The most significant findings from this study population (Table 1 and Figure 1) were that the COVID-19 vaccine acceptance rate was high at 580/723(80.22%) (Table 2). This COVID-19 vaccine acceptance rate could be attributed to the commendable work of health managers in northern Uganda in conducting consistent community sensitization, mobilization, and engagement using the village health teams (VHTs), which might have helped turn a vaccine-hesitant/inquisitive population into the opposite. This is consistent with other findings: stakeholder engagement, social mobilization, and equitable distribution of vaccines increase vaccine acceptance in low-income countries [21,22,23]. Thus, the authors suggest that the approach used to achieve this high COVID-19 vaccine acceptance rate in northern Uganda could be replicated in other parts of the country especially using the VHTs as agents of change.
Likewise, the COVID-19 vaccine acceptance was statistically and significantly associated with females, those with comorbidities, those who agreed that vaccines in health facilities in northern Uganda were safe, graduates, Catholics, Baganda tribe, districts of Lamwo and Agago, and non-smokers and ex-smokers.
The current study’s finding that the female gender was an independent predictor of COVID-19 vaccine acceptance in northern Uganda (Table 8) is not new, as other studies elsewhere in the world [24,25] have had similar findings. For example, high COVID-19 vaccine acceptance rates have been recorded among pregnant women in Northwestern Ethiopia [24] and Saudi Arabia [25]. Relatedly, many studies in Uganda show that females have better health-seeking behaviors than males [26,27,28,29]. Females’ better health-seeking behaviors than males have been similarly observed in many health activities implemented in northern Ugandan communities [27]. Additionally, females are more receptive to new health messages from the Ugandan government and have been at the forefront of fighting against many infectious diseases, including malaria [28]. Their compliance with health messages from the Ugandan Ministry of Health has been positive on several occasions. This includes reproductive health services, vaccination of children, voluntary counseling and testing for HIV and AIDs, cancer screening, and many health prevention and promotion activities [29]. However, a systematic review and meta-analysis by Stephanie showed that males had a more likely intention to get vaccinated against COVID-19 than females [30].
However, our findings that females were independent predictors of the COVID-19 vaccine acceptance in northern Uganda are new and contrast with many studies conducted in Uganda and Somalia [16,31,32]. This may be attributed to the rural nature of our study population, the study area, and the timing when the COVID-19 vaccine acceptance study was conducted in northern Uganda. The authors argue that the statistically significant association between the female gender and COVID-19 acceptance in northern Uganda has implications that the Ugandan Ministry of Health could deliberately bring on board females to work as behavior change communication agents in support of the ministry of health’s programs, including COVID-19 vaccine acceptance in communities.
Many studies in Uganda showed that those with comorbidities, particularly diabetes, hypertension, obesity, heart diseases, chronic obstructive pulmonary diseases (COPD), HIV, and AIDS, were more at risk of developing severe COVID-19 illness, and higher chances of hospitalization, and death [32,33,34,35,36]. Messages on the increased risks and susceptibility to the virus, getting the severe form of the disease, chances of hospitalization, and death had been spread widely through the mainstream and social media to the population, and most people had become aware. In addition, the Ugandan Ministry of Health prioritized the vaccination of the elderly and those with comorbidities in the early phases of the COVID-19 vaccine rollout in Uganda [32]. Participants in this study accepted the vaccination for many reasons, including the fear of getting infected, infecting a family member, fear of death, and worries that the COVID-19 medications would be forced on them if they did not get vaccinated (Table 3 and Table 4). Most notable was that the vaccines preferred by participants were provided, and choices on the type of COVID-19 vaccine were participants’ decisions (Table 5). Furthermore, some participants and their associates had tested positive for the coronavirus (Table 6) and had the disease experience, which impacted their decision to get vaccinated. So, the authors argue that whereas this was a timely intervention by the Ugandan Ministry of Health, in the future, a comprehensive study should be conducted to document the effects and impacts of the COVID-19 vaccination on the quality of life of participants with comorbidities.
