Factors associated with COVID-19 vaccine uptake among residents of the Kwahu South Municipality in the Eastern Region of Ghana

Abstract

Background

COVID-19 vaccination is essential for pandemic control in low-resource settings such as Ghana, where uptake is influenced by sociodemographic and community factors. This study examined the factors associated with COVID-19 vaccine uptake among residents of the Kwahu South Municipality in the Eastern Region of Ghana.

Methods

A community-based cross-sectional study was conducted on 384 adults aged ≥ 18 years. Data on sociodemographic characteristics, COVID-19 knowledge, and community-related factors were collected using a structured questionnaire. Differences between variables were assessed using chi-square tests and multivariable logistic regression was performed to identify independent factors associated with COVID-19 vaccine uptake at a 5% significance level.

Results

Higher education significantly increased COVID-19 vaccine uptake (AOR = 3.0, [3.55–6.12]), as did prior COVID-19 infection (AOR = 10.2, [7.1-13.65]), awareness of COVID-19 vaccine (AOR = 8.3, [6.1–10.9]) and previous vaccination experience (AOR = 7.9, [3.32–11.77]). In contrast, scepticism about vaccine effectiveness substantially reduced uptake (AOR = 12.0, [9.46–14.93]).

Conclusion

COVID-19 vaccine uptake in Kwahu South Municipality was 76.6%, influenced by prior COVID-19 testing, vaccine awareness, previous vaccination and perceived effectiveness. Those with prior testing and awareness of COVID-19 vaccines were more likely to be vaccinated, while doubts about the vaccine’s effectiveness reduced uptake. This highlights the role of health engagement and perceptions in vaccination behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-026-13063-6.

Background

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), emerged in late 2019 in China and quickly spread globally, leading to widespread health, economic, and social impacts [1, 2]. The World Health Organisation (WHO) declared COVID-19 a Public Health Emergency of International Concern (PHEIC) on January 30, 2020 [3, 4]. As of May 2023, approximately 756.9 million and 6.9 million deaths had been reported globally [5]. In Africa, the pandemic has been particularly challenging due to weak health systems, limited financing, and a high burden of comorbidities, with over 12 million cases and 252,000 deaths recorded by early 2023 [6–8]. Beyond health impacts, COVID-19 has intensified socioeconomic challenges, including poverty and educational disruption, although the continent has shown resilience through coordinated responses, community health worker engagement, and the implementation of public health measures [9].

Ghana recorded its first COVID-19 case on 12 March 2020, and the pandemic has since affected the economy, education, and healthcare, with 157,751 cases and 1,419 deaths reported by February 2022 [10]. An already resource-constrained health system, characterised by low nurse- and physician-to-population ratios, has been placed under significant strain [11]. In response, the government implemented multiple nonpharmacological measures, including physical distancing, school and border closures, public health communication, quarantine, contact tracing, and mask use [12, 13]. Despite these interventions, COVID-19 incidence continued to rise, largely due to suboptimal adherence to preventive measures linked to low risk perception [14].

Vaccination remains one of the most effective strategies for controlling the pandemic; however, its success depends on public acceptance [15–17]. Although 12.1 million vaccine doses had been administered by February 2022, only 23% of the targeted population was fully vaccinated, reflecting mixed acceptance levels [10, 18]. Poor vaccine uptake has been driven by sociodemographic factors, low perceived risk, fear of side effects, misinformation, and concerns about vaccine efficacy [19–22].

The Eastern Region of Ghana, particularly Kwahu South municipality, has experienced high COVID-19 prevalence, placing a significant strain on the local health system despite full implementation of national nonpharmacological measures [10]. Persistent community transmission has been exacerbated by widespread misconceptions and conspiracy theories surrounding COVID-19 vaccines, including fears of DNA alteration and sterilisation, leading to vaccine hesitancy [23]. The pandemic disproportionately disrupted the livelihoods of vulnerable populations, especially women, causing greater losses in financial than social assets and limiting their ability to maintain income and access essential farm inputs [24]. This low vaccine uptake threatens both individual and public health by prolonging the pandemic, hindering economic recovery, and further burdening an already fragile healthcare system.

This study assessed the factors associated with COVID-19 vaccine uptake among residents of Kwahu South municipality in the Eastern Region, Ghana. The findings provide critical insights to guide policymakers and healthcare providers in designing targeted vaccination campaigns and public health interventions to improve vaccine uptake, reduce COVID-19-related morbidity and mortality, and strengthen preparedness for future public health emergencies.

Methods

Study design

A community-based cross-sectional design was employed to assess the factors influencing COVID-19 vaccine uptake among residents of Kwahu South municipality in the Eastern Region, Ghana. The study adhered to STROBE. This study adopted the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in the drafting of this paper [25].

