Acceptance and Risk Perception of COVID-19 Vaccine in Uganda: A Cross Sectional Study in Western Uganda


 Background: Many countries have drawn their attention on developing Corona virus disease 2019 vaccine however there is less emphasis on whether this vaccine could be accepted in most of these countries. This study aimed to investigate acceptance and risk perception of COVID-19 vaccine in Uganda. Method: A simplified snowball sampling technique was used to select 1067 respondents of 18-70 years in western Uganda using an online questionnaire from July to September 2020. Vaccine acceptability and risk perception was assessed using odds ratio at 95% confidence interval using R software version 3.6.3. Results: The acceptance rate for vaccination against COVID-19 was (53.6%; 572/1067) with participants in the reference age group 18-20 (OR: 1; 95%CI: NA); males (OR: 2.1; 95%CI: 1.56-2.71; P=0.000); tertiary level of education (OR: 2.8; 95%CI: 1.25-6.11; P=0.009); students (OR: 3.19; 95%CI: 1.98-5.15; P=0.000) and non-salary earners (OR: 2.29; 95%CI: 1.53-3.44; P=0.000) significantly more likely to accept the vaccine. Results also showed that (46.4%; 495/1067) of the respondents were un-likely to accept the vaccine. About (44.6%; 476/1067) of the respondents were likely to accept vaccine clinical trials with participants in the reference age group 18-20 (OR: 1; 95%CI: NA), students (OR: 2.37; 95%CI: 1.49-3.77; P=0.000), marrieds (OR: 1.3; 95%CI: 1.03-1.69; P=0.028), and non-salary (OR: 1.56; 95%CI: 1.05-2.30; P=0.029) significantly more likely to accept clinical trials. There were (46.7%; 500/1067) of the respondents who perceived the vaccine as being risky with males (OR: 3.13; 95%CI: 2.33-4.21; P=0.000); students (OR: 2.59; 95%CI: 1.63-4.13; P=0.000); Civil servants (OR: 1.49; 95%CI: 0.98-2.25; P=0.063); and non-salary earners; (OR: 2.34; 95%CI: 1.57-3.47; P=0.000) who significantly perceived the vaccine as being more risky.Conclusion: The level of vaccine acceptance (53.6%) and risk perception (46.7%) was relatively average in western Uganda. In order to ensure successful vaccination process, the government needs to prioritize vaccine acceptance strategies especially among the risky group in the community.


Background
Many countries have drawn their attention on developing Corona virus disease 2019 (COVID-19) vaccine however there is less emphasis on whether this vaccine could be accepted in most of these countries (1). In Africa, COVID-19 outbreak continues to evolve many new numbers of infections and deaths. As of 7 July, there have been 493131 cases of COVID-19 and 11643 deaths reported from the African continent with a 25% increase in cases (2). Apparently, there are several clinical trials that have started in some parts of the world (3) but according to the African Academy of Sciences, only 2% of global clinical trials, for all types of vaccines take place in African (4). This is may be challenging because people of different ethnic backgrounds could react differently to the vaccine.
There is currently one clinical trial of a COVID-19 vaccine in sub-Saharan Africa taking place in South Africa, being run by the University of the Witwatersrand, in Johannesburg (4). Before the vaccine reaches to different parts of the African continent, it is paramount to establish vaccine acceptance in the region. This is because fear of vaccines has grown radically in the past years (5). In some communities, this fear has led to signi cantly increased rates of vaccine refusal which is associated with increases in illness and death from vaccine preventable diseases and imposing of large economic costs for health care to the society (5) (6). A widely accessible and acceptable vaccine is essential to mitigate the health and economic ravages of coronavirus disease 2019 (6). Scientist have previously argued out that the public must be helped to easily understand the huge in uence that vaccines have on the health of the population and we must continue to improve our ability to keep terrible diseases in check through the use of this tool (7) (8). There is presently no COVID-19 vaccine in Uganda however the ministry of health Uganda is working hard to acquire the vaccine by the end of 2020. However, before COVID-19 vaccine is introduced, it is suitable that public health o cials and policymakers prioritize effective COVID-19 vaccine-acceptance messages, especially those who are most vulnerable.
There are no studies that have been conducted about acceptance and risk perception of COVID-19 vaccine in Uganda. This study aimed at determining acceptability and risk perception of hypothetical COVID-19 vaccine in western Uganda. Our prospective hypothesis was that there will be a high vaccine acceptance and high risk perception of COVID-19 vaccine in western Uganda. The results from this study could help the government in identifying the risk population and develop better strategies for mass vaccination against COVID-19.

