The coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) [1]. In December 2019, the initial cases of COVID-19 were first identified and reported in Wuhan, China [2]. The WHO declared it a global pandemic on 11^th March 2020 [3]. A developing infectious disease outbreak, such as COVID-19, raises public health concerns about people’s hesitancy to be vaccinated [4]-[7]. Such hesitation endangers the safety of both the vaccinated and unvaccinated people, puts further strain on the already overburdened healthcare system, and jeopardises virus control [2]. COVID-19 led to an increase in morbidity and mortality, resulting in it being a major public health issue [8]. Significant efforts have been made to develop safe and effective vaccines [9]. By mid-2021, over three billion doses of COVID-19 vaccines had been administered [10].

The development of herd immunity after vaccinating the majority of the population made the vaccination of children and teenagers essential in stopping the COVID-19 pandemic [11][12]. However, vaccine hesitancy (VH), which is defined as a delay in accepting or refusing vaccines despite the availability of vaccine services, continues to be a barrier [7]. Children and teenagers under the age of 18 showed a high rate of parental VH against SARS-CoV-2 (40%), according to a survey of more than 5000 families in Bologna, Italy. Most notably, this was found in female parents of younger children (6 to 10 years old), parents under the age of 29, parents with low educational levels, and parents who primarily relied on information from the internet and social media and disapproved of mandatory vaccination policies [13].

Reasons for VH among young adults and teenagers have included underestimating the risk of infection, believing that innate immunity will provide enough protection, having special physical conditions that preclude vaccination and conspiracy theories [14]. A study reported that teenagers’ readiness to receive vaccinations is largely influenced by their level of trust in the effectiveness and safety of the vaccines [14]. Widespread mistrust of vaccines in Africa has led to widespread reports of high reluctance and low vaccination rates, which have been made worse by the dissemination of false information and myths [15]-[20].

Zambia reported its first case of COVID-19 on 18 March 2020 [21][22]. Concerns about COVID-19 and its effects in Zambia led to the implementation of preventive measures, including school closures, social distancing and a work-from-home policy among other control measures [23][24]. However, it is concerning that during the second and third waves in Zambia, the morbidity and mortality linked to COVID-19 rose considerably [15]. Lack of information, worries about the vaccine’s safety, scepticism of Western medicine, a preference for faith in God over conventional medicine, unclear eligibility information, and the perception that public figures used in the campaigns were not receiving injections were among the obstacles to the uptake COVID-19 vaccines [25]. Few studies have been conducted regarding the knowledge, attitudes, and acceptance of the COVID-19 vaccine among Zambian school-going children and adolescents [15][26]. Given this background, this study assessed the knowledge, attitude, and acceptance of the COVID-19 vaccines among pupils in the Kitwe and Ndola districts of Zambia.

This study assessed the knowledge, attitude and acceptance of the COVID-19 vaccine among pupils in Kitwe and Ndola districts of Zambia.

Overall, this study found that 86.1% of the pupils who participated had good knowledge about the COVID-19 vaccines. These findings are higher than the 68.2% reported from a study conducted in the Lusaka district [26]. Data in the Lusaka study was collected between September and November 2022 [26] while that in our Kitwe and Ndola districts study was collected in August 2023; this entails that with time, there’s an increase in opportunities to get information concerning the COVID-19 vaccines. Similarly, another study in New Delhi, India found high knowledge levels (99.5%) among participants regarding COVID-19 vaccines, but 60% were not aware of the possibility of breakthrough infection, which can be targeted while educating adolescents about vaccination [30]. In contrast, a study in Bangladesh among rural adolescents found that only a few respondents (11%) had adequate knowledge about the COVID-19 vaccines [31]. This can be because the information in the rural areas isn’t easily accessible, compared to our study, which was conducted in urban areas, where information can easily be obtained.

