COVID-19 Vaccine Confidence in Zimbabwe and Sierra Leone: An Application of Health Behavior Change Constructs

doi:10.21203/rs.3.rs-3296609/v1

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Research Article

COVID-19 Vaccine Confidence in Zimbabwe and Sierra Leone: An Application of Health Behavior Change Constructs

https://doi.org/10.21203/rs.3.rs-3296609/v1

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Introduction

Over the past three years, the global health community has been primarily focused on matters related to COVID-19, such as infection rates, mortality figures, and vaccination campaigns. While African countries, in general, experienced a milder COVID-19 impact compared to Western nations, they faced challenges in vaccine uptake. Specifically, Zimbabwe and Sierra Leone saw vaccine acceptance rates below global averages. This research delves into the underlying factors that influenced these disparities in vaccine acceptance in these two countries, using the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) as guiding frameworks.

Methods

This study utilized data from a cross-sectional survey encompassing 2,312 participants from areas where the Africa Christian Health Associations Platform (ACHAP) operates in Zimbabwe and Sierra Leone. The survey assessed respondents' views in line with core HBM and TPB constructs, in addition to their levels of vaccine acceptance. We then employed adjusted regression models to investigate the correlation between health behavior change theory constructs and vaccine confidence, taking into account variables like gender, age, education, and country of residence.

Results

Several associations were identified, including high vaccine confidence correlated with a heightened perceived threat of COVID-19, recognized benefits of vaccination, stronger perceived behavior control, and fewer perceived barriers to vaccination. Conversely, low vaccine confidence was linked to diminished perceived threats, an abundance of perceived barriers, weaker perceived behavior control, and heightened perceptions of barriers.

Discussion

Results underscore the significance and utility of theoretical constructs in understanding variations in vaccine confidence levels. They highlight the importance of relying on well-established theories to grasp decision-making mechanisms and to shape suggestions for behavior modification. Consequently, to boost vaccine acceptance, public health campaigns should focus on reshaping risk perceptions, addressing obstacles, emphasizing the advantages of getting vaccinated, and fostering a sense of self-efficacy within target communities.

The COVID-19 pandemic caused by SARS-CoV-2 has had a devastating effect globally. As of early March 2023, when Johns Hopkins University stopped compiling and reporting on global COVID-19 data, the total confirmed cases exceeded 676 million, with at least 6.8 million deaths worldwide (Dong et al., 2023). Despite faring better than other continents, Africa also suffered greatly from the COVID-19 pandemic. The World Health Organization (WHO) African Region reported more than 8.9 million cases and 174,243 deaths as of May 2, 2023 (Coronavirus, 2023). Zimbabwe and Sierra Leone are two Sub-Saharan nations impacted by the pandemic and rolling out COVID-19 vaccination programs. The COVID-19 pandemic caused by SARS-CoV-2 has had a devastating effect globally. As of early March 2023, when Johns Hopkins University stopped compiling and reporting on global COVID-19 data, the total confirmed cases exceeded 676 million, with at least 6.8 million deaths worldwide (Dong et al., 2023). Despite faring better than other continents, Africa also suffered greatly from the COVID-19 pandemic. The World Health Organization (WHO) African Region reported more than 8.9 million cases and 174,243 deaths as of May 2, 2023 (Coronavirus, 2023). Zimbabwe and Sierra Leone are two Sub-Saharan nations impacted by the pandemic and rolling out COVID-19 vaccination programs. Among the approximately 15.5 million people living in Zimbabwe, 11,239,749 are eligible to receive the vaccine. As of July 18, 2023, 7,332,243 had received at least one dose (65.2%) and 5,420,528 had been fully vaccinated (48.7%) (CDC Africa, 2023). Zimbabwe has experienced 264,276 cases and 5,671 COVID-19 deaths (Dong et al., 2023). In Sierra Leone, home to 8.42 million people, 4,977,483 are eligible to receive the vaccine. As of July 18, 2023, 4,693,903 had received at least one dose (94.3%) and 3,846,767 had been fully vaccinated (77.3%) (CDC Africa, 2023). In Sierra Leone there have also been a total of 7,760 confirmed cases logged and 126 COVID-19 deaths recorded (Dong et al., 2023).