Study site description

Kwahu South municipality, established in 1988, has a population of approximately 89,760 as of 2021, with a growth rate of 3.1%. It spans an area of 781 km² and is primarily situated on a ridge rising to 2,586 feet above sea level. Bordering Kwahu North, Fanteakwa, Kwahu West, Kwahu East, and Asante Akyem, the municipality comprises rural, semi-urban, and urban settlements. The population is predominantly Kwahu (66%), with significant Ewe (15%) and Asante (17%) communities, fostering ethnic harmony. Christianity is the predominant religion (89.5%), with traditionalists (3.6%), Muslims, and pagans making up the rest. Subsistence agriculture is the main occupation, employing (54.4%) of the labour force, particularly in rural areas (71.8%). There are forty (40) healthcare facilities in the municipality, which are made up of five (5) health centres and twenty-two (22) functional CHPS zones, with ten (10) having designated compounds. The municipality also has a district hospital, two private hospitals and a private maternity home. The district also has a midwifery training school [26].

Study population

The study population comprised adults (≥ 18 years) living in the Kwahu South Municipality at the time of the study.

Selection criteria

Inclusion criteria

The study included persons 18 years and above who had resided in the municipality for at least six months, were present at the time of the study and consented to participate.

Exclusion criteria

Those who declined consent were excluded from the study.

Sample size determination

The minimum sample size was determined for this study by using the Cochran formula [27].

where n= sample size, z² = Z score (95% CI = 1.96), q= (1-p), p= COVID-19 vaccine acceptance rate of 39% in a study among HCWs in Ghana in March 2021 [19] and d= margin of error of 0.05.

Adding a nonresponse rate of 5%, n = (0.05 × 366) + 366 = 384.

Thus, 384 persons who met the study’s inclusion criteria and consented to participate in the study were included in the study.

Sampling procedure

A multiple-sampling technique was used to select participants for this study. First, cluster sampling was used to divide the Kwahu South Municipality into six sub-municipalities, with sample sizes for each sub-municipality determined using proportional allocation.

In the second stage, two communities were randomly selected from each sub-municipality using simple random sampling. Lists of communities within each sub-municipality were used as the sampling frame, and selection was conducted through random draws, resulting in a total of twelve (12) communities. The allocated sample size for each sub-municipality was proportionally distributed across the selected communities.

In the third stage, households within each selected community were chosen using simple random sampling based on household lists obtained from the municipal assembly. Within the selected households, eligible participants were randomly selected using a ballot method. In households with more than three eligible individuals, simple random sampling was used to select a maximum of three. Households without eligible participants were also excluded. Data collection continued until the required sample size of 384 participants was achieved and participation was based on informed consent.

Data collection tool

Data was collected from participants via a structured questionnaire with closed- and open-ended questions adapted and modified. The open-ended questions allowed participants to respond to questions in their own words, whereas the closed-ended questions gave alternative responses for the participants to select. The questionnaire has five (5) sections. Section A utilised six (6) items to measure the sociodemographic characteristics of the participants. Section B utilised four (4) items to measure risk factors, COVID-19 testing and outcomes. Section C utilised seven (7) items to measure the knowledge of participants regarding COVID-19 and COVID-19 vaccines. Section D utilised three (3) items to measure COVID-19 vaccine acceptability, and Section E utilised eleven (11) items to measure community-related factors.

Data collection procedure

Participants were enrolled on the study through household visits conducted in the Kwahu South Municipality. After households were randomly selected, trained research assistants visited each selected household and introduced the study to the head of household and eligible members. The purpose, procedures, potential risks and benefits of the study were clearly explained in the local language or English as appropriate. Individuals who met the eligibility criteria were invited to participate. Informed consent was sought and participation was entirely voluntary. Data was then collected using a structured interviewer-administered questionnaire in a private setting. The selected community for pretesting was excluded from the main study. The study was conducted over three months, from March to May 2022.

Knowledge, acceptability and community factors

Knowledge factors assessed understanding of COVID-19 causes, symptoms, mode of transmission, preventive measures, vaccine types, route of administration and eligibility for vaccination. Also, acceptability factors included willingness to receive the vaccine as well as motivations and barriers. Finally, community factors encompassed the social and environmental influences on individual decisions, such as residential setting, societal influence and prior vaccination experience.

Measures

Dependent variable

This was measured by asking the respondents whether they had received the COVID-19 vaccine or not, with ‘Yes’ or ‘No’ as the response options.

Independent variables

The independent variables in the study included sociodemographic factors, risk factors, COVID-19 testing and outcomes, participants’ knowledge of COVID-19 and vaccines, vaccine acceptability, and community-related factors.

Sociodemographic factors were assessed with six (6) items. Risk factors, COVID-19 testing and outcomes were assessed with four (4) items. Knowledge of COVID-19 and COVID-19 vaccines was assessed with seven (7) items. The knowledge level of the respondents was measured by merging all 7 items and coding all appropriate answers as correct (1) or wrong (0). A composite variable was created, and an average mean score (19.3) was used as a benchmark. Scores above the mean were categorized as good knowledge, whereas scores below the mean were categorized as poor knowledge. This criterion was adopted from the literature [28]. COVID-19 vaccine acceptability and reasons for acceptability were assessed using three (3) items. However, the question “willingness to accept the COVID-19 vaccine” with responses “Yes or No” was only used to measure acceptability of the vaccine. Community-related factors were measured with eleven (11) items.

