Prevalence and factors associated with COVID-19 vaccine hesitancy among adults in Ghana: A population-based cross-sectional study in the Volta Region

doi:10.21203/rs.3.rs-4941032/v1

Background

Vaccines have been instrumental in preventing up to three million deaths globally, according to the WHO. Despite this, COVID-19 vaccine uptake has faced challenges due to vaccine issues, production difficulties, and various socio-demographic, economic, structural, and cultural factors.

Objective/aim

This study examined these factors influencing vaccine hesitancy among adults aged 18 and older in the Volta Region of Ghana.

Methods

A population-based cross-sectional study was conducted among 590 adults from three districts using multistage sampling. Respondents aged 18 years and above were recruited using a structured questionnaire and an interviewer administered approach. Data analysis was conducted using STATA version 16. The relationship between the dependent and independent variables was assessed through logistic regression analysis, with statistical significance determined at a p-value of less than 0.05.

Results

A 42.5% rate of vaccine hesitancy was found. Key predictors included being an artisan (aOR = 1.99), a trader (aOR = 3.64), lacking nearby healthcare centers (aOR = 1.52), residing in rural areas (aOR = 0.41), earning less than 500 cedis (aOR = 0.57), and having a larger household size (aOR = 0.37). Not receiving information on vaccine side effects from health personnel (aOR = 5.6) was also a significant factor (p < 0.05).

Conclusion

To enhance COVID-19 vaccine uptake and advance towards SDG 3, ensuring healthy lives and promote well-being for all at all ages, interventions should address structural, economic, and health system factors.

prevalence

vaccine

COVID-19

hesitant

Hohoe

The study found a significant vaccine hesitancy rate of 42.5%, highlighting reluctance towards COVID-19 vaccination. Demographic factors like occupation, residence, and income influenced hesitancy, underscoring socio-economic considerations in vaccination campaigns.
Structural and economic factors such as COVID-19 knowledge, healthcare access, and household size were linked to hesitancy, guiding strategies for enhancing vaccine accessibility.
Health system predictors of hesitancy included insufficient vaccine information, unavailability at vaccination sites, long distances to outreach sites, and limited knowledge about vaccine options, emphasizing the need to address health system barriers to improve public trust and ensure equitable vaccine access.

Key Implications

The Ghana Health Service (GHS) in collaboration with the Ministry of Health (MoH) should implement targeted vaccination strategies to reach diverse populations and other vantage locations within the Volta region and the country at large.
Furthermore, the media should help to enhance the dissemination of accurate information about COVID-19 and vaccination. This will promote informed decision-making and combat misinformation, thus fostering greater public confidence in vaccination efforts.
Finally, healthcare workers should be empowered and supported in the region and across the country to lead vaccination education and outreach initiatives. This will enhance vaccine acceptance and uptake across diverse cultural contexts.

Vaccines have demonstrated their life-saving potential against numerous preventable communicable diseases, with the WHO estimating the prevention of 2–3 million deaths globally through such initiatives [1]. Consequently, it has become a cornerstone of preventive medicine and vaccination ranks among the top ten public health accomplishments of the 20th Century [2]. It is emphasized that vaccine use is the most effective public health approach to curbing the spread of various infectious diseases [3]. Notably, vaccines represent a highly efficient means of mitigating future COVID-19 outbreaks [4]. The onset and rapid escalation of COVID-19 infections prompted nations to pursue preventive measures where various strategies were employed to curb the spread of COVID-19, and a pivotal development in this battle was the creation of the COVID-19 vaccine [5]. This led to intense global competition among scientists and institutions, resulting in record-breaking vaccine development efforts, driven by both noble intentions and commercial interests, to be the first to develop a vaccine to combat COVID-19 [6]. The urgency for a COVID-19 vaccine accelerated its production, bypassing some traditional phases, and culminating in vaccine development within an unprecedented time frame of 12–24 months [7].

Effective management of the COVID-19 pandemic hinges on the successful introduction of a vaccine to reduce disease severity and the continued adherence to safety measures to mitigate virus spread and lower infection rates [8]. However, the uptake of the COVID-19 vaccines since they were introduced, has been hindered by a complex interplay of factors, including the vaccine itself, production challenges, as well as various personal, psychosocial, environmental, and cultural elements [5, 9–12]. The WHO SAGE working group has classified the reasons for vaccination delays or refusals into the contextual, individual group, and vaccine-specific factors [13]. Vaccine hesitancy stems from a multitude of contributors, including aspects such as vaccine administrators, vaccination locations, vaccine types, timing of vaccine administration, cultural influences, geographic factors, and individual confidence [14, 15] A more in-depth analysis reveals that vaccine hesitancy is influenced by psychological, cognitive, and demographic factors [16, 17]. Myths and superstitious beliefs from some religious leaders and residents in the Volta Region have contributed to the voices opposing the COVID-19 vaccine [18, 19]. As a result, the region is among the lowest-performing in Ghana, with only about two out of every ten people completing the primary series of COVID-19 vaccination, compared to the national average of three out of ten as of the end of April 2023 [19]. The looming issue of vaccine wastage, stemming from the underutilization and expiration of vaccines, is a pressing concern within the Volta Region, especially in the context of high vaccine hesitancy [20]. Given the potential dire consequences of COVID-19 vaccine hesitancy, our study aimed to investigate the demographic, economic, structural, and health system factors influencing this hesitancy among adults aged 18 and above in the Volta Region of Ghana. Although vaccines were introduced as a solution to the growing public health concern of COVID-19, vaccine hesitancy has hindered their effectiveness, particularly in Ghana. Understanding this hesitancy in specific populations, such as the Volta Region, is crucial for future public health messaging. The findings will support the Ghana Health Service, the Ghana Medical Association, and the Ghana Registered Nurses and Midwives Association in addressing vaccine hesitancy and will contribute to the literature for future studies.

