COVID-19 vaccine acceptance and adherence to non-pharmaceutical interventions among employees of public transportations company in Addis Ababa, Ethiopia

ABSTRACT

This study examined the acceptability of the COVID-19 vaccines and measured adherence to non-pharmaceutical interventions among employees in public transportations in Addis Ababa, Ethiopia. In a public transportation company-based cross-sectional study, a self-administered questionnaire or a structured face-to-face interview was used to obtain information about willingness to get vaccinated, adherence to recommended non-pharmaceutical interventions, and source and quality of information about COVID-19 vaccines. Overall, 23.8% of 412 responding employees were willing to receive a COVID-19 vaccine. A majority (75.2%) never used facemasks, had poor knowledge about COVID-19 vaccines (82.3%), and had the opinion not to be susceptible to COVID-19 (81.1%). Better education increased the odds of being willing to get vaccinated (OR = 3.28, CI: (1.24–8.63)), male sex (OR = 2.45 (1.08–5.58)), history of chronic disease (OR = 3.01 (1.38–6.56)), watching TV for information on COVID-19 (OR = 14.79 (2.53–86.62)) or considering COVID-19, a severe disease (OR = 9.12 (3.89–21.35)). In addition, the opinion that vaccination can prevent COVID-19, trust in the vaccines, and assuming COVID-19 has an impact at the workplace increased the odds to accept vaccination significantly. In contrast, poor knowledge about the COVID-19 vaccines reduced accepting vaccination significantly (OR = 0.20 (0.09–0.44)). Acceptance of COVID-19 vaccines among public transportations workers in Addis Ababa is very low, which may be due to insufficient knowledge about the vaccines, cultural factors, religious beliefs, and a lack of or distorted information about the disease. Therefore, stakeholders should provide credible and tailored information to transportation workers on the severity and impact of COVID-19 and inform them about the effectiveness of the vaccines.

KEYWORDS:

• COVID-19
• acceptance
• public transportations
• Addis ababa

Introduction

Currently, COVID-19 is one of the leading causes of morbidity and mortality worldwide.¹ Due to system weakness and poor education, Africa’s healthcare systems do not have the power to deal with the epidemic,² and the failure to quickly uptake the vaccine increases the risk of the spread of disease.³ However, it has been shown that several countries in Africa have a slightly lower burden of COVID-19 compared to high-income countries like the United States, France, and Germany.^1,4 Ethiopia is among the resource-limited African countries, with insufficiently trained people, and the majority of residents having little practice with non-pharmaceutical interventions. However, the challenge of the virus increases alarmingly every day. Despite this, there are no confirmed data on the number of people who have tested positive for COVID-19 or who have been hospitalized and the vaccination rate in Addis Ababa due to the poor documentation system across the country.

During the outbreak, Ethiopia implemented several preventive and control measures including reducing contact, travel restrictions, early identification, and isolation of cases, as well as enforcement of public health guidelines recommended by WHO such as hand hygiene, use of face masks, and social distancing.^5,6 Accordingly, one of the key factors in containing the COVID-19 pandemic is to develop effective vaccines. Considering the impact of the epidemic worldwide, vaccination against COVID-19 appears to be essential in controlling the disease⁷ and vaccination has been effective to prevent disease.⁸ So far, there are more than 100 COVID-19 vaccine candidates in clinical testing. Of these, 11 vaccines were granted global access to emergency use and five of these vaccines were widely distributed and approved in many countries across the world.⁹ However, people have doubts about the safety and effectiveness of vaccines, including the timely protection against COVID-19.¹⁰

In sub-Saharan African regions, acceptance of the vaccine was low.¹¹ The low acceptance levels could be attributed to an increasing extent of false information and reports that make it challenging to find reliable sources of information. The highest level of vaccine hesitancy is reported at the global level within low- or middle-income countries.¹²

Public transport and its use by large numbers of people can contribute to the direct transmission of COVID-19 through respiratory droplets and indirect transmission through contaminated surfaces. These lead to public transport staff being at increased risk of infection.¹³ Workers in customer-oriented public transportations company (e.g., taxis, buses …) were more likely to be exposed to COVID-19 as compared to employees in other transportations company and vital non-transportation industries.¹⁴

Public modes of transportation in Addis Ababa include buses with the most popular buses such as (Anbessa bus, Higer bus, and Star Alliance bus), minibuses, and Edan taxis. In Addis Ababa, there are a total of 45 public transportation companies.¹⁵ Due to structural problems in public transportation in Addis Ababa, the exact figures of employees working in the public transportation companies are unknown. But the estimated number of workers from each public transportation company is approximately 3000, and overall, there are approximately 135,000 employees expected in the public transportation company.

