COVID-19 was declared a public health emergency of international concern (PHEIC) on January 30, 2020, by the World Health Organization (WHO), and a pandemic on March 11, 2020 [1][2]. As of 3^rd February 2023, there were over 750 million confirmed COVID-19 cases, over 6.8 million confirmed deaths, and over 13 million COVID-19 vaccine doses administered globally [3]. In Nigeria, as of 3^rd February 2023, there are over 266,463 confirmed cases and 3155 confirmed deaths, with 57% and 10% of the eligible population partially and fully vaccinated, respectively [4][5].

Earlier measures in curtailing the spread of the COVID-19 pandemic globally focused on non-pharmaceutical measures including wearing face masks, physical distancing, and hand hygiene [6]. COVID-19 vaccination has been described as a game changer in curtailing the pandemic, especially when used concurrently with non-pharmaceutical measures [7]. Vaccines became available in record time, with the COVID-19 Pfizer-BioNTech COVID-19 vaccine sent to the FDA for possible Emergency Use Authorization (EUA) on November 20, 2020, and authorized on December 11, 2020, only nine months after the pandemic declaration. Other COVID vaccines soon followed, including the Moderna vaccine, Johnson and Johnson vaccine, and AstraZeneca vaccine.

The administration of COVID-19 vaccines was prioritized among high-risk populations, including healthcare workers, the elderly, people living with pre-existing chronic health problems, and political leaders, after which other members of the population were vaccinated [8]. In Nigeria, the first batch of 4 million doses of AstraZeneca/Oxford COVID-19 vaccines arrived in the country on 2^nd March 2021; by 2^nd March 2022, one year after 1^st shipment, the country had received more than 65.8 million doses of various COVID-19 vaccines, with about 27 million doses in the pipeline [9][10]. As of 3^rd February, only 65,679,094 persons (57% of the eligible population) in Nigeria were reported to be fully vaccinated despite the availability of vaccines [5]. Previous studies from various countries have revealed that individuals who perceived taking the vaccine as important to protect themselves had higher odds of vaccine acceptance and uptake [11][12][13]. Vaccine acceptance and uptake were also positively associated with COVID-19 knowledge, worry or fear regarding COVID-19, higher income, younger age, and testing negative for COVID-19 [11]. However, chronic disease and female gender reduced the odds of vaccine acceptance [11]. The main reasons underpinning vaccine refusal in low- and middle-income countries including Nigeria, were misinformation, religious fanaticism, fear of side effects, cost, convenience of location, lack of confidence in vaccine effectiveness, and environment [12][13].

The objective of this study was to determine COVID-19 vaccine acceptance, uptake, and associated factors among inhabitants of selected catchment communities in Oyo and Ogun states in southwestern Nigeria.

Four hundred household decision-makers in 100 catchment communities were surveyed in Oyo and Ogun states between July to August 2021. The mean age of the respondents was 43.0 ± 11.0 years. The mean number of people living in the surveyed households was 5.4 ± 3.2 (Table 1). Most respondents were male (n = 322; 80.5%), married/cohabiting (n = 364; 91.0%), and the most common occupation was trader/farmer (n = 154; 39.1%). Of household respondents, 15 (3.8%) had underlying chronic illnesses.

About half (56.0%) of the participants agreed that the COVID-19 vaccine is free and accessible. Less than two-fifths (39.5%) agreed that COVID-19 has minimal adverse effects and is tolerable. The mean perception scores were average for the risk of contracting or dying from COVID-19 (3.06 out of a maximum obtainable score of 6), and Covid-19 vaccination benefits (1.16 out of a maximum obtainable score of 4) (Table 2).

Only 33 (8.3%) reported having ever had a COVID-19 test in the past, and all reported that the test was negative. Although 346 (86.5%) had heard about COVID-19 vaccination, only 47 (13.6%) had received a COVID-19 vaccine. Of the 299 respondents who reported not receiving COVID-19 vaccination, 299 (55.5%) said they were willing to receive the vaccine in the future. Of the 346 respondents who had heard about COVID-19 vaccination, 208 (60.1%) reported that they would encourage their family members to take it (Table 3).

Out of the 106 (35.5%) who were not willing to receive the vaccine, 67.7% reported fear of potential side effects, 15.0% noted that it is against their religious belief, and 10.5% claimed that it is a plan to depopulate the black race. Other less common reasons given for not being willing to take the vaccine included perceived effects on male potency, libido, and sterility; the vaccine being a mark of the devil and the vaccine being a tracking and monitoring device (Figure 1).

Table 1. Respondents’ background characteristics.

Univariate regression analysis demonstrated the following factors were associated with a significantly higher likelihood of having been vaccinated: female respondents vs male [Crude Odd Ratio (COR): 1.94 (1.56 - 2.42)], those that had secondary [COR: 2.18 (1.22 - 3.88)] or tertiary education [COR: 2.81 (1.56 - 5.07)] vs. no formal education, those who agreed that COVID-19 vaccine is free and accessible vs those who disagreed [COR: 2.37 (1.58 - 3.57)] and that COVID-19 vaccine has minimal side effects vs those who felt that there were

Table 2. Respondent’s knowledge and perception about COVID-19 vaccination uptake.

