Journal of Immunization

Journal of Immunization

Current Issue Volume No: 1 Issue No: 2

Research-article Article Open Access
  • Available online freely Peer Reviewed
  • Predictors Of COVID-19 Vaccine Hesitancy In North-Central Nigeria

    1 Center for Global Health Practice and Impact, Georgetown University, Washington DC, United States of America 

    2 Georgetown Global Health Nigeria, Federal Capital Territory, Abuja, Nigeria 

    3 Savannah Health System Innovation Limited, Federal Capital Territory, Abuja, Nigeria 

    Abstract

    COVID-19 vaccine hesitancy has emerged as a major challenge to global efforts to control the pandemic, particularly in Nigeria, where hesitancy to other effective vaccines such as polio and measles has been widely reported. Several individual, societal, and structural factors contribute to this behaviour and prevent the effectiveness of COVID-19 prevention efforts.

    Objectives

    This study sought to identify the predictors of COVID-19 vaccine hesitancy in the seven states of North-Central, Nigeria.

    Methods

    A population-based cross-sectional online survey was conducted among residents using a semi-structured questionnaire adapted from the WHO SAGE vaccine hesitancy scale and distributed via social media networks over 8-weeks.

    Results

    A total of 1,429 responses met the inclusion criteria and were analysed. Among the respondents, 60.7% were males, 47.5% were between the ages of 26 and 45, and 80.1% had postsecondary education. A total of 421 respondents (29.5%) were hesitant and unwilling to receive the vaccine. The reasons for hesitancy were concerns about side effects (37.1%), doubt about the existence of COVID-19 (11.0%), and the perception of time required to receive the vaccine (9.6%). Post-secondary education (AOR: 0.49, 0.36-0.66) and people of the Islamic faith (AOR: 0.68, 0.52-0.90) were found to be associated with lower levels of hesitancy.

    Conclusion

    The study found that vaccine hesitancy is a complex problem that is linked with multiple social determinants of health as lower educational attainment, lower income and Christian faith were found to be predictors of vaccine hesitancy. Confidence, Complacency and Convenience factors were expressed by respondents as concerns about side effects, doubt about the existence of COVID-19 and time required to receive the vaccines were the most prominent reasons for unwillingness to receive the vaccine. In order to protect the public health of communities, targeted interventions are required to increase vaccine acceptance by cultivating trust in vaccines, disseminating accurate information, and engaging with community stakeholders including religious groups.

    Author Contributions
    Received Jul 18, 2024     Accepted Aug 12, 2024     Published Sep 19, 2024

    Copyright© 2024 Olutola Ayodotun, et al.
    License
    Creative Commons License   This work is licensed under a Creative Commons Attribution 4.0 International License. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Funding Interests:

    Citation:

    Olutola Ayodotun, Bola Gobir Ibrahim, Bazira Deus, Agboola Samson, Ohunene Sanni Fatimah et al. (2024) Predictors Of COVID-19 Vaccine Hesitancy In North-Central Nigeria Journal of Immunization. - 1(2):10-24
    DOI 10.14302/issn.2577-137X.ji-24-5207

    Introduction

    Introduction

    The COVID-19 pandemic resulted globally in more than 769 million cases and 6.9 million deaths.1 Nigeria reported 256,028 confirmed cases and 3,143 confirmed deaths due to COVID-19 disease.2 The rapid spread of COVID-19 and associated mortality, especially among the elderly and people with comorbidities spurred efforts to develop vaccines for controlling the epidemic. Conventional vaccine development from the preclinical phase to licensing could take an average of over 10 years.3 However, epidemics in the last decade have accelerated the development of novel platforms that have shortened the time for vaccine sequencing from years to weeks.4 Leveraging these platforms and multisectoral collaborations, several vaccines were rapidly produced and approved for distribution to curb the scourge of the COVID-19 pandemic.

