Knowledge, Attitudes and Practices of High-Risk Groups Towards COVID-19 Vaccination in Kampala, Uganda

doi:10.21203/rs.3.rs-3143482/v1

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Research Article

Knowledge, Attitudes and Practices of High-Risk Groups Towards COVID-19 Vaccination in Kampala, Uganda

https://doi.org/10.21203/rs.3.rs-3143482/v1

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The uptake of the COVID-19 vaccine remains low in less wealthy countries especially in Africa. Uganda’s initial vaccination campaigns targeted healthcare workers, teachers, the security forces, individuals with comorbidities, the elderly, and students, notwithstanding, the low uptake led to vaccine wastage. Available literature indicates an association between knowledge, attitudes and uptake of health services including vaccination, however, such studies are limited as regards COVID-19. This study therefore assessed the knowledge, attitudes, and practices of selected groups at high risk of COVID − 19 infection towards COVID-19 vaccination in Kampala, Uganda.

A cross-sectional study using mixed methods of data collection was conducted in Kampala, Uganda among 576 groups. Multistage sampling was used to select the participants and a digitized semi-structured questionnaire was used to elicit data, that was analyzed in Stata 14. Descriptive statistics were presented as means, medians and the standard deviation for continuous variables while proportions were used for categorical variables and presented in frequency tables and figures. The modified Poisson regression model was used to establish the associations between predictor and outcome variables, while content analysis was used for the qualitative findings.

Overall, 576 respondents were interviewed; 53.1% (306/576) were males, 48%(278/576) were aged 18–29 years and 63.5%(366/576) attained tertiary education. About 63.5% (366/576) had a high knowledge of COVID-19 vaccines and vaccination, 70.5% (406/576) had a good attitude towards COVID-19 vaccines and vaccination. A total of 443 (76.9%) ( had received a COVID-19 vaccine, mainly AstraZeneca, 63.2% (280/443) than Pfizer 26% (115/443) or other vaccines. Over 60.1% (266/443) experienced side effects following vaccination. Sex, attitude towards, holding a leadership position, having convinced peers to receive the vaccine, having been convinced by peers to receive the vaccine and having been convinced by peers not to take COVID-19 vaccine were significantly associated with COVID-19 vaccination status. Females (adj. PR = 0.97; 95%CI: 0.89, 1.06) had a 3% likelihood of not being vaccinated compared with the males. Poor attitudes (adj. PR = 1.12; 95%CI: 1.12, 1.25) were associated with a 12% chance of not being vaccinated compared to those with a good attitude. Not holding a leadership position (adj. PR = 0.8; 95%CI: 0.72, 0.88) was associated with a 20% likelihood of not being vaccinated. Not having convinced peers to receive the vaccine (adj. PR = 0.52; 95%CI: 0.42, 0.64), not having been convinced by peers to receive the vaccine (adj. PR = 0.99; 95%CI: 0.88, 1.10) and not having been convinced by peers not to take Covid-19 vaccine (adj. PR = 0.92; 95%CI: 0.85, 0.99) were associated with a 48%, 1% and 8% less likelihood of being vaccinated.

A substantial gap in the knowledge and attitudes towards COVID-19 vaccines and vaccination, which was associated with the low vaccine. Sex, attitude, holding a leadership position, having convinced peers to receive the vaccine, having been convinced by peers to receive the vaccine and having been convinced by peers not to take COVID-19 vaccine were predicted COVID-19 vaccination status. This study recommends specific interventions targeting this high-risk group at the community level to address the gaps in knowledge and attitudes towards COVID-19 vaccines and the address negative peer influence inhibiting uptake.

COVID-19 has impacted nearly every sector of development in the world over. The health sector has particularly experienced monumental challenges in trying to cope with and respond to the pandemic. COVID-19 remains a major public health challenge having killed over 4.5 million people globally, approximately one year after it was first reported in December 2019 (WHO, 2021c) and continues to inflict disabilities on many that have recovered.

Vaccines have been critical in the fight against the COVID-19 pandemic, and since the introduction of vaccination, significant reduction of COVID-19 mortality and morbidities has been achieved (). Approximately a year after COVID-19 pandemic reported, the first COVID-19 vaccine was approved by the FDA for emergency use in December 2020 (FDA, 2020). Currently the various vaccine have been provisionally approved that include (Astrazeneca, Pfizer, Moderna, Johnson and Johnson, Sinovac and Sinopharm) These are rolled out in five safe and effective two-dose types (WHO, 2021a). Apart from Johnson and Johnson which is one single dose. The vaccine against SARS-CoV-2 protects one from getting and spreading the virus that causes COVID-19. The vaccine also protects against severe disease, hospitalization, and death however it does not prevent infection from COVID-19 (ref).) given a considered fully vaccinated (WHO, 2021a). Close to 6 billion vaccines doses have been administered worldwide so far and about 2.49 billion people are fully vaccinated to date. More than 75% of these have however been administered in just 10 countries (WHO, 2021g). In Africa, access to COVID-19 vaccine doses has been burdensome, and uptake has been gradual and slow.

Uganda received her first batch of the COVID-19 AstraZeneca vaccines of 864,000 doses in March 2021 (WHO, 2021d). As of December 2021, a total of 1.72 million vaccine doses were received in the country. These were prioritized for high-risk groups including healthcare workers, armed forces, the elderly, and those with co-morbidities. Moreover, full reopening of sectors such as education sector, transport sector, and high risk businesses such markets and highly crowded buildings, in part relied on the coverage of COVID-19 vaccination (UNICEF, 2021).

