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Human Vaccines & Immunotherapeutics Volume 17, 2021 - Issue 12
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Research Paper

Guarding against COVID-19 vaccine hesitance in Ghana: analytic view of personal health engagement and vaccine related attitude

Prince Clement Addoa Applied Sciences and Mathematical Education, Akenten Appiah-Menka University of Skills Training and Entrepreneurial Development, Kumasi, GhanaCorrespondence[email protected] [email protected]
ORCID Iconhttps://orcid.org/0000-0002-8105-7222View further author information
ORCID Icon,
Nora Bakabbey Kulbob School of Management and Economics, University of Electronic Science and Technology of China, Chengdu, ChinaORCID Iconhttps://orcid.org/0000-0002-3262-8156View further author information
ORCID Icon,
Kwamena Ato Sagoea Applied Sciences and Mathematical Education, Akenten Appiah-Menka University of Skills Training and Entrepreneurial Development, Kumasi, GhanaORCID Iconhttps://orcid.org/0000-0002-7803-7001View further author information
ORCID Icon,
Andy Asare Ohemengc School of Business, George Brown College, Toronto, CanadaORCID Iconhttps://orcid.org/0000-0002-5939-6578View further author information
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Enyonam Amuzud School of Public Health, University of Massachusetts Amherst, Amherst, MA, USAView further author information
Pages 5063-5068 | Received 25 Aug 2021, Accepted 17 Nov 2021, Published online: 14 Dec 2021

ABSTRACT

Vaccination is the most effective preventive measure against COVID-19 spread. While the WHO and other stakeholders fear vaccine nationalism, vaccine-hesitancy has become a topical issue among experts. Based on the evidence of vaccine hesitancy among Blacks, we explore the interrelatedness of psycho-social factors (personal health engagement, fear of COVID-19, perceived susceptibility, and vaccine-related attitude) likely to thwart vaccine acceptance in Africa. We sampled 1768 Ghanaian adults over 2 weeks from December 14, 2020, the first day a successful COVID-19 vaccine was administered in the US using an online survey. A higher level of personal health engagement was found to promote vaccine-related attitudes while reducing COVID-19 related fears, susceptibility, and vaccine hesitancy. Fear of COVID-19 and perceived vulnerability are significant contributors to the willingness to accept vaccination. This is an indication that health engagement alone will not promote vaccination willingness, but the fear and higher level of perceived susceptibility out of personal evaluation are essential factors in vaccination willingness. We recommend promoting health educational messages on COVID-19 vaccination ahead of any vaccination rollout in Africa, and such messages should contain some element of fear appeal.

Introduction

Vaccine hesitancy is among the top ten global threats to public health. According to the WHO, vaccine hesitance is the refusal or reluctance to accept vaccination despite its availability.Citation1 Vaccine hesitancy has become a key area for practitioners, governments, academia, and other public health stakeholders. Many believe that no one is safe until everyone is vaccinated in the wake of COVID-19. Before the release of WHO sanctioned COVID-19 vaccines (Pfizer-BioNTech and Moderna), several studies were on hesitancy toward a possible vaccine.Citation2–4 However, with some vaccines being administered and the expectation of many other vaccines to come, hesitancy issues seem not to be on the radial. There are recent reports on the number of blacks who, for various reasons, are hesitant to get any COVID-19 vaccine. According to a CNN report, close to a third of Black-Americans are reluctant to get COVID-19 vaccines even when Pfizer-BioNTech and Moderna are successfully rolled out,Citation5 which is an indication to take and consider vaccine hesitancy more seriously within the African continent.

In Africa, denialism of HIV as a etiology agent of AIDS resulted in about 333,000 preventable deaths.Citation6,Citation7 Conspiracy theories are equally identified as one of the reasons Nigeria is unable to eradicate polio. This is attributed to the belief that polio vaccines vaccine may have had human immunodeficiency virus (HIV), an anti-fertility hormone, and other carcinogenic (cancerous) substances.Citation8 Similarly, many conspiracy theories exist on COVID-19, including the fact that the effects of COVID-19 have not been as devastating in Africa as in other parts of the world, making many believe Africans have some immunity and the hot weather as an aiding factor. However, there is no proven fact concerning these theories, especially when Blacks worldwide are dying of COVID-19.Citation9 It is, therefore, essential to explore possible hesitancy to COVID-19 in the African context. Even before any COVID-19 vaccine made it to Africa, we believe this study will give stakeholders a better perspective on the nature of health engagement and vaccination protocol to employ.