According to the Strategic Advisory Group of Experts on Immunization (SAGE), vaccine hesitancy refers to a refusal or delay in acceptance of a vaccine despite its availability (McDonald, 2015). Vaccine hesitancy generally stems from factors related to complacency, convenience, and/or confidence (McDonald, 2015). Complacency may stem from a low perception of the disease risk, subsequently rendering the view that vaccination is unnecessary or of insufficient value when calculating a benefit-risk assessment. Confidence is an indicator of how effective the vaccine is considered to be in preventing infection with the disease. With respect to confidence, the rapid development of COVID-19 vaccines appears to have exacerbated vaccine anxiety and hesitancy around the globe, including in many African nations (Vanderslott et al., 2022). In Zimbabwe vaccine misinformation has been a challenge since at least 2010, when a religious-led campaign discouraging vaccine uptake led to a measles outbreak in the country (Machekanyanga et al., 2017). Recent studies have concluded that the discrediting of vaccines by religious organizations has impacted Zimbabweans' decisions to refuse the vaccine and has increased vaccine hesitancy generally (Dzinamarira et al., 2021; Kabakama et al., 2022). Early efforts to promote and administer COVID-19 vaccines in Sierra Leone were challenging due to distrust of the healthcare system generally and low trust in vaccines specifically (Enria et al., 2021), which may explain why vaccination rates in Sierra Leone were initially lower than most developing nations (Kabakama et al., 2022).

Theoretical constructs related to behavior change are beneficial in understanding, analyzing, and predicting the acceptance of health-promoting behaviors like immunizations and vaccinations. The Health Belief Model (HBM) is a value expectancy theory postulating that an individual’s desire to prevent an illness (value) and one’s belief that a specific health action available would prevent or ameliorate illness (expectancy) is predictive of specific health behaviors (Rosenstock et al., 1988). Key constructs of the HBM include perceived susceptibility, or an individual’s subjective perception of her risk of contracting a health condition, and perceived severity, an individual’s opinion of how serious a condition and its symptoms or health consequences would be if contracted or infected (Strecher & Rosenstock, 1997). The combination of perceived severity and susceptibility equates to an individual’s perceived threat. The HBM theorizes that for behavior change or action to occur, individuals must feel threatened by their current choices and the subsequent expected outcomes. The HBM also includes the constructs of perceived benefits and perceived barriers of action, which also impact health behavior change efforts. Perceived benefits highlight what can be expected, typically the positive effects of a specific action (Strecher & Rosenstock, 1997). Perceived barriers refer to the tangible and psychological costs of the health-promoting action. Other behavior change models likewise include perceptions as key constructs capable of predicting behavior. For example, perceived behavioral control, a construct of the Theory of Planned Behavior (TPB) represents an individual’s perception of either the ease or difficulty of performing or completing a specific action (Ajzen, 1991). While accurately perceiving both benefits and barriers requires the gaining of new knowledge or correcting existing misinformation (Strecher & Rosenstock, 1997), perceived behavior control is increased when barriers are lowered either through increasing access to necessary resources or the development of new skills needed to complete the action (Azjen, 1991). Both the HBM and the TPB have been used as a theoretical framework for predicting the uptake of numerous health-promoting behaviors, including COVID-19 vaccine uptake intentions (Hossain et al., 2021; Patwary et al., 2021; Shmueli, 2021; Wong et al., 2020; Zampetakis & Melas, 2021). Hossain et al. (2021) found the TPB to be the best theoretical model for explaining COVID-19 vaccine hesitancy among a study sample of adults in Bangladesh. Wong et al. (2020) found HBM constructs to predict potential COVID-19 vaccine acceptance in an online cross-sectional survey completed by a large sample of Malaysians. Zampetakis and Melas (2021) similarly supported HBM constructs in predicting COVID-19 vaccine uptake among a study sample of online cross-sectional respondents in Greece.

