Background: Vaccines are effective and ultimate solution that can decrease the burden of Coronavirus disease-19 worldwide. However, poor knowledge and unwillingness to accept this vaccine are key barriers to manage the coronavirus disease-19 pandemic in different country including Ethiopia. The control of pandemic principal will depend on acceptance of coronavirus disease vaccine. Therefore, there is paucity of evidence on coronavirus disease vaccine acceptance in the study area. The current study was aimed to assess willingness to accept coronavirus disease-19 vaccine and associated factors among adult clients attending Bule Hora University Teaching Hospital, west Guji zone, southern Ethiopia.

Methods:

Institution based cross sectional study was conducted among 385 study participants which was selected by Systematic random sampling technique. Data was collected through observation and structured questionnaires from April 10 to May 30, 2022. The collected data was cleaned and entered into Epi data 3.1 software before being exported to SPSS 25 statistical software for analysis. Bi-variable and multi-variable binary logistic regression model was used to identify the predictors of coronavirus disease-19 vaccine acceptance. The strength of association was measured using AOR with 95% confidence interval and significance was declared at p- value < 0.05.

Result: Magnitude of willingness to accept coronavirus disease-19 vaccine was 67.5 % (95%Cl: 63 -72). Good knowledge (AOR= 2.07, (1.17-3.64), history of chronic disease (AOR= 2.59(1.4-4.78) government employee (AOR= 2.35(1.1-5), favorable attitude (AOR= 14.15(5.25-37.46) and good adherence (AOR=1.74(1.023-2.97) were factors that significantly associated with willingness to accept coronavirus disease-19 vaccine.

Conclusion: Magnitude of willingness to accept coronavirus disease-19 vaccine was considerable and needs to be improved. Knowledge, attitude, chronic illness, adherence, and being government employee were factors that associated with willingness to accept coronavirus disease-19 vaccine. Community awareness, advocacy, social mobilization and health education should be given at different levels.

A COVID-19 vaccine is a vaccine intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), the virus that causes coronavirus disease 2019[1]. Vaccines are life-saving inventions that have been responsible for the suppression and control of many infectious diseases in many parts of the world [2]. In addition to providing direct immunity and preventing disease among vaccinated individuals, they have been shown to protect unvaccinated individuals through herd immunity, if a greater proportion of the population is immune [2].As the number of cases of coronavirus disease (COVID-19) is increasing world-wide, promising COVID-19 vaccine candidates are being produced, like Astra Zeneca, Johnson and Johnson and Sino pharm and Pfizer vaccine to fight the coronavirus disease (COVID-19) pandemic, researchers from all over the world have made remarkable efforts to create vaccines against the disease [3–5].

After the incidence of COVID- 19, pandemic WHO and health care institutions are working on prevention, diagnosis, and treatment including the development of COVID-19 vaccine were manufactured with one year after WHO confirmed COVID-19 to be the global public health emergence. Due to outstanding determination in vaccine research COVID-19 vaccine were developed within short period of time in vaccine history [6]. Astra Zeneca vaccine is one of vaccine developed in serum Institute of India (SII) were provided to Ethiopia on 6 march 2021 with the aim of reduction of recent COVID-19 infection [6]. The COVID-19 Vaccines Global Access (CovAx) facility allocated 7,620,000 doses of COVID-19 vaccine for Ethiopia of which about 2,184,000 doses were already received [7]. According to recent Global delivery plan, 5.4 million doses of the COVID-19 vaccine are expected to reach Ethiopia by May 2021, according to the ministry of health aim 20% of the population in Ethiopia is planned to be vaccinated by the end of 2021[8].

Thus, the main source of vaccine hesitance may be due to considerable amount of misinformation regarding the COVID-19 vaccine that was flowing on social media [9]. Globally, Willingness to accept the COVID-19 vaccine, reported to be 71.7% in the United Kingdom [10], and range from 31–74% in Hungary, Japan and Israel [11]. The willingness to take COVID-19 vaccine was found to be 40% in china [12]. In Africa around 63% of all participants surveyed were eager to accept the COVID-19 vaccine [13]. Systematic review and meta-analysis in Ethiopia revealed that over all magnitude of COVID-19 vaccine acceptance was 56.02% [14].