The government initiated several avenues including media publicity to provide information about COVID-19 and televised inoculation of influential persons like the president of Uganda, the minister of health, religious and cultural leaders among others (AP, 2021). This would boost confidence and trust to undertake vaccinations. These measures, coupled with the high morbidity and mortality during the second wave of the pandemic in Uganda, may have influenced a change in perception and consequently an led to an increase in the uptake of the vaccines (Agaba, 2021). Despite that a majority of 3000 persons died during the second wave between April and July 2021, only 367,000 Ugandans representing 0.8% had been fully vaccinated by the end of (give year) (WHO, 2021c). Allegations that influential persons were receiving safe brands of vaccines that were different from those administered to the masses still persisted and affected vaccine uptake (AP, 2021). Similarly, most of the high-risk population in Uganda, remained unvaccinated despite being given priority to receive the vaccines. Thus, there is need to assess the knowledge, attitudes, and practices towards high-risk groups on COVID-19 vaccination programs in Kampala.

Study design

This was a cross sectional study that employed mixed methods for data collection. To explore groups’ knowledge, perceptions, and practices towards the COVID-19 vaccination program we used a descriptive approach.

Study setting

This study was conducted in Kampala city, the capital and central business district of Uganda, surrounded by by Mukono district in the East, Buikwe district in the South, and Luweero district and Wakiso district in the North and West. Kampala city is currently estimated to have a population of 1,507,114, of which 724.326 are males and 782,754 are females (UBOS, 2016). The city has five administrative units which include central division, Kawempe division, Makindye division, Nakawa division and Rubaga division. The district houses Uganda’s national referral hospitals, including Mulago national specialized hospital, Kiruddu hospital, Kawempe hospital and Butabika national mental referral hospital and several Kampala Capital City Authority (KCCA) facilities.

Study population

For the quantitative component, the study population targeted high risk groups that included; the security personnel, teachers, front-line healthcare workers, people with underlying health conditions such as diabetes, hypertension, heart, kidney, or liver disease and students (WHO, 2021d). The study population in the qualitative component targeted individuals involved in the vaccination exercise that included healthcare workers and implementing partners as key informants.

Selection criteria

Inclusion criteria

All identified and selected groups who agreed to participation in the study and provided informed consent were included in this study. These included the following: security personnel, teachers, front-line healthcare workers, people above 50 years with underlying conditions such as diabetes, hypertension, heart, kidney, or liver disease and students (WHO, 2021d) and healthcare workers involved in vaccination and implementing partners supporting vaccination exercise. All these groups were selected regardless of their vaccination status. For the purposes of representativeness of views, the study purposively engaged two male parents and two female people for the qualitative approach.

Exclusion criteria

Groups who could give informed consent and selected groups who declined participation were excluded from this study.

Sample size determination

The Kish Leslie (1965) formula was used to determine sample size (Kish, 1965).

$$\text{n}=\frac{{\text{z}}^{2}\text{p}\text{q}}{{\text{d}}^{2}}$$

Where n is the sample size, z is the confidence interval. The 95% confidence interval is 1.96, d is the precision, 5% and p = 0.5 considering the prevalence of uptake of COVID-19 vaccination groups at 50.0% for lack of prior studies on this study domain in this population.

= 384.16
After adjusting for design effect (1.5), this yielded a sample size of 576 groups.

In the qualitative approach a total of 10 in-depth interviews, (IDIs) were conducted with 2 members from each of the five primary groups (priority groups) of security personnel, teachers, front-line healthcare workers, people with comorbidities ( diabetes, hypertension, heart, kidney, or liver disease) and 2 students,. In addition, 5 key informant interviews (KIIs) for the secondary and tertiary stakeholder categories, respectively and in total 10 KIIs were conducted.

Sampling procedures

Multistage sampling approach was used. Under stage 1, three of the 5 divisions of Kampala city with the lowest COVID uptake rate were purposefully selected. The total sample size was then divided equally among each of the five priority groups to obtain the number of respondents to pick from each group i.e., 576/5 = 115 participants for each category.

Quantitative data collection methods and tools

The research team identified the primary groups at their respective areas of work: health workers (health facilities); teachers (schools); students (Makerere University); security personnel (police posts) and people with comorbidities ( health facilities). The selection of teachers was based on a randomized selection of 5 schools from a list of all school in three city divisions of Kampala using the Ms Excel randomizer (). This gave a total of 15 schools for the study, that included private and public schools to ensure inclusion of participants from all socio-economic strata. The research team visited the schools from December 2021 to April 2022 and purposively interviewed teachers that were available at the time of the visit between 9:00am-12:00pm from Monday to Friday for 5 months? To realize the total of 115 teachers, 8 teachers were interviewed from each of the 15 school. Similarly, the 15 healthcare facilities and in total 115 healthcare workers from the three divisions were selected as previously described for the schools. The same approach was employed to selected 15 police posts and 115 police personnel. People with co-morbidities, were accessed from the selected health facilities in three divisions. During clinic days, the research team recruited individuals with such co-morbidities into the study, and in total 115 participants from 15 health care facilities were obtained. hospitals yielded 8 patients to give the required sample size.

students from Makerere University were considered for this study since other schools and institutions were closed at the time of data collection. Students from different colleges of the university were picked randomly using simple random sampling. A semi-structured questionnaire used to assess the knowledge, attitudes and practices of primary groups (list them) which contained questions about COVID-19 vaccine and vaccination program was modified from (Mohamed et al., 2021).