Study design and setting

The study employed a population-based cross-sectional design. It was carried out in the Volta Region of Ghana, specifically in the Hohoe, North Tongu and Ketu South municipalities. Despite the low COVID-19 vaccine uptake in the Volta region, including Hohoe, North Tongu, and Ketu South municipalities in the study on COVID-19 vaccine hesitancy is justified due to their diverse geographical and socio-economic contexts. Hohoe, as a key administrative and commercial centre, offers insights into vaccine hesitancy in urban and peri-urban settings. North Tongu, with its mix of rural and semi-urban communities, helps explore the impact of agricultural and rural lifestyles on vaccine uptake. Ketu South, located near the Togo border and known for its market activities, provides a perspective on how cross-border dynamics and coastal living influence vaccine perceptions. These municipalities offer a comprehensive understanding of vaccine hesitancy across different settings within the Volta Region, aiding in the development of targeted public health strategies. The Region has a total population of 1,659,040 [21]. It is located along the southern half of the eastern border of Ghana, which shares a border with the Republic of Togo. The Region shares a border on the west with the Greater Accra, Eastern and Brong Ahafo Regions, on the north with the Northern Region, and on the South with the Gulf of Guinea [22]. There are 18 Districts in the Volta Region with the capital as Ho Municipality. The Region was not exempted from the COVID-19 pandemic as it recorded a total of 346 positive cases as of December 2020 from all 18 Districts [23, 24]. This study adopted the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines in drafting this paper [25].

Study Population

The study was conducted amongst adult residents of three administrative districts/municipalities of the Volta Region; North Tongu District in the southern part of the Region, Ketu South District in the central part of the Region, and the Hohoe Municipality in the northern part of the region.

Inclusion criteria

Participants were selected based on the following inclusion criteria: they must be residents of one of the three selected municipalities in the Volta Region, be at least 18 years old, and provide informed consent to participate in the study.

Exclusion criteria

Non-residents, individuals under 18, and those who do not consent were excluded from the study.

Sample size determination

The minimum sample size for this study was obtained using the single proportion population formula (26), n =\(\:\frac{{Z(\alpha\:/2)}^{2}p(1-p)}{{e}^{2}}\). The sample size calculation assumed a margin of error of 0.05, a Z-score of 1.96 at a 95% Confidence Interval (CI) and an estimated proportion of vaccine hesitancy at 0.286 (28.6%) [27] and 0.10 (10%) non-response rate. A 10% non-response rate was used due to the vastness and the multi-districts employed in the study.

Definitions of terms or parameters in the formula:

n = sample size determined,

Z = Z-score, of 1.96 at 95% (CI)

P = estimated proportion of vaccine hesitancy present in the population (28.6%) or 0.286

e = margin of error of (5%) or (0.05)

Sample size (n) = \(\:\frac{{\left(1.96\right)}^{2}\times\:0.286\times\:(1-0.286)}{{\left(0.05\right)}^{2}}\)

n = \(\:\frac{3.8416\:x\:0.286\left(0.714\right)}{0.0025}\)

n = 313.79

Adding a non-response rate of 10%, n= (313.78) + 31.38; minimum sample size = 345.16

The sample size for the study was 590.

Sampling procedure

A multistage sampling method was employed in this study. Using purposive sampling first, three Municipalities were selected from the Volta Region. The region has registered and recorded the lowest rate of vaccine uptake of 18.2% and 32.5% [28, 29]. These Municipalities were purposively selected based on their location in the Volta Region and the COVID-19 vaccine uptake. The Municipalities were the Hohoe Municipality of the northern belt, the North Tongu District of the southern belt, and the Ketu South District of the central belt of the Volta Region.

To select the households used in this study, each community was stratified into rural and urban strata. The systematic sampling method was then used to select each household. This method was adapted from a study conducted in the Philippines [30]. To ensure that a proportionate number of households is obtained from each Municipality, the sampling was done by dividing the number of houses in each community by the estimated sample size for each Municipality. The derived figure was the basis for selecting the households systematically. Finally, a simple random sampling was used to sample the participants in the selected houses for the study. In households with more than one eligible respondent, a simple random sampling using the balloting method of “Yes” or “No” approach was used to sample one respondent. “Yes” and “No” were written on pieces of paper, folded in equal halves placed in a dry clean basket and mixed thoroughly for selection. Individuals in each household were allowed to select a piece of paper without replacement. An individual who chose a “Yes” was selected to participate in the study.

