Factors associated with the uptake of COVID-19 vaccines in the adult population, Asante Akim South, North and Central Municipalities, Ashanti region, Ghana, 2023

Abdul Gafaru Mohammed^1,&, Ruth Nimota Nukpezah², Georgia Ghartey³, Martin Osei⁴, Alice Sallar Adams³, Ernest Kenu^4,3

 

¹National Malaria Elimination Programme, Ghana Health Service, Accra, ²Department of Epidemiology and Disease Control, School of Public Health, University of Ghana, Accra Ghana, ³Ghana Field Epidemiology and Laboratory Training Programme, University of Ghana, Accra, Ghana, ⁴School of Nursing and Midwifery, University for Development Studies, Tamale, Ghana

 

 

^&Corresponding author
Abdul Gafaru Mohammed, National Malaria Elimination Programme, Ghana Health Service, Accra.

 

 

 

 

Strategies for the prevention of coronavirus disease (COVID-19) transmission are essential for the control of the pandemic, reclaiming daily life, and assisting in the recovery of economies [1]. Achieving global immunity is one such strategy, which has been recently accelerated by COVID-19 vaccine development. High rates of uptake of the vaccine connote progress towards the desired global immunity.

 

As of November 2022, nine vaccines had been approved for use by the World Health Organization (WHO)[2], with about 12 billion doses administered worldwide [3]. Ghana was the first African country to receive vaccines from the COVAX facility. As of 14 October 2022, only 27.4% of the total population had been fully vaccinated against COVID-19 in Ghana. In the Ashanti region, only 34.0% of the total population had been fully vaccinated as of October 2022 [4].

 

These numbers are relatively lower than the WHO immunization target rate of 70% (of a total country population), suggesting that the availability of COVID-19 vaccines may not translate into high rates of uptake. It is hence important to target the factors that influence uptake rates to help policymakers design appropriate interventions to reduce vaccine hesitancy.

 

There are various studies documenting factors that affect the acceptability and uptake of COVID-19 vaccination not just in Africa but elsewhere. The factors identified as determinants of COVID-19 vaccination acceptability and uptake in these studies include belief in the effectiveness of the vaccines, community perception, presence of an underlying condition, past exposure to COVID-19, availability of vaccines, awareness of the vaccination campaign, sex, age, marital status and the place of residence [5-8].

 

Despite the essential contribution of these studies to vaccination coverage, there is still limited data on the contextual-specific factors that influence the uptake of the COVID-19 vaccines after their deployment, to the Ghanaian populace in the Asante Akim municipalities. Similar studies have been conducted in other parts of Ghana to assess the perceived acceptability of the COVID-19 vaccines among the population prior to COVID-19 vaccine deployment [5-7]. However, the factors reported to influence the acceptability of a vaccine before its deployment might not translate to actual factors influencing uptake after deployment. It is hence important to unearth the more recent factors that are associated with the uptake of the vaccines after several months of deployment. This study aimed at determining the factors associated with the uptake of COVID-19 vaccines in the adult population of the Asante Akim South, Central, and North municipalities of the Ashanti Region in Ghana.

 

 

Study setting

 

The study was conducted in the Asante Akim municipalities of the Ashanti Region of Ghana. The Asante Akim municipalities are located 75km to the south of Kumasi, which is the capital of the Ashanti region of Ghana. Asante Akim is made up of three out of the 43 districts in the Ashanti region, namely Asante Akim South, Asante Akim North, and Asante Akim Central. It shares boundaries with the Bosome-Freho District to the Southwest. The municipality has an estimated population of 301,094, according to the 2020 census with 70% estimated rural dwellers. Each of the three districts in the municipality has four to six sub-districts. The area has more than 30 health facilities including hospitals, health centers, Community-based Health Planning and Services (CHPS), and maternity units. The municipalities have five hospitals including Akim Central Municipal Hospital, Agogo Presbyterian Hospital, Juaso Government Hospital, and Konongo-Odumasi Government Hospital. COVID-19 vaccination is conducted in all health facilities by public health units or immunization units in the area by community health nurses and other healthcare workers. Before the vaccination rollout, campaigns were carried out in the municipality to educate the inhabitants about the vaccines and the established vaccination sites.