    Within the first year of the COVID-19 pandemic, Janssen completed phase 3 trial of a potential COVID-19 vaccine5, and multiple options became globally available with greater access to vaccines in the developed countries compared to other nations.6 With availability of effective vaccines, overcoming hesitancy assumed priority. Vaccine hesitancy defined as delay in the acceptance or complete refusal of vaccines despite the availability of vaccines has been identified as one of the top 10 global public health problems.7 It is complex phenomenon that is influenced by factors such as age, culture, socio-economic status, and trust in the healthcare system.89

    The World Health Organization SAGE working group identified three barriers to vaccine uptake known as the 3C’s: Confidence/lack of confidence (in vaccines and lack of trust in the system that delivers them), complacency, (when perceived risks of vaccine-preventable diseases are low or when vaccination is considered secondary to other responsibilities at a given point in time) and convenience (which denotes the extent to which physical availability, affordability, and access to information and other immunization services exist).10 Research estimates suggest that herd immunity to COVID-19 would require more than 60% of the population to be vaccinated or infected naturally.11

    As of June 18, 2022, only 13% of Nigerians had completed all recommended COVID-19 vaccines despite the widespread availability of the vaccines12 This fell significantly short of the goal of vaccinating 40% of the population by December 2021. Suboptimal uptake of vaccines is not uncommon in Nigeria due to vaccine unavailability, lack of confidence in vaccines or complacency factors.13

    This study is designed to identify the predictors of COVID-19 vaccine hesitancy in the seven states of North-Central, Nigeria.

    Results

    Results

    The study recorded a total of 1,999 survey entries, of which 13 did not consent to participate in the survey, yielding a response rate of 99.3%. We excluded 557 responses for not meeting the inclusion criteria. Thus, the final sample size for this study was 1,429. Out of the 1,429 responses included in the study analysis, 1,008 (70.5%) were willing to accept or had received at least one dose of the COVID-19 vaccine while 421 (29.5%) were unvaccinated and hesitant as shown in Figure 1.

    Flow diagram of the study sample size Demographic characteristics of the respondents

    As shown in Table 1, more than a third (36.7%) of the respondents were residents of the Federal Capital Territory (FCT) while the rest resided in Benue (5.5%), Kogi (10.3%), Kwara (3.2%), Nasarawa (15.6%), Niger (16.7%), and Plateau States (12.0%). The majority of respondents were male (60.7%), 18 – 25 years old (43.3%), single (64.1%), Christian faith (57.2%), holders of post-secondary educational qualifications (80.1%), and employed (56.1%). Nearly half of the respondents (46.2%) had a monthly income between N30,000 and N150,000.

    Demographic characteristics of all respondents, N=1,429
    Variable N=1,429 %
    State of residence    
    FCT 524 36.7
    Benue 79 5.5
    Kogi 147 10.3
    Kwara 46 3.2
    Nasarawa 223 15.6
    Niger 238 16.7
    Plateau 172 12.0
    Gender    
    Female 562 39.3
    Male 867 60.7
    Age group (years)    
    18–25 618 43.3
    26–45 678 47.5
    >45 133 9.3
    Marital status    
    Single 916 64.1
    Married 404 28.3
    Previously married 109 7.6
    Religion    
    Christianity 817 57.2
    Islam 577 40.4
    Othersa 35 2.5
    Post Secondary education    
    No 285 19.9
    Yes 1,144 80.1
    Employment Status    
    Unemployed 628 43.9
    Employed 801 56.1
    Monthly Income    
    Less than #30, 000 523 36.6
    #30,000 - #150,000 660 46.2
    Above #150, 000 246 17.2
    Distribution of the sample by the socio-demographic characteristics and attitudes toward COVID-19

    According to Table 2, 29.5% of the participants were unwilling to receive the COVID-19 vaccine. The hesitancy was significantly associated with participants’ religious beliefs, post-secondary educational status, and monthly income (p < 0.05). Hesitancy was higher among the “Others” religious belief (participants with traditional beliefs and non-religious affiliations), participants with no post-secondary educational status, and participants who earned less than N30,000 monthly.