Study Variables

Outcome variable

The outcome variable in our study was COVID-19 vaccine hesitancy. This variable measured the proportion of participants who were either reluctant to get vaccinated or refused vaccination despite the availability of vaccination services, compared to those who readily took the vaccines. Vaccine hesitancy was assessed using six questions. Five questions used a Likert scale with four levels: "Strongly Agree," "Agree," "Disagree," and "Strongly Disagree." The sixth question was categorized as “1 = Yes” and “0 = No.”

Responses of "Strongly Agree" and "Agree" were combined and coded as "1," while "Strongly Disagree" and "Disagree" were combined and coded as "0." This coding was applied to the first five questions. We then generated a composite variable and computed a mean score for all six items. Participants with a score below the mean were considered hesitant, while those with a score above the mean were considered not hesitant.

Explanatory variables

For the study, two main explanatory variables were considered in our estimations. Thus; (I) modifying factors. These factors included certain characteristics and features that influenced a change in whether or not an individual was hesitant to the COVID-19 vaccine. Variables measured included the demographic characteristics of individuals, socioeconomic characteristics of individuals and some structural characteristics. Structural characteristics in this context included individual knowledge of the COVID-19 vaccine, its production, administration, side effects, its purpose and effectiveness. This was assessed using 20 questions in the questionnaire. (II) Health system factors. This was measured using different sets of questions derived from health care expenditure, attitudes of the health workforce, products and materials for vaccination, provision of vaccine, information circulating concerning COVID-19 vaccine, leadership and governance pertaining to COVID-19.

Data collection

Data were collected using a structured questionnaire adapted from similar studies [4, 31, 32]. The questionnaire was designed and administered electronically using the Kobo Toolbox and interviewer-administered to the community members. The questionnaire comprised five sections. Section A: socio-demographic characteristics, Section B: contained questions and items to determine COVID-19 vaccine hesitancy, Section C: contained questions to assess the factors influencing COVID-19 vaccine hesitancy based on the modifying factors and Section D: contained questions to determine the health system influencing COVID-19 vaccine hesitancy. Field assistants were recruited and trained to assist in data collection in each District. Announcements were made in the communities prior to the start of the data collection. This was done with the approval and support of Chiefs and community leaders. Data were collected in the homes of respondents and at their convenience and in languages respondents best understood.

Data analyses

Data were exported to STATA v.16 for cleaning and analysis. Data were analysed using both descriptive and inferential statistics. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to summarise the data. The inferential analysis used in this study was logistic regression. This was used to determine the influence of the independent variables on the dependent variable. The logistic regression used in this study was a multivariable logistic regression due to the presence of more than one independent variable (modifying factors, and health system factors) in the study. A test of probability values less than 5% (0.05) was considered statistically significant at a 95% confidence interval.

Ethics approval and consent to participate

All methods were in accordance with the Declaration of Helsinki. The University of Health and Allied Sciences Research Ethics Committee (UHAS-REC) reviewed the study and approved it with a reference [ID: UHAS-REC A.3[3] 22-23]. Permission was also obtained from the Ketu South, North Tongu and Hohoe Municipal Health Directorates before the commencement of the study. During data collection written informed consent was obtained from all of the participants.

Table I provides the distribution of the socio-demographic characteristics of the respondents. The respondents in this study were sourced from three Municipalities; Hohoe, Ketu South and North Tongu. The majority of the respondents were from the Ketu South Municipality (37.8%). A comparative majority of them were males (53.4%). Predominant among them were single (52.2%). Furthermore, most of the respondents had attained secondary education (47.3%) and were Ewes (87.8%). The dominant occupation in all three Municipalities was trading (21.4%). However, most of the respondents were unemployed (30.0%). Urban dwellers were dominant in this study 374 (63.4%). Most of the respondents were vaccinated 291 (49.3%). The mean and standard deviation for age and income in each of the three Municipalities were 34.80 (14.5) and 331.43 (776.3) respectively.

Table I: Socio-demographic characteristics of respondents (n=346)

Variable	Frequency (N)	Percentage (%)
District
Hohoe Municipality	215	36.4
Ketu South Municipality	223	37.8
North Tongu Municipality	152	25.8
Sex
Male	315	53.4
Female	275	46.6
Age [Mean (SD)]	34.80(14.5)
<30	149 43.1
30-49	100 28.9
>49	97 28.0
Marital status
Never Married	308	52.2
Married	223	37.8
Divorced	15	2.5
Cohabiting	10	1.7
Separated	16	2.7
Widowed	18	3.1
Level of education
No formal education	37	6.2
Basic education	128	21.7
Secondary education	279	47.3
Tertiary education	146	24.8
Ethnicity
Akan	44	7.4
Ewe	518	87.8
Other	28	4.8
Religion
Christianity	560	94.9
Islam	16	2.7
Traditional	14	2.4
Occupation
Unemployed	177	30.0
Civil Servant	65	11.0
Farmer	62	10.5
Fisherman/woman	10	1.7
Artisans	119	20.2
Trader	126	21.4
Student	31	2.2
Place of residence
Urban	374	63.4
Rural	216	36.6
Income [Mean (SD)]	331.43(776.2)
No income	158 45.6
<500	86 24.8
≥500	102 29.5
COVID-19 Vaccination
Yes	291	49.3
No	288	48.8
Prefer not to say	11	1.9