Therefore, vaccine up take can be influenced by various risk factors including perception that cause adverse effect, attitude towards vaccination, knowledge of vaccine, misconception, fear of unforeseen side effect, social influence and trust in the health care professional and having increased information about COVID-19 vaccine [15]. Being female, older age, marital status, residence, occupations, not having a health-related job, religion, educational status were statistically significantly associated with willingness to receive the COVID-19 vaccine [16].

However, poor knowledge and unwillingness to receive vaccination is potential barrier to handle the COVID-19 pandemic in long term and cause a heavy burden of morbidity, mortality and economic crisis around Globe. Since, vaccination are central to the control of COVID-19 its’ success relies on having safe and effective vaccination and also high level of vaccine up take by public over time [17, 18]

Globally, over 1.3 million doses of COVID-19 vaccine have been ordered with 4.1% of the individuals being fully vaccinated as of 10 May 2021[19]. In Africa with 49 countries now rolling out COVID-19 vaccines, as of May 2021, more than 30 countries have less than 1% coverage with a continental average of 2.5% [20]. Ethiopia received about 2.2 million doses of AstraZeneca COVID-19 vaccines in March, 2021 and sources disclose that close to 1.9 million people in Ethiopia have already been vaccinated for the first dose of AstraZeneca [21].

In Oromia, currently around 42.2% of health workers were accepted COVID-19 vaccine [22]. The suppression of the ongoing community spread of COVID-19 disease is only possible with adequate vaccine coverage to develop herd immunity within community and through mass media and non-governmental agency like WHO, government are continuously working to build vaccine literacy among the public to accept the vaccine when is available and appropriate [23]. Regardless of this effort to reduce the burden of COVID-19 via vaccination and other measure, unwillingness to take COVID-19 vaccine was increased worldwide and hindering the effort to control its spread [24].

However, knowledge, attitude toward COVID-19 vaccine, adherence level to mitigation measures, presence of chronic disease was not well known in the southern part of Oromia and study area [3, 25]. Therefore, the current study was aimed to assess willingness accept COVID-19 vaccine and its predictors.

Materials and Methods

Study design and setting

A cross sectional study was conducted at Bule Hora university teaching hospital west Guji zone, Oromia, south Ethiopia from April 10 to May 30, 2022. It is 467 kilometers from Addis Ababa. The hospital served around 1,568,547 people and employed 408 staff (117 administrative and 233 are clinical staffs). In the year 2021, about 3528 patients will be served in the outpatient service at Bule hora teaching hospital.

Inpatient services at Bule Hora University Teaching Hospital include obstetric, gynaecologic, and neonatal intensive care units, as well as medical and surgical wards. Outpatient services include ANC, Post-natal care, ART clinic, PMTCT, Family planning, ophthalmology care, psychiatry, dental care, Cervical Cancer screening, Under-5 OPD, Emergency OPD, and Adult OPD's. Additional services include laboratory and pharmaceutical services, as well as US and x-ray services.

Population and Sampling

All clients aged ≥ 18 years attending Bule Hora University teaching hospital were source population while, all randomly selected client aged ≥ 18 years attending Bule Hora University teaching hospital during data collection time were study population. Those clients who had got vaccinated were excluded.

The samples size for the first objective was calculated by using a single population proportion formula considering 59.4% [26] proportion of willingness to receive COVID-19 vaccine from previous study with assumptions of confidence level at 95%, a margin of error (d) 5% and adding 10% for non-response as follows:

The sample size for the second specific objective was determined by considering factors that were significantly associated with the outcome variable, two-sided confidence level of 95%, the margin of error of 5%, power of 80% and the ratio of exposed to unexposed 1:1 using EPI-Info software. Considering 10% for nonresponse the final sample size for the second objective was determined. Hence, the largest sample size was taken from first objective, 385.

Six out patients’ departments were chosen from a total department in the hospital using a simple random sampling technique by lottery method. A systematic random sampling procedure was used to choose clients from these six out patients departments that were chosen; the first clients was selected using a simple random sampling technique, and then others were selected at 9 regular intervals until the required sample size was reached.

Data Collection Procedure and Instrument

The data were collected through interview and observation using a pre-tested structured questionnaire, which was adapted from published papers [16, 25–27]. It consists of four sections including, socio-demographic characteristics, knowledge about COVID-19 vaccine, attitude towards COVID-19 vaccine, adherence to ward COVID19 mitigation measures, and willingness to receive COVID-19 vaccine. Prior to data collection, two days training was given for data collectors and supervisors on the study objectives, subject eligibility criteria and data collection methods. The data was collected by 6 BSc nurses and supervised by 2 BSc nurse.

