Acceptability of the Coronavirus Disease-2019 Vaccine Among Medical Students in Uganda: a Cross Sectional Study.

COVID-19 is still a major global threat and vaccination remains the long-lasting solution. Unanimous uptake of the COVID-19 vaccine is required to subsequently avert its spread. We therefore, assessed COVID-19 vaccine acceptability, hesitancy, and associated factors among medical students in Uganda. Methods This study employed an online descriptive cross-sectional survey among medical students across 10 medical schools in Uganda. A structured questionnaire as a Google form was sent to participants via WhatsApp. Data was extracted and analyzed using Microsoft Excel 2016 and STATA 16. Descriptive statistics, bivariate and multivariable analyses were performed. CI: 1.3–2.9, p 0.001), being single (aOR = 2.1, 95% p 0.022). Very high (aOR 3.5, 95% p < 0.001) or moderate (aOR = 2.2, 95% CI 1.2–4.1, p = 0.008) perceived risk of getting COVID-19 in the future, receiving any vaccine in the past 5 years (aOR = 1.6, 95% CI 1.1–2.5, p = 0.017), and COVID-19 vaccine hesitancy (aOR 0.6, 95% CI 0.4–0.9, p = 0.036).


Introduction
The Coronavirus disease-2019 (COVID-19) pandemic, caused by the novel severe acute respiratory syndromecoronavirus-2 (SARS-CoV-2) continues to create mayhem across the globe. COVID-has affected livelihoods and has imposed strains on the health care systems (1). Over 135 million people have been infected with SARS-CoV-2 resulting in over 2.9 million deaths worldwide (2). The African continent has continuously recorded fewer cases of COVID-19 with about 4.3 million cases and 115,321 deaths (2). Uganda reported 40,751 cases with 335 deaths as of 9th April 2021 (3).
Different preventive public health measures like lockdowns, hand washing, respiratory hygiene, and social distancing have been employed with little success (7). Much worse even, attempts to loosen these precautionary behaviors have culminated in the surge of cases in many countries (7). Leaving room for only an effective vaccine as a long-lasting solution in such a crisis (8, 9). Several vaccine candidates have been developed to date with some approved and others still undergoing clinical trials. Notably the New York based P zer-BioNTech, ModernaInc company, and the AstraZeneca/University of Oxford Vaccines have been approved for emergency use and already rolled out in some countries including Uganda (10). Although much progress has been made with vaccine development, uncertainty about the public acceptance of COVID-19 vaccination is still an important challenge (9). The World Health Organization (WHO) asserts that vaccine hesitancy is one of the top-ten threats to global health and this is exacerbated by the emerging conspiracies surrounding COVID-19and its vaccines (11).
Medical students are regarded as an insightful population that is open-minded, educated, medically informed.
They also represent the future health professionals, who are supposed to respond quickly to public health issues (12). Surprisingly, a study done in the United States of America reported that nearly one-quarter of the medical students were hesitant to be vaccinated as soon as an approved COVID-19 vaccine becomes available, despite self-perception of elevated risk of exposure to SARS-CoV-2 infection (13). Furthermore, another study done in Israel, reported a high rate of COVID-19 vaccine skepticism among medical staff implying that vaccination compliance, even among medically informed individuals isn't automatic (14).
The Ugandan government through the COVAX facility received its rst 864,000 doses of the AstraZeneca vaccine in early March (15). Subsequently, Uganda rolled out COVID-19 vaccination across the country, starting with priority groups consisting of healthcare workers, security personnel, teachers, humanitarian frontline workers, and patients at higher risk of severe COVID-19 disease among others (15).
In Uganda, medical students form a core part of the health care response team in regional and national referral hospitals making them a vulnerable group (16). They are also an important force in health education and communication in their various communities. It is therefore imperative to assess the acceptability and attitudes of these students towards the COVID-19 vaccine. To our knowledge, no such study has been done in Uganda, and Africa at large. Therefore, we aimed to assess COVID-19 vaccine acceptability, hesitancy, and associated factors among medical students in Uganda.