Through its public service announcement on coronavirus, the WHO has announced a new variant of COVID-19 referred to on social media as “COVID-19 vs. 2.0,” first reported in the UK, which is more contagious compared to version 1.Citation10,Citation11 This variant is already found in many parts of Africa’s populated countries, including Nigeria and South Africa. Many believe that the African continent might not be that ‘lucky’ with the current variant. Following the US, Canada, and the UK, the European Union has launched its mass COVID-19 vaccination programCitation12 with many other countries in the advanced stages of securing the vaccine for their citizens. As of December 27, 2020, no African country has secured any vaccines nor has published guidelines for mass vaccination. Many described as vaccine nationalism, where a country secures vaccines and prioritizes its citizens and domestic market ahead of others, is likely to impact the fight against COVID-19 in developing countries, including Ghana.Citation13

Even though debates on vaccine hesitancy are endless, many of these debates focused on countries outside Africa. They are mostly on efficacy and safety perceptions, beliefs, racial perception, prior vaccination history, side effects, source, trust, and attitude but not on interventional education.Citation3,Citation4,Citation14 In a related study, the authors recommended interventional education to avert possible hesitancy.Citation15 Understanding existing health engagement will be a starting point for planning and applying interventional education in dealing with COVID-19 vaccine hesitancy. Based on this call for interventional education and the evidence of vaccine hesitancy among Blacks, we explore the interrelatedness of psycho-social factors likely to thwart vaccine acceptance in Africa. Establishing these factors will provide stakeholders with enough ideas on the target groups and appropriate measures such as personalized counseling initiatives and education in tackling vaccine hesitancy ahead of any vaccination in Africa.

Health education and engagement are vital concepts that affect an individual’s preventive behavior.Citation16 The literature argues that personal health engagement (PHE), the involvement, empowerment, and personal proactiveness in the management of health-related issues affects people’s perceived severity, susceptivity, and efficacy in health matters.Citation17,Citation18 Research has advocated for further examination of vaccine-related PHE studies. Few works on COVID-19 vaccination have explored this concept in recent times as a behavioral health antecedent. PHE is known to change individuals from being dazed by the COVID crisis to recapturing a positive role in controlling their health and positively managing it.Citation19 PHE evaluates the level of consciousness people have of their responsibility and role toward their health.Citation20,Citation21

In filling these lapses, the current study surveyed Ghanaian resident adults to understand how PHE, perceived COVID susceptivity, vaccine attitude, and fear of COVID affect vaccine acceptance among African residents in Africa.

Direct association hypotheses

  1. Personal health engagement has a negative association with the fear of COVID-19.

  2. The fear of COVID-19 has a positive association with the COVID-19 vaccine attitude.

  3. The fear of COVID-19 has a positive association with the willingness to take a COVID-19 vaccine.

  4. Personal health engagement has a positive association with COVID-19-related vaccine attitude.

  5. Personal health engagement has a negative association with perceived COVID-19 susceptivity.

  6. Perceived COVID-19 susceptivity has a positive association with vaccine attitude.

  7. Perceived COVID-19 susceptivity has a positive association with the willingness to take a COVID-19 vaccine.

  8. Personal health engagement has a positive association with the willingness to take COVID-19 vaccines.

  9. Individual’s vaccine attitude has a positive association with their willingness to take COVID-19 vaccines.

We also proposed indirect associations between the variables, as indicated in .

A summary of the study’s direct path hypothesis is shown in .

Figure 1. Summary of hypotheses.

Figure 1. Summary of hypotheses.

Materials and method

Participants

A random sample of 1933 Ghanaian adults from all 16 regions responded to online questionnaire items over a 14-day period from December 14, 2020, the first day a successful COVID-19 vaccine was administered in the US to December 28, 2020. Knowledge about a successful vaccine, personal health engagement, perceived susceptivity to COVID-19 and the related fear of COVID-19, vaccine-related attitude, and the intention to accept vaccination against COVID-19 were asked. Additional self-reported items on gender, educational level, religiosity, and age distribution were asked. A publicly available survey platform and social media were used to administer the questionnaire with anonymous URLs after the formal ethical approval granted by the University of xxxxxx (double-blind). Respondents consented to participate and were allowed to exit the survey at any point.

Several quality-control checks were introduced. First, a question on whether or not the respondent had previously respondent to these items was introduced. All ‘Yes’ and ‘I think so’ responses were eliminated. Next, an average response time was calculated from the pretest and was used as one of the quality-control checks. The participants with less than half the average time, more than 80% of the same response (e.g., agree), those below age 18, and incomplete response were equally eliminated from the final dataset. A total of 1768 data sample was finally used for this study after the data cleaning. Demographic characteristics are presented in .

