos is one of the largest cities in the Amhara National Regional State and is currently being developed into a metropolitan city with 5 sub-cities. The study population consisted of all adults in Debre Markos who met the eligibility criteria, while the source population was all adults in Debre Markos city administration.

Eligibility Criteria

All adult residents aged ≥18 who were available during the data collection and voluntarily to participate in the study were included. Samples who did not live at least 6 months in Debre Markos, those who were not Ethiopians by their nationality, and those who had hearing problems were excluded from the study.

Sample Size Determination and Sampling Technique

The sample size was calculated using the single population proportion formula by taking 50% (P = .5) ashe proportion 0.05 Desired precision (d), 95% confidence interval, and a design effect of 2. n =  $\raisebox{1ex}{$(\mathrm{Z})2\mathrm{pq}$}\!\left/ \!\raisebox{-1ex}{$(\mathrm{d})2$}\right.$ Where; n = the minimum sample size, Z = 95% = 1.96, p = prevalence to be 0.5, q = 1-P, q = 0.5, d = Margin of sampling error tolerated (5%) = 0.05, n = 384, but since the sampling technique is multistage, we have to adjust for design effect.

Final sample size = n*DE, where DE = design effect = 2 Final Sample size = 384 × 2 = 768. Adding 10% for inappropriate and non-response rates, the minimum sample size was calculated to be 845.

Data Collection Procedure, Method, and Instrument

Data were collected through an interviewer-administered structured questionnaire, which was adopted from different kinds of literature.^10,11,17 The questionnaire was prepared in both Amharic and English versions which are separated into different sections. The first section included those questions related to sociodemographic characteristics followed by sections prepared to assess awareness and practices related to COVID-19 and vaccine, and participants’ WTR. Four trained data collectors (all pharmacists) collected the data.

Variables

Dependent variables

WTR Covid-19 vaccines

Independent variables

Age, Sex, Marital Status, Pregnancy Status, Having Children, Smoking, Weight, Educational level, Monthly income, Chronic Disease, previous experience of taking a vaccine, close with infected individuals, previous COVID infection history.

Data Quality Assurance

The selection of data collectors was based on their educational level and possible familiarity with medical and health policy research. The training was given to data collectors about the objectives of the study and the process of the data collection. Onsite supervision was done; meanwhile, doubts in the questionnaire were clarified. A pretest was done among 43 individuals in one Kebele to check the validity of the questionnaire, the Kebele was not included in the main study.

Data Entry and Analysis

Data were coded, cleaned, and entered into a computer and analyzed using STATA version 14. Descriptive statistics were used to calculate (mean, frequency and percentages), and results are presented using tables. Multiple logistic regression was used for analysis to see the relation between determining factors and individual WTR in the vaccines. Univariate analysis was done individually for each independent variable and those with a P-value less than .25 were eligible for multivariate analysis. And the rest were excluded from the analysis.

Results

Sociodemographic Characteristics of the Participants

In this research, 845 questionnaires were distributed to the participants, and 831 of them were returned, resulting in an overall response rate of 98.34%. Out of the total 831 participants, more than half were male (65.58%), and 461 (55.47%) were aged between 31and 40 years. The majority of the participants were married (72.80%), and 203 (24.43%) had children. Among the female participants, 45 (15.73%) were pregnant at the time of data collection. Two hundred sixty (31.29%) of the participants were active smokers, and 234 (28.16%) had 1 or more known chronic diseases (Table 1).

Table 1.

Sociodemographic Characteristics of Participants.