COVID-19 vaccine hesitancy among the respondents

The figure below shows COVID-19 vaccine hesitancy among the respondents. COVID-19 vaccine hesitancy was measured with six questions from the questionnaire; (I) I would like to take the COVID-19 vaccine if available, (II) I will describe my attitude towards taking a COVID-19 vaccine as very positive and keen, (III) I would take the COVID-19 vaccine when it is available in my locality, (IV) I would describe myself as eager to get a COVID-19 vaccine, (V) will take a COVID-19 vaccine because it is important and (VI) Have you been vaccinated against COVID-19. Respondents were asked to select to what extent they ‘disagree’ or ‘agree’ with the above questions using a Likert scale of; strongly agree, agree, disagree and strongly disagree. A composite variable was then created by coding ‘strongly agree and agree’ responses as ‘1’ and ‘disagree and agree’ responses as ‘0’. A mean score was then generated and participants who scored below the mean were categorized as (hesitant) whereas participants who scored above the mean were categorised as (not hesitant). Findings from the study revealed that the majority 339 (57.5%) of the respondents were not hesitant about the COVID-19 vaccines (Figure 1).

Association between demographic characteristics and vaccine hesitancy

From the logistic regression analysis (Table II), it was observed that the demographic factors associated with COVID-19 vaccine hesitancy were such that artisans (aOR=1.99, 95% CI: 1.13,3.51, P=0.017) and traders (aOR=3.64, 95% CI=2.05,6.44, P <0.001) were more likely to be vaccine-hesitant. People who lived in rural areas (aOR=0.41, 95% CI: 0.27,0.61, P <0.001) were less likely to be vaccine-hesitant likewise persons who earned less than 500 cedis (aOR=0.57, 95% CI: 0.26,0.97, P=0.042) and 500 cedis or more per month (aOR=0.42, 95% CI: 0.22,0.79, P=0.008).

Table II: Association between demographic characteristics and COVID-19 vaccine hesitancy

Variable	Vaccine Hesitancy		Chi-square () (p-value)	cOR (95% C.I) (p-value)	aOR (95% C.I) (p-value)
Variable	Not Hesitant n (%)	Hesitant n (%)	Chi-square () (p-value)	cOR (95% C.I) (p-value)	aOR (95% C.I) (p-value)
Study Sites
Hohoe Municipality	145(42.8)	70(27.9)		Ref	Ref
Ketu South Municipality	107(31.6)	116(46.2)		2.25(1.52, 3.31) <0.001	1.33(0.71, 2.49) 0.369
North Tongu District	87(25.7)	65(25.9)	16.96(<0.001)	1.55(1.01, 2.38) 0.046	0.81(0.48, 1.35) 0.415
Sex
Male	185(54.6)	130(51.8)
Female	154(45.4)	121(48.2)	0.45(0.503)
Age
<30	144(42.5)	105(41.8)
30-49	134(39.5)	110(43.8)
>49	61(18.0)	36(14.3)	1.83(0.401)
Marital status
Never Married	184(52.3)	12(49.4)
Married	119(35.1)	104(41.4)
Cohabiting	6(1.8)	9(3.6)
Divorced	7(2.1)	3(1.2)
Separated	11(3.2)	5(2.0)
Widow	12(3.5)	6(2.4)	6.16(0.291)
Educational Level
No formal education	19(5.6)	18(7.2)
Basic Education	58(17.1)	70(27.9)
Secondary Education	164(48.4)	115(45.8)
Tertiary Education	98(28.9)	48(19.1)	14.07(0.003)
Ethnicity
Akan	32(9.4)	12(4.8)
Ewe	289(85.3)	229(91.2)
Other	18(5.3)	10(4.0)	5.32(0.070)
Religion
Christianity	326(96.2)	234(93.2)		Ref	Ref
Islam	10(3.0)	6(2.4)		0.84(0.30, 2.33) 0.732	0.82(0.28,2.37) 0.708
Traditional	3(0.9)	11(4.4)	7.73(0.021)	5.11(1.41, 18.51) 0.013	5.67(0.94,34.32) 0.059
Occupation
Unemployed	112(33.4)	65(25.9)		Ref
Civil Servant	46(13.6)	19(7.6)		0.71(0.38, 1.31) 0.279	1.50(0.71,3.16) 0.283
Farmer	41(12.1)	21(8.4)		0.88(0,48, 1.62) 0.687	1.62(0.76,3.43) 0.120
Fishing	4(1.2)	6(2.4)		2.58(0.70, 9.50) 0.153	0.89(0.14,5.68) 0.904
Artisan	60(17.7)	59(23.5)		1.69(1.06, 2.72) 0.028	1.99(1.13, 3.51) 0.017
Trader	53(15.6)	73(29.1)		2.37(1.49, 3.79) <0.001	3.64(2.06, 3.51) <0.001
Student	23(6.8)	8(3.2)	28.50(<0.001)	0.59(0.25, 1.42) 0.244	1.02(0.39,2.67) 0.965
Place of Residence
Urban	189(55.8)	185(73.7)		Ref
Rural	150(44.3)	66(26.3)	20.03(<0.001)	0.45(0.32, 0.64) <0.001	0.41(0.27,0.61) <0.001
Income (Monthly)
No income	158(46.6)	161(64.4)		Ref
<500	79(23.3)	42(16.7)		0.52(0.34, 0.81) 0.003	0.57(0.26,0.97) 0.042
≥500	102(30.1)	48(19.1)	18.06(<0.001)	0.46(0.31, 0.69) <0.001	0.42(0.22,0.79) 0.008
Vaccinated Against COVID-19
Yes	264(77.9)	27(10.8)		Ref
No	67(19.8)	221(88.1)		32.25(19.93, 52.18) <0.001
Prefer not to say	8(2.4)	3(1.2)	270.53 (<0.001)	3.67(0.92, 14.64) 0.066