    Socio-demographic characteristics and Association with Vaccine Hesitancy
    Variable Hesitancy (N = 421, % = 29.5) Acceptance (N=1,008, % = 70.5) Total N = 1,429 p-value
    State of residence 0.12
    FCT 28 (35.4%) 51 (64.6%) 79  
    Benue 149 (28.4%) 375 (71.6%) 524  
    Kogi 53 (36.1%) 94 (63.9%) 147  
    Kwara 11 (23.9%) 35 (76.1%) 46  
    Nasarawa 52 (23.3%) 171 (76.7%) 223  
    Niger 75 (31.5%) 163 (68.5%) 238  
    Plateau 53 (30.8%) 119 (69.2%) 172  
    Gender 0.52
    Female 171 (30.4%) 391 (69.6%) 562  
    Male 250 (28.8%) 617 (71.2%) 867  
    Age group (years) 0.31
    18 – 25 195 (31.6%) 423 (68.4%) 618  
    26 – 45 190 (28.0%) 488 (72.0%) 678  
    Above 45 36 (27.1%) 97 (72.9%) 133  
    Marital status 0.25
    Single 274 (29.9%) 642 (70.1%) 916  
    Married 109 (27.0%) 295 (73.0%) 404  
    Previously married 38 (34.9%) 71 (65.1%) 109  
    Religion 0.00*
    Christianity 258 (31.6%) 559 (68.4%) 817  
    Islam 147 (25.5%) 430 (74.5%) 577  
    Othersa 16 (45.7%) 19 (54.3%) 35  
    Post Secondary Education 0.00*
    No 124 (43.5%) 161 (54.5%) 285  
    Yes 297 (26.0%) 847 (74.0%) 1, 144  
    Employment status 0.91
    Unemployed 184 (29.3%) 444 (70.7%) 628  
    Employed 237 (29.6%) 564 (70.4%) 801  
    Monthly Income 0.00*
    Less than #30, 000 185 (35.4%) 338 (64.6%) 523  
    #30,000 - #150,000 177 (26.8%) 483 (73.2%) 660  
    Above #150, 000 59 (24.0%) 187 (76.0%) 246  
    Reasons for Unwillingness to Receive COVID-19 Vaccine

    Concerns about side effects were the most common reasons for vaccine hesitancy (37.1%). Others expressed reasons such as doubt about the existence of COVID-19 (11.0%), the perception of time required to receive the vaccine (9.6%), dislike or fear of needles (7.2%) and possible complications caused by underlying medical conditions (5.5%). A few believed that the vaccines were not effective (6.5%) (Figure 2)

    Reasons among the COVID-19 Vaccine Hesitant Participants
    Sociodemographic Predictors of COVID-19 Vaccine Hesitancy

    According to Table 3, 29.5% of the participants were unwilling to be vaccinated now and when the vaccine becomes available. Religious belief and post-secondary educational attainment were found to be significantly associated with COVID-19 vaccination attitudes. Higher hesitancy rates were observed among Christians and religious beliefs classified as “others” compared to those of Islamic religious beliefs (p < 0.05). Respondents of Islamic faith were 32% less likely to be hesitant (OR 0.68, CI: 0.52-0.90) compared to respondents of Christian beliefs. Respondents with post-secondary education were found to be 51% less likely to be hesitant in comparison with those without post-secondary education (OR 0.49, CI: 0.36-0.66).