Validity and reliability of the instrument

The validity of this study was ensured by piloting the questionnaire with 5% of the sample. This provided feedback on the data collection tool, which was subsequently refined to improve its quality. The reliability of the instrument was assessed using Cronbach’s alpha (α) to determine the internal consistency of the multi-item, construct-based sections of the questionnaire, specifically the seven (7) items used to measure participants’ knowledge of COVID-19 and COVID-19 vaccines. A reliability coefficient (α) of 0.82 was achieved for these items, which is considered acceptable [29].

Data analysis

The data were exported into an Excel spreadsheet. Data cleaning and analysis were performed with STATA version 17.0. Descriptive statistics were performed and are presented in tables and graphs. Categorical data were summarized as frequencies and percentages. Continuous variables, such as age, are summarized as means, medians, and standard deviations. The chi-square test was used to determine the associations between the independent variables (sociodemographic factors, risk factors, COVID-19 testing and outcome, knowledge about COVID-19 and COVID-19 vaccines, COVID-19 vaccine acceptability, and community-related factors) and the outcome variable (COVID-19 vaccine uptake).

Variables were first analyzed in Model I an unadjusted bivariate logistic regression was used to estimate the Crude Odds Ratios (COR). This assessed the independent association between each independent variable and the outcome variable without controlling for other factors. Variables that showed statistically significant associations (p < 0.05) at this stage were considered candidates for multivariable analysis.

Subsequently, in Model II, the adjusted, the multiple logistic regression was performed to estimate the Adjusted Odds Ratios (AOR). In this model, all selected variables were entered simultaneously using a forward stepwise approach to control for potential confounding effects. This method begins with an empty model and sequentially adds significant variables based on their contribution to improving model fit and predictive strength. The AOR therefore reflects the independent effect of each variable on the outcome after adjusting for other variables in the model. Statistical significance was determined at a 95% confidence interval, with p < 0.05 considered statistically significant.

Results

Sociodemographic characteristics of the respondents

A total of 384 respondents participated in this study, with a 100% response rate. Approximately half 197 (51.3%) were females, with 168 (43.8%) of the respondents being less than 30 years of age, with a mean age of 29 years and a standard deviation (SD) of ± 6.2. Regarding educational status, 132 (34.4%) had completed basic/middle school, and 67 (17.5%) had no formal education. More than half 213 (55.5%) were single. More than two-thirds 279 (72.7%), of the respondents had a household size of 1–5, and the majority 308 (80.2%) of the respondents were Christians, as shown in Table 1.

Table 1.

Sociodemographic characteristics of the respondents (n = 384)

Variables	Frequency (n)	Percentage (%)
Sex
Female	197	51.3
Male	187	48.7
Age (years) Mean Age [SD]	29[± 6.2]
18–29	168	43.8
30–49	156	40.6
50 +	60	15.6
Educational level
No formal education	67	17.5
Basic/middle school completed	132	34.4
Senior High School completed	108	28.1
Tertiary	77	20.1
Marital Status
Married	171	44.5
Single	213	55.5
Household Size
1–5	279	72.7
6+	105	27.3
Religion
Christian	308	80.2
Muslim	59	15.4
Traditionalist	7	1.8
None of the Above	10	2.6

Risk factors, COVID-19 testing and outcomes

In terms of risk factors, COVID-19 testing results, and outcome results, 56 (14.6%) of the respondents had a history of chronic diseases, and among these chronic diseases, diabetes was the most reported condition among 37 (61.7%) of them. Only 59 (15.4%) of the respondents tested positive for COVID-19, of whom 51 (86.4%) tested negative (Table 2).

Table 2.

Risk Factors, COVID-19 Testing and Outcomes (n = 384)

Variables	Frequency (n)	Percentage (%)
History of chronic diseases
No	328	85.4
Yes	56	14.6
Type of chronic diseases affected with ( n  = 60) *
Diabetes	37	61.7
Pulmonary disease	3	5.0
Cardiovascular disease	8	13.3
Renal disease	10	16.7
Hepatic disease	2	3.3
COVID-19 testing and vaccination status
Tested for COVID-19
No	325	84.6
Yes	59	15.4
Test outcome
Negative	51	86.4
Positive	8	13.6