Association between structural and economic factors and COVID-19 vaccine hesitancy

Among the structural and economic factors assessed, knowledge of COVID-19, availability of a healthcare or vaccination centre, and household size were associated with COVID-19 vaccine hesitancy, such that those who did not have a healthcare centre close to them were more likely to be vaccine-hesitant (aOR=1.52, 95% CI: 1.03,2.23, P=0.034]. Those who did not have adequate knowledge of COVID-19 were more likely to be vaccine-hesitant (aOR=2.86, 95% CI: 1.98,4,13, P <0.001]. Families with a household size of 3 (aOR=0.55, 95% CI: 0.37,0.82, P=0.003) and more than 5 (aOR=0.37, 95% CI: 0.22,0.63, P<0.001) were less likely to be vaccine-hesitant (Table III).

Table III: Association between structural and economic factors and vaccine hesitancy

Variable	Vaccine Hesitancy		Chi-square () (p-value)	cOR (95% C.I) (p-value)	aOR (95% C.I) (p-value)
Variable	Not Hesitant n (%)	Hesitant n (%)	Chi-square () (p-value)	cOR (95% C.I) (p-value)	aOR (95% C.I) (p-value)
Structural Factors
Infected with COVID-19
Yes	9(2.7)	2(0.8)
No	318(93.8)	245(97.6)
Don’t Know	12(3.5)	4(1.6)	4.90(0.086)
Ever had a COVID-19 test
Yes, a positive test	8(2.4)	2(0.8)		Ref
Yes, a negative test	42(12.4)	121(4.8)		1.14(0.21, 6.11) 0.876
Not tested at all	289(85.2)	237(94.4)	12.56(0.002)	33.28(0.69, 15.59) 0.135
Health centre close to your home
Yes	145(42.8)	67(26.9)		Ref	Ref
No	187(55.2)	171(68.1)		1.98(1.39, 2.83) <0.001	1.52(1.03,2.23) 0.034
Don’t know	7(2.1)	13(5.2)	18.50(<0.001)	4.02(1.53, 10.53) 0.005	0.56(0.19, 1.32) 0.120
Where first heard of COVID-19 pandemic
Radio and Television	275(81.1)	201(80.1)
School	30(8.8)	24(9.6)
Workplace	8(2.4)	3(1.2)
Community PA system	2(1.0)	3(1.2)
Relatives	13(3.8)	9(3.6)
Friends	5(1.5)	8(3.2)
Health workers	3(0.9)	1(0.4)
Others	3(0.9)	2(0.8)	4.23(.0753)
Main source of information about the pandemic
MOH-Ghana	19(5.6)	4(1.6)
WHO-Website	7(2.1)	2(0.8)
Health Professionals	21(6.2)	13(5.2)
Social media	163(48.1)	134(53.4)
Relatives	38(11.2)	35(13.9)
Radio/TV	91(26.8)	63(25.1)	9.58(0.088)
Level of Knowledge
Knowledgeable	204(60.2)	92(36.6)		Ref	Ref
Not knowledgeable	135(39.8)	159(63.4)	31.92(<0.001)	2.61(1.87, 3.66) <0.001	2.86(1.98, 4,13) <0.001
Economic Factors
Type of housing conditions
Tatch House	8(2.4)	5(2.0)
Mudhouse	10(2.9)	11(4.4)
Brick House	304(89.7)	230(91.6)
Glass House	12(3.5)	5(2.0)	5.88(0.208)
Other	5(1.5)	0(0.0)
Number of people staying in household
<3	119(37.8)	128(52.0)		Ref	Ref
3-5	128(40.6)	86(35.0)		0.62(0.43, 0.90) 0.013	0.55(0.37, 0.82) 0.003
>5	68(21.6)	32(13.0)	13.24(<0.001)	0.44(0.27, 0.71) <0.001	0.37(0.22, 0.63) <0.001

Association between health system factors and COVID-19 vaccine hesitancy

Among the health system factors assessed, it was observed that COVID-19 vaccine hesitancy was more likely to occur when health personnel did not discuss possible side effects of taking the COVID-19 vaccine with clients (aOR=5.6, 95% CI: 2.12, 14.86, P <0.001) (Table IV).