An increased understanding of the attitudes related to COVID-19 vaccine acceptance and hesitancy is a priority in Zimbabwe and Sierra Leone. Mundagowa et al. (2022) used an online survey to examine vaccine hesitancy in Zimbabwe. Approximately half (49%) said they would accept the COVID-19 vaccines. Vaccine hesitancy among this sample was related to two HBM constructs. First, perceived benefits – how protective would the vaccine be? Three-fourths (76%) of the study sample expressed concerns about vaccine effectiveness. Second, perceived costs – how large would vaccination's tangible and/or psychological costs be? More than half (55%) of Zimbabweans in the study expressed concerns related to vaccine safety. Indeed, low perceived severity of COVID-19 infection was associated with low vaccine uptake, as more than half of respondents who had previously contracted COVID-19 indicated that their infection was not severe or that they had not experienced severe symptoms due to infection. Before vaccine availability, Sheku et al. (2021) reported that 20% of respondents to an online survey administered in Sierra Leone would reject the COVID-19 vaccines. In a similar online survey, Faye et al. (2022) found that 50% of respondents in Sierra Leone accepted COVID-19 vaccines, while 61% reported feeling at risk of getting infected with the virus. The strongest predictors of vaccine acceptance were perceived effectiveness and perceived safety of the vaccines. Demographic variables such as sex, rural/urban residence, and educational attainment were not significant factors associated with COVID-19 vaccine intentions in the study (Faye et al., 2022).

Further exploring theoretical constructs related to perceptions that can influence COVID-19 vaccination, namely perceived threat, perceived benefits, perceived barriers, and perceived behavioral control, is crucial in understanding COVID-19 vaccine confidence and hesitancy. This study aimed to use these perceptions as a framework to explore factors associated with both high COVID-19 vaccine confidence and low vaccine confidence in Zimbabwe and Sierra Leone.

Design. Data for this study came from a cross-sectional survey conducted simultaneously in Zimbabwe and Sierra Leone during July and August of 2022. Data collection was part of the Africa Christian Health Associations Platform (ACHAP) CoV-FaB project (“Promoting COVID-19 Vaccine Equity through Faith-Based Networks in Africa”), which aimed to understand COVID-19 attitudes and predictors of vaccine acceptance in both Zimbabwe and Sierra Leone in order to increase uptake in project communities. In both countries, assessments were conducted face-to-face using a questionnaire instrument designed by ACHAP with the agreement of global consortium partners, IMA World Health and Internews, and in-country implementing partners, the Zimbabwe Association of Church-Related Hospitals (ZACH) and the Christian Health Association of Sierra Leone (CHASL). The selection of Zimbabwe and Sierra Leone as study locations was based on their selection as CoV-FaB project countries and the willingness of ZACH and CHASL to engage in collaborative efforts. Ethical clearance for publication of study’s data was approved by the Brigham Young University Institutional Review Board (IRB#: IRB2023-026).

Sample. Participants in this study were selected from key institutions and groups engaged with the CoV-FaB project. They included government and non-government organizations, faith-based organizations including faith leaders, community members, health institutions, and journalist networks. Respondents were recruited from within the CoV-FaB project catchment area to reflect national stratifications from each country. Specifically, national distributions of gender and urban/rural living were mirrored because both characteristics could influence vaccine hesitancy.

ACHAP applied stratified national samples for conducting structured interviews. In Zimbabwe, 1,154 respondents were surveyed, with 374 from Mutoko, 385 from UMP, and 395 from Chikomba districts. In Sierra Leone, 1,149 responses were collected, with 623 respondents from Western Area Urban district and 526 respondents from Western Area Rural district. The total sample included 2,303 respondents.

Procedure. Participants were recruited from the communities within the catchment areas of ZACH and CHASL member facilities. Participants were recruited to participate in the face-to-face questionnaire. They were asked to acknowledge their interest and willingness by providing their contact information and scheduling a meeting date with the data collection team. Enumerators contracted by ZACH in Zimbabwe and CHASL in Sierra Leone collected the data. Enumerators traveled to respondents’ homes, obtained informed consent, and completed the 20-minute questionnaire. Respondents were assured that their participation was voluntary. Inclusion criteria included being 18 years of age or older and the ability to speak English. Enumerators entered data into smartphones and uploaded the data into a central database.

Measurement. The questionnaire instrument used in this study was constructed collaboratively and included inputs from ACHAP, IMA World Health, Internews, and in-country partners ZACH and CHASL. The instrument was adapted from the US Centers for Disease Control and Prevention’s Rapid Community Assessment guidelines for community surveys. The instrument was constructed in English, and specific items were pilot tested in focus groups conducted in Zimbabwe and Sierra Leone. The instrument was then revised in accordance with the feedback, and all partners agreed upon a final version. The questionnaire included five sections, including demographics, items measuring COVID-19 vaccination (e.g., vaccination status, vaccine refusal, etc.), and key theoretical constructs from the HBM and TPB related to perceptions.