Qualitative data collection methods

In-depth interviews were conducted with two primary groups (frontline health workers security operatives) from each division making a total of six in-depth interviews. Two key informant interviews were conducted with two respondents from each of the categories of secondary and tertiary groups making a total of 6 respondents. During the respective interviews, groups responded to open ended questions about the knowledge on COVID-19, the risk factors, signs and symptoms and COVID-19 vaccine/vaccination. Regards perceptions, groups responded to open ended questions relating to how they perceive themselves to be at a risk/susceptible of COVID-19 infection (perceived susceptibility), how severe they consider COVID-19 to be (perceived severity), what they think are the benefits of receiving COVID-19 vaccination (perceived benefits) and what barriers they faced during an attempt to get COVID-19 vaccination (perceived barriers). For practices, questions in the guides majorly assessed the uptake of the COVID-19 vaccines and advocacy for uptake of the COVID-19 vaccine by others who are eligible. Questions in the key informant interviews were on advocacy in the different stakeholder’s capacity for the uptake of COVID-19 vaccine. The emerging favorable and unfavorable practices as regards COVID-19 vaccination were summarized in form of a matrix.

Study variables and measurements

Dependent variables

The main outcome variable was practices of groups toward COVID-19 vaccination program in Kampala.

Measurement of outcome variables

Knowledge on COVID-19 vaccination was measured using a set of six questions. A correct answer for each question indicated a good knowledge on that question. To calculate the knowledge score from the six questions, each question answered correctly was awarded a score of 1 and 0 for any wrong response. The knowledge score therefore ranged from 0–6 depending on the number of passed or failed questions. The median score for the level of knowledge of the groups was taken as a cut-off point. Therefore, those who obtained a score above the median were considered as having a high level of knowledge and those who scored below the median were considered as having a low level of knowledge on COVID-19 vaccination.

A 3-point Likert scale (agree, neither agree nor disagree/neutral, disagree) was used to measure attitudes of groups towards COVID-19 vaccination with a set of 13 statements. The response to each statement indicated whether the respondent had a positive or negative attitude towards that statement. The attitude score ranged from 0–13 depending on the number of statements the respondent agrees or disagrees with. The median score of attitudes was taken as the cut-off point and those who obtained a score above the median were considered to have a positive attitude while those who scored below the mean were considered as having a negative attitude towards COVID-19 vaccination.

Independent variables

These were socio-demographic factors such as age, religion, marital status, education level, occupation, health insurance status and social factors such as, Peer pressure, employing institution’s demands, Stakeholder position in society, having dependents, having suffered from COVID-19, having a friend or relative who suffered from COVID-19. Peer pressure was assessed by asking a respondent if they were either under pressure by their peers or not at all to take the CPVID 19 vaccine. Employing institution’s demands were assessed by asking the respondent whether it was mandatory for employees to get vaccinated. Stakeholder position in society were assessed by asking if the respondent held a leadership position at work or home area.

Quality control and assurance

To ensure appropriateness of the questions for reliable and accurate information, pre-visits to the study setting and pretesting of the study instruments were done. The tool was pre-tested among groups in Makindye division. Makindye was considered because it has similar characteristics as our selected divisions in Kampala. Training of the research assistants on the research protocol and ethical issues surrounding the study was done. Furthermore, the research assistants were supervised during the field work.

Data management

The questionnaire was uploaded onto Kobocollect which helps to eliminate human errors and ensure completeness of data through enabling automatic skips and denials if a field is left unanswered. Quantitative data was also field edited for consistency. The data was then cleaned using excel version 19, edited for consistence, and then imported to STATA 15 for statistical analysis. For the qualitative data, all interviews were digitally recorded with permission from respondents. The researcher only contracted transcribers familiar with the language/s used during the interviews.

Data analysis

Quantitative data analysis

Descriptive analyses were done using Stata 15 to generate the mean, median and the standard deviation for continuous variables and proportions for categorical variables. Frequency tables and figures were used to present these results. Bivariate analysis done to determine associations between the predictors and outcome variable. At multivariable level, variables with a p-value less than 0.2 were included in the model. A p-value less than 0.05 was considered statistically significant. All results were summarized into tables and graphs.

Qualitative data analysis

The transcripts were proof-read before importing them into a qualitative data management software- atlas.ti6. Data coding and analysis conducted subsequently. An initial codebook using a sample of transcripts was developed. The developed codebook was then applied to the entire atlas project with any emerging codes added in the process. Thematic analysis was used and results were presented using themes with typical quotations from different groups’ interviews to summarize knowledge and perceptions. Content analysis was used for practices and these were summarized using a matrix.

Ethical considerations

Before conducting the study, ethical approval was sought from Makerere University Directorate of Research and graduate training (DRGT). Administrative clearance was obtained from KCCA and the institutions or local councils where study respondents were obtained. Written informed consent of each participant was sought before the start of the interview. All information collected was kept confidentially; no names or other identifying information was asked during data collection.