    Sociodemographic Predictors of COVID-19 Vaccine Hesitancy
    Variable Hesitant (n = 421, % = 29.5 Acceptance (n = 1008, % = 70.5 Total (N = 1,429) Crude OR (95% CI) P Value Adjusted OR (95% CI) P value
    State of Residence
    FCT 149 (28.4) 375 (71.6) 524 Ref   Ref  
    Benue 28 (35.4) 51 (64.6) 79 1.38 (0.84-2.27) 0.20 1.19 (0.71-2.00) 0.52
    Kogi 53 (36.1) 94 (63.9) 147 1.42 (0.96-2.09) 0.08 1.21 (0.81-1.81) 0.35
    Kwara 11 (23.9) 35 (76.1) 46 0.79 (0.39-1.60) 0.51 0.77 (0.38-1.59) 0.48
    Nasarawa 52 (23.3) 171 (76.7) 223 0.77 (0.53-1.10) 0.15 0.68 (0.46-1.00) 0.05
    Niger 75 (31.5) 163 (68.5) 238 1.16 (0.83-1.62) 0.39 1.09 (0.76-1.55) 0.64
    Plateau 53 (30.8) 119 (69.2) 172 1.12 (0.77-1.63) 0.55 1.07 (0.73-1.57) 0.74
    Gender
    Female 171 (30.4) 391 (69.6) 562 Ref   Ref  
    Male 250 (28.8) 617 (71.2) 867 0.93 (0.73-1.17) 0.52 1.00 (0.78-1.28) 0.98
    Age group (Years)
    18-25 195 (31.6) 423 (68.5) 618 Ref   Ref  
    26-45 190 (28.0) 488 (72.0) 678 0.84 (0.67-1.07) 0.17 0.92 (0.69-1.22) 0.58
    >45 36 (27.1) 97 (72.9) 133 0.81(0.53-1.22) 0.31 0.84 (0.49-1.47) 0.55
    Marital Status
    Single 274 (29.9) 642 (70.1) 916 Ref   Ref  
    Married 109 (27.0) 295 (73.0) 404 0.87 (0.67-1.12) 0.28 0.99 (0.72-1.36) 0.94
    Previously married 38 (34.9) 71 (65.1) 109 1.25 (0.83-1.91) 0.29 1.42 (0.84-2.40) 0.20
    Religion
    Christianity 258 (31.6) 559 (68.4) 817 Ref   Ref  
    Islam 147 (25.5) 430 (74.5) 577 0.74 (0.58-0.94) 0.01 0.68 (0.52-0.90) 0.01*
    Others 16 (45.7) 19 (54.3) 35 1.82 (0.92-3.61) 0.08 1.65 (0.81-3.33) 0.17
    Post-Secondary Education
    No 124 (43.5) 161 (56.5) 285 Ref   Ref  
    Yes 297 (26.0) 847 (74.0) 1,144 0.46 (0.35-0.60) 0.00 0.49 (0.36-0.66) 0.00*
    Employment Status
    Unemployed 184 (29.3%) 444 (70.7%) 628 Ref   Ref  
    Employed 237 (29.6%) 564 (70.4%) 801 1.01 (0.81-1.28) 0.91 1.00 (0.79-1.26) 0.99
    Monthly Income
    Less than #30, 000 185 (35.4) 338 (64.6) 523 Ref   Ref  
    #30,000 - #150,000 177 (26.8) 483 (73.2) 660 0.67 (0.52-0.86) 0.00 0.77 (0.59-1.01) 0.06
    Above #150, 000 59 (24.0) 187 (76.0) 246 0.58 (0.41-0.81) 0.00 0.66 (0.44-0.99) 0.05
    Source of Information about the COVID-19 vaccine

    As shown in Figure 3 below, healthcare providers were the predominant source of trusted information about the COVID-19 vaccine in 33.0% of the respondents. Others include social media (24%), friends, family, and/ or community members (23.3%) and the mass media (14.7%).

    The most trusted source of information about the COVID-19 vaccine and Vaccination
    Perceptions about the COVID-19 Vaccine among Hesitant Respondents

    The majority of respondents reported support for vaccination from community and religious leaders (85.5%). However, 68.8% of them expressed unwillingness to follow the advice of leaders.

    The majority lacked trust in the government’s ability to procure the highest quality vaccine (71.5%), 66.3% perceived the COVID-19 vaccine as unsafe while 62% perceived it as non-essential for preventing the COVID-19 virus. More than 40% expressed a lack of trust in health workers to safely deliver the vaccine (47.5%) and unfavourable clinic waiting time for vaccination as factors that discourage them from taking the COVID-19 vaccine. (43.2%), (Table 4).