Demographic items included sex, age, level of education obtained, and information about pre-existing medical conditions. COVID-19 vaccination items included whether the respondent had been vaccinated and whether they have ever refused the COVID-19 vaccine. A variable representing high vaccine confidence was constructed that included respondents who had been vaccinated and who never had at any point refused the vaccine. A separate variable was constructed to represent low vaccine confidence and consisted of respondents who had not been vaccinated and who had previously refused the vaccine.

Variables representing the HBM and TPB included perceived threat, perceived benefits, perceived barriers, and perceived behavior control. Perceived susceptibility and perceived severity were combined to represent perceived threat (to one’s health). A measure of perceived susceptibility included respondents who reported being ‘very concerned’ about contracting COVID-19 at work and outside (e.g., grocery store, etc.). Respondents who reported ‘yes’ to personally knowing someone in their family, group of friends, or community networks who became seriously ill or died because of COVID-19 and those that were very concerned about infecting family or friends with COVID-19 were coded a ‘yes’ on perceived severity. The perceived threat was computed by combining perceived susceptibility and perceived severity. It included high, medium, and low threat. Perceived benefits was a scaled variable (alpha = ) and was computed by summing positive statements about getting vaccinated (protect my health, protect the health of family/friends, protect the health of co-workers, protect the health of the community, to resume travel). A single item represented perceived barriers and included respondents who said they would have difficulty getting the vaccine. Perceived behavior control can represent an overall or global assessment of the extent to which an individual can navigate circumstances to, in this case, get vaccinated. In this study, individuals were coded as ‘yes’ on perceived behavior control if they said it would be very easy for them to get the vaccine for themselves.

Analysis. STATA 17 (College Station, Texas) was used for all analyses. Data were cleaned before analysis. Frequency statistics were computed to describe the study sample. Chi-square test statistics were computed to compare differences in HBM and TPB variables between Zimbabwe and Sierra Leone. Multivariate regression analysis was used to explore the HBM and TPB factors associated with high vaccine confidence and low vaccine confidence. All models controlled for sex, age, level of education obtained, and country.

Female respondents accounted for just over half of the sample (52.9%), with more female respondents in Zimbabwe (57.0%) than in Sierra Leone (48.9%) (see Table 1). Approximately half (50.3%) of all respondents were between 25 and 49 years of age, with Zimbabwe’s age distribution trending slightly older and Sierra Leone’s slightly younger. Most respondents in Zimbabwe (67.0%) and Sierra Leone (51.9%) had a secondary education, with Sierra Leone having a higher percentage of respondents having completed tertiary education, 27.6%, compared to 7.8% in Zimbabwe. Most respondents identified themselves as community members (68.2%), followed by “other” (13.9%) and community leaders (8.5%). A total of 43.8% of participants had received at least one dose of a COVID-19 vaccine, including more than half of Zimbabweans (55.6%) and 32% of Sierra Leonians.

Table 1

Demographics
Indicator	Zimbabwe	Sierra Leone	Total
	N = 1154	N = 1158	N = 2312
Female	57.0	48.9	52.9
Age (years)
10–19	9.8	9.6	9.7
20–24	13.2	23.2	18.2
25–49	48.1	52.4	50.3
50+	28.9	14.8	21.8
Education
Primary	25.2	20.5	22.9
Secondary	67.0	51.9	59.5
Tertiary	7.8	27.6	17.7
Group
Community member	68.9	67.5	68.2
Faith leader	4.2	6.6	5.4
Healthcare worker	1.5	6.6	4.0
Community leader	5.6	11.4	8.5
Other	19.9	7.9	13.9
Received COVID-19 Vaccine
One or more doses	55.6	32.0	43.8

High vaccine confidence was greater among Zimbabwe respondents, at 45.6%, compared to 19.5% in Sierra Leone (Table 2), where they also reported a greater percentage of low vaccine confidence at 48.7% (27.0% in Zimbabwe). When comparing theory variables across the two countries, there are noticeable differences. Perceived susceptibility and perceived severity combine to form a variable called perceived threat (to one’s health). Perceived threat is significantly lower in Sierra Leone compared to Zimbabwe. Respondents in Sierra Leone reported higher perceived barriers to vaccination (41.0–20.1%). By contrast, in Zimbabwe, respondents reported higher perceptions of the benefits of vaccination (50.8–35.8%). Zimbabwe respondents also reported higher perceived behavior control, 60.2%, compared to 38.6% in Sierra Leone.