Study design
The present study was a cross sectional study based on the survey data that was collected. The study population consisted of participants aged between 18 to 70 years of age. This study occurred between 3 rd July and 5 th September 2020 with in western Uganda. We used a simpli ed snowball sampling technique where respondents were requested to pass the invitations through emails or WhatsApp contacts. We designed a questionnaire that was administered online through Google forms on https://docs.google.com/forms/ due to limitations of person to person contact as a measure to minimize the virus spread. To ascertain quality, the questionnaire was pretested before the nal draft was made (additional le 1). The nal version contained demographic characteristics, and questions regarding to vaccine acceptance, willingness to participate in vaccine trials and risk perception of COVID-19 vaccine. Our inclusion criteria had adults above 18 years of age; those capable of using internet on a smart phone or computer; residents with in western Uganda and only those who gave consent to participate in the study. Further details of sample collection procedure are described by Harapan et al (9) (10)

Study variables
This study was based on the assumption that the vaccine would freely be availed and provided by the government of Uganda to its people.
The independent variables were the demographic characteristics that included; age, gender, education status, religion, occupation, marital status, monthly income, employment status, occupation and residence of the respondents. The dependent variables were; vaccine acceptance; vaccine trial acceptance and risk perception of the vaccine. The response required for dependent variables was either "YES" or "NO" 1. Vaccine acceptance: the question asked was developed in line with Harapan et al (9) (11) however, it was modi ed to suit our study design. The question was "If the government of Uganda is to provide free COVID-19 vaccine, would you accept to be vaccinated?" 2. Vaccine trial acceptance: the questions asked here were developed according to Harapan et al (9) and it was modi ed to suit our study design. The questions were "Have you ever participated in any vaccine trial before?" "When approached, would you accept to participate in COVID-19 vaccine trial?" 3. Risk perception of the vaccine: The source of this question was according to Malik et al (11) and we redesigned it as follows "Even before COVID-19 vaccine is available, what is your risk perception about this vaccine?" In order to minimize bias, we tried to remove unnecessary questions, broad questions like what do you think of covid-19 vaccine? We asked them simple, direct and balanced questions. We also kept the questionnaire short to at most 5 minutes completion. Long questionnaires irritate participants; and they begin giving random answers so as to complete the survey.

Sample size calculation
With a population size of 8,874,860 in western Uganda (24) a margin of error of 3%, con dence interval of 95% and a response distribution of 50% was assumed. The minimum recommended sample size calculated was 1067 individuals.

Statistical analysis
Data was cleaned and analyzed in R studio software version 3.6.3. Descriptive statistics (frequencies, percentage) were calculated for the sample demographic characteristics. Contingency tables were drawn and all responses concerning acceptance of COVID-19 vaccine; acceptance to participate in vaccine trials were compared against demographic characteristics. Odds Ratio, were calculated at 95% con dence interval with statistical signi cance when P≤0.05 using Fisher exact two tailed.

