The purpose of this study was to compare the uptake, resistance and hesitancy of the COVID-19 vaccine between the local residents and diaspora dwellers in SSA region of the African continent. Uptake of the COVID-19 vaccine was found to be twice as high among residents in the diaspora compared to local SSA residents. The WHO and Centers for Disease Control and Prevention (CDC) have suggested that the low vaccination rates in low-and-middle-income countries is in part, due to inequitable distribution of vaccines. Accessibility to vaccines may have played a role in the low uptake rates in our study. At the time of the study, half of the 52 African countries that had received vaccines had only vaccinated up to 2% of their population at the time of this study, and 15 countries had vaccinated up to 10%. However, majority of those residing in Africa and the diaspora were either resistant or hesitant to get vaccinated. This finding is different from that reported in a previous study  where a higher proportion of African residents and those in the diaspora were willing to accept the vaccine when offered. A survey conducted by CDC Africa prior to the introduction of vaccines on the continent found that the willingness to take the vaccine in 15 African countries ranged from 59–93%, which was in contrast with our findings of greater resistance towards COVID-19 vaccination. Studies conducted in the US and UK showed that Africans/Blacks were 13 times more likely to be hesitant than Whites [44–45] which is similar to the high proportions of SSA in diaspora who were either hesitant or resistant to taking COVID-19 vaccines.
Socio-demographic characteristics have been shown to play significant roles in vaccine hesitancy and resistance. In this study, age, region of origin, educational level, occupation and religion were significantly associated with either vaccine hesitancy or resistance among local and diaspora residents. Younger age groups among the local residents were almost twice likely to be hesitant and older age groups were less likely to be resistant to vaccines. This finding is consistent with other previous studies,[32, 37, 45–46] and may also be related to the fact that COVID-19 is more likely to present in the severe form among older age groups, making them more likely to accept the vaccine for their protection.
Local East African respondents were three times more likely to resist and almost five times more likely to be hesitant than West Africans. This may be due to misinformation about COVID-19  and its vaccines  which was reported to be more common in East African countries such as Tanzania. The results showed that the least educated respondents were less likely to be resistant or hesitant. This may be as a result of not comprehending the scientific arguments being advanced against the vaccines and having to make choices based on past experiences or the information they do understand. A recent study in the US showed a similar pattern with those with lower levels of education showing less hesitancy than those with higher. This is contrary to the results obtained in other studies.[35–37, 41–42] A statement by a 61 year old on Africa news may provide an insight into the mindset of those who are less educated thereby making them more likely to accept vaccination: "If in the time of our mothers, in the time we were little children if these "WhatsApp doctors" had existed (people who post unreliable medical information on social media) I think we would have all died because our mothers who did not go to school agreed to vaccinate us against smallpox, measles, polio -- all the other diseases without debate. Today, we are more educated, but curiously, we refuse vaccination. This is a certain danger for our society, according to what I have read here and there. The Congo is being blacklisted because we risk many deaths if we don't accept vaccination”.
Both local and diaspora healthcare workers showed less likelihood of being either resistant or hesitant as compared to non-healthcare workers in this study. Resistance and hesitancy have been found among health workers though lower when compared to non-healthcare workers.[50–55] However, Blacks /African health workers still show higher risk than their counterparts of being resistant/hesitant irrespective of the country they are in. Vaccine resistance and/or hesitancy is a hindrance to the vaccination campaign, as such, health workers who should be well educated about the vaccines are likely to exert an influence on others and possibly deter them from getting vaccinated. Most findings in the cited papers found that the fear of side effects was usually the reason for hesitancy and resistance among health workers. [51–53]
Among the local residents, individuals form other religions were less likely to be vaccine hesitant compared to those of the Christian faith. Religion has been reported to play a huge role in the life of Africans and influences their health seeking behavior.[56–57] Olagoke et al. reported that some religious views have contributed to the rejection of vaccination. However, an intervention study conducted among American Christians, showed that with proper presentation of scientific facts, such negative views can be changed. Community engagement with religious leaders has also been advocated as a means of addressing vaccine hesitancy.
Local residents who had been previously vaccinated for other conditions were less likely to be COVID-19 vaccine resistant or hesitant. This finding emphasizes the influence of past experiences which can build confidence in the efficacy of vaccines. Other studies have also shown a willingness to be vaccinated among those who had previously received vaccinations for other diseases such as flu, yellow fever, hepatitis.[61–62] Knowledge of COVID-19 vaccine was a significant factor among both local and diaspora residents. Knowledge has been shown to reduce resistance to vaccine acceptance. Africans in the diaspora were less likely to be hesitant or resistant to vaccines as compared to their counterparts residing in Africa. This may still be related to misinformation and the need for health messages to be relayed in the languages familiar to the people. Recent studies have shown a decline in those who are hesitant and this has been attributed to the availability of accurate information that reduces fear and leads to making informed decisions. Exposure to accurate information and increased knowledge about COVID-19 vaccines may help those who are hesitant to be more receptive to vaccines. Among local residents, higher perception scores showed a lower odd of being either resistant or hesitant. The perception that one is likely to be at risk of contracting a disease can result in people taking appropriate measures to protect themselves from contracting the disease.
Strengths and limitations
This is the first large scale study to compare acceptance of COVID-19 vaccines between sub-Saharan African local residents and those in the diaspora. The study employed robust analyses to control for potential confounders to reduce the possibility of a bias. The distribution of the questionnaire in both English and French languages using an internet-based methodology, which was the only reliable means to disseminate information at the time of this study to a wider audience. Notwithstanding these strengths, the study has some limitations. For example, the study did not explore concerns about vaccine safety which may be an important determinant of vaccine hesitancy. The cross-sectional nature of the study means that causation cannot be determined. The survey was distributed electronically using social media platforms and emails, and this may have inadvertently excluded some potential participants whose opinions may have differed, such as those without internet access and people living in rural areas, where internet penetration remains relatively low. The survey was presented in English and French and thus inadvertently excluding some of the Portuguese or Arabic-speaking SSA countries from participating. Although the study showed satisfactory internal validity, its generalization or transferability to all SSA countries may be limited. Despite the wide distribution of the survey, only few SSA living in diaspora participated compared to many who lived in SSA. However, robust analysis was conducted through the use of proportions for comparison and the use of regression analyisis to ensure adequate control of potential confounders.