*Multiple responses

Knowledge of COVID-19 disease and COVID-19 vaccines

In assessing the knowledge of respondents on COVID-19 and COVID-19 vaccines, more than two-thirds of 270 (70.3%) knew that COVID-19 was caused by a virus. Regarding symptoms of COVID-19, 302 (23.6%), 243 (19.0%) and 202 (15.8%) reported cough, difficulty breathing and loss of smell or taste, respectively, as the most common symptoms. Two-thirds 330 (63.5%) and 117 (22.5%) of the respondents also reported sneezing without covering their nose or coughing without covering their mouth and shaking their hands with infected persons as the dominant mode of disease transmission, respectively. Most 174 (45.3%) respondents knew that isolation was the action taken if a person was suspected or confirmed of having COVID-19 infection. Among the COVID-19 vaccines used in Ghana’s immunisation, AstraZeneca was known by the majority (282; 37.6%) of the respondents, and almost all of them (375; 96.7%) knew that injection was the mode of administration, as shown in Table 3. Approximately half of the 218 (50.1%) participants reported that all persons aged 18 years and above were eligible to receive COVID-19 vaccines. In terms of respondents’ knowledge of COVID-19 and COVID-19 vaccines, the results revealed that half 197 (51.3%) had poor knowledge, whereas the remaining 197 (48.7%) had good knowledge (Figure 1).

Table 3.

Knowledge of COVID-19 disease and COVID-19 vaccines

Variables	Frequency (n)	Percentage (%)
Causes of COVID-19
Don’t know	46	12.0
Germ/Virus	270	70.3
Vaccines	5	1.3
Not wearing a nose mask	63	16.4
Symptoms of COVID-19 (n=1278) *
Cough	302	23.6
Fever	173	13.5
Tiredness	40	3.1
Difficulty breathing	243	19.0
Loss of smell or taste	202	15.8
Loss of weight	17	1.3
Loss of appetite	101	7.9
Runny nose	188	14.7
Others	12	0.9
Mode of COVID-19 transmission (n=520) *
Eating with an infected person	24	4.6
Sharing a sponge and towel with an infected person	18	3.5
Sneezing without covering the nose/Coughing without covering the mouth	330	63.5
Shaking hands with infected persons	117	22.5
Others	4	0.8
Don’t know	27	5.2
Action taken if a person is suspected/confirmed of having COVID-19
Don’t know	53	13.8
Isolated	174	45.3
Quarantined	157	40.9
COVID-19 vaccines used in Ghana (n=750) *
AstraZeneca	282	37.6
Sputnik V	20	2.7
Johnson & Johnson	281	37.5
Pfizer	109	14.5
Moderna	58	7.7
Mode of COVID-19 vaccine administration (n=388)
Oral	1	0.3
Injection	375	96.7
Intravenous	2	0.5
Don’t know	10	2.6
Eligible persons for COVID-19 vaccination (n=435) *
All persons including children	6	1.4
All persons aged 18 years and above	218	50.1
All persons aged 15 years and above	161	37.0
Only persons less than 18 years	1	0.2
Only persons with underlying conditions	26	6.0
Don’t know	23	5.3

*Multiple responses

Fig. 1.

Knowledge level of respondents on COVID-19 and COVID-19 vaccines

COVID-19 vaccine acceptability

The majority (303, 78.9%) of the respondents were willing to accept COVID-19 vaccines, and a few (81, 21.1%) were unwilling to get vaccinated. Among the reasons reported for accepting the vaccine, personal protection against the infection was the major reason reported by 263 (57.3%) respondents, and the fear of side effects was a barrier to the majority of the 43 (44.3%) who were unwilling to get vaccinated (Table 4).

Table 4.

COVID-19 vaccine acceptability

Variables	Frequency (n)	Percentage (%)
Willingness to accept the COVID-19 vaccine
No	81	21.1
Yes	303	78.9
Reason for acceptability ( n  = 459) *
Protection against COVID-19 infection	263	57.3
Protection of other relatives against COVID-19 infection	135	29.4
Work requirement	53	11.6
No reason	8	1.74
Reason for non-acceptability ( n  = 97) *
Fear of side effects	43	44.3
Vaccine not effective in preventing COVID-19 infection prevention	11	11.3
Fear of injection	21	21.7
Distrust in the management of COVID-19 by the authorities	2	2.1
No reason	20	20.6

*Multiple responses

Community-related factors

In assessing community-related factors and COVID-19 vaccine uptake, the findings revealed that more than half of the 200 (52.1%) of the respondents resided in rural areas. Almost all the participants (377, 98.2%) had heard about the COVID-19 vaccine. Almost all the participants (365, 96.8%) were aware of the place where they could access COVID-19 vaccines, and a few (29, 7.6%) of the respondents had family members/friends who were confirmed to be positive for COVID-19. Close to two-thirds of 245 (63.8%) had ever received other vaccines apart from their childhood vaccines. Notably, a few respondents (40, 10.4%) within the community had ever had friends or relatives who experienced serious side effects from vaccination, and the majority (22, 55.0%) reported poor management of these side effects. A high proportion 24 (60.0%) of the respondents reported observing adverse side effects following vaccination from friends/relatives, discouraging them from vaccination (Table 5).

Table 5.