Table 2

Theoretical Constructs by Country
	Zimbabwe		Sierra Leone		Sig
	N	%	N	%
Perceived severity	422	38.0	138	12.1	***
Perceived susceptibility	577	50.9	407	36.9	***
Perceived threat					***
Low	349	31.0	603	54.6
Medium	540	47.8	469	42.4
High	240	21.3	33	3.0
Perceived barriers	232	20.1	475	41.0	***
Perceived benefits	586	50.8	414	35.8	***
Perceived behavior control	695	60.2	447	38.6	***
High vaccine confidence	526	45.6	226	19.5	***
Low vaccine confidence	312	27.0	564	48.7	***

* p < .01, p < .05, * p < .1

Adjusted regression models explored the HBM and TPB variables and the association with high and low vaccine confidence. Each model controlled for sex, age, education, and the respondent’s country. In the model considering high vaccine confidence (Table 3), all theory variables were significant and in the expected direction. Compared to a low perceived threat, both medium (OR = 2.142; p < .001) and high perceived threat were positively related to high vaccine confidence (OR = 2.674; p < .001). Perceived barriers was negatively associated with high vaccine confidence (OR = 0.173; p < .001), such that higher perceived barriers was associated with decreased odds of vaccine confidence. Perceived benefits (OR = 1.482; p < .001) of getting vaccinated and perceived behavior control (OR = 2.189; p < .001) were both associated with increased odds of high vaccine confidence.

Table 3

HBM and TPB factors associated with high vaccine confidence, n = XXXX.
High Vaccine Confidence	Coef.		St.Err.	t-value		p-value	[95% Conf		Interval]	Sig
Perceived threat	1		.	.		.	.		.
Medium	2.142		.269	6.06		0	1.674		2.74	***
High	2.674		.487	5.40		0	1.872		3.822	***
Perceived barriers	.173		.037	-8.28		0	.114		.262	***
Perceived benefits	1.482		.06	9.77		0	1.369		1.603	***
Perceived behavior control	2.189		.293	5.85		0	1.683		2.846	***
Constant	.086		.024	-8.86		0	.05		.147	***
Mean dependent var		0.328			SD dependent var			0.469
Pseudo r-squared		0.285			Number of obs			2189
Chi-square		790.135			Prob > chi2			0.000
Akaike crit. (AIC)		1998.633			Bayesian crit. (BIC)			2055.545
Note: Model controlled for gender, age, education, and country; * p < .01, p < .05, * p < .1

In the model exploring the relationship between the theory variables and low vaccine confidence (Table 4), medium perceived threat (OR = 0.439; p < .001) and high perceived threat (OR = 0.54; p < .001) were both negatively associated with low vaccine confidence; increases in perceived threat was related to decreased odds that respondents reported low vaccine confidence. Perceived barriers was positively related to increased odds of reporting low vaccine confidence (OR = 2.001; p < .001). Perceived benefits of vaccination and perceived behavior control were both negatively related (OR = 0.762; p < .001; OR = 0.429; p < .001, respectively), such that increases in both were related to decreased odds of also reporting low vaccine confidence.

Table 4

HBM and TPB factors associated with low vaccine confidence, n = XXXX.
Low Vaccine Confidence	Coef.		St.Err.	t-value		p-value	[95% Conf		Interval]	Sig
Perceived threat	1		.	.		.	.		.
Medium	.439		.047	-7.69		0	.356		.542	***
High	.54		.103	-3.24		.001	.372		.784	***
Perceived barriers	2.001		.268	5.17		0	1.539		2.603	***
Perceived benefits	.762		.028	-7.28		0	.708		.82	***
Perceived behavior control	.429		.056	-6.50		0	.333		.554	***
Constant	1.891		.447	2.70		.007	1.19		3.004	***
Mean dependent var		0.386			SD dependent var			0.487
Pseudo r-squared		0.187			Number of obs			2189
Chi-square		546.130			Prob > chi2			0.000
Akaike crit. (AIC)		2393.711			Bayesian crit. (BIC)			2450.623
Note: Model controlled for gender, age, education, and country; * p < .01, p < .05, * p < .1

