COVID-19 remains a significant global health threat, with more than 9 million cases and 174,286 deaths attributable to the virus occurring in the African region (1). In Uganda, the SARS-CoV-2 virus which causes COVID-19 has resulted in more than 170,000 cases and 3,600 deaths within the general population as of December 31, 2023 (1), exacerbating the strain on an already challenged healthcare system. Persons with underlying health conditions, such as diabetes mellitus (DM) face an amplified risk of severe outcomes from COVID-19. While over 463 million people are living with DM globally and yet this number is expected to increase to 700 million by 2045 (2), people with DM are particularly susceptible to severe complications from COVID-19(3) and face an estimated twofold higher risk of death compared to those without DM (4–7). This heightened risk of severe COVID-19 outcomes is associated with factors such as poor glycaemic control and obesity (8, 9). Given this heightened vulnerability, prioritizing persons with DM for vaccination is strongly recommended (10). Moreover, the World Health Organization (WHO) has advocated for 100% vaccination uptake among all people with underlying health conditions(11) emphasizing the critical importance of vaccinating this high-risk cohort to mitigate the impact of COVID-19 on their health outcomes.
COVID-19 vaccination is the mainstay of prevention against infection in the general population, but, most importantly, among high-risk groups such as persons with DM. For instance, by the end of the first year of vaccination, COVID-19 vaccination had prevented 63% of global deaths (12). In Uganda, the initiation of mass COVID-19 vaccination occurred in March 2021 with the deployment of 864,000 doses of the AstraZeneca vaccine. Subsequently, accelerated mass vaccination campaigns incorporated various vaccines, including Johnson & Johnson’s Janssen, Pfizer-BioNTech's Pfizer, Inc., Oxford-AstraZeneca from Oxford University and AstraZeneca, and Sinopharm from China National Pharmaceutical Group Co., Ltd. and the Beijing Institute of Biological Products Co. (13). The Ugandan MoH prioritized six high-risk groups at the launch of the first phase of mass COVID-19 vaccination among which were persons with underlying health conditions aged below 50 years, estimated at 500,000 at the time (14). Despite this prioritization, by November 21, 2022, a mere 10% of those with underlying health conditions had received a COVID-19 vaccine (15). Unfortunately, specific data regarding the uptake of COVID-19 vaccination among persons with DM in Uganda remain unclear, highlighting a significant gap in the COVID-19 vaccination behavior among this particular high-risk subgroup.
The uptake of COVID-19 vaccination among persons with diabetes mellitus (DM), particularly in the sub-Saharan region, remains below optimal levels. Within the sub-Saharan region, only 6–14% of persons with DM have completed the primary series of a COVID-19 vaccine (16, 17). In contrast, higher rates of full vaccination, approximately 25% and 55%, were observed among those with DM in China and Saudi Arabia, respectively. This poor uptake among persons with DM is partly attributed to social-demographic factors and their perceptions regarding COVID-19 vaccines and the virus (16–21). Literature on the COVID-19 vaccination behavior among persons with DM predominantly is mainly based on studies conducted in nations with greater access to COVID-19 vaccines, leaving a gap in understanding within low-income countries such as Uganda. Moreover, despite an estimated 10% uptake of COVID-19 vaccination among persons with comorbidities in Uganda (15), specific data regarding the full vaccination uptake among those with DM is scanty. Additionally, similar to many parts of the world, COVID-19 vaccination remains voluntary, placing the decision to be fully vaccinated solely on the individual. Given the high risk among persons with DM, the Ugandan Ministry of Health (MoH) and collaborating organizations must understand both their uptake of the vaccines and influencing factors to adapt vaccination sensitization campaigns for persons living with DM in Uganda. This study sought to estimate the level of uptake of full COVID-19 vaccination among persons living with DM and its correlates in Uganda through a lens of Hochbaum and Rosenstock’s Health Belief Model (HBM) developed in 1952. The HBM is a social behavior change model designed to explain and predict health behavior based on four major blocks: perceived risk, perceived severity, perceived benefits, and perceived barriers. The model also integrates the individual’s self-efficacy, that is, the self-belief in conducting the health behavior (22), and the cues to action – the triggers that prompt an individual to perform a health behavior that could either be internal or external cues (22, 23).