Study Variables and measurement

Outcome variable

Willingness to accept COVID-19 vaccine

Independent variables

Socio demographic factors: age, sex, educational status, income, occupation status, marital status, residence sand ethnicity.

Knowledge of COVID-19 vaccine, adherence to ward COVID-19, attitude toward COVID-19 vaccine, and information about COVID-19 vaccine.

Operational Definition

Willingness Mean a state of being prepared or readiness to receive COVID19 vaccine. COVID-19 vaccine acceptance was measured using “Yes” and “No” questions, the participant was asked “Are you willing to be vaccinated against COVID-19?” [26]

Knowledge Has eight items that was used to assess knowledge level of client about COVID-19 vaccine. Those who correctly answered the question, coded as “1”, while incorrect one was given “0” values. Participant who scored 70% and above was considered as having good knowledge while those who scored less than 70% was considered as having poor knowledge towards the COVID-19 vaccine [26].

Attitude mean it’s a settled way of thinking or point of view about COVID-19 vaccine, of patient attending hospital was assessed by assigning one point for each correct answer and the attitude level indicated by Likert scale. Those clients who are strongly agree 5 points, agree 4point, Nutral 3 point, disagree 2 strongly disagree got 1 for positive question and vice versa for negative one. The respondent attitude range from1 to 25 with cutoff point greater than equal ≥ 44% (11–25) were considered as favorable attitude while less < 40% were taken as unfavorable attitude toward COVID-19 vaccine [26].

Data Quality control

To ensure data quality pre-test was conducted among 5% of the sample size in Yabello General Hospital to ensure the validation of the tool. Hence, amendment was done based on the feedback of the pre-test before the commencement of the final data collection. Two days training was given for the data collectors and supervisors on the aim of the study, clarity of the measuring tool, and ethical considerations. The quality of data was monitored frequently in the field through close supervision of data collectors. All completed questionnaire was checked for their completeness, accuracy and consistency by supervisor and investigator before leaving the health facility. The reliability of variables such as knowledge (Cronbach’s α = 0.792), attitude (Cronbach’s α = 0.782) and adherence to mitigation measure (Cronbach’s α = 0.791) acceptance toward COVID-19 was determined using Cronbach’s alpha coefficient.

Data Processing and Analysis

The coded data were entered in to epidata software version 3.1 and it was exported to SPSS version 25 for further analysis. Descriptive statistics were computed to describe sample population characteristics relevant to the variables. Logistic regression was fitted to identify factors associated with willingness to accept COVID-19 vaccine. The analysis was conducted to select candidate variables for the multivariable model. Those variables that show association with willingness at a p-value less than 0.25 was included in multivariable logistic regression model. Both crude and adjusted odds ratios with their corresponding 95% confidence interval were used to determine the strength of association. Multicollinearity was checked by using VIF to see correlation between independent variables, the result showed that no variables with VIF > 10 was observed. The model goodness of fit was tested by the Hosmer and Lemeshow statistical test, the model was considered a good fit since it was found to be non-significant for Hosmer and Lemeshow (P = 0.651). Statistical significance was declared at p-value < 0.05.

A COVID-19 vaccine is a vaccine intended to provide acquired immunity against severe acute respiratory syndrome coronavirus 2 (SARSCoV-2), the virus that causes coronavirus disease 2019[1]. Vaccines are life-saving inventions that have been responsible for the suppression and control of many infectious diseases in many parts of the world [2]. In addition to providing direct immunity and preventing disease among vaccinated individuals, they have been shown to protect unvaccinated individuals through herd immunity, if a greater proportion of the population is immune [2].As the number of cases of coronavirus disease (COVID-19) is increasing world-wide, promising COVID-19 vaccine candidates are being produced, like Astra Zeneca, Johnson and Johnson and Sino pharm and Pfizer vaccine to fight the coronavirus disease (COVID-19) pandemic, researchers from all over the world have made remarkable efforts to create vaccines against the disease [3–5].