Graduates were more likely to accept the COVID-19 vaccines than other educational strata (Table 7). This was statistically significant in bivariate and multivariable logistic regression analyses (Table 7 and Table 8) like another study conducted in Uganda [36]. We can attribute this to the vast information and knowledge on the coronavirus received through numerous sources that informed their decisions. However, findings from this study noted that previous exposure to the virus, the fear of death, the fear of getting infected with the virus, and worries that they would be forced to take COVID-19 medication contributed significantly to their decision to accept the COVID-19 vaccine (Table 3, Table 4, Table 6). This finding concurs with many African studies, which showed that higher educational levels were associated with the COVID-19 vaccine acceptance [15,25,36].
In addition, the Ugandan Ministry of Health prioritized COVID-19 vaccines for institutions, particularly the security forces, health workers, government parastatals, and learning institutions, in the first batch of the vaccine rollout in Uganda in early 2021 [32]. The Ugandan government advised teachers not to enter classrooms without proof of COVID-19 vaccination for fear of spreading the virus to pupils and students. This directive was followed and enforced by the management of most teaching institutions. In addition, most employees of these institutions mentioned above were graduates. Thus, considering the enforcement of directives instituted on these institutions, we, the authors, argue that graduates’ acceptance of the COVID-19 vaccine was either voluntary or coercion since some jobs were conditionally tagged with a COVID-19 certificate, especially those in educational training institutions. We believe these issues should be reviewed in future comprehensive studies.
Participants from the districts of Agago 76/83(91.57%) and Lamwo 58/62(93.55%) showed a higher COVID-19 vaccine acceptance rate compared to the other seven districts in the Acholi subregion (Table 8). Most participants from the two districts agreed that vaccines in their health facilities were safe (Table 2), and this was significantly associated with the COVID-19 vaccine acceptance (Table 7). Studies show that vaccine acceptance is linked to the community’s confidence in the healthcare systems, the health workers, cultural background, attitudes, beliefs, perception, political, environmental, personal factors, and compliance to face mask-wearing guidelines [11,37,38,39]. The authors found that the two districts, just like the others, set up COVID-19 district task forces layered to the village health teams (VHTs) who promoted COVID-19 vaccinations at all levels [40]. The village health teams are vital in connecting the community with the health care systems [40]. Authors argue that the roles of VHT in disease prevention and promotion in the Ugandan healthcare systems are sometimes under-looked by some policymakers. Still, they are critical change agents, and their position in the Ugandan health delivery systems should be promoted to enhance their contribution to the healthcare systems. This finding implies that for the Ugandan Ministry of Health to achieve higher COVID-19 vaccine acceptance in the region, the model of layered task forces up to the village level using the VHTs should be adopted. The authors believe that VHTs have played a significant role in convincing the community to accept the COVID-19 vaccine in the two districts.
Interestingly, we found that the religious denomination Catholic was more likely to accept the COVID-19 vaccine 295/354(83.33%) than the others (Table 8). Too, among the catholic participants, 53/354(14.97%) had been infected with coronavirus, 51/354(14.41%) had a family member infected; 89/354(25.14%) a friend; 75/354(21.89%) a colleague and 52/354(14.69%) a neighbor. The nature and experience of the COVID-19 illness contributed to their decision to accept the COVID-19 vaccine. In addition, most of the study population in the Acholi sub-region were Catholics (Table 1). Furthermore, many large health facilities run by the Catholic church are well distributed in the sub-region. These include three major hospitals, three health centers, for example, St. Mary’s hospital, Lacor in Gulu, and its two health centers of Opit HCIII in Omoro and Amuru HC III in Amuru districts. In Kitgum, St. Joseph’s hospital serves Kitgum, Lamwo, Agago, and Pader districts, and an HC III in Padibe in the Lamwo district. In the Agago district, Kalongo Hospital serves the Agago, Kitgum, and Pader populations. These catholic founded health facilities were centers actively involved in the COVID-19 vaccination rollout in the region. In addition, clear messages from the Catholic institutions, including its leader, the Archbishop of Gulu, urging the population to get vaccinated, contributed significantly to the COVID-19 acceptance in the region.
