Acceptance of the coronavirus disease-2019 vaccine among medical students in Uganda

Background COVID-19 is still a major global threat for which vaccination remains the ultimate solution. Uganda reported 40,751 cases and 335 deaths as of 9 April 2021 and started its vaccination program among priority groups like health workers, teachers, those with chronic diseases among others in early March 2021. Unanimous uptake of the COVID-19 vaccine is required to subsequently avert its spread; therefore, we 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 via Google Form was conveniently sent to eligible participants via WhatsApp. Each medical school had a coordinator who consistently shared the data tool in the WhatsApp groups. Chi-square or Fisher’s exact test, and logistic regression were used to assess the association between vaccine acceptability with demographics, COVID-19 risk perception, and vaccine hesitancy. Results We surveyed 600 medical students, 377 (62.8%) were male. COVID-19 vaccine acceptability was 37.3% and vaccine hesitancy 30.7%. Factors associated with vaccine acceptability were being male (adjusted odds ratio (aOR) = 1.9, 95% CI 1.3–2.9, p=0.001) and being single (aOR= 2.1, 95% CI 1.1–3.9, p=0.022). Very high (aOR= 3.5, 95% CI 1.7–6.9, 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). Conclusions This study revealed low levels of acceptance towards the COVID-19 vaccine among medical students, low self-perceived risks of COVID-19, and many had relied on social media that provided them with negative information. This poses an evident risk on the battle towards COVID-19 in the future especially when these future health professions are expected to be influencing decisions of the general public towards the same.


Introduction
The coronavirus disease-2019 (COVID-19) pandemic, caused by the novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) continues to create mayhem across the globe. COVID-19 has affected livelihoods and has imposed strains on the health care systems [1]. Over135 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 9 April 2021 [3].
Various chemotherapeutic and biologic therapies, like hydroxychloroquine, remdesivir, convalescent plasma, and tocilizumab, have been tried to treat COVID-19 patients [4][5][6] with no conclusive specific curative effect. 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 Pfizer-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-19 and its vaccines [11].
Medical students are regarded as an insightful population that is open-minded, educated, and 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 USA 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, is not automatic [14].
The Ugandan government through the COVAX facility received its first 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 15 March and Sunday 21 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 6000-8000 students.

Study population
Medical students pursuing the following undergraduate degree programs in these various universities were targeted: Bachelor of Medicine and Bachelor of Surgery

Inclusion and exclusion criteria
Individuals aged 18 years or older, currently, students in the abovementioned universities who consented to participate, were included and those students who could not 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 identified all the existing WhatsApp groups of medical students in the various universities through a coordinator for each specific university. The Google Form link to the questionnaire was then sent to the potential participants via the identified WhatsApp groups.

Data collection tool
We adapted a validated questionnaire as used by Tamam and colleagues [17] and modified it to suit our study population. The questionnaire was structured into four sections. The first section captured socio-demographic information including age, sex, program of study, university, religion among others. The second section assessed COVID-19 pandemic-related information entailing whether the participant was confirmed to be infected with COVID-19 or thought so, if they knew anyone who was infected and confirmed by laboratory test. It also assessed what they thought was the magnitude of threat COVID-19 posed to them, the entire Uganda, and if they believed to have already acquired immunity against COVID-19. The third section was about acceptance and hesitancy to COVID-19 vaccines where participants were asked if they would take the vaccine when availed and give reason for their answers. It also assessed if participants had been reluctant or refused to take vaccines in the past 5 years. The fourth section assessed the attitude towards the COVID-19 vaccine.

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, TX, 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

Acceptability of COVID-19 vaccine and associated factors among medical students
The majority of the participants (n=376, 62.7%) were not willing to be vaccinated against COVID-19. The most cited reasons for not taking up the vaccine were concerns about safety (n=242, 64.4%) and having heard or read negative information about the vaccine (n=201, 53.5%). Of those that reported to have heard negative information about COVID-19 vaccine (n=575, 95.8%), the biggest sources were from social media (n=521, 90.6%), and friends (n=325, 56.5%) (Fig. 1). For the participants willing to take up the COVID-19 vaccine (n=224, 37.3%), the major reasons for acceptance were to protect oneself (n=191, 85.3%) and others (n=142, 63.4%) from COVID-19. Close to half (n=111, 49.6%) of the participants believed in vaccines and immunization. Table 2 summarizes reasons for acceptance and hesitancy of the COVID-19 vaccine.
Of the 224 participants willing to be vaccinated, the majority (n=84, 38%) were indifferent to the particular vaccine they would take, 34% (n=77) would wish to take the Pfizer-BioNTech vaccine, and only 19% the AstraZeneca vaccine (Fig. 2).
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 five years (p=0.028) and reluctance or hesitancy to vaccination (p=0.004) were significantly associated with acceptability of COVID-19 vaccine (Table 3).

Vaccine hesitancy among medical students
About two third (66.8%, n=401) of the participants had not received any vaccine in the past 5 years. 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).

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 find the COVID-19 vaccine acceptability, hesitancy, and associated factors among medical students in Uganda. To our knowledge, this is the first 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%) [18]. 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 [19]. 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 [18]. This finding 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 [20].This study reveals that males are twice more likely to take up the COVID-19 vaccine than their female counterparts, a finding that has been reported by other studies [19,21]. Our earlier study among Ugandan medical students showed higher negative attitudes among females towards COVID-19 which further underscores this finding [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 findings are much lower than reported among Egyptian medical students (46%) [18]; however, relatively similar findings 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%) [22].This discrepancy could be explained by the variable impact of COVID-19 across the globe with a less severe form of the disease and cases in Africa and Uganda in particular. This could directly affect individuals' risk perception of COVID-19 and undermine their decision to take up the vaccine.
In a multicenter study, Evridiki et al. reported that increased risk perception towards COVID-19 was associated with the likely uptake of the COVID-19 vaccine [19].Indeed our results show that the highest proportion (30.5%) of students perceived a slight risk of getting COVID-19 in future, and 34.3% were not worried about the disease and it is surely not surprising that uptake was likely among participants that perceived high risk of getting COVID-19 in the future. The most given reason for hesitancy towards the COVID-19 vaccine in this study was concern about its safety and side effects as similarly reported in various other studies [13,18,19,22].
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 influence decisions of the general public who seek information from them towards the uptake of vaccines [23,24]. 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. [21] reported that respondents who did not rely on social media as their source of information were likely to accept the vaccine similar to Saied et al. [18] who showed that the hesitancy group reported social media as their major source of COVID-19 information. It is 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 was not 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 medical students to take up the vaccine and providing information about the safety and effectiveness of these vaccines