An effective vaccination strategy must be implemented to prevent and reduce the risks of COVID-19 transmission^7,8 in public transport, and knowledge about reasons for vaccination hesitancy is crucial for governments and policymakers to address barriers against vaccination acceptance. In Ethiopia, vaccination acceptance rates have increased among health professionals, urban populations, and university students.¹⁶ Public transportation employees are listed among those most vulnerable to get infected by SARS-CoV-2 and to spread the virus to others,¹⁷ are generally at risk of infection by respiratory pathogens,¹⁸ and might not be effectively trained in applying preventive measures (non-pharmaceutical interventions) and may not adhere to vaccination recommendations.

So far, there has been no study on the uptake of the COVID-19 vaccine in public transports in Addis Ababa. Therefore, this study was designed to examine the acceptability of the COVID-19 vaccine, and measure adherence to non-pharmaceutical interventions among employees in public transportations company in Addis Ababa to forward relevant recommendations toward the vaccination strategies and related public health actions.

Materials and methods

Description of the study area

This study was conducted at Addis Ababa, the capital city of Ethiopia, which is located at an altitude of 2500 m above sea level and has an area of over 540 sq. km. Addis Ababa has 11 sub-cities with 126 Weredas. The city is also the capital city of Africa; due to this, it hosts several international organizations like the African Union, United Nations, etc. In 2022, Addis Ababa has a total of 5, 228,000 inhabitants.¹⁹

Study design, period, and sampling procedure

A public transportation company-based cross-sectional study was done on the acceptability of vaccines and adherence to COVID-19 non-pharmaceutical interventions among employees of public transportations company in Addis Ababa, Ethiopia, from June 21 to July 06, 2022. The study used a single proportion method to grasp the number of responding employees. The participants were recruited from 23 public transportations company (bus terminals) in Addis Ababa using a random sampling technique. There is no prior study conducted on COVID-19 vaccine acceptance among employees of public transportation in Addis Ababa. Hence, 50% proportions, 95% confidence level, and 5% marginal error were used. Based on this information, 383 samples were estimated; then by adding 8% non-response rates, the final sample size became 414. Then, an equal number of employees in each transportation terminal were selected from the 23 randomly selected public transportation terminals. Finally, 412 employees filled out full information about vaccine acceptance and adherence to non-pharmaceutical intervention questions.

Data collection instrument

The data were collected through a self-administered questionnaire or structured face-to-face interviews. The questionnaire was originally prepared in English and translated into Amharic (the local language) for interviews (See appendix).

Study variables

In this study, the intention to obtain the COVID-19 vaccine was defined as acceptance. This was the outcome variable and measured using the question “Are you willing to receive the COVID-19 vaccine?” And the responses are either “Yes” or “No.” While the independent variables such as Age, Sex, Marital status, Educational level, Religion, Family size, history of chronic disease, Watching TV, Listing radio, Info from parents or friends or Facebook are considered as the background characteristics whereas, ‘Usage of face masks,’ ‘Avoided to touch or share foodstuffs,’ ‘Hand washing,’ ‘Avoid shaking hands from greetings,’ ‘The opinion that vaccination can prevent COVID-19,’ ‘The opinion to be susceptible to COVID-19,’ ‘Only old people susceptible to COVID-19,’ ‘COVID-19 is a severe disease,’ ‘Assuming COVID-19 has an impact at the workplace,’ ‘Trust on the COVID-19 vaccine,’ and ‘Knowledge toward the COVID-19 vaccine, which was measured using different questions such as clinical symptoms, spreads from an infected person to an uninfected, protection method, etc., and finally, this variable was labeled as “good” or “poor” knowledge based on the right answers responded by the respondents’ are considered as adherence to COVID-19 non-pharmaceutical interventions (See appendix).