Table 3. Respondents’ awareness, uptake, and willingness to receive COVID-19 vaccination.

side effects [COR: 3.67 (2.68 - 5.02)]. Furthermore, the higher the respondent’s COVID-19 vaccine benefits perception score [COR: 1.74 (1.61 - 1.87)], the higher the likelihood of being vaccinated. In contrast, the older age of respondents [COR: 0.99 (0.98 - 0.10) or higher knowledge score on infection prevention and control (IPC) measures [COR: 0.87 (0.82 - 0.91)] were associated with a

Figure 1. Reasons for non-willingness to take COVID-19 vaccination.

lower likelihood of being vaccinated. Respondents who were suffering from chronic diseases [COR: 0.29 (0.14 - 0.59)] had a lower likelihood of being vaccinated when compared to their colleagues who were civil servants or had no chronic diseases, respectively (Table 4).

Respondent’s age [adjusted odds ratio (AOR): 0.99 (0.98 - 1.00)], gender [3.41 (2.60 - 4.47), Ref; male], perception score on COVID-19 vaccine benefits [AOR: 1.55 (1.41 - 1.70)], knowledge score on IPC measures [AOR: 0.79 (0.74 - 0.84)], a positive agreement that COVID-19 vaccine is free and accessible [AOR: 2.03 (1.30 - 3.19), Ref; No] and safe [AOR: 4.04 (2.77 - 5.88), Ref; No] were the factors that were significantly associated with COVID-19 vaccine uptake at multivariate level after adjusting for other factors.

We assessed respondents’ prior COVID-19 testing, vaccine access, and related factors in the study settings. Only 8.3% of our respondents in both study locations had ever been tested for COVID-19 before the survey. This finding is in keeping with the WHO Regional Office for Africa reports which show that only one in seven (14.2%) of COVID-19 cases are detected in Africa [18]. Furthermore, a Nigeria Centre for Disease Control report showed that only about 1.7% of the populace has so far been tested for COVID-19 since the onset of the pandemic in 2020 [19]. The testing rate in Nigeria is low considering the large population (estimated to be more than 200 million). South Africa has tested approximately 23% of its population while the testing rate is currently about 3% in Egypt and Kenya respectively [20]. WHO has asserted that COVID-19 testing is a critical component of the overall prevention and control of the disease [21].

Table 4.Examines association between exploratory variables and COVID-19 vaccination uptake at univariate and multivariate levels.

*Statistically significant at a p-value of less than 0.05.

The Nigerian national COVID-19 response teams have primarily focused their testing efforts on international travelers and their contacts. Although these efforts are commendable, there is an urgent need for a well-articulated, community-based, and user-friendly COVID-19 testing program utilizing existing Rapid Diagnostic Testing (RDT) kits. In some regions of the country, these activities have begun, but they need to be scaled up. This becomes crucial in the era of the Omicron variant, which has a very high rate of community transmission. In addition, the number of reference laboratories equipped with PCR machines to confirm cases must be increased. In Nigeria, only 157 (84 public and 73 private) out of 5349 laboratories are currently accredited for this purpose.

The current study revealed that despite the high COVID-19 vaccine awareness rates in the study settings, only 13.6% of the study participants have been vaccinated. Empirical evidence shows a low vaccination rate in Nigeria compared with other countries. For instance, the most recent report by “Our World in Data” revealed that only 4.5% of Nigerians had received one dose while a lower proportion (2.1%) had been fully immunized as of 27^th December 2021 [22]. In comparison, full immunization rates were 26.6% in South Africa, 1.7% in Mali, 5.3% in Senegal, and 7.3% in Kenya [22].

Reasons for the low COVID-19 vaccination rate documented by this study, and perhaps in Nigeria overall, can be multi-factorial. Firstly, it could have been due to the relative scarcity of vaccines in the country. Frontline healthcare workers, the elderly, those with pre-existing chronic health problems, and political leaders were given priority for the first batch of about 4 million doses of COVID-19 vaccines which arrived in Nigeria in March 2021 through the COVAX facility 7 [9]. The second batch of over 4 million Moderna vaccines, meant to benefit the general populace, arrived (1^st August 2021) and may have not been sufficiently distributed [23]. Additionally, the low uptake could be due to the existing and widely circulated conspiracy theories regarding COVID-19 causation in Nigeria. Many Nigerians are still doubtful of the existence of the disease, as they believe that the virus is caused by 5G technology and cannot survive in the hot Nigerian weather [24]. Many believe that COVID-19 is being promoted by political leaders to give them the platform to further loot the national treasury [25]. Also, some prominent Nigerian religious and political leaders have openly condemned COVID-19 vaccination acceptance. The religious leaders believe the vaccine is a mark of the anti-Christ and so warn their followers against acceptance [26].