 

Study design

 

A cross-sectional study was conducted among adults in the Asante Akim municipalities to assess the uptake of COVID-19 vaccination. A semi-structured questionnaire was used to collect information on the uptake of COVID-19 vaccines and participant characteristics. Data for the study was collected from January to March 2023.

 

Study population and eligibility

 

The study included all adults aged 18 years and above who were residents of the Asante Akim South, Central, or North municipalities. People visiting the municipalities and those who could not participate due to sickness were excluded from the study. The study participants were engaged in their homes.

 

Sample size estimation and sampling process

 

We estimated the sample size using the Cochrane sample size estimation formula

 

 

Where p = proportion of adults who would accept COVID-19 vaccines in previous studies = 70% [9,10]. Z (standard value for a 95% confidence level) = 1.96, and d (margin of error) = 5%.

 

We estimated a minimum sample size of 323 participants. A multistage sampling approach was used to sample participants for the study. The first stage involved the simple random sampling of subdistricts from each of the municipalities. In sampling the subdistricts from each of the three municipalities, the names of all subdistricts were written on pieces of paper and placed in a box, shaken and the number of subdistricts of interest randomly selected from the box. More than two-thirds of subdistricts were sampled from each municipality; Asante Akim Central (3 subdistricts/4 subdistricts), North (3 subdistricts/4 subdistricts), and South municipality (4 subdistricts /6 subdistricts). The second stage involved the simple random sampling of communities from each of the selected sub-districts. The communities in each of the sub-districts were grouped into two strata, stratum A (list of rural communities in the subdistrict) and stratum B (list of urban communities in the sub-district). Two communities were then selected from each sub-district, one community from stratum A and one community from stratum B. A probability proportionate to size sampling approach was then used to determine the number of participants to sample from each of the selected communities using the estimated adult population of the communities obtained from the municipal health directorates. On the day of data collection in each of the sampled communities, sequential numbers were assigned to each household on the list for the community. For example, if there were 100 households, we numbered them from 1 to 100. We proceeded to use a random number generator to select a number between 1 and the total number of households. The household that corresponds to the randomly generated number was the first house to be selected for the data collection in the community. In each selected household, one adult who meets the eligibility criteria was selected for the study. Research assistants collected data from study participants in their homes. The Ghana Health Service Ethics Review Committee approved the study.

 

Training and pretesting

 

Research assistants were recruited from the Asante Akim Central Municipal Health Directorate to support data collection. A 3-day training exercise was organized to educate the research assistants on the nature of the research, data collection tool, data collection process, and privacy and confidentiality issues in data collection. Before the actual data collection process, the semi-structured questionnaire developed was pre-tested in the Okai Kwei North district of the Greater Accra region. Issues from the pretest such as timing and problems with a few questions were addressed before the actual data collection took place.

 

Data collection

 

Data was collected using a semi-structured questionnaire adapted and modified from previous studies on the uptake of COVID-19 vaccination and routine immunization studies conducted in different settings [11-13]. The questionnaire was designed and deployed on a Kobo-collect tool for electronic data collection. The questionnaire was made up of three sections. A section on sociodemographic characteristics, i.e. age, sex, residence, educational level, employment status, and marital status. A section on uptake of COVID-19 vaccination, the type of vaccine taken, the number of doses, and whether the participant was fully or partially vaccinated, and a last section on individual-level factors such as the presence of underlying conditions, testing for COVID-19, previous history of COVID-19, contact with someone with COVID-19, having a relative or close friend being positive for COVID-19, awareness of the vaccination campaign and knowing where to get the vaccine. Each interview lasted for approximately 20 - 30 minutes. Three data validation meetings were organized during the data collection process. Each questionnaire was reviewed to ensure the correct data was collected.

 

Data analysis

 

Data was extracted from the kobo-collect tool at the end of the data collection period. The extracted data was cleaned and imported into STATA version 15.1 for statistical analysis. The data were analyzed descriptively, and all categorical variables such as sex, occupation, residence, religion, educational status, vaccine uptake, and underlying condition were summarized into frequencies and proportions. Continuous variable such as age was summarized into mean and standard deviation. A binary logistic regression model was performed to assess the association between the uptake of COVID-19 vaccination and the various participant characteristics. A stepwise regression model which uses likelihood ratios was used to select variables for the adjusted logistic regression model. Significance level for the adjusted logistic regression was set at 5%. Robust standard errors were performed to adjust for clustering using place of residence (urban or rural) as the clustering variable.