Results
Demographic characteristics of the respondents  There were (46.7%; 500/1067) of the respondents who perceived the vaccine as being risky as shown in Table 2. Participants in the age group 51-60 years perceived that the vaccine would be risky (OR: 1.26; 95%CI: 0.72-2.23; P=0.471). The male respondents were three times more likely to perceive the vaccine (OR: 3.13; 95%CI: 2.33-4.21; P=0.000). Those ended at tertiary level of education and the students considered the vaccine being more risky   Institute (UVRI) is partnering with Imperial College London to start the rst Covid-19 vaccine trial in the country by December, 2020. However, the success or failures of vaccine trials are community driven (12). In order to avoid anti-vaccination campaigns like in the early 1996 and 1997, where the oral polio vaccine was criticized by the public that the oral poliovirus vaccine was contaminated with HIV and ineffective, the government needs proper mobilization and community engagement (13) (26). In 2019, the Congo's Ebola vaccine hesitancy was geared by community mistrust due to social and cultural factors that arose during the West Africa Ebola outbreak, even though these communities seriously needed the Ebola vaccine (14). Studies have shown that vaccine refusal is associated with increases in illness and death from vaccine preventable diseases which is also secondary to large economic costs for health care (6). Our study shows that 46.4% (Table 1,2&3) are not willing to take the vaccine however despite the very high bene t-to-risk ratio of vaccines, the fear of negative side effects can discourage many people from getting vaccinated from killer diseases (15).
In general comparison of vaccine acceptance levels in our ndings (Table 1), there were higher acceptance levels of hypothetical COVID-19 vaccine in countries such as Chine (91.3% (16); Indonesia (93.3%) (9) and USA (69%) (17). We attribute these differences to low levels of global vaccine clinical trials in African (4), inadequate research facilities and limited funding needed in development of vaccines (18). Financial and knowledge constrains in most African countries, have cause highest mortality rates by infectious diseases (19). However, low vaccine acceptance in Uganda could be attributed to fear or potential risks that can be encountered especially where a vaccine has not been well evaluated. A similar study in sub-Saharan Africa showed an overall positive acceptance towards the new malaria vaccine however there were challenges of inadequate community engagement due to lack of information about the vaccine and fear of the vaccine side effects (20).
Africa has a high population and a growing economy (21), which would be an advantage for increasing potential market for vaccines however there is a lot of political prejudice and policy setting in uence which may be a factor hindering good health service delivery to the people (18). It is popular that in most African countries political leaders often misuse government resources meant for health service procurements (22).
According to our results, it shows that 46.9% of the respondents had fear for the vaccine. Previous study on HIV vaccine trial in Uganda showed that before researchers start any trials of HIV vaccines, they need to gain support from politicians, the media, and the general public. Generally, all stakeholders must be involved in discussions about important scienti c, social, legal, ethical, and other concerns before the study begins (23). We believe that this approach could help mitigate fears about COVID-19 vaccination and clinical trials in the community.
Among the most risky group were the males respondents, students, low income earners (< 1,000, 000) and those with no salary income who perceived the vaccine as being risky. When carrying out community sensitization, efforts have to be made by the government to ensure that this group of people in followed closely.
Therefore the government of Uganda through its Scientists, policymakers, and public health experts must start involving communities now as discussions and plans progress toward nding a vaccine not after the scienti c breakthrough but before. There is need to sensitize the population against their fears early enough before the trials can progress. The government can establish messages and trainings for its people especially the risky group regarding vaccination against COVID-19. This can be done through radios, televisions, newspapers, seminars and phone messages.

Conclusion
The level of vaccine acceptance (53.6%) and risk perception (46.7%) was relatively average in western Uganda. Most risky groups unlikely to receive the vaccine included those aged 61-70, unemployed; pagans; unmarried and urban dwellers. Additionally, male participants; students; civil servants and nonsalary earners; regarded the vaccine as being more risky. If this group is not attended to, it may lead to increased COVID-19 infections; deaths which can propagate to economic down fall of the country. In order to ensure successful vaccination process, the government needs to prioritize vaccine acceptance strategies especially among the risky group in the community.

Study Limitations
With this study being purely an online based survey, it was not possible to know if the responses were really genuine. The study being online based could also have omitted those without phones, computer and internet. We could have left out more vulnerable persons or persons who could have preferred vaccination hence the low level of acceptance obtained.