Study Design
We conducted an online, descriptive, cross-sectional study between Monday 15th March and Sunday 21st March 2021 using a quantitative approach.

Study Setting
The study was carried out in 10 universities in Uganda offering undergraduate medical degrees, namely, Makerere University (Mak), Mbarara University of Science and Technology (MUST), Gulu University (GU), Kampala International University (KIU), Kabale University (KU), Busitema University (BU), Islamic University in Uganda, Soroti University (SU), King Caesar International University, and Uganda Christian University (UCU).
Mak, GU, MUST, BU, KU, and SU are public universities, and the remaining universities are private. The combined population size of all these medical schools is about 6,000-8,000 students.

Study Population
Medical students pursuing the following undergraduate degree programs in these various universities were

Inclusion and Exclusion Criteria
Individuals aged 18 years or older, currently, students in the above-mentioned universities who consented to participate were included and those students who couldn't access the internet were excluded.

Sampling Procedure and Data Collection
During this study, Uganda was in a partial lockdown with schools, universities, and institutions partially opened conducting hybrid physical and Open Distance E-Learning. Therefore, we opted to use WhatsApp Messenger (Facebook Inc) for enrolling potential participants based on our previous experience with conducting studies among medical students (16). We employed convenience sampling where we identi ed all the existing WhatsApp groups of medical students in the various universities through a coordinator for each speci c group.
The Google Form link to the questionnaire was then sent to the potential participants via the identi ed WhatsApp groups.

Study Variables
Independent variables were the demographic characteristics including sex, age, education program, religion, residence, education institution, and sources of information on COVID-19 and COVID-19 vaccines and dependent variables were the acceptability, hesitancy, trust, and attitudes towards COVID-19 vaccine.

Data Management Analysis
Fully completed questionnaires were extracted from Google Forms and exported to Microsoft Excel 2016 (Microsoft Corporation) for cleaning and coding. The cleaned data was exported to STATA (StataCorp LLC, Texas, USA) version 16.0 for analyses. Numerical data was summarized as means (standard deviations) or median (inter-quartile range) for parametric and non-parametric data, respectively. Categorical data was summarized as frequencies and proportions. Associations between independent variables and dependent variables were assessed using the chi-square test or Fisher's exact test and logistic regression analysis in STATA 16.0 software. A P < .05 was considered statistically signi cant.
On bivariate analysis, sex (p = 0.001), belief of getting COVID-19 in the future (p < 0.001) or having already had it (p < 0.029), perceived risk of COVID-19 to an individual (p = 0.001) and Uganda at large (p < 0.001), belief on effectiveness of the vaccine (p < 0.001), vaccination uptake in the previous ve years (p = 0.028) and reluctance or hesitancy to vaccination (p = 0.004) were signi cantly associated with acceptability of COVID-19 vaccine, Table 3. were less likely to take up the COVID-19 vaccine, Table 4. However, (30.7%, n = 184), reported having been hesitant. The most alluded to reason for vaccination hesitancy was concern about vaccines safety or their side effects (n = 78, 19.9%), Table 5. Did not know where to get vaccination 31 7.9 Someone else told me that the vaccine was not safe 27 6.9 Someone else told me they had had a bad reaction from the vaccine 19 4.9 Had a bad experience with previous vaccinator/health clinic