 

Data availability

 

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

 

Ethical considerations

 

The Ghana Health Service Ethics Review Committee granted ethical clearance for the study (GHSERC:068/01/23). All participants provided verbal and written informed consent for participation in the study. Data was collected devoid of personal identifiers such as names and contacts. Collected data was accessible by only the principal investigator. All preventive measures against COVID-19 were taken to prevent the spread of the disease between study participants and research assistants.

 

 

Demographic characteristics and COVID-19 vaccination status among adults, Asante Akim Municipalities, 2023

 

Out of 362 dwellers of the Asante Akim Municipalities survey, 95.0% (344/362) agreed to participate in the study. Out of the 344 study participants, 78.2% (269) were urban residents. More than half of the participants were females (51.7%, 178), unemployed (67.2%, 231), Christians (80.5%, 277) and single (53.8%, 185). The average age of participants was 32.7± SD: 10.2 years, with 40.7% of the adults aged 21 - 30 years. Most of the participants studied had university or college-level education (39.2%) and earned above 1000 Ghana cedis (32.0%) every month. Majority of the adults studied were vaccinated 75.0% (258/344) (Table 1).

 

Individual-level factors and COVID-19 vaccination status among adults Asante Akim Municipalities, 2023

 

More than one-third, 40.1% (137/344) of the adults studied had previous contact with a COVID-19 patient. Most 57.8% (197/344) of the adults had never been diagnosed with COVID-19. More than half 68.7% (235/344) were aware of the ongoing vaccination campaign and 74.1% (255/344) had a relative who had previously received the vaccine. Overall, more than two-thirds 75.0% (95%CI:70.1 - 79.5) of the adults studied were vaccinated against COVID-19. The level of vaccine uptake was higher among adults who had previous contact with COVID-19 patients 88.3% (95%CI:81.7 - 93.1) compared to those who had no contact with COVID-19 patient 65.8% (95%CI:58.9 - 72.3). However, a higher vaccine uptake level of 88.2% (81.7 - 92.9) was seen among those with a previous diagnosis of COVID-19 compared to those without a previous diagnosis of COVID-19 65.9% (95%CI:58.9 - 72.5). Higher vaccination rates were recorded among those aware of the campaign 83.8% (95%CI:78.4 - 88.2) than those who were not aware of the campaign. Those with a relative who had previously received a COVID-19 vaccine had a high vaccination rate 84.3% (95%CI:79.3 - 88.5) than those without a relative who had previously received the COVID-19 vaccine (Table 2).

 

Factors associated with the uptake of COVID-19 vaccination among adults, Asante Akim Municipalities, 2023

 

In an adjusted logistic regression, after controlling for age, sex, income level, employment status and religion, place of residence-urban (aOR=34.1, 95%CI:15.55 - 74.67), married participants (aOR=2.62, 95%CI:1.04-6.53), being aware of the ongoing vaccination campaign (aOR = 4.2, 95%CI: 1.14 - 15.36), having an underlying condition (aOR=3.5, 95% CI: 1.60-7.89), history of COVID-19 (aOR=3.4, 95% CI: 1.18-9.78), contact with COVID-19 positive patient (aOR=3.8, 95%CI: 2.12-7.08), having a vaccinated relative (aOR = 6.4, 95%CI: 5.06 - 8.10) and community perception of vaccine safety (aOR = 11.8, 95%CI: 4.36 32.06) were found to be significantly associated with the uptake of COVID-19 vaccine among the adults (Table 3).

 

 

The study revealed more than two-thirds of the respondents had been vaccinated against COVID-19, with varying representation among the various demographic and individual-related factors. This is consistent with the findings of six national surveys in sub-Saharan Africa where the COVID-19 vaccine acceptance rate ranged from 64.5% in Mali to 97.9% in Ethiopia [14]. Also, two other studies in Ghana and Nigeria reported similar COVID-19 acceptance levels of 62% and 80% respectively [10,13]. However, the reported uptake level is higher than the acceptance rate reported in similar studies in other parts of Ghana where the vaccine acceptance rate was less than 45% [7,15,16]. The disparity in the reported acceptance level could be attributed to the study population. The other studies were conducted among a rural Ghanaian populace compared to this current study with more than 60% urban residents. The more than 70% vaccine uptake recorded in the Asante Akim Municipalities indicates a majority of the populace trusts the vaccine and is taking steps to protect themselves from the disease. The high COVID-19 vaccine coverage in the municipalities implies a possible reduction in the risk of infection and risk of hospitalization [17, 18]. The uptake level recorded in this study is also within the estimated COVID-19 vaccine uptake levels required for the attainment of herd immunity in the populace [19-21].

