COVID-19 vaccine hesitancy in Africa: a scoping review

Background Vaccination against the novel coronavirus is one of the most effective strategies for combating the global Coronavirus disease (COVID-19) pandemic. However, vaccine hesitancy has emerged as a major obstacle in several regions of the world, including Africa. The objective of this rapid review was to summarize the literature on COVID-19 vaccine hesitancy in Africa. Methods We searched Scopus, Web of Science, African Index Medicus, and OVID Medline for studies published from January 1, 2020, to March 8, 2022, examining acceptance or hesitancy towards the COVID-19 vaccine in Africa. Study characteristics and reasons for COVID-19 vaccine acceptance were extracted from the included articles. Results A total of 71 articles met the eligibility criteria and were included in the review. Majority (n = 25, 35%) of the studies were conducted in Ethiopia. Studies conducted in Botswana, Cameroun, Cote D’Ivoire, DR Congo, Ghana, Kenya, Morocco, Mozambique, Nigeria, Somalia, South Africa, Sudan, Togo, Uganda, Zambia, Zimbabwe were also included in the review. The vaccine acceptance rate ranged from 6.9 to 97.9%. The major reasons for vaccine hesitancy were concerns with vaccine safety and side effects, lack of trust for pharmaceutical industries and misinformation or conflicting information from the media. Factors associated with positive attitudes towards the vaccine included being male, having a higher level of education, and fear of contracting the virus. Conclusions Our review demonstrated the contextualized and multifaceted reasons inhibiting or encouraging vaccine uptake in African countries. This evidence is key to operationalizing interventions based on facts as opposed to assumptions. Our paper provided important considerations for addressing the challenge of COVID-19 vaccine hesitancy and blunting the impact of the pandemic in Africa. Supplementary Information The online version contains supplementary material available at 10.1186/s41256-022-00255-1.


Introduction
Reports from several countries in Africa suggest a lower burden of the novel coronavirus disease 2019 (COVID- 19) pandemic, relative to countries such as the United States, Italy, and Peru [1][2][3]. However, factors influencing the pandemic's trajectory across Africa are not generalizable. These drivers are diverse, including a nation's experience dealing with communicable diseases, connectivity among communities, infection fatality ratios, low physical access to health facilities, as well as low testing rates [4,5]. Considering the debilitating health, social, and economic consequences of COVID-19, a marked increase in infection and mortality rates may be particularly devastating for African countries with under-resourced healthcare systems. Governments have instituted measures to contain the spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), including various forms of social distancing measures. The economic ramifications of these health restrictions disproportionately affect the populations in this region who are primarily informal workers. With their livelihoods predicated on in-person interactions, such workers do not readily adhere to lockdowns and similar measures [6][7][8].
Mass immunization has been demonstrated to be the most effective intervention for curtailing communicable disease pandemics and is therefore adopted and implemented by several countries [9,10]. Despite the innumerable deaths that have been prevented by vaccines, the emergence of vaccine hesitancy and its penetration into mainstream views threaten to undermine the future success of immunization campaigns. Specifically, the demonstrated efficacy of vaccines in curbing the spread of COVID-19 has not necessarily translated to a decrease in global vaccine-hesitancy [11,12].
According to the World Health Organization (WHO), vaccine hesitancy is the "delay in acceptance or refusal of vaccines despite availability of vaccination services" [13]. This phenomenon has been highlighted by the WHO as one of the ten threats to global health. False rumours about vaccine side-effects often spread via social media. Additionally, negative experiences with the healthcare system, and general distrust towards the government have established the perfect milieu for vaccine-hesitant attitudes across Africa. The accelerated development, approval, and roll-out of COVID-19 vaccines further fuel pre-existing distrust and suspicion. Thus, regions that historically struggle with adequate supplies and equitable access to healthcare also face a new hurdle-insufficient vaccine uptake.
The goal of this scoping review was to synthesize the current literature on vaccine-hesitant attitudes in Africa. This is necessary to establish an understanding of the multiplicity of perceptions and attitudes towards the COVID-19 vaccine, and to help frame strategies for addressing them.

Protocol
This scoping review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews [14]. Literature that was examined included those indexed in Scopus, Web of Science, African Index Medicus, and OVID Medline on the topic of attitudes, acceptance, or hesitancy towards the COVID-19 vaccine in Africa. Covidence [15] was used for managing deduplication of studies, as well as for screening, full text review, and data extraction.

Eligibility criteria
Eligible studies met the following inclusion criteria of being (1) peer-reviewed, published, and indexed in Scopus, Web of Science, African Index Medicus, or OVID Medline; (2) primarily discussing or evaluating COVID-19 vaccine acceptance/hesitancy; (3) focused on Africa or included African countries; (4) published in English; (5) published between January 1, 2020, to March 8, 2022. Letters to the editor, non-empirical studies, reviews, or protocols were also excluded from the review.

Search strategy
The searches on all four databases were done on March 8, 2022. Detailed search strategies and search results are presented in the Additional file 1. Bibliographies of articles that were included for review were also scanned to capture any literature that was missed from the formal search.