The present study found that there was no relationship between the gender of participants and their level of knowledge. contrary to findings in a similar study among pupils in Lusaka, where females had a higher knowledge compared to males [26]. Overall, none of the socio-demographics was associated with knowledge such as the grade of the participants, whether the participants lived with their parents or guardians. On the contrary, a study in Bangkok, Thailand found that an increase in the grade of the participants was an increase in levels of knowledge towards COVID-19 vaccines [32]. A study in China also found that sociodemographics have an influence on the knowledge of individuals concerning COVID-19 vaccines [33].

When participants were asked about their primary sources of information, mass media (TV and radio) emerged as the most common, followed by social media. This finding aligns with the observation that social media serves as the main source of information among participants with higher Vaccine Consistency Belief Scale (VCBS) scores [34]. Healthcare workers ranked third as sources of information, while family, friends, and other channels were the least cited. Understanding these information sources is crucial for designing effective future vaccination programs, as it enables targeted communication strategies that address the most influential and trusted platforms within the community [35]. The results indicate that mass media and social media are the primary sources of information among participants. To enhance adolescent engagement, public health communication strategies should leverage these platforms by incorporating youth-oriented formats such as short, visually engaging videos and interactive content. Collaborating with trusted online personalities and peer influencers could further strengthen message credibility and promote positive health behaviours, including vaccine acceptance.

In this study, it is shown that TV/Radio were the main sources of knowledge among participants and social media, therefore more awareness must be made on TV/Radio programs and social media platforms. The school populace should limit the mongers with the help of the school administration and also reassure the school-going pupils about the effectiveness and side effects of the COVID-19 vaccines. Having good knowledge about COVID-19 vaccines is cardinal to increase acceptance of the vaccines and it is important to provide reliable and scientific sources of information that are peer-reviewed to reach the public at large.

Concerning the attitude towards the COVID-19 vaccines, half (50.7%) of the total participants had a positive attitude towards the vaccines, which is contrary to the findings in Thakurgon district, Bangladesh, 27% of the participants had a positive attitude towards COVID-19 [31]. However, similar findings of half participants having a positive attitude towards COVID-19 and vaccines were found in Hubei province of China [36]. Higher findings of (68%) were reported in the United States [35]. In the Lusaka district, similar findings were also found (49.96%), where half of the participants had a positive attitude [26]. The difference in these findings may be due to differences in sample size and socio-demographic characteristics.

In this study, the acceptance rate was 30.6% which was low. Although the study found high knowledge levels about COVID-19 vaccination (86.1%), uptake remained low due to misinformation and fear. This indicates that general awareness can coexist with specific, influential misbeliefs that strongly shape behavior. Misconceptions about vaccine safety or long-term effects may persist despite adequate knowledge, underscoring the need for targeted communication strategies that address and dispel these fears through trusted and relatable sources. The low acceptance of COVID-19 vaccines reported in our study is contrary to the findings in China (75.59%), Saudi Arabia (64.7%) [37][38], and acceptance rate of 69.1% in Korea [39]. In Ethiopia, an acceptance rate of 71% was reported [40] and in Germany, 68.3% were willing to take the vaccine [41]. The variation in the present study might be due to socioeconomic differences, which usually determine accessibility to health services and health information.

The uptake level of the vaccine in this study was 21.1%, on the other hand, in the United States of America, at least 26.1% received a dose and 29.2% of the participants in the Lusaka district had received at least one dose of COVID-19 vaccine [26][42]. In another study among Sub-Saharan Africans between rural and urban residents, uptake of COVID-19 vaccines varied among the rural 14.2% and urban 25.3% [43]. However, in a study, 74.8% of adolescents were vaccinated in the United States [44].

In this study, female participants who were willing to be vaccinated were 96/336 (28.6%) while male participants were 130/418 (31.1%). These findings are in line with reports that indicated that males are more likely to accept the vaccine compared to females [45] although other findings reported that females were more likely to accept vaccination against COVID-19 compared to males [38]. A study done in Ethiopia reported that being female increases the odds of vaccine acceptance [40]. Therefore, strategic methods should be used to increase vaccination uptake among school-going children and adolescents in Zambia, these findings contribute to the existing knowledge by broadening the ongoing plans on the motivation for and hesitancies of obtaining the COVID-19 vaccine and thereby promoting vaccination uptake.