 

This study reported a significant association between the place of residence and COVID-19 vaccination. Urban residents were found to have increased odds of being vaccinated compared to rural dwellers. This is comparable with the findings of a study conducted among urban and rural residents in Nigeria where urban dwellers had higher vaccination rates compared to their rural counterparts [22]. Also, a study conducted at the China-Vietnam border area reported a higher willingness for vaccine uptake among urban residents [23]. However, our finding was inconsistent with the results of a study conducted in Tamil Nadu, India where rural dwellers had increased odds of accepting COVID-19 vaccines [24]. The difference in findings could be attributed to the sampling approach used by the authors. Our study used a probability sampling approach to recruit participants compared to the non-probability approach used in the study in Tamil Nadu. The high odds of vaccine uptake among urban residents in the municipalities could be attributed to the accessibility of COVID-19 vaccination sites, whereas numerous vaccination centers were set up in health facilities and other vantage points in the urban communities, some rural communities had only one or none set-up for vaccination, particularly during weekends when a majority of them are available. This calls for more attention to the rural populace in the Asante Akim municipalities. Literature has suggested that dwellers of rural settings hold a high level of trust in health professionals to deliver accurate and right information when it comes to diseases and their treatment [25,26]. To increase vaccine uptake among rural dwellers, health workers should include education on COVID-19 vaccine safety during home visits, outpatient, and antenatal consultations.

 

Awareness of vaccination increased the odds of vaccination, which is consistent with empirical evidence from a study in Ethiopia [27]. Awareness increases the opportunity to build confidence in vaccine source, efficacy, and safety [27,28]. In this study, since many of the respondents were educated, there is an increased chance of a more accurate source of information hence influencing the uptake of the vaccine among those who are aware. Public sensitization and education activities through television, radio, and direct engagement should be adopted. This will inform members of the area about ongoing vaccination campaigns and the relevance of vaccination. Awareness messages should include areas selected as vaccination sites, the importance of vaccination, possible side effects, and all safety issues. Health workers, community-based surveillance volunteers, and religious leaders should be used in propagating the message to the masses in the communities.

 

This study also evinced that having a vaccinated relative increased the odds of being vaccinated, which could also be due to the awareness and assurance that is created when an individual has a family member who has been safely vaccinated. Proper awareness and education, both from external sources and close associations like vaccinated relatives could then influence perceived vaccine safety and confidence.

 

Marital status was another factor that significantly influenced COVID-19 vaccination coverage among adults in the Asante Akim Municipalities. Adults who were married had increased odds of receiving the vaccines compared to adults who were not married. Married adults are often embedded in larger social networks which might have structured health information dissemination. This can lead to increased awareness and higher vaccination rates. Also, they might perceive themselves and their families at higher risk and thus be more inclined to get vaccinated to protect their loved ones. This implies that health campaigns might benefit from leveraging the influence of spouses and family members to encourage vaccination, especially in populations where marital status correlates with higher vaccination rates.

 

Furthermore, the perception of community members regarding the safety of COVID-19 vaccines was another factor influencing vaccine uptake. Participants who perceived COVID-19 vaccines to be safe had higher odds of uptake compared to their counterparts. This is comparable with the findings of other studies where perceived vaccine safety increased the acceptability and willingness of participants to receive the vaccine [6,29]. To increase vaccine uptake in the municipalities, it is essential to tailor sensitization messages towards demystifying the negative perception held by some members on vaccine safety. In propagating safety messages, religious leaders, community leaders, and traditional healers should be engaged to spearhead information delivery to the people. A properly planned and executed vaccination sensitization campaign in the municipalities will not only increase the uptake of COVID-19 vaccines but will also improve the uptake of routine vaccines.

