Willingness to Receive COVID-19 Vaccine and Associated Factors Among College Students in Gondar City, Northwest Ethiopia

Abstract

Background:

The increasing incidence of coronavirus disease 2019 (COVID-19) continues to cause morbidities, mortalities, and economic crises worldwide. College students are among the high-risk groups to acquire the disease for many reasons. Thus, the COVID-19 vaccine is the most effective and safe method to control this deadly disease. Although World Health Organization advocates vaccination is the best approach to tackle COVID-19, refusal of vaccination is a global problem. Evidence of reaching out to college students is scarce in Ethiopia, particularly in the study area. Therefore, this study aimed to assess willingness to receive the COVID-19 vaccine and associated factors among college students in northwest Ethiopia.

Methods:

An institution-based cross-sectional study was conducted among 626 participants from January 12–26, 2021. Data were collected using a pretested, self-administered questionnaire, and a multistage sampling technique was used. Data were entered into Epi Info version 7.1.5.2 and exported into SPSS version 20 for analysis. Both bivariable and multivariable logistic regression analyses were used to identify associated factors. The level of significance was determined based on a p-value < 0.05.

Results:

In this study, the student’s willingness to receive COVID-19 vaccine was 34.2% [95% confidence interval (CI): 30.9–38.1]. Being third-year student [adjusted odds ratio (AOR) = 1.88; 95% CI: 1.27–2.77], being male (AOR = 1.45; 95% CI: 1.02–2.09), being married (AOR = 2.07; 95% CI: 1.28–3.33), ever watching TV (AOR = 0.39; 95% CI: 0.24–0.65), and having a positive attitude toward COVID-19 prevention (AOR = 2.33; 95% CI: 1.61–3.39) were the factors significantly associated with the willingness to receive the COVID-19 vaccine.

Conclusion:

Willingness to receive the COVID-19 vaccine among college students was low. Sensitization of students about COVID-19 vaccine safety and effectiveness before directly giving the vaccine is recommended. Moreover, concerned bodies should provide improved health education to students to bring a favorable attitude toward the COVID-19 vaccine.

Introduction

Coronavirus disease 2019 (COVID-19) pandemic has exploded since cases were first identified in Wuhan City, China (Awadasseid et al., 2020). Currently, more than 141 million cases of COVID-19 and more than 3 million deaths have been reported globally. Individuals of all ages are at risk for infection and severe disease [Rivera-Figueroa et al., 2020; World Health Organization [WHO], 2021a]. After the World Health Organization (WHO) declared COVID-19 as a pandemic, governments have globally imposed several preventive measures and protocols to decrease the spread of COVID-19. Preventive measures include the following: using face masks properly and consistently, keeping a 2-meter distance between individuals, handwashing with soap, avoiding touching eyes and nose with an unclean hand, and avoiding overcrowded areas (Baye, 2020). Among other preventive measures, vaccination is one of the most powerful public health preventive interventions that have the greatest impact on the reduction of the burden from infectious diseases and their related mortality (Remy et al., 2014).

The vaccine for COVID-19 has been running multiple trials, and the first vaccine was authorized on December 21, 2020, by European Union (European Medicines Agency, 2020). Then with a further trial, the currently used vaccine, AstraZeneca, was approved on January 29, 2021 (Rzymski et al., 2021). This vaccine is also adopted by the Ethiopian government and distributed all over the country (| WHO | Regional Office for Africa, 2021c). Accordingly, Ethiopia received 2.184 million doses of the COVID-19 vaccine on March 7, 2021. After that, the Ethiopian Ministry of Health (MOH) officially launched the COVID-19 vaccination on March 13, 2021 [World Health Organization [WHO], 2021b].

However, due to the inadequate supply of COVID-19 vaccines, governments have prioritized high-risk groups to receive the initial supply of vaccines. These high-risk groups include health care workers, older persons, and people with chronic comorbid conditions and respiratory problems (Soares et al., 2021).