    Perceptions about the COVID-19 Vaccine among Hesitant Respondents
    Factors No Yes
    Leaders, gatekeepers, and pro-vaccination
    Do religious leaders in your community support taking the COVID-19 vaccine? 61 (14.5%) 360 (85.5%)
    Do politicians, teachers, and health workers in your community support vaccination? 29 (6.9%) 392 (93.1%)
    Do you follow the advice of your religious/cultural leaders about the COVID-19 vaccination? 289 (68.6%) 132 (31.4%)
    Does your religion/culture recommend against the COVID-19 vaccination? 355 (84.3%) 66 (15.7%)
    Political influences
    Do you trust that your government is deciding in your best interest concerning the COVID-19 vaccine 265 (62.9%) 156 (37.1%)
    Are you convinced that your government purchases the highest quality of the COVID-19 vaccine 301 (71.5%) 120 (28.5%)
    Do you trust that the government is making the best efforts to store the vaccines in the right conditions? 288 (68.4%) 133 (31.6%)
    Geographical barriers
    Does distance limit you from getting the vaccine? 264 (62.7%) 157 (37.3%)
    Does clinic time or waiting at the clinic prevent you from getting the COVID-19 vaccine? 239 (56.8%) 182 (43.2%)
    Pharmaceutical industry
    Do you think governments are pushed by the pharmaceutical industries to recommend vaccines? 106 (25.2%) 315 (74.8%)
    Do you trust the pharmaceutical companies that produce the COVID-19 vaccine? 303 (72.0%) 118 (28.0%)
    The Vaccines/Vaccination issues
    Do you think the vaccine is safe 279 (66.3%) 142 (33.7%)
    The COVID-19 vaccine is essential for us 261 (62.0%) 160 (38.0%)
    Do you trust the healthcare workers to safely administer the vaccine to you? 221 (52.5%) 200 (47.5%)
    Is the vaccination process convenient, i.e., is it easier for you to get vaccinated 262 (62.2%) 159 (37.8%)
    Do you think that if everyone in society maintains preventive measures (face masks, social distancing, etc.), COVID-19 can be eradicated without vaccination? 136 (32.3%) 285 (67.7%)

    Discussion

    Discussion

    The COVID-19 pandemic resulted in significant disruption in the health and livelihoods globally. Despite the evidence that vaccines offer viable protection against the disease, achieving universal acceptance remains an uphill task. Nigeria has reported challenges with the uptake of several vaccines in different parts of the country including vaccines that were aimed at the prevention of infant mortality 10111718. In this study, 29.5% of the respondents in the North-Central region were unwilling to receive the COVID-19 vaccine. A similar study in Southwest Nigeria reported a vaccine hesitancy rate of 25.5%,15 and an African survey of 34 countries reported a hesitancy rate of 37% among the general population.16

    On a global level, vaccine hesitancy rates above 50% have been reported in China, Malaysia, Australia, Pakistan and Italy. 8171819 Some sociodemographic factors such as education, religion and income were found to be significantly associated with vaccine hesitancy in our study. this shows that the lack of post-secondary education was associated with a 51% higher risk of hesitancy. Our findings are consistent with other studies that have established the value of education in influencing health-seeking behaviours.20 Reliable sources of such information such as educational and health institutions are important in shaping knowledge and attitudes that increase uptake of vaccines, and other health-seeking activities such as social distancing, usage of masks and other proven health interventions that prevent the spread of the COVID-19 virus. Half of the hesitant respondents indicated reliance on social media and friends or family as their trusted sources of information about the COVID-19 vaccine. These sources are often prone to information biases, particularly during a period of massive anti-vaccine campaigns and misinformation. The study also found that higher household income above the national minimum wage with respondents that earning significantly above the minimum demonstrating a 42% reduction in risk. This is consistent with the likelihood of attainment of post-secondary education among higher-earning respondents.

    Respondents of the Islamic faith had a 32% lower risk of hesitancy compared to the Christians. The impact of faith on health and social behaviours is very profound in Nigeria. Many adopt mannerisms or practices that conform to the teachings of religious leaders or community leaders. The notable anti-vaccine messaging that emanated from some prominent Christian leaders at the beginning of the pandemic may have contributed to vaccine hesitancy among some members of the faith.21 The majority of religious and community leaders supported COVID-19 vaccination efforts but over two-thirds of hesitant persons were unswayed by the support of their religious or community leaders to accept the vaccine.