Demographic characteristics of the respondents

Of the 576 respondents, an equal proportion of 20% (115/576) represented teachers, health workers, security personnel, students and people with co- morbidities, 53.1% (306/576) were males while 48.3% (278/576) were aged between 18–29 years. More than half 63.5% (366/576) of the respondents attained tertiary education, 47.6% (274/576) were single and more than a third 39.4% (227/576) were Anglican. Most of the respondents 84.9% (489/576) did not have health insurance, 55.6% (320/576) were in a position of leadership and over 73.6% (424/576) had dependents (Table 1).

Table 1

Background characteristics of the studied groups in the COVID-19 vaccination program in Kampala.
Variable	Description	Frequency (n = 576)	Percentage (%)
Participant category	Healthcare worker	115	20.0
	Person with comorbidity	115	20.0
	Security personnel	115	20.0
	Student	116	20.0
	Teacher	115	20.0
Sex	Male	306	53.1
Sex	Female	270	46.9
Age (in years) (mean = 32.35, S.D = ± 9.88)	18–29	278	48.3
	30–39	164	28.5
	40–49	92	16.0
	50+	42	7.3
Education level	No formal education	9	1.6
	Primary	68	11.8
	Secondary	133	23.1
	Tertiary	366	63.5
Marital status	Single	274	47.6
	Married	257	44.6
	Separated/divorced	29	5.0
	Widowed	16	2.8
Religion	Anglican	227	39.4
	Catholic	197	34.2
	Muslim	64	11.1
	Pentecostal	70	12.2
	Others (specify)	18	3.1
Have health insurance	Yes	87	15.1
Have health insurance	No	489	84.9
In a position of leadership at work place/home area	Yes	320	55.6
In a position of leadership at work place/home area	No	256	44.4
Have dependents (family/ relatives under your care)	Yes	424	73.6
Have dependents (family/ relatives under your care)	No	152	26.4

4.2 Knowledge on COVID-19 vaccination

Close to two thirds of the respondents, 63.5% (366/576) had a high knowledge of COVID-19 vaccines and vaccination (Table 2). AstraZeneca 79.7% (459/576) and Pfizer 61.3% (353/576) were the most mentioned types of vaccines while sinopharm 3.1% (18/576) was the least mentioned. Almost all, 99.3% (572/576) knew the route of administration, 84.7% (488/576) mentioned that two or more doses are given, while 51.7% (298/576) pointed out that two or more doses are given except for Johnson and Johnson. More than half of the respondents, 56.4% (325/576) wrongfully mentioned that COVID-19 vaccination protects the receiver from infection while 74.0% (426/576) wrongfully mentioned that COVID-19 vaccination cannot protect other people who have not received the vaccine.

A higher proportion of the respondents 77.1% (444/576) had received all necessary vaccines and 71.5% (412/576) knew a friend or relative who suffered from COVID-19. More than three quarters of the respondents, 79.3% (457/576) and 9.4% (54/576) had convinced their peers to either take or not to take the COVID-19 vaccine, respectively. Similarly, and 77.4% (446/576) and 55.2% (318/576) had been convinced by peers to either to take or not take the COVID-19 vaccine, respectively as shown in (Table 2) below.

Table 2

Knowledge on COVID-19 vaccines and vaccination among selected groups in Kampala City.
Variable	Description	Frequency (n = 524)	Percentage (%)
Types of COVID-19 vaccines*	AstraZeneca	459	79.7
	Pfizer	353	61.3
	Sinovac	66	11.5
	Johnson and Johnson	376	65.3
	Mordana	143	24.8
	Sinopharm	18	3.1
	I don’t know	71	12.3
Route of administration of vaccine	Injection	572	99.3
Route of administration of vaccine	I don’t know	4	1.0
Number of doses*	Two or more doses	488	84.7
	Two or more except Johnson and Johnson	298	51.7
	I don’t know	42	7.3
COVID-19 vaccination protects receiver from being infection	Yes	325	56.4
	No	226	39.2
	I don’t know	25	4.3
COVID-19 vaccination protects other people even though they have not been vaccinated.	Yes	123	21.4
	No	426	74.0
	I don’t know	27	4.7
Vaccine production involves animal study, clinical trials with thousands of people and evaluation by the authority to ensure efficacy and safety	Yes	348	60.4
	No	30	5.2
	I don’t know	198	34.4
Received all necessary vaccines in your life	Yes	444	77.1
	No	61	10.6
	Don’t know	71	12.3
Friend/relative suffered from COVID-19	Yes	412	71.5
	No	151	26.2
	Don’t know	13	2.3
Convinced peers to take the COVID-19 vaccine	Yes	457	79.3
Convinced peers to take the COVID-19 vaccine	No	119	20.7
Convinced peers Not to take the COVID-19 vaccine	Yes	54	9.4
Convinced peers Not to take the COVID-19 vaccine	No	522	90.6
Peers convinced you to take the COVID-19 vaccine	Yes	446	77.4
Peers convinced you to take the COVID-19 vaccine	No	130	22.6
Peers convinced you Not to take the COVID-19 vaccine	Yes	318	55.2
Peers convinced you Not to take the COVID-19 vaccine	No	258	44.8
Knowledge level	High	366	63.5
Knowledge level	Low	210	36.5