Data extraction
Title, abstract screening, and full text reviews were conducted independently by two authors following the inclusion and exclusion criteria. The following information was extracted from articles that were included for data extraction: last name of the first author, year of publication, study design, country of focus, sample description, sample size, reported acceptance or hesitancy rate, reported factors and reasons associated with acceptance or hesitancy.

Results
A combined total of 536 records from our initial search in the aforementioned databases were eligible for title and abstract screening. Duplicates (n = 245) were removed, and 291 studies were eligible for title and abstract screening. One hundred and eighty-six (186) articles were deemed irrelevant and were removed, leaving 105 studies for full text screening. During the full text screening, 34 studies were excluded because they were either non-peer reviewed, letters to the editor or protocols, not focused on vaccine hesitancy, not focused on Africa, or the full text was not available. The remaining 71 articles were included in the final analysis. The selection process is shown in the PRISMA flow diagram (Fig. 1).

Characteristics of the included studies
There was heterogeneity in the included articles in terms of country of focus and participant characteristics (Table 1).

Participant characteristics
The study samples were mostly drawn from the general public, university or college students or from healthcare settings, with adults aged ≥ 18 years, and sample sizes ranging from 14 [19] to 11,895 [18].

Themes from included studies
Two major themes were captured in the included studies: COVID-19 vaccine acceptance rate and factors associated with or reasons for vaccine acceptability or hesitancy.

COVID-19 vaccine acceptance rate
The rate of acceptance of COVID-19 vaccine ranged from 6.9 to 97.9% (Table 2). Twenty-one representing 29.6% of the included studies reported lower than 50% acceptance. The lowest acceptance rate of 6.9% was reported by Chinawa and colleagues [20] and the highest acceptance rate of 97.9% was reported by Kanyanda and colleagues [18].