    Our study identified a combination of confidence, convenience, and complacency factors as influencers of vaccine hesitancy. Nearly half of the vaccine-hesitant respondents cited a lack of confidence in the safety and side effect profile of the vaccines as the reasons for their unwillingness to be vaccinated. Other studies have documented similar findings. 2224 More than two-thirds of respondents expressed a lack of trust in both the government of Nigeria and pharmaceutical companies to deliver the vaccine with the sole purpose of improving quality of life. Similar attitudes to vaccines have been demonstrated with the polio vaccination drive where citizens in Northern Nigeria perceived the vaccines to contain compounds with sterilization properties that will prevent childbearing.13 The unprecedented speed in the development of COVID-19 vaccines and perceived inequalities in vaccine distribution contributed in fuelling vaccine hesitancy. The Oxford/AstraZeneca vaccine that was initially delivered to Nigeria through COVID-19 Vaccines Global Access (COVAX) initiative was perceived as inferior to the Moderna and Pfizer vaccines that were available in the high income countries. These findings are consistent with the findings of Lar son et al.23 that a lack of trust in the healthcare system, government, and economic systems has a profound effect on vaccine acceptance. Nomhwange, et al., (2022) similarly reported that the COVID-19 vaccine hesitancy was attributed to uncertainties about the safety of the vaccine, and the negative information that was circulated about COVID-19 vaccines on social media26.

    Complacency factors were demonstrated by those who expressed that the COVID infection was not real, the vaccine was not required and those who felt the use of universal precautions and personal protective equipment were adequate to address the epidemic. This may be potentiated by the high risk of misinformation among hesitant respondents as more than 50% of them relied on sources that are prone to biases such as social media, friends, and others for information about the vaccine. Examples of pervasive misinformation about the COVID-19 vaccine include rumours of the vaccine as a means of inoculating tracking chips into humans, the COVID-19 epidemic is a punishment from God, the illness is an effect of 5G technology deployment, while some believed it was just the regular flu.25

    Convenience factors were expressed by more than a third of the respondents who indicated that distance from homes to vaccination centres, the perceived waiting time required to complete the vaccination, and the process of vaccination were unfavourable for them. These factors are likely associated with the cost of transportation or the opportunity costs of vaccination over other activities of priority such as work.

    This study provides a perspective on the COVID-19 vaccine hesitancy in a large region of Nigeria. Though similar studies have been conducted in other states or regions of the country, this adds to the body of knowledge about the magnitude of vaccine hesitancy and the factors that drive them in a large region of Northern Nigeria. We acknowledge some limitations of the study which may have affected the generalizability of its findings. This includes online survey methodology with possible selection and response biases. Participants were those with access to internet, computers or smartphones. In addition, the inferences from this study relate to the COVID-19 vaccine and may not apply to vaccines for other diseases.

    Conclusion

    Conclusion

    This study's findings reaffirm vaccine hesitancy as a threat to COVID-19 prevention efforts in the North Central region of Nigeria. It enhances our understanding of the predictors of vaccine hesitancy and the reasons why people refuse to be vaccinated with the COVID-19 vaccine. The study found that vaccine hesitancy is a complex problem that is linked with multiple social determinants of health as lower educational attainment and Christian faith were found to be predictors of vaccine hesitancy. Confidence, Complacency and Convenience factors were expressed by respondents as concerns about side effects, doubt about the existence of COVID-19 and the time required to receive the vaccines were the most prominent reasons for unwillingness to receive the vaccine. The study highlights the importance of leveraging trusted sources of information, such as healthcare workers and social media, to disseminate accurate and timely information about COVID-19 and the vaccine. To protect the public health of communities, targeted interventions are required to increase vaccine acceptance by cultivating trust in vaccines, disseminating accurate information, and engaging with community stakeholders including religious groups.

    Affiliations:
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