From the qualitative interviews, respondents similarly portrayed high knowledge level in regards to COVID-19 vaccines and vaccination. Respondents were aware of the types of vaccines, dosage, and route of administration and the importance of the vaccines. Respondents were quoted saying; “Vaccination is more of immunizing, introducing antibodies into the body to develop a stronger immunity towards a certain disease for example COVID-19. Vaccines were manufactured to reduce on the severity. It doesn’t cure, and uptake of the vaccine doesn’t mean that one will not get COVID-19, it just reduces severity of the disease.” (IDI, Healthcare worker, female)

“The types COVID-19 vaccines are Moderna, AstraZeneca, Pfizer, JJ (Johnson and Johnson), but I think there are others, though am not sure about them. Route of administration is Intramuscular where they inject on the upper right arm. For dosage, all the other types except one, you get 2 doses or more, its only Johnson (Johnson and Johnson) where you get one dose, but the other types are for 2 doses or more. For instance, if you have got today your first dose, after some time you get your second dose, but for Johnson you get only one dose.” (IDI, Student, female) “Interval depends on the type of vaccine where for AstraZeneca, I heard that you wait for 3 months, Pfizer is one month then the rest am not sure. JJ (Johnson and Johnson) is a single dose, then vaccination is apparently free of charge, and I think the vaccine contains the medicated virus which they inject you to stimulate your immunity.” (IDI, Teacher, male)

4.3 Attitudes towards COVID-19 vaccines and vaccination

Most of the respondents 70.5% (406/576) had a good attitude towards COVID-19 vaccines and vaccination, 92.9% (535/576) agreed that vaccination was important, 81.8% (471/576) agreed that COVID-19 vaccine protects from severe disease and hospitalization as shown on Table 3 below. On the other hand, close to a third of the respondents 32.8% (189/576) agreed that COVID-19 vaccines may not be safe, 30.0% (173/576) agreed that the vaccines may not be effective and 69.6% (401/576) were worried about the side effects. Nearly a fifth of the respondents 18.2% (105/576) agreed that they would wait a little longer before being vaccinated, 10.4% (60/576) agreed that they would stick to SOPs without taking the vaccination, while over 29.9% (172/576) agreed that there was no difference between the vaccinated and the non-vaccinated.

Table 3

Attitudes towards COVID-19 vaccines and vaccination among selected groups in Kampala City.
Variable	Description	Frequency (n = 576)	Percentage (%)
Getting vaccinated against COVID-19 is important to me.	Agree	535	92.9
	Neutral	19	3.3
	Disagree	22	3.8
COVID-19 vaccine protects me from severe disease and hospitalization.	Agree	471	81.8
	Neutral	75	13.0
	Disagree	30	5.2
After vaccination, we can live a normal life style	Agree	397	68.9
	Neutral	97	16.8
	Disagree	82	14.2
COVID-19 vaccines are recommended by scientists, WHO and MOH	Agree	562	97.6
	Neutral	6	1.0
	Disagree	8	1.4
COVID-19 vaccines may give me the COVID-19 infection	Agree	84	14.6
	Neutral	366	63.5
	Disagree	126	21.9
COVID-19 vaccine may not be safe	Agree	189	32.8
	Neutral	238	41.3
	Disagree	149	25.9
COVID-19 vaccine may not be effective	Agree	173	30.0
	Neutral	249	43.2
	Disagree	154	26.7
Worried about the adverse effects of the vaccine	Agree	401	69.6
	Neutral	145	25.2
	Disagree	30	5.2
I will wait a little longer before I get the vaccine	Agree	105	18.2
	Neutral	463	80.4
	Disagree	8	1.4
I will stick to the SOPs but no vaccination	Agree	60	10.4
	Neutral	487	84.6
	Disagree	29	5.0
There is no difference between the vaccinated and non-vaccinated	Agree	172	29.9
	Neutral	360	62.5
	Disagree	44	7.6
Speedy production of the vaccine did not compromise it's safety	Agree	235	40.8
	Neutral	138	24.0
	Disagree	203	35.2
My risk of getting sick with COVID-19 is bigger than the risk of side effects from the vaccine	Agree	438	76.0
	Neutral	73	12.7
	Disagree	65	11.3
Attitude score	Good attitude	406	70.5
Attitude score	Poor attitude	170	29.5

Qualitatively, respondents expressed both positive and negative perceptions towards COVID-19 vaccines and vaccination. The majority talked about safety, effectiveness and side effects. “Personally I saw the side effects of what people were experiencing shortly after the vaccine, for example, I got scared and chickened out and I decided I’d rather follow SOPs than getting those side effects. The side effects I observed were severe joint pain, severe headache, and you know how the vaccine works, it imitates the virus once it’s introduced into the body such that the body can generate antibodies against the virus, so they were showing the symptoms of real COVID-19 and I feared that what if my body is unable to resist the symptoms.” (IDI, Health worker, female)

“I don’t think they are effective because from what we see in news, people are dying even from those countries where the vaccines were made, so they are not really 100% effective.” (Police officer, male)

“I cannot say that they’re 100% safe because these are new drugs, I don’t think those vaccines underwent all the trial procedures because it was an emergency and they had to provide the vaccines as soon, which makes me think they may not be totally safe.” (IDI, Student, male)

“When one is vaccinated, they have some immunity against COVID-19, if they get it after being vaccinated, it doesn’t affect you badly like one who hasn’t been vaccinated.” (Key informant, male)

4.4 Practices related to COVID-19 vaccination.

More than three quarters of the respondents 76.9% (443/576) had received a COVID-19 vaccine. Of these, 78.8%(349/443) had received two or more vaccines and 79.9% (354/443) had completed vaccination schedule as in Fig. 1.