Even though safe and efficient vaccines against COVID-19 are vital for ending the pandemic, vaccine hesitancy is increasing worldwide (Lazarus et al., 2021). According to a strategic advisory group of experts on immunization, vaccine hesitancy is a delay in acceptance or refusal of vaccination despite the availability of vaccination for a specific pandemic disease (MacDonald and SAGE Working Group on Vaccine Hesitancy, 2015). In many countries, vaccination refusal and misinformation have created major obstacles to achieve optimal vaccine coverage and community immunity (Dubé and MacDonald, 2020). In addition, vaccine apprehension, particularly concerning the COVID-19 vaccine, leads to a false perception that the vaccine has not been thoroughly tested for safety and efficacy (Beck, 2020).

Currently, different studies have emerged examining college students’ attitudes toward and intent to receive the COVID-19 vaccine. Studies conducted in China among college students and the population showed that students who had a family member who had received a COVID-19 vaccine and a seasonal flu vaccine had more positive attitudes toward COVID-19 vaccination (Lin et al., 2020; Kecojevic et al., 2021; Rzymski et al., 2021). Another study conducted in Italy among university students revealed that 77.52% of students were willing to get the flu vaccine and 94.73% were willing to be vaccinated against COVID-19 when available (Barello et al., 2020). A study in United States of America showed that the accessibility of media channels increased willingness of people to take the vaccine (Piltch-Loeb et al., 2021). In addition, being a medical student, having undertaken a previous vaccination against flu, and having a high level of concern and perceived vulnerability to the COVID-19 pandemic, sex, residence, education, and occupation were predictive factors for taking COVID-19 vaccination (Danabal and Magesh, 2021; El-Elimat et al., 2021; Pastorino et al., 2021).

Scholars revealed that the effect of COVID-19 on the specific high-risk groups and the general population is somewhat different, which might cause a dissimilar response to COVID-19 vaccination (Borowiak et al., 2021). College students who resumed their education during the pandemic are among the subpopulation at a high risk of COVID-19 disease. The crowded setting of classes and frequent movement of students between the community and colleges inflate the widespread COVID-19 infection (Walke et al., 2020). In Ethiopia, studies addressing the highly vulnerable college students are scarce, particularly in the study area. Therefore, understanding college students’ willingness to receive a COVID-19 vaccine and identifying influencing factors may help in the development and implementation of the different strategies, thereby increasing the uptake of the COVID-19 vaccine and curbing COVID-19 infection. Moreover, it is reasonable to include these age groups since they are reluctant to accept others’ ideas and follow their viewpoints only. Thus, this study assessed the willingness of the COVID-19 vaccine and associated factors among college students in Gondar city, northwest Ethiopia. Based on our objectives, we hypothesized the following points: To what extent are students willing to receive the COVID-19 vaccine? and Do sociodemographic factors affect the willingness of students to receive the COVID-19 vaccine?

Materials and Methods

Study Setting and Design

An institution-based cross-sectional study was conducted from January 12–26, 2021, in Gondar city public colleges. Gondar city is located 166 km away from Bahir Dar, the capital city of Amhara regional state, and 750 km away from Addis Ababa, the capital of Ethiopia. According to the population projections of Ethiopia for all regions at the Woreda level from 2014 to 2017, the total population of the city was estimated to be 306,246. Among these, 156,276 are women (Abebe, 2013). Currently, it has 4 public colleges, which are Teachers Training College, two Technical and Vocational Education and Training (TVET) colleges, and Teda Health Science College. According to each college official’s report, more than 12,000 students are attending their education in a face-to-face way.

Source Population

All regular public college students attend their education in Gondar city.

Study Population

The study population consisted of all students in the selected departments who were available during the data collection period.

Sample Size Determination and Sampling Technique

The sample size was determined using a single population proportion formula with the following assumptions: the proportion of willingness to take the COVID-19 vaccine 50% (since there was no similar study), 95% confidence level (CI), and 5% margin of error.

Thus, = = 384, where n = required sample size, α = level of significant, z = standard normal distribution curve value for 95% CI = 1.96, p = willingness to receive the COVID-19 vaccine among college students, and d = margin of error. After considering a design effect of 1.5 and a 10% non-response rate, the final sample size was 634.

A multistage sampling technique was employed to reach out to the study participants. First, we classified Gondar city colleges as health and non-health colleges because the reference population is different. Then, 9 departments were randomly selected by lottery method from among the 30 total departments. The list of the students was obtained from each department, and the sampling frame was prepared. After proportional size allocation was done for each department, the study participants were selected using a simple random sampling technique (Figure 1).