Table IV: Association between health system factors and COVID-19 vaccine hesitancy

Variable	Vaccine Hesitancy			Chi-square () (p-value)	COR (95% C.I) (p-value)	aOR (95% C.I) (p-value)
Variable	Not Hesitant n (%)	Hesitant n (%)		Chi-square () (p-value)	COR (95% C.I) (p-value)	aOR (95% C.I) (p-value)
Enough information provided by the health system
Yes	190(56.1)		62(24.7)		Ref	Ref
No	149(43.9)		189(75.3)	57.91(<0.001)	3.89(2.72, 5.56) <0.001	1.46(0.59, 3.57) 0.412
Vaccines available at the vaccination unit
Yes	103(30.4)		30(11.9)		Ref	Ref
No	2326(69.6)		221(88.1)	28.06(<0.001)	3.22(2.06, 5.02) <0.001	0.46(0.17, 1.19) 0.110
Distance from vaccination outreach is far
Yes	187(55.2)		177(70.5)		Ref	Ref
No	152(44.8)		74(29.5)	14.39(<0.001)	0.51(0.36, 0.73) <0.001	1.33(0.52, 3.42) 0.549
Insufficient information about vaccine manufacturers
Yes	223(65.8)		198(78.1)		Ref	Ref
No	116(34.2)		55(21.9)	10.61(<0.001)	0.54(0.37, 0.78) <0.001	0.97(0.31, 3.07) 0.960
Concerned about information provided about COVID-19
Yes	227(67.0)		184(73.3)
No	112(33.0)		67(26.7)	2.75(0.097)
Misinformation and disinformation about the vaccine
Yes	220(64.9)		192(76.5)		Ref	Ref
No	119(35.10)		59(23.5)	9.20(0.002)	0.57(0.39, 0.82)0.003	0.533(0.08, 3.46)0.510
Insufficient and incorrect data about vaccine
Yes	212(62.5)		87(74.5)		Ref	Ref
No	127(37.5)		64(25.5)	9.43(0.002)	0.57(0.40, 0.82)0.002	0.33(0.05, 2.26)0.257
Service providers charge money
Yes	7(2.6)		0(0.0)
No	262(97.4)		25(100.00)	0.67(0.414)
Health personnel are always not available
Yes	69(25.6)		8(32.0)
No	200(74.4)		17(68.0)	0.47(0.490)
Concerned about attitude of health personnel
Yes	206(76.6)		18(72.0)
No	63(23.4)		7(28.0)	0.26(0.607)
Person giving injection was nice and interactive
Yes	257(95.5)		22(88.0)
No	12(4.5)		3(122.0)	2.68(0.101)
Personnel giving injection was careful and concerned
Yes	256(95.2)		22(88.0)
No	13(4.8)		3(12)	2.28(0.131)
Personnel discuss side effects of the vaccine
Yes	202(75.1)		13(52.0)		Ref	Ref
No	67(24.9)		25(48.0)	6.20(0.013)	2.78(1.21, 6.39) 0.016	5.62(2.13, 14.87) <0.001

The study examined the prevalence and predictors of COVID-19 vaccine hesitancy among various populations. The findings indicated that more than half of the respondents (57.5%) were not hesitant about COVID-19 vaccination. This rate is comparable to those in some high-income countries, such as Russia (54.9%), Poland (56.3%), and France (58.9%) [33] .However, some upper and middle-income countries reported higher non-hesitant rates, such as Ecuador (97.0%) and Indonesia (93.3%) [33].

Comparing the study's results with other African countries, Nigeria, Mali, and Burkina Faso showed higher non-hesitant rates of 86.2%, 64.8%, and 79.5%, respectively [34,35]. Within Ghana, two studies conducted in the 16 administrative Regions of the country found the vaccine uptake rate to be 65% and 40.7% respectively [11,31]. Another study conducted in the Bono Region of Ghana found that 73.7% of the participants were non-hesitant to the COVID-19 vaccine. Furthermore, a study classified the vaccine hesitancy rate according to the region of residence in Ghana. The study identified that the North East (65.10%), Greater Accra (57.87%), Ashanti (54.67%), Savannah (54.55%), and Upper West (53.08%) regions were most likely to take up the COVID-19 vaccines [36]. Comparatively, findings from the current and existing studies conducted in Ghana show that the COVID-19 vaccine non-hesitancy rate in the country is encouraging.