Furthermore, radio recorded messages from the Archbishop urging the people to vaccinate with the COVID-19 vaccines were consistently aired in the local media and the church-founded radio stations (Radio Maria and Radio Pacis) in support of COVID-19 vaccination campaigns. In this, the authors propose that the Ugandan Government could use the catholic church structures to deliver and implement health programs in the region successfully. In addition, the authors found that the most hesitant religious denomination was the Muslims, where only 20/26(76.9%) had accepted the COVID-19 vaccine (Table 3), and most participants cited the lack of confidence in the government programs and their messages. Because of this, we propose that those practicing the Muslim faith should be approached and engaged to participate more in health activities in the future to achieve better health campaign results.
Furthermore, most of the Baganda tribe that participated in the research got vaccinated with the COVID-19 vaccine 44/49(89.89%) (Table 7). Although the tribe was an independent predictor of COVID-19 vaccine acceptance in this study population, this finding should be interpreted with caution as there were only 49/723(6.77%) participants from this tribe in the study population. The fear of having been exposed to the virus, the fear of death, the fear of infecting family members, and the fear of being forced to take the COVID-19 medication were part of the reasons for accepting the COVID-19 vaccine (Table 3). In addition, factors around their ill health and those close to them could have equally contributed to the COVID-19 vaccine acceptance; for example, 6/49(12.24%) had been infected with the virus; 12/49(24.49%) had a family member; 18/49(36.73%) had friends; 5/49(10.20%) had colleagues, and 5/49(10.20%) had neighbors infected respectively. Thus, factors surrounding these participants significantly contributed to the COVID-19 acceptance among this tribal group as COVID-19 vaccine acceptability has been found to depend on one’s cultural background, attitudes, beliefs, perception, political, environmental, personal factors, or compliance to face mask-wearing guidelines [37,38,39].
Finally, the findings that non-smokers and ex-smokers were independent predictors of COVID-19 vaccine acceptance in this study population have attracted much interest (Table 8). These participants were more confident in the COVID-19 vaccine’s ability to reduce the virus’s chances of infecting them. Still, they were driven by the fear factor and worries about the possibility of being forced to take the medication or miss out on their jobs (Table 3). This is like findings in a refugee camp in Bidibidi in Uganda, where the Authors found that the COVID-19 vaccine acceptance rate among the refugees was 78% and was associated with the beliefs that the vaccine would stop the spread of the virus [41] as seen in these groups of non-smokers and ex-smokers. In addition, findings show that respondents that were uncertain whether the COVID-19 vaccine would stop transmissions were less likely to get the vaccine (adjusted odds ratio, aOR = 0.70; 95% confidence interval, CI = 0.51–0.96) than respondents that were not uncertain. Respondents who did not want to go to health facilities (aOR = 0.61; 95% CI = 0.44–0.84) were also less likely to accept the COVID-19 vaccine than their counterparts who wanted to go to health facilities [41].
In summary, our current study found a high COVID-19 vaccine acceptance rate of 580/723 (80.22%) in a rural population of northern Uganda. This survey was conducted after the second wave of COVID-19 in Uganda, where several prominent people lost their lives. This current acceptance rate in northern Uganda was lower than a South African study at 90% [15] but higher than a Somali study at 77% [16] and another Ugandan study at 60% [8]. Whether the high burden of COVID-19 in South Africa could have contributed to the significantly higher vaccine acceptance rate will be reviewed in future studies.
Therefore, these authors propose that the most effective strategy for reducing the COVID-19 vaccine hesitancy in the Ugandan setting should include educating the population on COVID-19 and its vaccines. Authors suggest that educating the people through a community engagement strategy remains the best way to dispel the myths, misconceptions, rumors, conspiracy theories, and fears about the virus. Thus, the authors argue that encouraging healthy behaviors toward coronavirus will keep Ugandans safe, a virus that has ravaged the world so much.
Strengths and limitations of this study
The study has limitations in the study design, cross-sectional study where one-time information from participants is gathered and analyzed. These have shortcomings in that the views and opinions of participants are not static; they vary according to the prevailing environmental situations. In this, we suggest a need for a prospective or a longitudinal assessment of the COVID-19 vaccine acceptance in the future, ensuring that all data are measured and recorded accordingly. This data is vital as it is one of the well-documented and completed data for over 723 participants from the Acholi subregion regarding COVID-19 vaccine acceptance in the recent period. Findings from this study show a high acceptance rate despite results from other parts of Uganda.
Generalizability of the results
These findings should be cautiously interpreted and generalized to regions with low-resource settings in Uganda.