FIGURE 1

Data Collection Instrument and Procedures

A self-administered, semi-structured, and pretested questionnaire was used to collect data. The questionnaire was prepared after reviewing different published articles (Akalu et al., 2020; Asemahagn, 2020; Maheshwari et al., 2020; Berihun et al., 2021) and WHO guidelines (Ortiz-Prado et al., 2020), which was first in English and translated to the local language (Amharic) with the assistance of language experts to make it simple and understandable. The questionnaire contains the sociodemographic characteristics of respondents, knowledge, attitude, and practice of COVID-19 preventive measures and willingness to receive the COVID-19 vaccine. A total of four male BSc midwives data collectors and one MSc midwife supervisor have participated in the data collection process. During the data collection, important COVID-19 preventive precautions were undertaken.

Data Quality Control

The questionnaire was pretested on 5% of the calculated sample size to assess the validity of the tool. One-day training was given for all data collectors and supervisors regarding the aim of the study, the contents of the tool, and methods for data collection. To ensure confidentiality and prevent information contamination, questionnaires were distributed and collected on the same day. The collected data were checked for completeness before data entry by the supervisor and the research team.

Data Processing and Analysis

Data were entered into Epi Info version 7.1.5.2 and exported to SPSS version 20 for analysis. Bivariable and multivariable logistic regression analyses were used to determine factors associated with willingness to receive the COVID-19 vaccine. Variables with a p-value of < 0.25 in the bivariable analysis were included in the multivariable logistic regression to adjust for possible confounders. A p-value of < 0.05 with a 95% CI for the adjusted odds ratio (AOR) was used to determine the level of significance. The descriptive parts of the result are presented by texts, tables, and figures.

Ethics Approval and Consent to Participate

The study was conducted under the Ethiopian Health Research Ethics Guideline and the declaration of Helsinki. Ethical clearance was obtained from the Institutional Ethical Review Board of the University of Gondar (approval number: V/P/RCS/05/767/2021). A letter of cooperation was obtained from the Gondar city education office and each college administrative office. Then, written informed consent was obtained from each study participant after the purpose of the study was explained. Any student who was not willing to participate in the study was not forced, no personal identifications were included in the datasheet, and all data taken from the participants were kept strictly confidential and used only for the study purpose.

Operational Definition and Measurement

The outcome variable willingness to receive the COVID-19 vaccine was assessed by asking “will you get vaccinated without a dilemma, if you get the COVID-19 vaccine?” If the respondents answered “yes,” it is considered as willing to receive the COVID-19 vaccine and labeled as “1” for analysis, while if the respondents answered “no,” it is considered as not willing to take the COVID-19 vaccine and labeled as “0.”

Good knowledge: Those respondents who scored above the mean of knowledge questions were taken as having good knowledge toward COVID-19 prevention (Kassie et al., 2020).

Positive attitude: Those respondents who scored above the mean of attitude questions were taken as having a positive attitude to the prevention of COVID-19 (Kassie et al., 2020).

Good practice: Those respondents who scored above the mean of practice questions were taken as having good preventive practice to COVID-19 (Alrubaiee et al., 2020).

Results

Sociodemographic Characteristics of the Study Participants

In this study, a total of 626 study participants were included in the analysis, making a response rate of 98.7%. The mean age of study participants was 23.01 (SD ± 4.155) years, and three-quarters of them were classified under the age group of 18–24. The majority (79.9%) of the respondents were unmarried and more than half (53.2%) of them were second-year students. About 70.9% of participants were from non-health colleges. More than three-quarters (77.3%) of the study participants have watched television (Table 1).

Students’ Knowledge, Attitude, and Practice Toward COVID-19 Preventive Measures

Out of the total study participants, 433 (69.2%) had good knowledge, 319 (51%) had a positive attitude, and 426 (68.1%) had good practice to COVID-19 preventive measures.

Willingness to Receive the COVID-19 Vaccine Among College Students

Willingness to receive the COVID-19 vaccine was found to be 34.2% (95% CI: 30.9–38.1) (Figure 2). The most common reasons for refusal of accepting the COVID-19 vaccine were fear of side effects on daily activity (59.4%), perceiving the vaccine may not be effective to COVID-19 prevention (69.6%), and the vaccine may not be safe (74%) (Table 2).