 

Sex of participants has also been reported in various studies to influence the acceptability or uptake of COVID-19 vaccines [8,30-32]. However, our study found no significant association between sex and vaccine uptake. Although more males were approximately vaccinated compared to females, the difference was not significant.

 

A limitation of this study was the high proportion of urban residents who earned GH₵1000 or more in the study. To address this limitation, robust standard errors were used to adjust for the sampling effect. However, these findings could be more applicable to affluent, urbanized strata of the Ghanaian population. Further studies should be conducted looking at lower-income community viewpoints to provide a more rounded viewpoint of international, national, and localized vaccine confidence and hesitancy.

 

 

More than 70% of the adults studied were vaccinated against COVID-19. The predictors of COVID-19 vaccine uptake identified were being married, history of COVID-19, having a vaccinated relative and underlying condition, having previous contact with a COVID-19 patient, and positive community perception of the vaccine safety.

 

 

Authors declared no competing interests.

 

 

All authors were involved in conceptualizing and designing the study. Data was curated by AGM and RNN. Data was analyzed by AGM, MO, and GG. The initial manuscript was drafted by AGM and GG but all authors made significant intellectual contributions leading to the final manuscript. All authors read and approved the final manuscript.

 

 

The authors wish to express their profound gratitude to the data collectors and research assistants.

 

 

Table 1: Background characteristics and COVID-19 vaccination status among adults, Asante Akim Municipalities, 2023

Table 2: Individual-level factors and COVID-19 vaccination status among adults Asante Akim Municipalities, 2023

Table 3: Factors associated with the uptake of COVID-19 vaccination among adults, Asante Akim Municipalities, 2023

 

 

1. Somerville M, Curran JA, Dol J, Boulos L, Saxinger L, Doroshenko A, Hastings S, Reynolds B, Gallant AJ, Shin HD, Wong H, Crowther D, Macdonald M, Martin-Misener R, Comeau J, McCulloch H, Tricco AC. Public health implications of SARS-CoV-2 variants of concern: a rapid scoping review . BMJ Open [Internet]. 2021 Dec 2 [cited 2024 Sep 1];11(12):e05578. https://doi.org/10.1136/bmjopen-2021-055781 PubMed | Google Scholar


2. World Health Organization. WHO Coronavirus (COVID-19) Dashboard [Internet]. Geneva (Switzerland): World Health Organization; 2022 [cited 2024 Sep 2].


3. Ghana Health Services. COVID-19 Vaccination Updates [Internet]. Accra (Ghana): Ghana Health Services; 2022 [cited 2024 Sep 2].


4. World Health Organization. Weekly epidemiological update on COVID-19 - 21 December 2022 [Internet]. Edition 123. Geneva (Switzerland): World Health Organization; 2022 Dec 21 [cited 2024 Sep 2]. 13 p. Download 20221221_Weekly_Epi_Update_123a4e86d14-a160-4d2b-b919-95177f4a085b.pdf.


5. Lamptey E, Serwaa D, Appiah AB. A nationwide survey of the potential acceptance and determinants of COVID-19 vaccines in Ghana . Clin Exp Vaccine Res [Internet]. 2021 May 31 [cited 2024 Sep 1];10(2):183-190. https://doi.org/10.7774/cevr.2021.10.2.183 PubMed | Google Scholar


6. Aram SA, Hagan JE, Mansoh GKA, Saalidong BM, Lartey PO, Ahinkorah BO, Seidu A, Ameyaw EK, Appiah A, Hotor DW, Gyimah J. Association between health and safety perceptions of COVID–19 vaccine and its uptake in Ghana. Public Health Challenges [Internet]. 2022 Oct 13 [cited 2024 Sep 1];1(4):e20. https://doi.org/10.1002/puh2.20 PubMed | Google Scholar


7. Afrifa-Anane GF, Larbi RT, Addo B, Agyekum MW, Kyei-Arthur F, Appiah M, Agyemang CO, Sakada IG. Facilitators and barriers to COVID-19 vaccine uptake among women in two regions of Ghana: A qualitative study. PLoS One [Internet]. 2022 Aug 17 [cited 2024 Sep 1];17(8):e0272876. https://doi.org/10.1371/journal.pone.0272876 PubMed | Google Scholar