Discussion
Since the start of the COVID-19 pandemic, mitigation strategies including rapid vaccine development and rollout have been implemented to curb the spread of the virus. Governments are faced with an unprecedented need to acquire vaccines, distribute them, and immunize large populations at a pace and scale that has not been done before [55]. However, vaccine hesitancy remains a major obstacle, even amongst cohorts that are not known to be particularly reluctant to accept vaccines or other health interventions.
This review presents a mapping of the relevant literature and findings on attitudes to COVID-19 vaccines in Africa. The included studies were mostly cross-sectional studies that investigated diverse populations. The low levels of vaccine acceptance recorded in many of the included studies contrasts studies that were carried out    Efficacy concern, safety concern, and disbelief over the existence of COVID-19 in Nigeria Yassin et al. [52] Healthcare workers 400 63.8 Safety and side effect concerns were associated with vaccine hesitancy Zewude et al. [53] Teachers and bank employees   in other regions like Europe and the Americas [56], China [57], Kuwait [58], and the United Kingdom [59].
Ditekemena and colleague's study showed that people in middle-income or high-income groups were more willing to get immunized [39]. Participants in some studies [39,54,60] also mentioned financial considerations as hindrances. Thus, even though many countries in Africa are vaccinating the populace for free, the reticence from resource-constrained communities could point to a miscommunication about who bears the cost. Similarly, the financial burden on such communities likely goes beyond the vaccine themselves to include transportation to vaccination centres which might not be proximal to them, childcare costs and other barriers.
Interestingly, vaccine hesitancy was persistent among students and healthcare workers [26,37,51,54,61]. Healthcare workers are often role models for vaccine uptake, especially for populations expressing low levels of trust towards vaccines. In many cases, they are gatekeepers for public health messaging, and their interactions could encourage health-seeking behaviours such as receiving vaccines [26,62]. As such, vaccine hesitancy among them is especially concerning given their involvement at the forefront of immunization campaigns and other clinical interventions. In contrast, research on health providers conducted in Italy, Saudi Arabia, France, and China [63][64][65][66][67] have shown greater acceptance of vaccines. In Nzaji and colleagues' study [26], there was a differentiation between the various types of health workers that were surveyed. Doctors were more likely to accept the vaccines compared to nurses and laboratory technicians.
Kanyike and colleagues [63] underscored the fact that participants reported such high levels of hesitancy because of the relatively slower infection rates compared to other countries. Caserotti and colleagues [68] established a link between risk perception and acceptance of COVID-19 vaccines. Thus, the reduced perception of risk and mortality in many African countries can be related to widespread vaccine hesitancy [56]. For instance, the recovery rate from COVID-19 in Cameroon at the time of Dinga et al. 's study [40] was 80%. In Ahmed and colleagues' study [38], participants reported their decreasing adherence to COVID-19 prevention protocols like physical distancing and wearing facemasks. This correlates with an increase in flu-like symptoms, spurring a consequent rise in vaccine acceptance. This instance of the perception of increased risk encouraging vaccine uptake is quite interesting. This exemplifies the import of contextual factors of cultural norms as well as misinformation on acceptance and hesitancy rates even in instances of similar awareness of heightened risk. National sensitization campaigns must therefore heed these contextual nuances to ensure that public health messaging is catered to specific socioeconomic and sociocultural groups.
In general, more men than women were open to COVID-19 vaccinations. Ngoyi and colleagues [69] attributed this to a widespread impression that men were more at risk of poor outcomes from COVID-19 infections. These gendered patterns of vaccine acceptance match findings from other COVID-19 literature including a study mapping global trends with participants from eight countries [56,70]. Contrastingly, Faezi and colleagues' study [71] which also included participants from countries outside Africa had women showing a higher propensity for vaccines.
The studies listed a diversity of explanations for why participants refused to be vaccinated. A common reason was the concern for vaccine side effects. Zewude and Zikarge [53] found that participants were particularly averse to the AstraZeneca vaccine. This sentiment was likely fueled by reports of serious side effects such as blood clots and other complications, as well as the decision by several European countries to halt AstraZeneca vaccinations for a period to investigate the adverse reactions.
With regards to the fear of side effects, an explanation that was cited in almost all research contexts was the role of misinformation especially on social media platforms. Social media holds substantial power at mediating the perpetuation of misinformation on anti-vaccine campaigns [72][73][74]. The major sources disseminating false information that were cited by some studies [39,40,63,69] were social media-based, and to a lesser extent traditional media. Interestingly, even though they are medical students, 91% of the respondents of Kanyike and colleagues' study [63] reported they sourced information on COVID-19 from social media, rather than from health experts. Misinformation from social media fueled their vaccine hesitancy although they expressed a self-perception of an increased risk due to their participation in COVID-19 health interventions. As these results prove, social media wields immense power in effective dissemination of information and in influencing health-seeking behaviors. These influences must be fundamental considerations in national campaigns to address vaccine hesitancy. It would involve tailoring the content of campaigns to appeal to people more strongly than the misinformation that they so easily accept.
Other key commonalities from the included studies include mistrust of vaccine manufacturers [36,40] and the notion that COVID-19 vaccines would be used as targets to harm Africans [26,[37][38][39][40]63]. Respondents were mistrustful because the pharmaceutical companies are foreign, and scientists from their respective countries were not involved in developing the vaccines. Further longitudinal studies will be necessary to complement the findings of these studies considering the advanced stages of vaccination campaigns in many countries. This would also be relevant for studies [75][76][77][78] which were based on hypothetical situations prior to vaccine availability.
Additionally, the global need to attain high levels of vaccination rates will require more than one effective vaccine approach due to geographic diversity [55]. Educational interventions that highlight vaccine safety and efficacy have been recognized in the literature as an urgent need to combat misinformation to increase compliance rates [79]. As Zewude and Zikarge [53] demonstrated, vaccine hesitation could be fueled by public response to particular vaccines, in this case AstraZeneca. The messages in these interventions should therefore be tailored to reflect the differing concerns for specific vaccines. These educational programs could be more impactful if targeted towards the individuals whom we have highlighted as especially concerned about getting vaccinated.
Although education may not address the underlying causes for mistrust and prevent conspiracies from evolving within communities, we believe that education especially in the context of a novel infection is important in creating awareness and dispelling fears that might contribute to conspiracies or distrust towards prevention and control measures. However, it is important to acknowledge that education as an intervention must be accompanied by other efforts such as understanding historical and cultural contexts of disease, ensuring transparency within public media, and involving community leaders in efforts to respectfully engage in dialogue around prevention and control measures.
The global health community needs to act as a united front while promoting the adaptation of local strategies to address the root causes of mistrust and skepticism for COVID-19 vaccines. This must be done in a respectful manner that acknowledges rather than dismisses the concerns of individuals who are genuinely wary about the safety and efficacy of the available vaccines. Lessons can be learned that will promote vaccine acceptance even for existing vaccines among historically non-compliant groups.
The robust and comprehensive nature of the search strategy is a strength of this paper. With regards to limitations, a critical appraisal of studies included in this review was not carried out as the objective of this review is to present available and relevant evidence in a time-sensitive manner to aid decision-making on strategies to urgently curb vaccine hesitancy during the COVID-19 pandemic in Africa. Moreover, studies were only included from the English language; this may have excluded studies that were written in a different language but still relevant to our research question.

Conclusions
This scoping review illustrated the current state of evidence regarding COVID-19 vaccine hesitancy in Africa. Our synthesis revealed that factors that drove vaccine hesitant sentiments across Africa varied from fear of adverse events following vaccination, distrust towards the pharmaceutical industry, as well as myths surrounding immunization. This evidence would be instrumental in addressing the sources and manifestations of skepticism towards vaccines to stop COVID-19 and its manifold impacts. This is integral as global efforts for equitable COVID-19 vaccine distribution are underway. The persistence of outbreaks and emergence of variants of concern make this endeavor even more pertinent for helping to frame educational and other approaches for reducing vaccine hesitancy in Africa. Further, identifying the determinants and facilitators of vaccine hesitancy is critical to improving both the current and future success of vaccine rollout. This evidence would be particularly useful for policy makers and health promotion stakeholders.