Characteristics	Category	Frequency	Percentage
Age	21-30 years	234	28.16
	31-40 years	461	55.47
	41-50 years	105	12.64
	51 years or more	31	3.73
Sex	Male	545	65.58
	Female	286	34.42
Marital status	Single	226	27.20
	Married	605	72.80
Pregnancy status (n = 286)	Yes	45	15.73
	No	241	84.27
Do you have children?	Yes	203	24.43
	No	628	75.57
Smoking and smoking history	Yes	260	31.29
	No	526	63.30
	x-smoker	45	5.41
Body mass index	<18.5	249	16.1
	18.5-<25	709	46.0
	25.0-<30	510	33.1
	Greater than 30	74	4.8
Educational level	High school or less	74	4.8
	Diploma	84	5.4
	University student	112	7.3
	Bachelor	725	47.0
	MSc and above	547	35.5
Household average monthly income (ETB)	<2000	115	13.84
	2000-4000	453	54.51
	4001-6000	107	12.88
	>6000	156	18.77
Do you have any chronic disease	Yes	234	28.16
	No	597	71.84

Note. ETB = Ethiopian Birr; x-Smoker = individuals who had a smoking history but are not active smokers.

Awareness About COVID-19 Transmission Methods, Symptoms, and Prevention Techniques

More than 90% of the participants (789) knew that COVID-19 can cause fever, but only 6.02% (50) identified diarrhea as a possible symptom of COVID-19 infection. Additionally, 72.56% (603) of the participants believed that COVID-19 can be transmitted through inhalation or respiratory droplets of an infected person, while 91.22% (758) thought that physical distancing can help prevent the risk of getting COVID-19 (Table 2).

Table 2.

Participants’ Awareness of COVID-19 Transmission Methods, Symptoms, and Prevention Techniques.

Variables	Category	Frequency	Percentage
What are the symptoms of COVID-19?*	Chills	467	56.20
	Diarrhea	50	6.02
	Cough	652	78.45
	Otitis media	121	14.56
	Loss of smell and taste senses	345	41.52
	Fever	789	94.95
How is COVID-19 transmitted?*	Drinking unclear water	215	25.87
	Eating unclean food	208	25.03
	Inhalation or respiratory droplets of an infected person	603	72.56
	Eating or touching wild animals	123	14.80
What procedure do you think may prevent COVID-19 infection?*	Wearing mask	723	87.00
	Washing hands with soap regularly	695	83.63
	Physical distancing	758	91.22
	Avoid touching face/mouth/nose/eyes	646	77.74
	Avoid eating meat	134	16.13
	Consume herbs	46	5.54

^*The percentages are not additive, one individual may have multiple answers.

Attitudes and Practices Towards COVID 19 and Its Vaccinations

According to this study, 8.66% (72) of the 831 participants had taken vaccines for other diseases in the last year. Only 2.77% (23) of the participants had a history of COVID-19 infection, and around 14.80% (123) of the participants had someone close to them with a history of COVID-19 infection. Additionally, 78.70% (684) of the participants wore face masks as protection from COVID-19, and only 13.60% (113) had tested to see whether they had been infected with COVID-19. Finally, 29.12% (242) of the participants showed their willingness to be vaccinated if they had access to them (Table 3).

Table 3.

Participants’ Attitudes and Practices Toward COVID-19 and Vaccination.

Variables	Category	Frequency	Percentage
Did you take any vaccine for other diseases last year?	Yes	72	8.66
	No	759	91.34
Do you know anyone close to you who has been infected with COVID-19?	Yes	123	14.80
	No	708	85.20
Have you ever been infected with COVID-19?	Yes	23	2.77
	No	808	97.23
What procedures have you taken to protect yourself from COVID-19?	Wearing a face mask	654	78.70
	Washing hands with regular soap	442	53.19
	Using sanitizers	315	37.91
	Social distancing	143	17.21
	Avoid touching face/mouth/nose/eyes	167	20.10
Have you tested to see if you have COVID-19?	Yes	113	13.60
	No	718	86.40
If a vaccine is offered to you for COVID-19, are you willing to take it?	Yes	242	29.12
	No	589	70.88
Did you take any vaccine for other diseases last year?	Yes	72	8.66
	No	759	91.34
Do you know anyone close to you who has been infected with COVID-19?	Yes	123	14.80
	No	708	85.20
Have you ever been infected with COVID-19?	Yes	23	2.77
	No	808	97.23
What procedures have you taken to protect yourself from COVID-19?	Wearing a face mask	654	78.70
	Washing hands with regular soap	442	53.19
	Using sanitizers	315	37.91
	Social distancing	143	17.21
	Avoid touching face/mouth/nose/eyes	167	20.10
Have you tested to see if you have COVID-19?	Yes	113	13.60
	No	718	86.40
If a vaccine is offered to you for COVID-19, are you willing to take it?	Yes	242	29.12
	No	589	70.88