Community-Related Factors and COVID-19 Uptake (n = 384)

Variables	Frequency (n)	Percentage (%)
Place of residence
Rural area	200	52.1
Urban area	184	47.9
Heard about the COVID-19 vaccine
No	7	1.8
Yes	377	98.2
Any known place for COVID-19 vaccination in this community ( n  = 377)
No	12	3.2
Yes	365	96.8
Family members/friends confirmed positive for COVID-19
No	355	92.5
Yes	29	7.6
Ever received any other vaccination apart from the childhood vaccines
No	139	36.2
Yes	245	63.8
Any relative/friend experienced a serious side effect from vaccination before
No	344	89.6
Yes	40	10.4
How was the side effect of vaccination managed? ( n  = 40)
Poorly managed	22	55.0
Properly managed	18	45.0
Discouragement from COVID-19 vaccines due to observed side effects from a relative/friend ( n  = 40)
No	16	4.0
Yes	24	60.0
Received COVID-19 Vaccine
No	90	23.4
Yes	294	76.6

Respondents’ sources of information

The findings concerning the respondents’ sources of information revealed that the majority (320, 41.1%) had their sources of information from health professionals, and only a few (4.0%) had their information from other sources (Fig. 2).

Fig. 2.

Respondents’ Sources of Information on COVID-19 and COVID-19 Vaccines

COVID-19 vaccine uptake

Findings on COVID-19 vaccination uptake revealed that more than half 294 (76.6%) had received the COVID-19 vaccine and that 90 (23.4%) had not received a jab (Fig 3).

Fig. 3.

COVID-19 Vaccine Uptake among Respondents

Factors associated with COVID-19 vaccine uptake

A bivariate analysis was conducted to identify factors influencing the use of COVID-19 vaccines among the study participants, as depicted in Table 6. Model I (unadjusted) revealed significant factors influencing COVID-19 vaccine uptake. In terms of sociodemographic characteristics, individuals aged 50 years and above were three times more likely to be vaccinated against COVID-19 than younger adults (COR = 2.9, 95% CI: [1.16–7.25], p = 0.022). In addition, participants with with basic (COR = 2.7, 95% CI: [1.38–5.20], p = 0.004, secondary (COR = 2.0, 95% CI: [1.01–3.85], p = 0.045) and tertiary educational (COR = 2.3, 95% CI: [1.08–4.76], p = 0.030) had significantly higher odds of vaccination compared with those with no formal education. Compared with married individuals, single individuals had 40% lower odds of vaccination (COR = 0.6, 95% CI: [0.35–0.94], p = 0.029), and persons with large household sizes (six or more) had reduced odds of COVID-19 vaccine uptake (COR = 0.5, 95% CI: [0.32–0.87], p = 0.012). Compared with being Christian, being Muslim was associated with reduced odds of vaccination uptake (COR = 0.3, 95% CI: [0.16–0.50], p < 0.001).

Table 6.