Contrary to the high rate of vaccine non-hesitancy in this current study [37], further reported that the Volta Region recorded the lowest COVID-19 vaccine acceptance rate (32.5%) among the 16 regions in Ghana. The discrepancy between the current study and that of Acheampong et al. could be due to the different seasons in which both studies were conducted (the early stage of COVID-19 vaccine intervention in 2021 compared to the later stage of the COVID-19 vaccine intervention in 2022-2023). Usually, the early stages of most interventions experience low acceptance as compared to the later stages of the intervention [38]. As the years went by, doubts and misconceptions would have been cleared hence, more patronage and uptake. However, to maintain and improve the COVID-19 vaccine acceptance rate in the Volta Region, it is expedient that the Region and its health personnel resort to more resilient and community-driven interventions targeted at increasing COVID-19 vaccine coverage.

Vaccine hesitancy was influenced by a complex interplay of socio-cultural, sociodemographic, health, and other modifying factors. Key reasons for hesitancy included concerns with vaccine safety and efficacy, fertility concerns and conspiracy theories, vaccine data insufficiency and misinformation [31,34,39].

Conversely, higher acceptance was associated with a strong belief in the vaccine's protective benefits. Individuals who understood and trusted that the vaccine would shield them from severe illness and death were more likely to accept it. Additionally, accessibility to the vaccine played a significant role; easier access to vaccination centres and services was linked to higher acceptance rates [40]

The current study reported that demographic, structural and economic factors are significantly associated with COVID-19 vaccine hesitancy. Rural dwellers and those with steady incomes were less hesitant. Similar findings were reported in America [41] and Ghana [42]. Rural dwellers were less hesitant about the COVID-19 vaccine because they perceived the benefits to outweigh the risks and trusted new interventions from reliable sources. Policies promoting vaccination campaigns led by local community health workers also played a role. Therefore, efforts to increase vaccine uptake should focus on urbanized communities in the Volta Region, where hesitancy may be higher. Furthermore, respondents earning a monthly income were less hesitant to get vaccinated likely because they had the financial means to travel to vaccination centers. The initial vaccination campaign required individuals to go to health centres for their shots, which was more feasible for those with financial support. This highlights the need for more vaccination centres in low-income communities to accommodate those without financial means. Additionally, increasing vaccination outreach in the Volta Region and strengthening the role of community health volunteers is crucial. These volunteers, being residents, are more familiar with the community and are trusted by its members, making them effective in promoting vaccination efforts.

The current findings contradict other studies [43,44], which showed that rural residents and those with monthly incomes were more likely to be vaccine-hesitant. This difference may be due to rural residents’ lower education levels and limited access to accurate vaccine information, leading to fear and conspiracy beliefs [45,46]. Educating rural communities about the COVID-19 vaccine through health facilities and social media can help dispel misconceptions and improve vaccine acceptance. Additionally, media gatekeeping can prevent the spread of false information, potentially increasing vaccine uptake.

Regarding occupation, artisans and traders were more likely to be hesitant, possibly due to their work schedules and lack of knowledge about the vaccine. Targeted interventions in market areas and better education through trusted community health workers could improve uptake [47–49].

The low level of knowledge and understanding about the vaccines among traders and artisans likely contributes to their vaccine hesitancy. Additionally, artisans may feel secure in their workplaces and perceive the virus as more prevalent in hospitals and professional workplaces. This could explain the relatively low COVID-19 vaccine uptake in the Volta Region [50,51], where these groups constitute 84.3% of the population [21]. The increased rate of vaccine hesitancy among artisans and traders could be due to their long working hours, which leave little time for them to visit vaccination centres. Traders, for example, are at the market from morning to evening and are unlikely to take time off during their sales period to get vaccinated. To address this, vaccination efforts should be extended to central markets in major communities in the Volta Region. Targeted interventions are essential to reduce vaccine hesitancy among non-professional workers in this area.

Concerning structural and economic factors, the current study found that respondents with low or inadequate knowledge about COVID-19, and those concerned about the long distance to healthcare or vaccination centres, were more likely to be hesitant about vaccination compared to those with adequate knowledge and closer access to health centres. Additionally, respondents with household sizes of 3 or more than 5 were less likely to be hesitant about the COVID-19 vaccine. Supporting these findings, a showed that participants who accepted the COVID-19 vaccine had better knowledge, confidence, and understanding of it [52]. The study highlighted that a lack of knowledge, understanding, and perception of the risk and safety of the vaccine led to low acceptance rates in the Pakistani population, aligning with the current study's results. Furthermore, the odds of knowing which vaccine to get, understanding how vaccines work, and believing that vaccines strengthen the immune system were significantly higher in the vaccine acceptance group compared to the vaccine-hesitant group (OR: 5.4, 3.5, & 3.1, respectively).

In line with the current findings, other Ghanaian studies have also identified common reasons for COVID-19 vaccine hesitancy. Respondents often cited a lack of information about the vaccine (50.6%), perceived danger (32.1%), governmental mistrust (21.4%), and concerns about vaccine safety and conspiracy theories (9.1%) [31,53]. From a public health perspective, this underscores the importance of adequate knowledge about an intervention to increase its uptake. Inadequate knowledge regarding COVID-19 and its vaccine is likely a major determinant of low vaccine uptake in the Volta Region, indicating that interventions should focus on educational campaigns.