The purpose of this study was to use HBM and TPB constructs related to perceptions as a framework to explore factors associated with both high COVID-19 vaccine confidence and low vaccine confidence in Zimbabwe and Sierra Leone. Nearly all findings from the current study detailing vaccine confidence in these two countries support the tested theoretical constructs. Further exploring constructs related to perceptions, namely perceived threat, perceived benefits, perceived barriers, and perceived behavioral control, that can influence COVID-19 vaccination is crucial in understanding vaccine confidence and hesitancy.

All theoretical constructs related to perceptions included in the current study were strongly supported by study results. Higher levels of perceived threat, perceived benefits, and perceived behavioral control should each theoretically predict higher vaccine confidence and higher actual vaccine acceptance. Compared to Sierra Leoneans, Zimbabweans in the current study perceived COVID to be a greater threat as measured by perceived severity of infection and perceived susceptibility to infection. Similarly, participants from Zimbabwe perceived COVID-19 vaccines to be of greater benefit than Sierra Leoneans and perceived that they could also easily get vaccinated if desired. Finally, lower perceived barriers reported by Zimbabweans are also predictive of higher vaccine uptake. In total, each of these HBM and TPB study measures accurately predicted higher rates of vaccine acceptance and vaccine uptake by Zimbabwean participants in this study.

Perceived threat of COVID-19 varied greatly between participants from Zimbabwe and Sierra Leone. More than half of Sierra Leoneans perceived COVID to be of ‘low’ threat, and just 3% considered COVID a ‘high’ threat. Low perceptions of COVID-19’s threat in Sierra Leone are not necessarily misperceptions. Across nearly three years of the pandemic in Sierra Leone there have been a total of 7,760 cases and 126 deaths, equating to a case-fatality ratio (CFR) of 1.62%. By comparison, in just over two years of the Western Africa Epidemic of Ebola in Guinea, Liberia, and Sierra Leone, there were 28,610 cases and 11,308 deaths, including approximately 4,000 deaths in Sierra Leone. Ebola’s CFR during this epidemic was 39.5% (History of Ebola Disease Outbreaks, 2023). All preventable deaths are tragic, and mortality rates are only one measure of a disease’s devastating impact on society, but it would be understandable if the Sierra Leoneans in the current study perceived the threat of COVID-19 to be lower given their country’s recent catastrophic experience with Ebola.

Of note, and as predicted by the theoretical constructs examined, the current study found that vaccine confidence was more than twice as high in Zimbabwe than in Sierra Leone. Sheku et al. (2021) surveyed Sierra Leonians to better understand general COVID-19 vaccine hesitancy. The authors found three primary concerns among their study sample: 1) safety and efficacy given these vaccines’ rapid development and approval; 2) distrust of the government and healthcare system; and 3) disbelief in the reality of the COVID-19 pandemic (Sheku et al., 2021). The spread of misinformation in Sierra Leone regarding the legitimacy of the virus and the safety of the COVID-19 vaccine likely increased vaccine hesitancy throughout the country. Some healthcare workers in Sierra Leone, including physicians, nurses, and medical students, also remained hesitant (Yendewa, 2022). Such reports help explain the comparatively low level of vaccine confidence among Sierra Leonians in the current study.

Nearly half of the current study’s participants in Zimbabwe were found to have high vaccine confidence. Furthermore, higher vaccine confidence among Zimbabweans in this study is consistent with higher numbers of participants from Zimbabwe reporting that they had received at least one dose of a COVID-19 vaccine. These findings are remarkably consistent with the reporting from Mundagowa et al. (2022) who noted that prior to COVID-19 vaccine availability, exactly half (50%) of Zimbabweans surveyed indicated they would accept the vaccine. It should again be noted that while vaccine confidence and receiving at least one dose of a COVID-19 vaccine were both higher among Zimbabweans in the current study, national COVID-19 vaccination rates are nearly 35% higher in Sierra Leone (94.3%) than in Zimbabwe (65.2%) (CDC Africa, 2023). In this case it the current study sample is not representative of either country as a whole.