Factors Affecting Participants WTR COVID 19 Vaccines

For the logistic regression, all possible independent variables were used in bivariate analysis, and those with P values less than .25 were considered for multivariate analysis. Age, Sex, Smoking Habit, Monthly income, having Children and Chronic Disease were eligible for multivariate analysis.

From the multivariate analysis result; Age, sex, having children and Chronic disease were significantly associated with WTR COVID 19 vaccines at P-value < .05. For every 1-year increase in the ages of the participants, the likelihood that the participants accepted to receive the vaccine increases approximately by 2.6 times (AOR = 2.56; 95% CI = [1.87-3.23]). Female participants (AOR = 3.45; 95% CI = [2.07-5.26]) had 3-fold likelihood of accepting the vaccines and those participants who had children (AOR = 1.21; 95% CI = [1.02-1.90]) and history of chronic disease (AOR = 2.98; 95% CI = [1.67-3.50]) were 1.2 and 3-fold more likely of accepting the vaccines respectively (Table 4).

Table 4.

Logistic Regression Analysis Shows Determinant Factors for Participants WTR COVID 19 Vaccines.

Variables	Category	COR	95% CI		AOR	95% CI
			Lower	Upper		Lower	Upper
Age*	------	1.92	1.23	2.92	2.56	1.8673	3.2301
Sex*	Female	2.1	1.73	4.91	3.45	2.06791	5.2554
	Male	1			1
Smoking habit	Yes	1.28	1.12	3.01	1.46	0.893	2.0126
	No	1			1
Monthly income	-------	1.50	1.44	2.75	3.23	0.2450	5.1801
Having children*	Yes	1.62	1.49	2.12	1.21	1.0180	1.9002
	No	1			1
Chronic disease*	Yes	2.55	1.58	4.32	2.98	1.6712	3.5015
	No	1			1

^*Significantly associated variables.

Discussion

The study aimed to evaluate the willingness of Debre Markos city residents to receive COVID-19 vaccines and identify the factors that influence it. The study found that the willingness to receive COVID-19 vaccines was significantly influenced by sociodemographic factors such as age and sex, as well as medical factors such as chronic diseases.

The study found that 29.12% of the participants expressed their willingness to receive COVID-19 vaccines. This percentage is similar to the results of studies conducted in other countries such as Ethiopia (31.4%), ¹⁴ Syria (37%), ¹⁸ Istanbul (34.6%), ¹⁹ and Syria (35.92%). ²⁰ However, the percentage is lower than the findings of studies conducted in other places such as, in Gurage zone Ethiopia (61%), ¹² Southern Ethiopia (46.1%), ¹⁶ Dessie Ethiopia (64%), ²¹ Ohio (59.1%), ¹⁵ low and middle income countries (80%), ²² Japan (65.7%), ¹⁷ Iran (78%), ²³ United Kingdom (88.8%), ²⁴ US (75%), ²⁵ Pakistan (70.8%), ²⁶ China (88.6%), ²⁷ and Libya (79.6%). ²⁸ The study highlights the need to strongly advocate for the importance of vaccinations to tackle COVID-19 expansion and reduce mortality rates. The disparities observed might be due to the difference in the type of study populations or the difference in the geography of the study settings.