From the qualitative findings, respondents expressed the availability of various vaccine types and accessibility experiences as drivers of vaccine uptake and preference of vaccines. Respondents were quoted saying; “I’ll receive the one dose of Johnson and Johnson because I don’t have to get a second jab, the problem is that it’s not on market like the rest, so in case it’s not around I’ll have to get what’s around.” (Health worker, male)

“My peers have embraced Johnson (Johnson and Johnson) because when AstraZeneca arrived, there were stories that it’s fake so most of my colleagues went for Johnson, and even those that had taken their first dose of AstraZeneca went for Johnson as their second dose because they allowed them to.” (Student, male)

Side effects of COVID-19 vaccination experienced by the groups.

Overall, 51.4% (296/576) of the respondents had suffered COVID-19 symptoms; of these, 78.4%(232/296) were vaccinated. Of the 43.1%(248/576) who had ever tested for COVID-19, 88.3% (219/248) had been vaccinated against COVID-19. About 78.4% (40/51) of those who reported suffering from COVID-19 had been vaccinated as shown in Fig. 2 above.

Table 4

Distribution of vaccination status of risk groups in Kampala City by selected characteristics.
Variable	Overall n()	Vaccinated n = 443	Unvaccinated n = 133
Ever had COVID-19 symptoms
Yes	296 (51.4)	232 (78.4)	64 (21.6)
No	266 (46.2)	200 (75.2)	66 (24.8)
I don’t know	14 (2.4)	11 (78.6)	3 (21.4)
Symptoms suffered *
Fever	142 (48.0)	112 (78.9)	30 (21.1)
Cough	203 (68.6)	160 (78.8)	43 (21.2)
Headache	145 (49.0)	118 (81.4)	27 (18.6)
Loss of taste and smell	104 (35.1)	81 (77.9)	23 (22.1)
Aches and joint pains	90 (30.4)	71 (78.9)	19 (21.1)
Chest pain	55 (18.6)	38 (69.1)	17 (30.9)
Others	63 (21.3)	51 (81.0)	12 (19.1)
Ever been tested for COVID-19
Yes	248 (43.1)	219 (88.3)	224 (11.7)
No	328 (56.9)	29 (68.3)	104 (31.7)
Ever suffered from COVID-19
Yes	51 (20.6)	40 (78.4)	11 (21.6)
No	197 (79.4)	179 (90.9)	18 (9.1)
Period when suffered from COVID-19
Before vaccination	32 (62.8)	21 (65.6)	11 (34.6)
After one dose	8 (15.7)	8 (100.0)	0 (0.0)
After complete vaccination	11 (21.6)	11 (100.0)	0 (0.0)

As shown on the Table 4 above, its clear that those vaccinated were more than those who were not vaccinated (Vaccinated, n = 443, and Unvaccinated n = 133).

The study participants reported with headache ranked highest (81.4%) followed by Fever (78.9%) and Aches and joint paint followed by cough and others as shown clearly on the Fig. 3 above.

4.5 Factors associated with COVID-19 vaccination practices.

At multivariable analysis, sex, attitude towards vaccines and vaccination, holding a leadership position, having convinced peers to receive the vaccine, having been convinced by peers to receive the vaccine and having been convinced by peers not to take Covid-19 vaccine were significantly associated with COVID-19 vaccination practices. Females (adj. PR = 0.97; 95%CI: 0.89, 1.06) had a 3% likelihood of not being vaccinated compared with the males. Poor attitudes (adj. PR = 1.12; 95%CI: 1.12, 1.25) were associated with a 12% chance of not being vaccinated compared to those with a good attitude. Not holding a leadership position (adj. PR = 0.8; 95%CI: 0.72, 0.88) was associated with a 20% likelihood of not being vaccinated. Not having convinced peers to receive the vaccine (adj. PR = 0.52; 95%CI: 0.42, 0.64), not having been convinced by peers to receive the vaccine (adj. PR = 0.99; 95%CI: 0.88, 1.10) and not having been convinced by peers not to take Covid-19 vaccine (adj. PR = 0.92; 95%CI: 0.85, 0.99) were associated with a 48%, 1% and 8% less likelihood of being vaccinated.