Respondents with concerns about the proximity of vaccination centres were more likely to be hesitant, aligning with this findings that accessibility to vaccination services influences acceptance or refusal [54]. This is supported by a study that showed that health facility proximity and accessibility impact vaccine uptake [55]. A study identified infeasible travel distances as barriers to immunization, highlighting the need to reduce such barriers to increase vaccine uptake. This is particularly important in less accessible rural areas, where improving primary healthcare centres to provide vaccines locally is crucial [56].

The study's coefficient estimates for modifying factors were positive (0.156) and significant (p = 0.003), indicating that increased structural and socioeconomic status could paradoxically increase vaccine hesitancy. This contrasts with previous research suggesting higher socioeconomic status correlates with greater vaccine acceptance [57,58]. This suggests that in the Volta Region, factors such as knowledge of COVID-19, healthcare availability, and household size may drive hesitancy. While correlation does not imply causation, this finding calls for further research and tailored public health interventions.

Additionally, the study found that healthcare workers' failure to discuss possible side effects with clients contributed to vaccine hesitancy. This is supported by various studies indicating that inappropriate dissemination of vaccine information is a major reason [59–61]. Effective communication of vaccine side effects is crucial for acceptance [59,60,62]. A study found that adequate information from healthcare professionals significantly increased vaccine acceptance among respondents in Ghana [63]. This aligns with a study which highlighted that a positive relationship between health professionals and patients enhances vaccine acceptance [64]. Additionally, the attitudes and knowledge of health professionals are critical in effectively recommending vaccines [65,66]. These findings underscore the importance of strong interpersonal relationships and effective communication in boosting vaccine uptake.

The overall parameter estimate for health system factors in this study was negative (-0.639) and highly significant (p < 0.001), indicating that enhancing health system activities to combat vaccine hesitancy could significantly reduce hesitancy rates. This finding suggests that making the health system more friendly and accessible is essential for increasing vaccine uptake in the Volta Region, consistent with previous findings [54].

Limitation of the study

This study had several limitations. Participants' responses regarding the COVID-19 vaccine may have been influenced by factors such as emotional state and recall bias, as well as social desirability, leading them to provide answers they believed were more socially acceptable rather than their true opinions or experiences. Additionally, the study was conducted solely in the Volta Region, which limits the generalizability of the findings to other regions or countries, as cultural factors influencing vaccine hesitancy may vary. The study’s focus on explaining rather than exploring in-depth the factors associated with vaccine hesitancy further constrains the depth of understanding. Finally, the factors influencing vaccine hesitancy are subject to change over time due to shifts in the pandemic situation, policies, and media coverage, which may affect the relevance of the study's findings in different contexts.

Vaccine hesitancy in this current study was found to be significantly associated with demographic, economic, structural, and health system factors. Respondents residing in rural areas and those with a stable monthly income were less likely to be hesitant about the COVID-19 vaccine. Conversely, the occupation of respondents played a role in vaccine hesitancy, with traders and artisans more likely to be hesitant. Additionally, respondents who lacked knowledge about COVID-19 and the vaccine, or who did not have a health centre nearby, were more likely to be hesitant compared to their counterparts. Health system factors also influenced vaccine hesitancy; respondents were more likely to be hesitant when health workers did not discuss the possible effects of the vaccination compared to when they did.

These findings emphasize the importance of aligning efforts with Sustainable Development Goal 3 (SDG 3), which aims to ensure healthy lives and promote well-being for all at all ages. To address vaccine hesitancy and support SDG 3, targeted vaccination campaigns should be implemented in market squares and other strategic locations in the Volta Region. This approach will reach traders and artisans, ensuring they have the opportunity to get vaccinated without disrupting their work schedules.

Enhanced public communication is also crucial. Media gatekeepers in the Volta Region should be encouraged to filter and disseminate accurate information regarding COVID-19 and its vaccination. This can help counteract misinformation and improve public knowledge. Additionally, motivating and supporting health workers to be the primary sources of information and education on COVID-19 vaccination is essential. When health workers discuss the possible effects of the vaccine, it can significantly reduce vaccine hesitancy.

Data availability statement

All data supporting this research is provided within this manuscript. Dataset however can be requested.

Acknowledgements

We would like to acknowledge all our study participants for their cooperation and voluntary participation during the data collection.

Funding

This research was self-funded by the principal investigator.

Authors contribution

CSF conceptualised study. MG and CSF analsysed and presented study findings. EET and HU supervised and reviewed the study conceptualization and methods. CFS, SS, DMO prepared the manuscript. EET, HA and CSF finally reviewed the manuscript for submission. All authors read and accepted final version of manuscript.

Competing interests

The authors declare that they have no competing interests.

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No competing interests reported.

Prevalence and factors associated with COVID-19 vaccine hesitancy among adults in Ghana: A population-based cross-sectional study in the Volta Region

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Abstract

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Introduction

Materials and Methods