Data processing and analysis

Absolute and relative frequencies are presented for all variables. They were cross-tabulated by the willingness to get vaccinated (yes/no) and the association to the respective independent variable was analyzed by chi-square tests. Variables that were significant at the 5% level in these univariate analyses were submitted to a multiple logistic regression with the willingness to get vaccinated as an outcome. Odds ratios and 95% confidence intervals were computed for the explanatory variables. For all analyses SPSS 21.0 (IBM Corp., Armonk, NY) was used.

Ethics approval and consent to participate

Ethical approval was obtained by the ethical review board of the Jimma University Institute of Health Science (Ref. No.: 067/2022). The participants were informed about the purpose of the study and provided written consent.

Results

Socio-demographic characteristics and source of information about COVID-19 and vaccination of participating public transportation workers

Overall, 412 employees of the public transportation company of Addis Ababa participated and filled their background characteristics as well as non-pharmaceutical intervention measurements. Among them, 23.8% were willing to receive a COVID-19 vaccine. The majorities (85.2%) were male, 51.2% were 25–34 years of age, and 51.5% were single, 51.7% had had secondary and beyond education, 85.2% had history of chronic disease, and 85% were watching TV for information on COVID-19 (Table 1).

Table 1. Socio-demographic characteristics and source of information about COVID-19 and vaccination of participating public transportation workers and their relationship to the intention to get vaccinated against COVID-19.

Variable	Categories	counts	%	Willingness to receive the COVID-19 vaccine		p-value
				No (%)	Yes (%)
Sex	Male	351	85.2	60.6	39.4	.002
	Female	61	14.8	78.9	21.1
Age	15–24 years	132	32	69.7	30.3	.100
	25–34	211	51.2	79.6	20.4
	>34 years	69	16.7	78.3	21.7
Religion	Orthodox	186	45.1	78.5	21.5	.045
	Muslim	135	32.8	68.1	31.9
	Protestant	85	20.6	83.5	16.5
	Catholic	6	1.5	83.3	16.7
Marital status	Single	212	51.5	75.5	24.5	.098
	Married	172	41.7	74.4	25.6
	Divorced	28	6.8	92.9	7.1
Education level	No formal education	81	19.7	85.2	14.8	.021
	Primary education	118	28.6	79.7	20.3
	Secondary & above	213	51.7	70.9	29.1
Family size	1–3	315	76.5	77.1	22.9	.590
	4–6	82	19.9	74.4	25.6
	≥7	15	3.6	66.7	33.3
History of chronic disease	No	351	85.2	80.3	19.7	<.001
	Yes	61	14.8	52.5	47.5
Watching TV	No	62	15.0	96.8	3.2	<.001
	Yes	350	85.0	72.6	27.4
Info from Parents	No	367	89.1	76.0	24.0	.794
	Yes	45	10.9	77.8	22.2
Listening Radio	No	353	85.7	75.9	24.1	.733
	Yes	59	14.3	78.0	22.0
Info from friends	No	394	95.6	75.9	24.1	.468
	Yes	18	4.4	83.3	16.7
Info from Facebook	No	238	57.8	78.6	21.4	.189
	Yes	174	42.2	73.0	27.0

A majority (75.2%) never used facemasks, had poor knowledge about COVID-19 vaccines (82.3%), and 81.1% had the opinion not to be susceptible to COVID-19. More than four-fifths (85.7%) perceived that COVID-19 was a severe disease, and had the opinion that only older people to be susceptible to COVID-19 infection (81.3%) (Table 2).

Table 2. Adherence to COVID-19 non-pharmaceutical interventions, attitudes toward vaccines and toward COVID-19 in relation to willingness to get vaccinated.