Factors associated with COVID-19 vaccine uptake

Variables	COVID-19 Vaccination uptake				Model I	Model II
	No = [90]n (%)		Yes [294]n (%)		COR (95% Cl)p-value	AOR (95% Cl)p-value
Sociodemographic factors
Sex
Female	44(48.9)		153(52.0)		Ref	-
Male	46(51.1)		141(48.0)		0.9(0.55–1.41),0.601	-
Age [Years]
18–29	41(45.6)		127(43.2)		Ref	Ref
30–49	43(47.8)		113(38.4)		0.8(0.51–1.39), 0.517	5.5(0.75–12.08), 0.065
50 +	6(6.7)		54(18.4)		2.9(1.16–7.25),0.022**	2.1(1.20–7.89),0.993
Educational level
No formal education	25(27.8)		42(14.3)		Ref	Ref
Basic/Middle School	24(26.7)		108(36.7)		2.7(1.38–5.20), 0.004**	3.0(3.55–6.12), 0.001*
Senior High School	25(27.8)		83(28.2)		2.0(1.01–3.85), 0.045**	-
Tertiary	16(17.8)		61(20.8)		2.3(1.08–4.76), 0.030**	-
Marital status
Married	31(34.4)		140(47.6)		Ref	Ref
Single	59(65.6)		154(52.4)		0.6(0.35–0.94), 0.029**	6.1(0.12–9.50), 0.993
Household Size
1–5	56(62.2)		223(75.9)		Ref	Ref
6+	34(37.8)		71(24.2)		0.5(0.32–0.87), 0.012**	0.17(0.01–12.74), 0.424
Religion
Christian	59(65.6)		249(84.7)		Ref
Muslim	27(30.0)		32(10.9)		0.3(0.16–0.50), < 0.001**	-
Traditionalist	1(1.1)		6(2.0)		1.4(0.17-12.0), 0.747	-
None	3(3.3)		7(2.4)		0.6(0.14–2.20), 0.401	-
Risk Factors, COVID-19 Testing and Outcome
History of chronic disease
No	79(87.8)		249(84.7)		Ref
Yes	11(12.2)		45(15.3)		1.3(0.6–2.6),0.469	-
Tested for COVID-19
No	84(93.3)		241(82.0)		Ref	Ref
Yes	6(6.7)		53(18.0)		3.1(1.3–7.4),0.012**	10.2(7.1-13.65), 0.002**
Knowledge on COVID-19 and COVID-19 vaccines
Poor knowledge	55(61.1)		142(48.3)		Ref	Ref
Good knowledge	35(38.9)		152(51.7)		1.7(1.0-2.72),0.034**	6.0(0.07–48.51), 0.424
COVID-19 Vaccine Acceptability
Willingness to accept the COVID-19 vaccine						-
No	64(71.1)		17(5.8)		Ref
Yes	26(28.9)		277(94.2)		4.5(3.8–6.7), 0.045**	-
Reason for acceptability
Protection against COVID-19 infection
No	6(23.1)		34(12.3)		Ref	-
Yes	20(76.9)		243(87.7)		2.1(0.8–5.7),0.127	-
Protection of other relatives against COVID-19 infection
No	16(61.5)		149(53.8)		Ref	-
Yes	10(38.5)		128(46.2)		1.4(0.6–3.1),0.450	-
Work requirement
No	25(96.2)		222(80.1)		Ref	-
Yes	1(3.9)		55(19.9)		6.2(0.82–46.71),0.077	-
Reason for non-acceptability
Fear of side effects
No	30(46.9)		8(47.1)		Ref	-
Yes	34(53.1)		9(52.9)		1.0(0.3–2.9),0.989	-
Vaccine not effective in preventing COVID-19 infection
No	58(90.6)		12(70.6)		Ref	Ref
Yes	6(9.4)		5(29.4)		4.0(1.05–5.38),0.042**	12.0(9.46–14.93), 0.021*
Fear of injection
No	48(75.0)		12(70.6)		Ref	-
Yes	16(25.0)		5(29.4)		1.3(0.38–4.10),0.721	-
Community-Related Factors
Place of Dwelling						-
Rural area	45(50.0)		155(52.7)		Ref
Urban area	45(50.0)		139(47.3)		0.9(0.6–1.4),0.651	-
Heard about the COVID-19 vaccine
No	6(6.7)		1(0.3)		Ref	Ref
Yes	84(93.3)		293(99.7)		20.9(16.48–22.26),0.005**	8.3(6.1–10.9), 0.049**
Source of information
Media personnel	62(73.8)		220(75.1)		1.1(0.6–1.8),0.812	-
Health professional	65(77.4)		225(87.0)		2.0(1.6–3.62),0.032**	1.0(1.0-3.80), 0.027**
Neighbour/Relative	40(47.6)		104(35.5)		0.61(0.37–0.99),0.045**	-
Social media	8(9.5)		23(7.9)		0.8(0.3–1.9),0.623	-
Any known place for COVID-19 vaccination in this community
No	6(7.1)		6(2.1)		Ref	Ref
Yes	78(92.9)		287(98.0)		3.7(1.3–11.7),0.028**	1.9(0.01–2.29), 0.963
Family members/friends confirmed positive for COVID-19
No	88(97.8)		267(90.8)		Ref	-
Yes	2(2.2)		27(9.2)		4.4(1.0-19.1),0.045**	-
Ever received any other vaccination apart from the childhood vaccine
No	56(62.2)		83(28.2)		Ref	Ref
Yes	34(37.7)		211(71.8)		4.2(2.6–6.9), < 0.001**	7.9(3.32–11.77), 0.023**
Any relative/friend experienced a serious side effect from vaccination
No	80(88.9)		264(89.8)		Ref	-
Yes	10(11.1)		30(10.2)		0.9(0.4–1.9),0.805	-
Side effect management
Poorly managed	5(50.0)		17(56.7)		Ref
Properly managed	5(50.0)		13(43.3)		0.7(0.2–3.2),0.714
Discouragement from vaccination due to the observed adverse side effects from a relative/friend
No	75(83.3)		277(94.2)		Ref	-
Yes	15(16.7)		17(5.8)		0.3(0.14–0.64), 0.002**	-

**Statistically significant associations at 95% Cl, COR= crude odds ratio; AOR=adjusted odds ratio

With respect to COVID-19 testing, those who tested positive had 3 times greater odds of vaccination (COR = 3.1, 95% CI: [1.3–7.42], p = 0.012). Adequate knowledge about COVID-19 and its vaccines increased the likelihood of vaccination by 1.7 times (COR = 1.7, 95% CI: [1.03–2.72], p = 0.034), whereas willingness to accept vaccines increased the odds of vaccination by 4.5 times (COR = 4.5, 95% CI: [3.81–6.7], p = 0.045). Conversely, those who perceived COVID-19 vaccines as ineffective were 4 times more likely to refuse vaccination (COR = 4.0, 95% CI: [1.05–15.38], p = 0.042).