Discussion
Vaccine hesitancy has been a domain of concern globally for several decades now and the picture is more contentious with the current COVID-19 vaccination due to the infodemic and conspiracies surrounding the disease (14). In this study, we set out to nd the COVID-19 vaccine acceptability, hesitancy, and associated factors among medical students in Uganda. To our knowledge, this is the rst study of its kind in Uganda and the African continent at large to examine acceptance and hesitancy towards the COVID-19 vaccine among health care students.
Firstly, our study reveals that only 37.3 % of Ugandan medical students are willing to take up the COVID-19 vaccine. This acceptance level is slightly higher than reported among Egyptian medical students (35%) (17).
Acceptance levels are much higher among students from Italy (86.1%) (12), South Carolina (60.6%) (1), and nursing students (43.8%) across seven countries (18). The most cited reasons for acceptance of the COVID-19 vaccine were protecting self and others from COVID-19 similar to a study among Egyptian medical students (17). This nding is supported by Brewer et al. who reported that anticipated regret for lack of action (i.e., not getting a vaccination and being infected and/or infecting loved ones)is correlated with a higher likelihood of vaccination (19). This study reveals that males are twice more likely to take up the COVID-19 vaccine than their female counterparts, a nding that has been reported by other studies (18,20). Our earlier study among Ugandan medical students showed higher negative attitudes among females towards COVID-19 which further underscores this nding (16).
Secondly, we found that 30.7% of the medical students were hesitant about the COVID-19 vaccination.
Hesitancy towards COVID-19 vaccination among university students has been reported elsewhere. Our ndings are much lower than reported among Egyptian medical students (46%)(17) however relatively similar ndings were reported among medical students in Malta(30.5%)(11), slightly higher than hesitancy among medical students from South Carolina (24.3%)(1), and Michigan (23%) (13), and way higher than that reported among medical students in Italy (13.9%) (12)and India (10.6%) (21). This discrepancy could be explained by the concern about its safety and side effects as similarly reported in various other studies (13,17,18,21).
Medical or health care students are thought to be a medically updated and insightful population that would readily take up the vaccine which is paradoxically unlikely. Health care professionals have also been relied on to in uence decisions of the general public who seek information from them towards the uptake of vaccines (22,23). Therefore in such a situation where they are hesitant warrants more public campaigns and advocacy engaging all people irrespective of their medical knowledge background on the safety and importance of this vaccination.
The pandemic has been surrounded by a lot of conspiracies that could have greatly swayed many people into hesitancy. From our study having heard negative information about the vaccine and its side effects ranked high among reasons for hesitancy. Furthermore, social media was reported as the major source of negative information about the COVID-19 vaccine. Indeed Sallam et al (20) reported that respondents who didn't rely on social media as their source of information were likely to accept the vaccine similar to Saied et al (17) who showed that the hesitancy group reported social media as their major source of COVID-19 information. It's therefore imperative that medical students are encouraged to rely more on other sources of information with censored information than social media.

LIMITATIONS
One of the limitations in this study was the unequal distribution of respondents from the different medical schools and the relatively low sample size compared to the total number of students in these universities. This is due to the difference in the total number of students with newer universities having fewer students and the low response to online studies, especially that it wasn't incentivized. Sampling bias due to convenience sampling used in the study limits the representativeness of the study. Self-selection bias may also have occurred due to some potential respondents not having internet access and thus not being aware of the existence of the survey.

STRENGTHS OF THE STUDY
The study provides results from a large cross-section of students in 10 different universities and variable programs therefore the results can be generalized. Sending daily reminders to the eligible participants on the targeted WhatsApp groups lessened possible response bias associated with online surveys.

FUTURE DIRECTIONS/RESEARCH
A qualitative research study involving a larger sample size to dig deeper into the sentiments of both medical and non-medical students about the COVID-19 vaccine could provide more precise information for targeted messages towards demystifying and changing the attitude of this group of the population towards COVID-19 vaccination.

Conclusion
In conclusion, this study has shown high low levels of acceptance towards COVID-19 vaccine among medical students which poses an evident risk on the battle towards the COVID-19 in the future especially when we are seeing third waves in some countries. There is a lot of complacency towards COVID-19 with low perceived risks among medical students in Uganda and the majority has been corrupted by the negative information on social media that has swayed them into hesitating vaccination. Much effort needs to be geared towards encouraging  Figure 1