Variable	Categories	Counts	%	Willingness to receive the COVID-19 vaccine		p-value
				No (%)	Yes (%)
Use face mask	Never	310	75.2	78.7	21.3	.044
	Sometimes	81	19.7	71.6	28.4
	Always	21	5.1	57.1	42.9
Avoid touching or sharing foodstuff	Never	37	9.0	86.5	13.5	.065
	Sometimes	137	33.3	80.3	19.7
	Always	238	57.8	72.3	27.7
Frequency of washing hands	Never	43	10.4	72.1	27.9	.046
	Sometimes	156	37.9	70.5	29.5
	Always	213	51.7	81.2	18.8
Avoid shaking hands from greetings	Never	86	20.9	70.9	29.1	.179
	Sometimes	108	26.2	73.1	26.9
	Always	218	52.9	79.8	20.2
Knowledge about COVID-19 vaccine	Good	73	17.7	49.3	50.7	<.001
	Poor	339	82.3	82.0	18.0
COVID-19 can be prevented by vaccination	No	180	43.7	91.1	8.9	<.001
	Yes	232	56.3	64.7	35.3
Are you susceptible to COVID-19	No	334	81.1	78.4	21.6	.028
	Yes	78	18.9	66.7	33.3
Only old people susceptible to COVID-19	No	77	18.7	77.9	22.1	.696
	Yes	335	81.3	75.8	24.2
COVID-19 is a severe disease	No	353	85.7	81.6	18.4	<.001
	Yes	59	14.3	44.1	55.9
Trust in COVID-19 vaccines	No	304	73.8	83.2	16.8	<.001
	Yes	108	26.2	56.5	43.5
COVID-19 has an impact on the workplace	No	270	65.5	80.7	19.3	.003
	Yes	142	34.5	67.6	32.4

Association with the intention to get vaccinated against COVID-19 were significant in univariate analysis for the following variables, sex, education level, history of chronic disease, religion, watching TV, wearing a mask, avoiding touch or sharing foodstuff, washing hands frequently, knowledge, preventing method, susceptibility, the severity of the disease, trust in the vaccine, and impact on work (Tables 1 and 2).

Multivariate analysis of variables associated with willingness to receive the COVID-19 vaccine

The Hosmer-Lemeshow test was not significant, indicating acceptable fit of the logistic model. Logistic regression analysis reveals education level, sex, history of chronic disease, watching TV, knowledge about COVID-19 vaccines, and rating it as an effective prevention method, rating of the severity of COVID-19, trust in the vaccine, and agreeing that the infection has an impact at the workplace as significantly (p < .05) associated with the willingness to receive a COVID-19 vaccine (Table 3).

Table 3. Adjusted odds ratio of factors associated with willingness to receive the COVID-19 vaccine.

Variable	Categories	p-value	AOR	95% C.I. for AOR
				Lower-Upper
Sex	Male	.032	2.45	(1.08, 5.58)
Education level	No formal (Ref.)
	Primary education	.005	4.51	(1.56, 13.05)
	Secondary & above	.016	3.28	(1.24, 8.63)
History of Chronic Disease	Yes	.006	3.01	(1.38, 6.56)
Watching TV	Yes	.003	14.79	(2.53, 86.62)
Use facemask	Never (Ref.)
	Sometimes	.776	0.89	(0.38, 2.05)
	Always	.629	1.45	(0.36, 6.43)
Avoid touching or sharing foodstuff	Never (Ref.)
	Sometimes	.501	0.53	(0.09, 3.34)
	Always	.648	1.50	(0.26, 8.64)
Frequency of washing hands	Never (Ref.)
	Sometimes	.362	2.04	(0.44, 9.43)
	Always	.459	0.57	(0.13, 2.51)
Knowledge about COVID-19 vaccine	Poor	<.001	0.20	(0.09, 0.44)
COVID-19 can be prevented by vaccination
	Yes	<.001	3.88	(1.82, 8.29)
Are you susceptible to COVID-19	Yes	.272	1.55	(0.71, 3.36)
COVID-19 is a severe disease
	Yes	<.001	9.12	(3.89, 21.35)
Trust in COVID-19 vaccines	Yes	<.001	7.90	(3.79, 16.47)
COVID-19 has an impact on the workplace
	Yes	.015	2.26	(1.17, 4.35)

Better education was associated with a higher intention to get vaccinated. Responding employees with at least primary education had an odds ratio of 4.51 (95% CI: 1.56, 13.05) against the reference with no formal education and, employees with at least secondary education had an odd ratio of 3.28 (95% CI: 1.24, 8.63). Male employees had significantly higher odds to be willing to get vaccinated than women (OR: 2.45; 95% CI: 1.08, 5.58).

Employees with a history of chronic disease had significantly increased odds of being willing to get vaccinated (OR: 3.01; 95% CI: 1.38, 6.56). Participants who watched TV for information were more likely to be willing to get vaccinated (OR: 14.79; 95% CI: 2.53, 86.62). Conversely, poor knowledge of the COVID-19 vaccinations significantly decreased willingness to get vaccination (OR: 0.20; 95% CI: 0.09, 0.44).