The study found that the likelihood of showing willingness to receive COVID-19 vaccines increased with age. Participants of higher age were more likely to show their willingness to receive COVID-19 vaccines. For every 1-year increment in the age of participants, the likelihood of showing willingness to receive COVID-19 vaccines increased by 2.6 times. The possible explanation for this finding is that as age increases, the tendency of getting COVID-19 might also increase due to multiple medical problems related to aging. Therefore, older people may seek to take vaccines due to fear of death compared to younger individuals. This Finding is supported by studies done in Turkey, ¹⁹ Bangladesh, ²⁹ and another scoping review. ³⁰ On contrary, the study done in Italy ³¹ reveals that younger people were more likely to show their WTR compared with elderly individuals. However other studies done in Afghanistan ³² and Saudi Arabia ³³ indicate age had no association.

Being female was significantly and positively associated with WTR (AOR = 3.45), which is supported by a single study conducted in Ethiopia. ¹⁴ Oppositely, findings of studies done in Addis Ababa, ³⁴ Costa Rica, ³⁵ Saudi Arabia, ³³ US, ³ Turkey, ¹⁹ Survey across countries, ³⁶ and a scoping review ³⁰ indicated males were more likely to show their WTR vaccines if it is available to them. Although it is challenging to scientifically explain this variation, one possible explanation is that women in Ethiopia are more connected to their children and family. They may be more concerned about their children than men, which could increase their WTR COVID-19 vaccines. Furthermore, having children was more likely to predict WTR. Those who had children were more likely to receive COVID-19 vaccines compared to those who did not. This is supported by a similar study conducted in Addis Ababa. ³⁴

Respondents with chronic disease were 3 times more likely to receive COVID 19 Vaccines if it was available to them. This is supported by a study done in Turkey. ¹⁹ Concurrently, in the UK clinically vulnerable individuals were more likely to seek COVID 19 vaccine. ²⁴ Chronic patients are more susceptible to infections, which may lead to increased their willingness to receive vaccinations due to heightened public concern.

Our study was conducted only on inhabitants of a single city, which may limit its generalizability to all Ethiopians. Additionally, since our study design is cross-sectional, it may be difficult to establish a causal relationship between the determinant factors and the individuals willingness to take vaccinations. Therefore, we suggest that future researchers consider conducting multi-center studies with robust study designs.

The study suggests that there is a need to raise awareness about the full range of symptoms associated with COVID-19, as only 6.02% of the participants identified diarrhea as a possible symptom of COVID-19 infection. Public health campaigns, social media, and other channels can be used to achieve this goal.

Encouraging more people to get vaccinated is crucial to controlling the spread of COVID-19, since only 29.12% of the participants had expressed their eagerness to take COVID-19 vaccines if they had access to them. Governments and health organizations can launch vaccination drives and provide incentives to encourage people to get vaccinated. Widespread testing is recommended to identify and isolate infected individuals, since only 13.60% of the participants had tested to see whether they had been infected with COVID-19. Governments and health organizations can make testing more accessible and affordable to encourage more people to get tested. The majority of the participants believed that physical distancing can help prevent the risk of getting COVID-19. Governments and health organizations can continue to promote preventive measures such as physical distancing, wearing masks, and washing hands regularly. The study also highlights several areas where further research is needed, such as the prevalence of chronic diseases among the population and the effectiveness of awareness campaigns. Governments and health organizations can invest in research to better understand the impact of COVID-19 and its vaccinations on public health and develop more effective strategies to control its spread.

Conclusion

Although most of the participants were aware of the possibility of COVID-19 causing fever and its transmission, only a small percentage of the total participants showed their willingness to receive the vaccine if it was available to them. A strong advocacy campaign is needed to increase awareness. Older age, being female, having children, and chronic disease were potential positive predictors that showed a significant association at a P-value less than .05. Individuals with chronic diseases need to get a priority to get those vaccinations.