Table 1. Study sample demographics

Measurements

The PHE scale has seven dimensions: health ownership, motivation to change behavior, actionable, utilize support network, knowledge, resourcefulness, and adaptability.Citation22 A modified version of this PHE scale directed to COVID-19 measured over a 7-point Likert scale (strongly agree to strongly disagree) with a reliability score of 0.83 was used in this study. The seven-item fear of COVID-19 (FC-19) scale with a reliability score of 0.89, measured over a 7-point scale, was used to measure the fear of COVID-19.Citation23 The items include (“It makes me uncomfortable to think about Corona,” “My hands become clammy when I think about Corona,” “I am afraid of losing my life because of Corona”). Covid-19 Susceptibility (CS) was measured with a modified (COVID-19 specific) health belief model self-examination 5-item susceptibility subscale (Cronbach alpha score = 0.88).Citation24 The items include “The possibility that I will have COVID-19 very high,” In comparison to others, the possibility that I will have COVID-19 is high”. The 12-item vaccination attitudes examination (VAX) scale scored over a 7-point Likert-like scale was adapted and revised concerning COVID-19. All items were positively stated (Cronbach alpha = 0.89).Citation25 The items include “I do not worry about the unknown effects of vaccines in the future,” “I will feel safe after being vaccinated,” and “I can rely on vaccines to stop serious infectious diseases.” Finally, vaccination willingness (VW) was measured with a single item, “How willing are you to take a COVID-19 vaccine?” over a 7-point score.Citation26

Results

Shown in is the baseline characteristics of the respondents. The highest proportion (52.715%) of the respondents are between 18 and 35, with men representing about 57% One percent (1%) of the respondents stated that their belief system is against vaccination. The majority of the 67.986% have college/university or higher levels of education.

Spearman’s correlation test in suggests a significant correlation between the critical variables with all the indexes below the 0.7 thresholds vouching for no multicollinearity and the grounds for conducting regression analysis.

Table 2. Spearman’s test of correlation

In is the direct and total effects of the model. The parameter estimates revealed a significant, negative association between public health engagement toward COVID-19 vaccination and the fear of COVID-19 (β = −0.439; p < .001). Also, the relationship between personal health engagement concerning COVID-19 vaccination and COVID-19 susceptivity produced a negative effect (β = −0.476; p < .01). The results here point to the fact that as an individual’s health engagement on COVID-19 increases, their fear and susceptivity to COVID-19 decreases significantly and explains about 43% and 47% of the variance in fear of COVID-19 and COVID-19 susceptivity, respectively. The direct relationship between personal health engagement and vaccine attitude (β = 0.633; p < .001) and vaccination willingness (β = 0.177; p < .01), however, produced a significant, positive effects. Both COVID-19 and COVID-19 susceptivity fear have a significantly positive association with vaccine attitude and vaccination willingness. As such, the fear of COVID-19 (β = 0.273; p < .01), COVID-19 susceptivity (β = 0.331); p < .01), and personal health engagement resulted in about 56% of variance in vaccinate attitude. With all contributing positive significant effects, we can argue that even though personal health engagement reduces the fear and susceptivity to COVID-19, their combined effect as far as this study is concerned resulted in an increasingly positive change in vaccine attitude. After controlling for age, gender, level and education, and religiosity, the model produced a little over 73% of the variance in the willingness to accept COVID-19 vaccination among the study population.

Figure 2. Direct and total effects.

Figure 2. Direct and total effects.

Indirect path analysis is presented in . The relationships as established between these variables were partially mediated. In particular, the fear of COVID-19, COVID-19 susceptivity, and vaccine attitude were the mediating variables playing simple, parallel, and serial mediations are different stages. With the partial mediation effect of the fear of COVID-19, person health engagement produced a positive significant relationship with vaccination willingness (β = .037. SE = .083, LL = .051, UL = .091) and vaccine attitude (β = .018. SE = .092, LL = .099, UL = .372), such that an increased PHE resulted in the reduction in the fear of COVID-19 and its susceptivity leading to people positive attitude toward vaccines and the willingness to take COVID-19 vaccine. Similarly, the mediation effects of COVID-19 susceptivity yielded a significant positive effect over the relations of PHE and VAX (β = .056. SE = .068, LL = 1.233, UL = 1.324) and with VW (β = .177. SE = .038, LL = 1.097, UL = 1.437). This indicates that, although the increase in personal health engagement on COVID-19 will reduce their susceptivity, their interaction will improve people’s attitude about vaccines and increase their willingness to take COVID-19 approved vaccines. Likewise, the serial mediation of the fear of COVID-19 and vaccine attitude between personal health engagement and vaccination willingness and COVID-19 susceptivity and vaccine attitude between personal health engagement and vaccination willingness resulted in positive and significant effects. We argue based on the results that, whereas the fear of COVID-19, the perceived susceptivity and vaccine attitude are probable antecedents that increase individuals’ willingness to take COVID-19 vaccines and are also significant mediating variables between personal health engagement and the willingness to take COVID-19 vaccine positively.