After the incidence of COVID- 19, pandemic WHO and health care institutions are working on prevention, diagnosis, and treatment including the development of COVID-19 vaccine were manufactured with one year after WHO confirmed COVID-19 to be the global public health emergence. Due to outstanding determination in vaccine research COVID-19 vaccine were developed within short period of time in vaccine history [6]. Astra Zeneca vaccine is one of vaccine developed in serum Institute of India (SII) were provided to Ethiopia on 6 march 2021 with the aim of reduction of recent COVID-19 infection [6]. The COVID-19 Vaccines Global Access (CovAx) facility allocated 7,620,000 doses of COVID-19 vaccine for Ethiopia of which about 2,184,000 doses were already received [7]. According to recent Global delivery plan, 5.4 million doses of the COVID-19 vaccine are expected to reach Ethiopia by May 2021, according to the ministry of health aim 20% of the population in Ethiopia is planned to be vaccinated by the end of 2021[8].

Thus, the main source of vaccine hesitance may be due to considerable amount of misinformation regarding the COVID-19 vaccine that was flowing on social media [9]. Globally, Willingness to accept the COVID-19 vaccine, reported to be 71.7% in the United Kingdom [10], and range from 31–74% in Hungary, Japan and Israel [11]. The willingness to take COVID-19 vaccine was found to be 40% in china [12]. In Africa around 63% of all participants surveyed were eager to accept the COVID-19 vaccine [13]. Systematic review and meta-analysis in Ethiopia revealed that over all magnitude of COVID-19 vaccine acceptance was 56.02% [14].

Therefore, vaccine up take can be influenced by various risk factors including perception that cause adverse effect, attitude towards vaccination, knowledge of vaccine, misconception, fear of unforeseen side effect, social influence and trust in the health care professional and having increased information about COVID-19 vaccine [15]. Being female, older age, marital status, residence, occupations, not having a health-related job, religion, educational status were statistically significantly associated with willingness to receive the COVID-19 vaccine [16].

However, poor knowledge and unwillingness to receive vaccination is potential barrier to handle the COVID-19 pandemic in long term and cause a heavy burden of morbidity, mortality and economic crisis around Globe. Since, vaccination are central to the control of COVID-19 its’ success relies on having safe and effective vaccination and also high level of vaccine up take by public over time [17, 18]

Globally, over 1.3 million doses of COVID-19 vaccine have been ordered with 4.1% of the individuals being fully vaccinated as of 10 May 2021[19]. In Africa with 49 countries now rolling out COVID-19 vaccines, as of May 2021, more than 30 countries have less than 1% coverage with a continental average of 2.5% [20]. Ethiopia received about 2.2 million doses of AstraZeneca COVID-19 vaccines in March, 2021 and sources disclose that close to 1.9 million people in Ethiopia have already been vaccinated for the first dose of AstraZeneca [21].

In Oromia, currently around 42.2% of health workers were accepted COVID-19 vaccine [22]. The suppression of the ongoing community spread of COVID-19 disease is only possible with adequate vaccine coverage to develop herd immunity within community and through mass media and non-governmental agency like WHO, government are continuously working to build vaccine literacy among the public to accept the vaccine when is available and appropriate [23]. Regardless of this effort to reduce the burden of COVID-19 via vaccination and other measure, unwillingness to take COVID-19 vaccine was increased worldwide and hindering the effort to control its spread [24].

However, knowledge, attitude toward COVID-19 vaccine, adherence level to mitigation measures, presence of chronic disease was not well known in the southern part of Oromia and study area [3, 25]. Therefore, the current study was aimed to assess willingness accept COVID-19 vaccine and its predictors.

Materials and Methods

Study design and setting

A cross sectional study was conducted at Bule Hora university teaching hospital west Guji zone, Oromia, south Ethiopia from April 10 to May 30, 2022. It is 467 kilometers from Addis Ababa. The hospital served around 1,568,547 people and employed 408 staff (117 administrative and 233 are clinical staffs). In the year 2021, about 3528 patients will be served in the outpatient service at Bule hora teaching hospital.

Inpatient services at Bule Hora University Teaching Hospital include obstetric, gynaecologic, and neonatal intensive care units, as well as medical and surgical wards. Outpatient services include ANC, Post-natal care, ART clinic, PMTCT, Family planning, ophthalmology care, psychiatry, dental care, Cervical Cancer screening, Under-5 OPD, Emergency OPD, and Adult OPD's. Additional services include laboratory and pharmaceutical services, as well as US and x-ray services.

Population and Sampling

All clients aged ≥ 18 years attending Bule Hora University teaching hospital were source population while, all randomly selected client aged ≥ 18 years attending Bule Hora University teaching hospital during data collection time were study population. Those clients who had got vaccinated were excluded.