FIGURE 2

Factors Associated With Willingness to Receive the COVID-19 Vaccine

The bivariable analysis revealed that year of study, sex of the study participants, living with family, marital status, maternal education, paternal education, watching TV, listening to the radio, attitude, and knowledge were significantly associated with willingness to receive the COVID-19 vaccine. However, year of study, sex, marital status, watching TV, and attitude were the factors associated with the outcome variable in the multivariable logistic regression. Accordingly, being third-year students were 1.88 (AOR = 1.88, 95% CI: 1.27–2.77) times more likely to accept the COVID-19 vaccine as compared with being second-year students. Similarly, the odds of willingness to receive the COVID-19 vaccine were 1.45 times higher among male students (AOR = 1.45, 95% CI: 1.02–2.09) compared with female study participants. In addition, the odds of willingness to receive the COVID-19 vaccine were 2.07 times higher among married participants (AOR = 2.07, 95% CI: 1.28–3.33) compared with unmarried participants. Participants who have ever watched TV were 61% (AOR = 0.39, 95% CI: 1.28–3.33) less likely to be willing to receive the COVID-19 vaccine as compared with their counterparts. Moreover, participants who had a positive attitude toward COVID-19 prevention were 2.33 (AOR = 2.33, 95% CI: 1.61–3.39) times more likely to be willing to receive the COVID-19 vaccine as compared with those participants who had a negative attitude toward COVID-19 prevention (Table 3).

Discussion

The best modalities for tackling the surge of COVID-19 pandemic disease are applying the standard precautions of COVID-19 prevention and getting the COVID-19 vaccine. But, COVID-19 vaccination refusal is a great issue globally, particularly in sub-Saharan Africa (Sallam, 2021). Therefore, this institutional-based cross-sectional study aimed to assess willingness to receive the COVID-19 vaccine and associated factors among college students in Gondar city, Northwest Ethiopia, 2021. This study result showed that willingness to receive the COVID-19 vaccine was 34.2%.

This finding is in line with studies done in Ethiopia (31.4%) (Belsti et al., 2021), Jordan (37.4%) (El-Elimat et al., 2021), and the United States (36%) (Shekhar et al., 2021). However, it is lower than studies conducted in China (91.3%) (Wang et al., 2020), New York (86.1%) (Ciardi et al., 2021), Uganda (53.6%) (Echoru et al., 2021), and Ghana (39.3%) (Kabamba Nzaji et al., 2020). Also, this finding is lower than studies done in some parts of Ethiopia, such as the Gurage zone (70.7%) (Mose and Yeshaneh, 2021) and Sodo town (45.5%) (Mesele, 2021). This variation might be due to the differences in sociodemographic, sociocultural, socioeconomic, and source populations. For instance, the study in China was conducted in all adult Chinese populations. In addition, 55.4% of these adults had a bachelor’s degree and 67.3% of them were married. However, the study participants in this study were students and only 20.1% of them were married. Empirical evidence supports that a higher level of education increases the odds of willingness to get the COVID-19 vaccine (Abdulah, 2021; Handebo et al., 2021).

In contrast, willingness to receive the COVID-19 vaccine was higher than a study done in Congo, in which 27.7% of the study participants were willing to take the vaccine (Kabamba Nzaji et al., 2020). This inconsistency might be due to differences in the time gap and the study population. In our study, the COVID-19 vaccine willingness was assessed after the information was distributed through different media, and the attitude and knowledge level of the population changed as compared with the initial time of the COVID-19 vaccine began to be delivered. During the initial phase of the COVID-19 vaccine campaign, there were misinformation and rumors shared with the population about the vaccine’s safety, side effects, and efficacy, which will lead to hesitancy to get the vaccine. In addition, the study population from the Congo study was health care providers, so everyone can expect that health care providers may have a better way of understanding the vaccine effectiveness and possible side effects as compared with college students (Wang et al., 2021).