These factors could have also been responsible for the low willingness to accept COVID-19 vaccines among our non-vaccinated respondents. Only 55.5% of the unvaccinated were willing to receive the vaccine and only 60.1% of the vaccinated were willing to recommend the vaccine for their family members. Our results are similar to results from Adejumo et al., who interviewed Nigerian healthcare workers in 4 specialized hospitals in Ondo, Edo, and Delta states, and found that about 55.5% of their respondents had positive perceptions of the COVID-19 vaccine and were willing to accept vaccination. This is particularly concerning given that healthcare workers are expected to have better information on the benefits of vaccination, and we rely on them to encourage others to be vaccinated [27]. A low COVID-19 acceptance rate has been documented in other settings as well. The proportion of those willing to accept COVID-19 vaccination was as low as 28% in the Democratic Republic of Congo,

56.2% in Ethiopia while China and Bangladesh had much higher reported willingness to accept the COVID-19 vaccine, at 91% and 85%, respectively [28][29][30]. Additionally, the perceived low case-fatality rate of the disease in Nigeria may contribute to low vaccine acceptability. Currently, the estimated case-fatality rate for the disease is 1.2% in Nigeria compared to the global rate of 2.1% [31][32].

Other reasons reported by study participants for lack of willingness to receive the COVID-19 vaccine include fear of side effects, vaccination not in tandem with religious views, and the perception that vaccination was designed to depopulate the black race. This highlights the need for more structured and sustainable health education interventions, to dispel many of the misconceptions regarding COVID-19 causes and prevention. All relevant stakeholders, particularly religious and political leaders, should be involved in planning, implementing, and evaluating health education interventions to ensure that they are effective. All channels of communication should be engaged, and easy-to-understand COVID-19 vaccine-related information should be widely disseminated in local languages.

Participants who perceived the vaccine to be free and accessible were twice as likely to be vaccinated as those who did not, thus, decentralization of COVID-19 vaccination to improve accessibility should help to overcome the hidden costs of receiving the vaccines and hopefully promote uptake. The perception that the vaccine had few side effects and was well tolerated was associated with a 4-fold higher likelihood of being vaccinated, thus there is the need to provide additional education to counteract the misperceptions around vaccine side effects and other myths regarding COVID-19 vaccines. While COVID-19 vaccines are known to cause mild to moderate side effects, like many other vaccines, they are overwhelmingly safe. Despite this, some people still believe that researchers rushed the development process and that COVID-19 vaccines may not be effective and safe for humans [33]. In addition, the Nigerian media continues to promote misinformation, for example, stating that the COVID-19 vaccine causes infertility in women and can make people bleed to death [32]. Globally, it has been widely circulated that mRNA-based COVID-19 vaccines have the potential to change human DNA [33]. It is critical to provide people with reliable information to counter these misperceptions to improve vaccine uptake.

Additional messaging on the accessibility, safety, and health benefits of COVID-19 vaccination has the potential to improve vaccine uptake. To ensure wide dissemination, government officials should seek to engage prominent Nigerian bloggers, social media influencers, actors, and musical artists to promote COVID-19 vaccination exercises and ensure that social media platforms such as Facebook, Instagram, and WhatsApp provide accurate information. Incorporation of religious leaders and faith-based organizations in COVID-19 vaccination programming will also help promote information dissemination, prevent and reduce fear and stigma, provide reassurance to people in their communities, and promote health-saving practices such as COVID-19 vaccination uptake.

Furthermore, messaging should emphasize using a combination of pharmaceutical and non-pharmaceutical strategies (the “Swiss cheese” model), and that either vaccination or non-pharmaceutical measures, such as IPC, do not guarantee one hundred percent protection against COVID-19 infection.

This study may be subject to social desirability bias, in which respondents gave answers that they believed were socially acceptable rather than giving responses that reflected their actual individual life experiences. To attempt to reduce this bias as much as possible, the goal of the research was clearly explained to them, and the confidentiality of their information was assured. This study did not document the type of vaccine received by the participants and the disaggregation of the vaccination uptake by the dose received either 1^st, the 2^nd, or the booster dose.

Uptake of COVID-19 testing and vaccination, as well as willingness to receive vaccination, were low. In addition to legitimate concerns over vaccine accessibility, several misconceptions must be addressed. There is an urgent need for policymakers and the Nigerian COVID-19 response teams to embark on well-designed awareness campaigns capable of dispelling the myths regarding COVID-19 causes/vaccines and improving positive perceptions of Nigerians regarding the health benefits of COVID-19 vaccination.

The authors would like to appreciate the entire technical team of the US Center for Disease Control CARES ACT project, the management team of APIN Public Health Initiatives, the United States Center for Disease Control, and the state governments of Benue, Plateau, Oyo, and Ogun states, Nigeria.

Sustaining Care Seeking for fever and ANC services at Nigerian Health Facilitiesin four States in Nigeria

VACCINATION ACCEPTABILITY QUESTIONNAIRE