The samples size for the first objective was calculated by using a single population proportion formula considering 59.4% [26] proportion of willingness to receive COVID-19 vaccine from previous study with assumptions of confidence level at 95%, a margin of error (d) 5% and adding 10% for non-response as follows:

The sample size for the second specific objective was determined by considering factors that were significantly associated with the outcome variable, two-sided confidence level of 95%, the margin of error of 5%, power of 80% and the ratio of exposed to unexposed 1:1 using EPI-Info software. Considering 10% for nonresponse the final sample size for the second objective was determined. Hence, the largest sample size was taken from first objective, 385.

Six out patients’ departments were chosen from a total department in the hospital using a simple random sampling technique by lottery method. A systematic random sampling procedure was used to choose clients from these six out patients departments that were chosen; the first clients was selected using a simple random sampling technique, and then others were selected at 9 regular intervals until the required sample size was reached.

Data Collection Procedure and Instrument

The data were collected through interview and observation using a pre-tested structured questionnaire, which was adapted from published papers [16, 25–27]. It consists of four sections including, socio-demographic characteristics, knowledge about COVID-19 vaccine, attitude towards COVID-19 vaccine, adherence to ward COVID19 mitigation measures, and willingness to receive COVID-19 vaccine. Prior to data collection, two days training was given for data collectors and supervisors on the study objectives, subject eligibility criteria and data collection methods. The data was collected by 6 BSc nurses and supervised by 2 BSc nurse.

Study Variables and measurement

Outcome variable

Willingness to accept COVID-19 vaccine

Independent variables

Socio demographic factors: age, sex, educational status, income, occupation status, marital status, residence sand ethnicity.

Knowledge of COVID-19 vaccine, adherence to ward COVID-19, attitude toward COVID-19 vaccine, and information about COVID-19 vaccine.

Operational Definition

Willingness Mean a state of being prepared or readiness to receive COVID19 vaccine. COVID-19 vaccine acceptance was measured using “Yes” and “No” questions, the participant was asked “Are you willing to be vaccinated against COVID-19?” [26]

Knowledge Has eight items that was used to assess knowledge level of client about COVID-19 vaccine. Those who correctly answered the question, coded as “1”, while incorrect one was given “0” values. Participant who scored 70% and above was considered as having good knowledge while those who scored less than 70% was considered as having poor knowledge towards the COVID-19 vaccine [26].

Attitude mean it’s a settled way of thinking or point of view about COVID-19 vaccine, of patient attending hospital was assessed by assigning one point for each correct answer and the attitude level indicated by Likert scale. Those clients who are strongly agree 5 points, agree 4point, Nutral 3 point, disagree 2 strongly disagree got 1 for positive question and vice versa for negative one. The respondent attitude range from1 to 25 with cutoff point greater than equal ≥ 44% (11–25) were considered as favorable attitude while less < 40% were taken as unfavorable attitude toward COVID-19 vaccine [26].

Data Quality control

To ensure data quality pre-test was conducted among 5% of the sample size in Yabello General Hospital to ensure the validation of the tool. Hence, amendment was done based on the feedback of the pre-test before the commencement of the final data collection. Two days training was given for the data collectors and supervisors on the aim of the study, clarity of the measuring tool, and ethical considerations. The quality of data was monitored frequently in the field through close supervision of data collectors. All completed questionnaire was checked for their completeness, accuracy and consistency by supervisor and investigator before leaving the health facility. The reliability of variables such as knowledge (Cronbach’s α = 0.792), attitude (Cronbach’s α = 0.782) and adherence to mitigation measure (Cronbach’s α = 0.791) acceptance toward COVID-19 was determined using Cronbach’s alpha coefficient.

Data Processing and Analysis

The coded data were entered in to epidata software version 3.1 and it was exported to SPSS version 25 for further analysis. Descriptive statistics were computed to describe sample population characteristics relevant to the variables. Logistic regression was fitted to identify factors associated with willingness to accept COVID-19 vaccine. The analysis was conducted to select candidate variables for the multivariable model. Those variables that show association with willingness at a p-value less than 0.25 was included in multivariable logistic regression model. Both crude and adjusted odds ratios with their corresponding 95% confidence interval were used to determine the strength of association. Multicollinearity was checked by using VIF to see correlation between independent variables, the result showed that no variables with VIF > 10 was observed. The model goodness of fit was tested by the Hosmer and Lemeshow statistical test, the model was considered a good fit since it was found to be non-significant for Hosmer and Lemeshow (P = 0.651). Statistical significance was declared at p-value < 0.05.