The results of regression modeling designed to control for differences between countries also supported each theoretical construct measured with all HBM and TPB variables statistically significant and in the expected direction. These results are consistent with other studies of COVID-19 vaccine confidence, intentions, and/or uptake from around the world. The perceived threat of COVID-19 morbidity and mortality, a combination of perceived susceptibility and perceived severity, has been the focus of many such studies. In their study of adults in France, Schwarzinger et al. (2021) found a strong association between the refusal of COVID-19 vaccines and lower perceived severity of the disease if infected. The authors noted that the benefit-risk assessment of COVID-19 vaccination was perceived as unfavorable, particularly among younger working adults. Relatedly, a heightened perception of COVID-19 severity, when compared to the seasonal flu, was associated with an increased acceptance of COVID-19 vaccines amongst adults in Italy (Caserotti et al., 2021). Hilverda and Vollmann (2021) studied perceptions of COVID-19 among Dutch university students and concluded that heightened perceived severity of COVID-19 was associated with increased concern about the disease and both stronger vaccine intentions and vaccine uptake. Perceived risk of COVID-19 infection among study participants in South Africa, mediated by perceived vaccine efficacy, was found to be associated with intentions to receive the COVID-19 vaccines (Kollamparambil et al., 2021). Like the current study, Shmueli and colleagues (2021) combined HBM and TPB constructs in their study of Israeli adults. The authors noted perceived severity, perceived benefits, and perceived behavioral control as significant determinants of participants’ intention to receive COVID-19 vaccines. These finding from around the globe provide strong support for the use of HBM and

TPB constructs in the development of interventions to promote confidence in, and acceptance of, COVID-19 vaccines.

The current study’s findings should be interpreted with several key limitations in mind. First, all study data were gathered via self-report with no inspection of vaccination records. Second, this study used data from, and made comparisons between, two countries with many differences and unique experiences related to disease. Country-specific context related to recent diseases outbreaks and past performance of health systems may help explain the difference in perceptions of COVID-19 among the two countries in the current study. Finally, despite the current study’s large sample size, results are not generalizable to all of Zimbabwe or Sierra Leone and should thus be interpreted with care. Namely, vaccination percentages found in the current study vary from national vaccine uptake percentages reported elsewhere. Despite these limitations, the current study adds to the literature supporting established theoretical constructs from the HBM and TPB while building support for adherence to theory in the development and implementation of public health programming.

Ethics approval and consent to participate: Ethical clearance for publication of study’s data was approved by the Brigham Young University Institutional Review Board (IRB#: IRB2023-026).

Consent for publication: Not applicable.

Availability of data and materials: The data that support the findings of this study may be available from Corus International and the African Christian Health Association. but restrictions apply to the availability of these data, which are not publicly available. Data request may be considered from the authors upon reasonable request and with permission of Corus International and the African Christian Health Association. Rebecca Waugh ([email protected]) can be reached for data inquiries.

Competing interests: I declare that the authors have no competing interests as defined by BMC, or other interests that might be perceived to influence the results and/or discussion reported in this paper.

Funding: Osprey Foundation provided funding for this study.

Authors' contributions:

JW and BC did the analysis.

RW, SS, JW, ML, BC, and CH contributed to the survey design.

SS, AM, and RW contributed to the data collection.

SS, AM, MM, RG, JW, ML, BC, CH, RW, and DC all contributed to the manuscript design and preparation.

Authors' information (optional): N/A

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No competing interests reported.

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COVID-19 Vaccine Confidence in Zimbabwe and Sierra Leone: An Application of Health Behavior Change Constructs

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Version 1

Abstract

INTRODUCTION

METHODS

RESULTS

* p < .01, p < .05, * p < .1

DISCUSSION

Declarations

References

Additional Declarations

Status:

Version 1

COVID-19 Vaccine Confidence in Zimbabwe and Sierra Leone: An Application of Health Behavior Change Constructs

Status:

Version 1

Abstract

INTRODUCTION

METHODS

RESULTS

*** p < .01, ** p < .05, * p < .1

DISCUSSION

Declarations

References

Additional Declarations

Status:

Version 1

* p < .01, p < .05, * p < .1