Community factors also played a significant role, with awareness of vaccine availability increasing the odds by 20.9 times (COR = 20.9, 95% CI: [16.48–22.26], p = 0.005). Information from health professionals doubled the likelihood of vaccination (COR = 2.0, 95% CI: [1.6–3.62], p = 0.032), and knowing where to access vaccines increased the odds of vaccination by 3.7 times (COR = 3.7, 95% CI: [1.3–11.7], p = 0.028). Having close contacts such as relatives/friends with COVID-19 cases also increased the likelihood of vaccination by 4 times (COR = 4.4, 95% CI: [1.0–19.1], p = 0.045), and persons who had received any vaccines apart from childhood vaccines were 4 times more likely to receive COVID-19 vaccines (COR = 4.2, 95% CI: [2.6–6.9], p < 0.001). While observing serious side effects in relatives or friends was not significantly associated with vaccine refusal, individuals who were discouraged from vaccination because of these observed side effects were 97 times more likely to refuse the COVID-19 vaccine (COR = 0.3, 95% CI: [0.14–0.64], p = 0.002).

After adjusting for other confounding variables in Model II (adjusted), individuals with a basic educational level were significantly more likely to receive a COVID-19 vaccine (AOR = 3.0, 95% CI: 3.55–6.12, p = 0.001). Participants who had tested positive for COVID-19 were also more likely to vaccinate (AOR = 10.2, 95% CI: 7.13–13.65, p = 0.002), whereas those perceiving vaccines as ineffective had higher hesitancy (AOR = 12.0, 95% CI: 9.46–14.93, p = 0.021). Awareness (AOR = 8.3, 95% CI: [61.1–10.89], p = 0.049) and prior vaccination experience (AOR = 7.9, 95% CI: [3.32–11.77], p = 0.023) significantly increased uptake.

Discussion

In this study, a high uptake rate of the COVID-19 vaccine was observed (76.6%), which was higher than rates reported in Ghana (37.8%), Tanzania (18%), and Uganda (49.7%) [30–32]. This difference may reflect disparities in perceived risk and severity of the disease across regions, as well as differences in study timeframes and the intensity of educational campaigns, highlighting the impact of health education on vaccine awareness and uptake. However, it is important to note that vaccine uptake was self-reported, and social desirability bias may have led participants to overstate their vaccination status, potentially inflating the observed uptake rate.

Educational attainment had a significant effect on COVID-19 vaccine use, with individuals possessing at least a basic education demonstrating a 3-fold increase in uptake. Similar trends were observed in Ghana, Uganda and Sweden, where higher education correlated with increased vaccination rates [30, 33, 34]. This underscores the pivotal role of education in public health interventions. Nevertheless, unmeasured confounders such as access to healthcare facilities and exposure to health campaigns may have also influenced these associations. Despite these limitations, targeted educational interventions have significantly improved knowledge, attitudes, acceptance, and utilisation of COVID-19 vaccines [35], suggesting that well-designed interventions can overcome educational disparities. In contrast, formal education did not consistently translate into higher vaccine acceptance but was associated with greater hesitancy, possibly reflecting increased scepticism, selective interpretation of information, or mistrust in official public health messaging [36].

A low COVID-19 testing rate was reported among 15.4% of the study population, compared with 76.0% in Chicago [37], which may be due to differences in testing availability and logistics across countries. Testing was associated with higher vaccine uptake from this, mirroring findings from previous studies [34, 37, 38]. However, self-reporting and recall bias may have influenced these associations, as participants may misremember or misreport their testing history. These findings emphasise the importance of accessible testing facilities to promote vaccination during infectious disease outbreaks.

Belief in vaccine ineffectiveness strongly influenced vaccine uptake, with individuals holding this perception being 12 times more likely to refuse vaccination. These findings are consistent with those of a study among adults in Ghana [39] and South Africa [40], and reflect the pervasive impact of misinformation on vaccine acceptance in Africa. Nevertheless, the spread of misinformation and disinformation about COVID-19 vaccines has greatly contributed to the global decline in vaccine acceptance, worsening the impact of the third and fourth waves of the pandemic [41, 42]. Targeted public health campaigns are crucial for improving vaccine uptake by addressing misconceptions and building trust. Effective education from health workers, stakeholders, and media can help combat misinformation about COVID-19 vaccines.

Community factors, such as community members being aware of the existence of COVID-19 vaccines within the community, increased the odds of COVID-19 vaccination uptake. These findings are in line with a study from China [43]. Although mass educational campaigns improve vaccine awareness, health workers emerged as the most influential information source, with individuals informed by health workers showing significantly higher odds of COVID-19 vaccine uptake than those relying on other sources. Similar findings were reported in Uganda and Hong Kong [30, 44]. Additionally, similar findings suggest that trust in healthcare workers can play a crucial role in increasing COVID-19 vaccination rates [45]. Strengthening the role of health workers in disseminating accurate information could lead to more effective public health strategies, improving vaccine acceptance and reducing the spread of misinformation.