Willingness to get vaccinated had significantly higher odds with the opinion that vaccination can prevent COVID-19 (OR: 3.88; 95% CI: 1.82, 8.29). The likelihood that participants who considered COVID-19 was indeed a severe illness were more likely to be gets vaccinated (OR: 9.12; 95% CI: 3.89, 21.35). The finding also reveals that employees who had trust in the vaccines increased the odds to accept vaccination significantly (7.90. 95% CI: 3.79, 16.47). Additionally, respondents’ intentions to get vaccinated were higher while they agreed that the infection had an impact at the workplace (OR: 2.26; 95% CI: 1.17, 4.35) (Table 3).

Discussion

In this study, very low vaccine acceptance rates were recorded among transportation workers. The vaccination rate in other studies were 39% in Ghana;²⁰ 56.2% in Dessie, Ethiopia;¹³ 65% in Wollega, Ethiopia;²¹ and 73% in southwest Ethiopia.¹⁴ It seems that the vaccination rate in Ethiopia is better than the rate intending to get vaccinated among the employees in this study. This may be due to insufficient knowledge about the vaccines, cultural factors, religious beliefs, and lack of or distorted information about the disease, and a negative attitude toward the vaccine in the transportation company. Nevertheless, it is believed that vaccination played an important role in decreasing the burden of various transmittable diseases.²²

The study found that better education increased the odds of employees being willing to get vaccinated. This finding is supported by a study conducted in Australia,²³ the Middle Eastern or North African countries,²⁴ and Iraq²⁵ that showed willingness to get vaccinated is increasing with higher education. Likewise, male participants had significantly higher odds of accepting the vaccine than female participants. In contrast, a study conducted in Burkina Faso, Malawi, Uganda, and Mali showed that vaccine acceptances among genders do not significantly differ. However, the study conducted in sub-Saharan African regions²⁶ and Somalia²⁷ supported the finding of the present study. The probable reason might be men are more exposed to various media and compile information related to the COVID-19 vaccine compared with females.

Vaccination acceptance was higher among those suffering from a chronic disease, which has also been reported in another study from Ethiopia,²⁸ and is in line with reports from WHO²⁹ and Australia.³⁰ This may be due to the widely spread information about a higher mortality and morbidity in chronically ill persons. Watching TV as source of information on COVID-19 was associated with higher odds to be willing to get vaccinated, which is consistent with reports conducted earlier in Ethiopia stating that TV was the most trusted source of information about COVID-19 vaccination.^14,28 Poor knowledge about COVID-19 vaccines reduced the odds for accepting vaccination, in agreement with previous reports from Ethiopia²⁸ and France.²⁹ This finding is also supported by a study conducted by Lazarus et al³⁰ that reported a positive association between knowledge and vaccination acceptance. Furthermore, in line with our expectation, we could show that employees’ assumption that COVID-19 has an impact at the workplace was positively associated with the acceptance of the vaccination. Also the opinion that vaccination could prevent COVID-19 increased the odds of accepting vaccination, consistent with a previous study from Ethiopia.²⁸ Employees considering COVID-19 a severe disease were more likely to accept vaccination, in line with a previous report from Ethiopia¹³ and numerous other studies.

As expected, trust in COVID-19 vaccines increased the odds of accepting vaccination significantly. This finding is in line with other studies^31,32 indicating that trust is a key factor in accepting vaccination. This is the first study conducted in the city transportations company of Addis Ababa; therefore, the findings might give important directions, and help decision-makers to address crucial points of vaccine hesitancy to improve vaccination rate in the transportation company of Addis Ababa.

Strengths and limitations of the study

This study has two advantages. First, since it is the first to be conducted in the Addis Ababa city transportations company, the findings may provide crucial directions and help decision-makers in addressing key concerns about vaccine hesitancy in order to improve vaccination rates in the Addis Ababa transportation company. Second, this study used a cross-sectional design based on a public transportation company and a random sample technique; as a result, the outcome may reflect the level of COVID-19 vaccination acceptability in the transport company’s whole population. This study was limited by the lack of exact study population figures and data on any employees who tested positive or were admitted to the hospital while working for a transport company in Addis Ababa.