In the present study, most participants had not suffered from COVID-19 640/754 (84.9%), this can influence their acceptance because they feel they do not need the vaccine. Those who do not think the preventive measures are stressful to follow were 393/754 (52.1%), these findings are higher than the ones found in the Lusaka district 36.3% [26]. However,50.7% in Addis Ababa, Ethiopia did follow the preventive measures [46]. 380/754 (50.4%) of the participants were afraid of the vaccine, and when asked why they felt that way, they said the vaccine has terrible side effects. This mirrors the findings that people’s intention to get vaccinated is influenced by variables as such side effects [47].

In the current study, participants who suffered from chronic conditions had (46.9%) positive attitude towards the COVID-19 vaccine while those who did not have any chronic condition had (51%) positive attitude and a study in the USA among adolescent cancer survivors reported 37.1% vaccine hesitancy [48]. Limited understanding of diseases and their prevention, coupled with misconceptions and parental disapproval, can significantly affect the acceptance of COVID-19 vaccines among pupils. Parental or guardian consent serves as a key structural determinant of vaccine uptake, particularly among adolescents, whose decisions are often shaped by family attitudes and beliefs. Supportive parental perspectives can enhance vaccine confidence and participation, while disapproval or misinformation within households may restrict access even when adolescents are personally receptive. Strengthening parental engagement and education, alongside adolescent-focused interventions, is therefore critical to improving vaccine acceptance and coverage.

We are aware that this study had some limitations that should be considered when interpreting the findings. First, the study employed a cross-sectional design, which captures data at a single point in time and therefore cannot establish causal relationships between knowledge, attitudes, and vaccine uptake. Second, data were self-reported, which may be prone to recall bias and social desirability bias, as participants could have provided responses they perceived as more acceptable. Third, the study was conducted among school-going adolescents and youths in selected districts (Kitwe and Ndola) of the Copperbelt Province; therefore, the findings may not be generalisable to out-of-school adolescents or other regions of Zambia with different sociodemographic characteristics.

Additionally, the study mainly focused on quantitative data and did not include qualitative interviews that could have provided deeper insights into the cultural, psychological, and contextual factors influencing vaccine hesitancy and acceptance. Finally, the study only assessed COVID-19 vaccine attitudes and uptake, and thus, its findings may not fully reflect perceptions toward other routine adolescent vaccines such as HPV or tetanus.

Table 7 shows the policy implications and recommendations of this study. This study highlights key policy implications for improving vaccine uptake among adolescents and youths in Zambia. Despite high knowledge levels, vaccine uptake remained low, underscoring the need for policies that address fear, misinformation, and structural barriers. Strengthening school-based vaccination programmes through collaboration between the Ministries of Health and Education, enhancing risk communication via mass and social media, and engaging trusted figures such as teachers, parents, and community leaders can build vaccine confidence. Additionally, gender-sensitive and community-driven approaches, supported by robust monitoring and data systems, are essential to bridge the gap between awareness and actual vaccine uptake among young people.

Table 7. Policy implications, recommendations, and future directions for improving vaccine uptake among adolescents and youths.

The study revealed that most participants had good knowledge of COVID-19 vaccines, and about half demonstrated a positive attitude; however, a low vaccine acceptance was recorded and only 21.1% had been vaccinated. Fear of side effects significantly influenced vaccine acceptance, particularly among those who had experienced or been exposed to COVID-19 cases. Mass media, especially television and radio, were identified as the main sources of vaccine information. These findings highlight the need for targeted educational and behavioural interventions that leverage mass media and social media platforms to dispel misinformation, reduce fear, and promote vaccine confidence and uptake among adolescents and youths in Zambia.

Data Collection Tool

Questionnaire

Knowledge, Attitude, and Acceptance of COVID-19 Vaccines among School-going Adolescents and Youths: Findings and Implications