In our hypothesis, we confirm that some sociodemographic factors like being men, being a third-year student, and being married were factors affecting the willingness of the COVID-19 vaccine. The odds of having the willingness to receive the COVID-19 vaccine among male students were 1.45 times higher as compared with their counterparts. This study is supported by studies done in Ethiopia (Mesele, 2021), China (Wang et al., 2020), Jordan (El-Elimat et al., 2021), and Uganda (Echoru et al., 2021). The possible reason might be men are more exposed to different media and gather information related to the COVID-19 vaccine compared with women. These might provide comprehensive information and build a positive attitude and knowledge toward COVID-19 vaccine acceptance. Another reason might be that there is a sex difference in COVID-19 case mortality (Green et al., 2021) and immunity differences among men and women (Biswas, 2020).

This study revealed that the year of study of the students was positively associated with willingness to receive the COVID-19 vaccine. Accordingly, those third-year students were 1.88 times more likely to be willing to receive the COVID-19 vaccine as compared with second-year students. This might be due to the fact that willingness to get the COVID-19 vaccine is influenced by educational level. Evidence supports that a higher educational level increases individuals’ willingness to receive the COVID-19 vaccine (Abdulah, 2021). This is because people with a higher level of education might have a better possibility of grasping and applying knowledge, thus, they will respond to and accept the COVID-19 vaccine.

The marital status of respondents was also a predictor of willingness to receive the COVID-19 vaccine. Thus, married participants were 2.07 times more likely to be willing to receive the COVID-19 vaccine compared with their counterparts. This finding is supported by a study done in China (Wang et al., 2020). However, it is not consistent with the finding of the study done in Ethiopia (Belsti et al., 2021). This may be due to the fact that most married participants could share additional information with their husbands. Besides, married people may feel responsible and may take care of the family. This increases the awareness and changes the attitude of participants toward the importance of the COVID-19 vaccine. Moreover, the lack of shared information, motivation, decision, and responsibility from the husband in unmarried participants may affect willingness to get the COVID-19 vaccine.

Students who had a positive attitude toward COVID-19 prevention were 2.33 times more likely to be willing to receive the COVID-19 vaccine as compared with those students who had a negative attitude. This finding was consistent with studies done in Congo (Kabamba Nzaji et al., 2020), Jersey (Kecojevic et al., 2021), and China (Zhang et al., 2021). This might be due to the fact that participants who were optimistic and convinced that the disease would eventually be successfully controlled were more inclined to accept the COVID-19 vaccine as compared with those participants who had a poor attitude toward the disease, its transmission, and controlling movements were less likely to be willing to receive the COVID-19 vaccine.

This study also demonstrates that watching TV was a significant predictor of willingness to receive the COVID-19 vaccine. Accordingly, students who have ever watched TV were 61% less likely to be willing to receive the COVID-19 vaccine as compared with their counterparts (AOR: 0.39, 95% CI: 0.24–0.65). This finding contradicts a study done in Wolayita Sodo town (Mesele, 2021). It is expected that people who were exposed to different mass media have a better understanding and positive attitude toward the COVID-19 vaccine (Piltch-Loeb et al., 2021). Despite their huge contribution in maintaining a positive attitude toward COVID-19 prevention, some carless and private media centers may disseminate negative information. In this case, a single negative and uncertain information has the potential to disrupt the long-term collected trust of the participants.

These findings imply that, despite advocation being done by WHO and MOH of Ethiopia on the benefit of the COVID-19 vaccine, statistics are still indicative of low willingness to receive the COVID-19 vaccine. The authors strongly believe in the need for further health education and reiteration of the benefits of vaccines by different teaching methods.

Strength and Limitation of the Study

We used a self-administered survey by applying the standard precaution of COVID-19 prevention, which gives better data quality than an online survey. The finding shares the drawback of a cross-sectional study design. A longitudinal study may have paramount importance for such reports. Moreover, these sampled students are not representative of the whole population.

Conclusion

Nearly one-third of students had a willingness to receive the COVID-19 vaccine, which is low compared with previous studies. Being a third-year student, being men, being married, watching TV, and having a positive attitude toward COVID-19 prevention were factors associated with willingness to receive the COVID-19 vaccine. Thus, concerned bodies should prepare effective strategies that have the potential to increase the students’ willingness to receive the COVID-19 vaccine without hesitation. Thus, health education and sensitization of the students about the importance of the COVID-19 vaccine should be provided. In addition, care should be taken to mass media to disseminate factual information in a way that is adherent to the ministry of health and WHO.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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