Conclusions

The study shows that overall, 23.8% of 412 responding employees were willing to receive a COVID-19 vaccine. The low rate of acceptance may be due to insufficient knowledge about the vaccines, cultural factors, religious beliefs, lack of or distorted information about the disease, and a negative attitude toward the vaccine in the public transportation company. Therefore, stakeholders should provide credible and tailored information to transportation workers on the severity and impact of COVID-19 and inform them about the effectiveness of the vaccines.

Abbreviations

COVID-19	=	Coronavirus disease of 2019
SPSS	=	Statistical Packages for Social Science
WHO	=	World Health Organization

Author contributions

All authors made a significant contribution to the study in the conception, study design, execution, acquisition of data, analysis, and interpretation of the results, drafting, and revising or reviewing of the article.

Data availability and sharing statement

The dataset used in the present study has been in the hands of the corresponding author. So, it will be sent upon reasonable request.

Acknowledgments

We appreciate all the employees of public transportation company in Addis Ababa who participated in this study, supervisors, and data collectors, and special thanks to Jimma University for their support during the study.

Disclosure statement

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

Additional information

Funding

This study was funded by Jimma University. However, the university had no contributions in the design, collection of data, data analysis, and interpretation of the results, and in writing the article

Appendix

Part I: Adherence to non-pharmaceutical interventions related questions

1. How often did you use facemasks in workplace?

   1. Never

   2. Sometimes

   3. Always

2. How often did you avoid touching or sharing foodstuff?

   1. Never

   2. Sometimes

   3. Always

3. How often did you wash your hands frequently with soap and water or using alcohol-based hand?

   1. Never

   2. Sometimes

   3. Always

4. How often did you avoid your hands from greetings?

   1. Never

   2. Sometimes

   3. Always

5. Do you susceptible to COVID-19?

   1. Yes

   2. No

6. Do you believe that COVID-19 infection is severe disease?

   1. Yes

   2. No

7. Do you think that only old people are susceptible to COVID-19?

   1. Yes

   2. No

8. Do you believe that COVID-19 infection is severe disease?

   1. Yes

   2. No

9. Do you have a trust on the COVID-19 vaccine?

   1. Yes

   2. No

10. Do you think that COVID-19 has serious impact on workplace?

    1. Yes

    2. No

11. Do you believe that COVID-19 can be prevented by vaccine?

    1. Yes

    2. No

12. Are you willing to receive the COVID-19 vaccine?”

    1. Yes

    2. No

Part II: COVID-19 knowledge assessment measured questions

1. What are the main clinical symptoms of Covid-19? (Multiple response is possible)

   1. Fever

   2. Fatigue

   3. Dry cough

   4. Muscle pain

   5. Sore throat

   6. Diarrhea

   7. Difficulty breathing

   8. Body weakness

   9. Other

   10. If other, Specify ______________

2. People like you are not at high risk of getting COVID-19 at the workplace?

   1. Yes

   2. No

   3. I don’t know

3. How Coronavirus spreads from an infected person to an uninfected person? (multiple responses is possible)

   1. Through respiratory droplets when cough, sneeze, speak, sing or breath

   2. Direct contact with contaminated hands, fomite, surfaces, etc)

   3. Transmit by air (airborne)

   4. Transmit if there is a close contact between people

   5. I don’t know

   6. Other (specify)________________

4. Which of the following conditions are possible ways of the transmission of the coronavirus?

   1. Crowded area

   2. inadequately ventilated spaces

   3. Hand shaking

   4. Kissing for greetings

   5. Exchange or sharing materials

   6. Sharing food or drinking

   7. Sharing toilet

   8. Touching our eyes without having cleaned their hands first

   9. Touching our nose without having cleaned their hands first

   10. Touching mouths without having cleaned their hands first.

5. Persons infected with COVID-19, but have no symptoms cannot transmit the virus to others.

   1. Yes

   2. No

   3. Don’t know

6. How can protect ourselves from COVID-19? (Multiple response is possible)

   1. Use facemask

   2. Not shaking hands

   3. Avoiding touching eyes, nose and mouth before washing hands

   4. Keeping physical distance of at least 2 meter

   5. Washing hands frequently with soap and water

   6. Cleaning hands using alcohol-based hand rub

   7. Avoid going to crowded places such as bus stations, market, religious places, sport