Table 3. Indirect mediated paths

Discussions

Our work explored the interrelatedness of psycho-social factors likely to thwart vaccine acceptance in Africa. We surveyed Ghanaian resident adults (18+) to understand how personal health engagement, perceived COVID susceptivity, vaccine attitude, and fear of COVID affect vaccine acceptance among African residents in Africa.

First, we have established and confirmed the essential role of personal health engagement in dealing with health and safety. The fear associated with COVID-19 and the tendency of people contracting COVID-19 can be minimized with increased personal health engagement.Citation27 When people are receiving the right information, and in a timely manner, they take better control and responsibility for their health.Citation28 From our result, people’s fear for covid-19 has been curtailed by how much health literacy and education they are exposed to. Such well-informed people are associated with less fear for the pandemic, and the more information and support available to people, the less susceptive they feel to COVID-19. Even though existing works have pointed to a significant number of people willing to be vaccinated, the majority of blacks are hesitant for lack of health engagement.Citation2–4,Citation29

The level of personal health engagement among the sample population has indicated a positive association with the willingness to accept COVID-19 vaccination. Simply put, personal health engagement reduces hesitancy toward COVID-19 vaccination. Providing people with the right and timely medical literacy is paramount in understanding the values of immunization.Citation14,Citation28

Attitude has been used to predict behavioral intentions across many fields of study.Citation30 Few have made specific references to the attitude connected to COVID-19 vaccination.Citation3,Citation28,Citation29 As reported in this article, our finding supports existing works that argue that prior vaccine usage and attitudes toward vaccines generally predicted the intention to receive the COVID-19 vaccine.Citation2,Citation31 As used in this works, the vaccine-related attitude was also in line with studies that opined that vaccine attitude has a partial mediation effect on the relationship between health engagement and vaccine acceptance.Citation2,Citation3 It indicates that focusing on health engagement toward attitudinal change reduces COVID-19 vaccine hesitancy among black communities.

Finally, we argue that health engagement has reduced people’s fear for COVID-19 and their perceived susceptibility but increases their attitude to accept vaccination. When this is achieved, individuals become less hesitant to vaccination.

Limitations

Even though we succeeded in unveiling significant insights into the impacts of psycho-social factors in dealing with COVID-19 vaccine hesitancy among Africans, we identified timing and sampling as the major limitations of the study. Online surveys are the most effective means of reaching a larger population within the shortest time and safer, especially when face-to-face data collection is not possible in a pandemic like this. However, it has produced results from the few privileged who have access to favorable resources. We believe that the response and outcomes may vary during the developmental state of COVID-19 vaccines and when vaccination is ongoing in different parts of the world except for Africa. The level of safety in other parts of the world could influence the attitude and acceptance of the vaccine in this work differently from earlier studies. We recommend that any form of generalization be done cautiously.

Conclusion

Ensuring that people are well informed about their health and the complications that come with COVID-19 even after a successful recovery could reduce unnecessary fear and susceptibility and improve the behavioral intentions toward vaccination. Based on this study’s results, personal health engagement increases the possibility of accepting to be vaccinated and reduces susceptibility and the fear associated with COVID-19. Although the finding supports many existing studies, it is essential to note that this is one of the first works that combined all these antecedents, particularly within the African continent, ahead of mass COVID-19 vaccination. We acknowledge that a multifactorial health behavioral approach including community health engagement and psycho-social commitment will improve people’s chances of being vaccinated. Whiles our work is not the first in linking personal health engagement, vaccine-related attitude, and fear to vaccine hesitancy, it may serve as a guide to understanding and guarding against any form of vaccine hesitancy in Africa since prior findings acknowledged that attitude and hesitancy might be country, racial and context-specific.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

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