Community members with a history of receiving vaccines other than childhood routine vaccines were 8 times more likely to be vaccinated against COVID-19. This finding aligns with a study showing that people who had received influenza vaccines were 50% more likely to be fully vaccinated against COVID-19 than those who had not received the influenza vaccine [46]. The increased rate of COVID-19 vaccination among those with a history of influenza vaccination may be due to their confidence in the safety and effectiveness of vaccines. These findings underscore the importance of ensuring COVID-19 vaccine safety at all levels to encourage greater uptake.

The adverse side effects of vaccines have been one of the stumbling blocks in increasing COVID-19 vaccination coverage [47]. Notably, this study revealed that individuals who witnessed their relatives, friends, or neighbours experiencing effects from COVID-19 vaccines were three times more likely to avoid being vaccinated. This highlights the need for health authorities and experts to communicate openly about vaccine side effects, emphasising their rarity and mildness compared with COVID-19 risk. Additionally, maintaining strict vaccine safety protocols and managing any adverse effects are crucial to ensuring confidence in vaccination.

Strengths and limitations of the study

The study employed a cross-sectional design, offering a snapshot of the factors influencing COVID-19 vaccine uptake among residents of Kwahu South Municipality in the Eastern Region of Ghana. This approach allowed for a broad understanding of the factors involved and enabled the findings to be generalised across the six subdistricts where the study was conducted. The use of diverse languages in the survey addressed language barriers, allowing respondents to express themselves more freely.

However, several limitations should be acknowledged. First, the cross-sectional nature of the study precludes causal inferences. Second, vaccination status and COVID-19 testing history were self-reported, which may be subject to recall bias and social desirability bias. However, participants were assured of confidentiality, and questions were framed clearly to improve accuracy. Third, non-response bias could not be ruled out, as individuals who declined participation may differ systematically from respondents in their attitudes or behaviours toward COVID-19 vaccination. Finally, because the study was conducted during a specific period of the pandemic, the findings may not capture temporal changes in vaccine availability, public perception, or policy shifts, which could influence vaccine uptake over time.

Nevertheless, these limitations do not nullify the study’s findings, which make a meaningful contribution to the public health discourse on COVID-19 vaccination.

Conclusion

The study found that COVID-19 vaccine uptake in Kwahu South Municipality was high, with 76.6% of respondents vaccinated. However, uptake was significantly associated with factors such as prior COVID-19 testing, awareness of the vaccine, previous vaccination history, educational level, and perceptions of vaccine effectiveness. After adjusting for confounders, prior testing, vaccine awareness, previous vaccination experience and perceived ineffectiveness of the vaccine remained significant factors. The findings highlight that both prior health experiences and perceptions about vaccine effectiveness played a key role in influencing vaccine uptake.

Recommendation

To boost COVID-19 vaccination uptake, trust in the healthcare system must be restored. The Ghana Health Service and Municipal Health Management Team should prioritise transparent communication, information dissemination, and ethical education to rebuild individual trust. Community-based education efforts, led by trained health workers through information centres, public gatherings, and community durbars, should be scaled up to reach diverse populations. These interventions should provide clear, comprehensive information on the benefits of COVID-19 vaccination, address misconceptions, and highlight protection against COVID-19 and its complications. To ensure effectiveness, these programs should incorporate monitoring and evaluation frameworks, including pre- and post-intervention surveys, community feedback mechanisms, and coverage tracking. This will allow successful strategies to be scaled and adapted across other municipalities.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

AOR

Adjusted odds ratio

CHPS

Community-based Health Planning and Services

CI

Confidence interval

COR

Crude odds ratio

COVID-19

Coronavirus Disease 2019

GHS

Ghana Health Service

HCWs

Healthcare Workers

PHEIC

Public Health Emergency of International Concern

SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2

SDG

Sustainable Development Goals

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

UNICEF

United Nations International Children’s Emergency Fund

WHO

World Health Organisation

Author contributions

AGL, EE, and AZD conceptualised the study. The methodology was developed by AGL, DA A, NH, EE and AZD. DMO and EE carried out the formal analysis and interpretation. Writing of the original draft was performed by DMO and EE. DMO, EE, AGL, DAA, NH, and AZD reviewed and edited the manuscript. AZD provided supervision and contributed to reviewing and editing the study. All authors read and approved the final manuscript.

Funding

This research received no external funding.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval

for the study was obtained from the University of Health and Allied Sciences Research Ethics Committee (UHAS-REC), with protocol identification number UHAS-REC B.10 [051] 21–22, which also covered the pilot testing of the study. Permission was also granted by the Kwahu South Municipal Health Directorate (KSMHD). Informed consent was obtained from all participants through written consent, documented via signatures or thumbprints. The study adhered to the Declaration of Helsinki principles. Data confidentiality was also ensured.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.