Table 5

Factors associated with COVID-19 vaccination practices among selected groups in Kampala City
Variable	COVID-19 Vaccination practices		CPR(95%CI)	APR at 95%CI	P-values
Variable	Good (n=)	Poor (n=)	CPR(95%CI)	APR at 95%CI	P-values
Sex
Male	238 (53.7)	67 (50.8)	1.0	1.0
Female	205 (46.3)	65 (49.2)	0.97 (0.89–1.06)	1.11 (1.02–1.21)	0.015
Attitude score
Poor attitude	120 (27.1)	49 (37.1)	1.0	1.0
Good attitude	323 (72.9)	83 (62.9)	1.12 (1.01–1.25)	1.12 (1.02–1.23)	0.019
Hold a position of leadership
Yes	270 (61.0)	49 (37.1)	1.0	1.0
No	173 (39.1)	83 (62.9)	0.80 (0.72–0.88)	0.90 (0.82–0.99)	0.032
Convinced peers to take COVID-19 vaccine
Yes	390 (88.0)	66 (50.0)	1.0	1.0
No	53 (12.0)	66 (50.0)	0.52 (0.42–0.64)	0.56 (0.42–0.74)	P < 0.001
Was convinced by peers to take Covid-19 vaccine
Yes	344 (77.7)	101 (76.5)	1.0	1.0
No	99 (22.4)	31 (23.5)	0.99 (0.88–1.10)	1.17 (1.04–1.31)	0.008
Was convinced by peers not to take Covid-19 vaccine
Yes	248 (56.0)	69 (52.3)	1.0	1.0
No	195 (44.0)	63 (47.7)	0.97 (0.88–1.06)	0.92 (0.85–0.99)	0.021
The CPR (95%CI) for those with a "Good" attitude is 1.12 (1.01–1.25), which indicates that individuals with a positive attitude towards vaccination are 12% more likely to have good vaccination practices compared to those with a "Poor" attitude. The APR (95%CI) for females is 1.11 (1.02–1.21), which indicates that females have a 11% higher chance of having good COVID-19 vaccination practices compared to males. This difference is statistically significant (p-value = 0.015). Among those not in leadership positions, 62.9% have poor vaccination practices, and 37.1% have good practices. The CPR (95%CI) for those not in leadership positions is 0.80 (0.72–0.88), suggesting that individuals in leadership positions are 20% more likely to have good vaccination practices compared to those who are not as shown in Table 5 above

The study aimed to assess the knowledge, attitudes and practices towards COVID-19 vaccination among groups in Kampala. The main findings of the study revealed that about 63.5% of the respondents had a high level of knowledge of COVID-19 vaccines and vaccination, 70.5% had a good attitude while 76.9% had good COVID-19 vaccination practices. Sex, attitude, holding a leadership position, having convinced peers to receive the vaccine, having been convinced by peers to receive the vaccine and having been convinced by peers not to take COVID-19 vaccine were significantly associated with COVID-19 vaccination practices.

Close to two thirds of the respondents had a good knowledge about Covid-19 vaccines and vaccination. Respondents were aware about the types of vaccines, vaccine dosage, and route of administration. These findings conquer with those reported by Sakr et al. (2021) in a cross-sectional study conducted among young Lebanese population which reported a knowledge level of 67.1%. However, a cross-sectional study conducted in India reported a slightly lower level of knowledge (58.6%) among their respondents (Singh et al., 2022). The high proportion of knowledgeable respondents about COVID-19 vaccines and vaccination revealed by this study can be attributed to the high level of attention accorded to the COVID-19 pandemic right from its first discovery in December 2019. Several messages from international agencies such as the WHO, CDC and other science-oriented entities were aired through the internet and media houses. In Uganda, the ministry of health did well in providing health messages through radio and TV shows, social media and the internet. In addition, the president held several public addresses through which general information about COVID-19 was shared with the population. Despite knowledge not being significantly associated with vaccination uptake in the current study, it is documented that a good knowledge of vaccines and vaccination better equips the population to make informed decisions about a health program (WHO, 2019). Besides, a good knowledge among the population indicates low levels of misinformation and myths about a health program, and could possibly influence uptake. This therefore warrants targeted programs to improve knowledge levels on the vaccines and vaccinations among the 36.5% of the target individuals that were found with low knowledge levels.

Positive attitudes towards vaccines and vaccination were also found among the majority of the respondents in this study. Just like knowledge, positive attitude can be attributed to the efforts of the ministry of health and the government of Uganda in providing information about COVID-19 to the public. It can also be noted that the proportion of those who had high knowledge levels was not very different from those with good attitudes. Positive attitudes towards COVID-19 vaccination have also been reported in other studies. For example, a cross-sectional study conducted across India reported positive attitudes in 62.1% of the 501 respondents of the general public (Singh et al., 2022). In another cross-sectional study among healthcare workers in Uganda, 78.4% of the respondents reported positive attitudes towards the vaccines (Kamacooko et al., 2021). Positive attitudes as indicated by our study and those by other scholars, were significantly associated with uptake of the COVID-19 vaccines. Individuals with a good attitude towards COVID-19 vaccines and vaccination were more likely to be vaccinated compared with those who showed a poor attitude (Adane et al., 2022). It is therefore evident in this study that attitudes towards vaccination are better predictors of uptake than knowledge. This finding corroborates with the theory that knowledge of a health practice is never enough to guarantee uptake or utilization and has been reported with programs on utilization cervical cancer screening services. It has also been expressed in literature that even the doctors who very well know the negative effects of using certain psychoactive substances are among the prominent users of alcohol and cigarettes with some of them even dying from related health complications (Alistair Gardiner, 2021, Denis Campbell, 2019). This therefore shows that public health entities in Uganda need to implement more awareness raising campaigns to improve attitudes of the public towards COVID-19 vaccines and vaccination. Interventions targeted at addressing the relationship between vaccination and onset of adverse events might yield better results given that qualitative respondents assigned the poor attitudes to the fact that they witnessed healthy individuals suffer severe symptoms and some even died. Improve attitudes and possibly uptake of the vaccines might among the top priority interventions for public health.