8. Alhassan RK, Aberese-Ako M, Doegah PT, Immurana M, Dalaba MA, Manyeh AK, Klu D, Acquah E, Ansah EK, Gyapong M. COVID-19 vaccine hesitancy among the adult population in Ghana: evidence from a pre-vaccination rollout survey. Trop Med Health [Internet]. 2021 Dec 16[cited 2024 Sep 1];49(1):96. https://doi.org/10.1186/s41182-021-00357-5 PubMed | Google Scholar


9. Alhassan RK, Owusu-Agyei S, Ansah EK, Gyapong M. COVID-19 vaccine uptake among health care workers in Ghana: a case for targeted vaccine deployment campaigns in the global south. Hum Resour Health [Internet]. 2021 Nov 6 [cited 2024 Sep 1];19(1):136. https://doi.org/10.1186/s12960-021-00657-1 PubMed | Google Scholar


10. Okai GA, Abekah-Nkrumah G. The level and determinants of COVID-19 vaccine acceptance in Ghana. PLoS One [Internet]. 2022 Jul 8 [cited 2024 Sep 1];17(7):e0270768. https://doi.org/1371/journal.pone.0270768 PubMed | Google Scholar


11. Vassallo M, Clement N, Lotte L, Manni S, Sindt A, Bertrand PM, Durant J. Prevalence and Main Clinical Characteristics of Fully Vaccinated Patients Admitted to Hospital for Delta Variant COVID-19. Front Med [Internet]. 2022 Mar 2 [cited 2024 Sep 1];9:809154. https://doi.org/10.3389/fmed.2022.809154 PubMed | Google Scholar


12. Moisoglou I, Passali C, Tsiachri M, Galanis P. Predictors of COVID-19 Vaccine Uptake in Teachers: An On-line Survey in Greece . J Community Health [Internet]. 2022 Oct 15 [cited 2024 Sep 1];48(1):59-66. https://doi.org/10.1007/s10900-022-01144-x PubMed | Google Scholar


13. Adedeji-Adenola H, Olugbake OA, Adeosun SA.Factors influencing COVID-19 vaccine uptake among adults in Nigeria . Yunusa I, editor. PLoS One [Internet]. 2022 Feb 24 [cited 2024 Sep 1];17(2):e0264371. https://doi.org/10.1371/journal.pone.0264371 PubMed | Google Scholar


14. Kanyanda S, Markhof Y, Wollburg P, Zezza A. Acceptance of COVID-19 vaccines in sub-Saharan Africa: evidence from six national phone surveys . BMJ Open [Internet]. 2021 Dec 15[cited 2024 Sep 1];11(12):e055159. https://doi.org/10.1136/bmjopen-2021-055159 PubMed | Google Scholar


15. Amponsah-Tabi S, Djokoto R, Opoku S, Senu E, Boakye DK, Azanu WK, Ankobea-Kokroe F, Owusu-Asubonteng G, Ansah RO, Owusu E, Ackah-Avoh E, Kwayie AA, Boateng EA, Azavil RP, Ennin F. Knowledge, attitude and acceptability of COVID-19 vaccine among residents in rural communities in Ghana: a multi-regional study . BMC Infect Dis [Internet]. 2023 Jan 31 [cited 2024 Sep 1];23(1):60. https://doi.org/10.1186/s12879-023-08029-x PubMed | Google Scholar


16. Frimpong LK, Gbedemah SF, Eshun F, Okine P, Korsah AM. COVID-19 Vaccination Acceptance and Its Associated Factors: Insights from Rural and Urban Settlements in the Yilo Krobo Municipality in Ghana . Ghana J Geogr [Internet]. 2022 Dec 17 [cited 2024 Sep 1];14(3):1-27. https://doi.org/10.4314/gjg.v14i3.1 Google Scholar


17. Azami M, Moradi Y, Moradkhani A, Aghaei A. SARS-CoV-2 seroprevalence around the world: an updated systematic review and meta-analysis. Eur J Med Res [Internet]. 2022 Jun 2 [cited 2024 Sep 1];27(1):81. https://doi.org/10.1186/s40001-022-00710-2 PubMed | Google Scholar