Regarding the practices related to COVID-19 vaccination, more than three quarters of the respondents had good practices. Given that the respondents in this study are considered among the COVID-19 high-risk groups due to the nature of their work involving interaction with large numbers of people from the general public, vaccination is an important protective measure and ought to be taken up. Being a public health intervention, it not only protects them as essential personnel but also the people they serve. These findings collaborate those of a cohort observational and surveillance study conducted in Israel which reported up to 79% uptake of COVID-19 vaccines among health workers. It is however evident that in this study, close to a quarter (23.1%) of the respondents had not been vaccinated. When compared against the total population of workers in these essential services, it sums up to a huge number of essential service providers who are at a considerably high risk of acquisition and spread of COVID-19. This therefore necessitates strengthening of programs aimed at improving uptake of COVID-19 vaccines among these high-risk groups.

As revealed, sex was significantly associated with practices related to Covid-19 vaccination. Females were 3% less likely to be vaccinated compared with the males. Vaccine hesitancy among women can be explained by the widespread misinformation about the side effects of COVID-19 vaccines among women including blood clots, infertility, and effects on existing pregnancies (Krista, 2021). COVID-19 vaccine hesitancy among female respondents is also reported and explained by Issanov et al. (2021).

In this study, having a leadership position either in the community of one’s residence or at work was significantly associated with practices related to COVID-19 vaccines. Leaders are very critical in determining success of health programs. Their practices can influence the rest of the community that looks up to them. The uptake of COVID-19 vaccines therefore greatly relied on the examples portrayed by the leaders. As observed, the president of Uganda, several ministers and traditional leaders received the vaccines live on air and this was done to boost the confidence and trust of the people in the vaccines (The Independent, 2021). Leaders therefore should be encouraged to portray positive perceptions towards COVID-19 vaccines and also encourage subjects to respond positively to vaccination campaigns.

Social factors such as peer influence were also significantly associated with vaccination practices. In this study, not having convinced peers to receive the vaccine, not having been convinced by peers to receive the vaccine and not having been convinced by peers not to take Covid-19 had a 48%, 1% and 8% less likelihood of being vaccinated respectively. Peers are among the influential relationships for health seeking behaviors (Rogers et al., 2021). This could explain the observed results that individuals who were negatively influenced and those who negatively influenced others in regards to COVID-19 uptake had were less likely to be vaccinated themselves.

Findings revealed that over 63.5% of the respondents had a high level of knowledge about COVID-19, 70.5% had a good attitude towards COVID-19 vaccination while 76.9% had good COVID-19 vaccination practices. Sex, holding a leadership position, having convinced peers to receive the vaccine, having been convinced by peers to receive the vaccine and having been convinced by peers not to take Covid-19 vaccine were significantly associated with COVID-19 vaccination practices. Similarly, attitude towards COVID-19 vaccines and vaccination predicted practices, unlike knowledge.

Recommendations

The ministry of health, ministry of defense and ministry of education should come together and conduct sensitizations within available structure to address the established gaps in Knowledge, attitudes and practices related to COVID-19 vaccines and vaccination program.

The MOH should come up with audience specific messages aiming at addressing myths, misinformation, negative beliefs and misconceptions regarding COVID-19 vaccines and vaccination among the targeted groups.

The Ministry of Health should devise strategies targeted at increasing access to vaccine related information in all communities. This can be achieved through the use of existing structures and media outlets to pass on vital information to the target groups.

I hereby confirm that all methods used in this study were performed in accordance with the relevant guidelines and regulations.

Ethical Approval and Consent to participate.

The study was approved by the Institutional Review Board of College of veterinary medicine animal resources and Biosecurity in the School of Biosecurity Biotechnical and Laboratory Sciences (SBLS), under the Department of Biosecurity Ecosystems and Veterinary Public Health (BEP) of Makerere University for approval. Permission was sought from the office of the Directorate of Public Health and Environment, Kampala City Council.

Consent for Publication

Not Applicable

Availability of data and Materials

The data used to support our conclusions are presented in this publication and the related information files.

Competing Interests

The authors claim to have no conflicts of interest.

Funding

No funding was obtained for this study.

Author’s Contribution

KGB_Carried out concept writing, and participated in Proposal, dissertation, and manuscript development OFL, JO: Participated in Data Analysis DM, MOO, SZ,KGB,OFL_Participated in the review of the manuscript CK, MS, OFL_Participated in the review of the study protocol, data analysis, and manuscript development and review All authors read and approved the manuscript.

Acknowledgements

I wish to thank Kampala City Central Authority (KCCA) for granting me permission to do the study. I am grateful to all the persons who helped me during this study.

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No competing interests reported.

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Knowledge, Attitudes and Practices of High-Risk Groups Towards COVID-19 Vaccination in Kampala, Uganda

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Abstract

Figures

Introduction

Methodology

Study design

Study setting

Study population

Selection criteria

Inclusion criteria

Exclusion criteria

Sample size determination

Sampling procedures

Quantitative data collection methods and tools

Qualitative data collection methods

Study variables and measurements

Dependent variables

Measurement of outcome variables

Independent variables

Quality control and assurance

Data management

Data analysis

Quantitative data analysis

Qualitative data analysis

Ethical considerations

Results

Demographic characteristics of the respondents

4.2 Knowledge on COVID-19 vaccination

4.3 Attitudes towards COVID-19 vaccines and vaccination

4.4 Practices related to COVID-19 vaccination.

4.5 Factors associated with COVID-19 vaccination practices.

Discussion

Conclusion

Recommendations

Declarations

References

Additional Declarations

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