18. Olschewski H, Eber E, Bucher B, Hackner K, Handzhiev S, Hoetzenecker K, Idzko M, Klepetko W, Kovacs G, Lamprecht B, Löffler-Ragg J, Meilinger M, Müller A, Prior C, Schindler O, Täubl H, Zacharasiewicz A, Zwick RH, Arns BM, Bolitschek J, Cima K, Gingrich E, Hochmair M, Horak F, Jaksch P, Kropfmüller R, Pfleger A, Puchner B, Puelacher C, Rodriguez P, Salzer HJF, Schenk P, Stelzmüller I, Strenger V, Urban M, Wagner M, Wimberger F, Flick H. Management of patients with SARS-CoV-2 infections with focus on patients with chronic lung diseases (As of 10 january 2022): Updated statement of the Austrian Society of Pneumology (ASP) . Wien Klin Wochenschr [Internet]. 2022 Apr 21[cited 2024 Sep 1];134(9-10):399-419. https://doi.org/10.1007/s00508-022-02018-x PubMed | Google Scholar


19. Madhi SA. COVID-19 herd immunity v. learning to live with the virus.. S Afr Med J [Internet]. 2021 Aug 5 [cited 2024 Sep 1];111(9):852-6. https://doi.org/10.7196/samj.2021.v111i9.16005 Purchase or subscription required to access full text. Google Scholar


20. Mallapaty S. Are COVID vaccination programmes working? Scientists seek first clues. Nature [Internet]. 2021 Jan 22 [cited 2024 Sep 1];589(7843):504-5. https://doi.org/10.1038/d41586-021-00140-w Purchase or subscription required to access full text. Google Scholar


21. Aschwanden C. Five reasons why COVID herd immunity is probably impossible. Nature [Internet]. 2021 Mar 18 [cited 2024 Sep 1];591(7851):520-2. https://doi.org/10.1038/d41586-021-00728-2 Purchase or subscription required to access full. Google Scholar


22. Ojo TO, Ojo AO, Ojo OE, Akinwalere BO, Akinwumi AF. Determinants of COVID-19 vaccine uptake among Nigerians: evidence from a cross-sectional national survey . Arch Public Health [Internet]. 2023 May 26 [cited 2024 Sep 1];81(1):95. https://doi.org/10.1186/s13690-023-01107-1 PubMed | Google Scholar


23. Liu B, Zhang M, Li X, Liu L, Li Q, Liang Z, Xu L, Li L, Su Y. Influence of epidemic situation on COVID-19 vaccination between urban and rural residents in China-Vietnam border area: A cross-sectional survey . PLoS One [Internet]. 2022 Jul 21 [cited 2024 Sep 1];17(7):e0270345. https://doi.org/10.1371/journal.pone.0270345 PubMed | Google Scholar


24. Joshi A, Surapaneni KM, Kaur M, Bhatt A, Nash D, El-Mohandes A. A cross sectional study to examine factors influencing COVID-19 vaccine acceptance, hesitancy and refusal in urban and rural settings in Tamil Nadu, India. PLoS One [Internet]. 2022 Jun 9 [cited 2024 Sep 1];17(6):e0269299. https://doi.org/10.1371/journal.pone.0269299 PubMed | Google Scholar


25. Wang J, Jing R, Lai X, Zhang H, Lyu Y, Knoll MD, Fang H. Acceptance of COVID-19 Vaccination during the COVID-19 Pandemic in China. Vaccines [Internet]. 2020 Aug 27 [cited 2024 Sep 1];8(3):482. https://doi.org/10.3390/vaccines8030482 PubMed | Google Scholar


26. Reiter PL, Pennell ML, Katz ML. Acceptability of a COVID-19 vaccine among adults in the United States: How many people would get vaccinated? Vaccine [Internet]. 2020 Aug 20[Version of Record 2020 September 17; cited 2024 Sep 1];38(42):6500-7. https://doi.org/10.1016/j.vaccine.2020.08.043 PubMed | Google Scholar


27. Asres F, Umeta B. COVID-19 vaccines: awareness, attitude and acceptance among undergraduate University students . J Pharm Policy Pract [Internet]. 2022 Apr 26 [cited 2024 Sep 1];15(1):32. https://doi.org/10.1186/s40545-021-00397-6 PubMed | Google Scholar


28. National Academies of Sciences, Engineering, and Medicine. Increasing Uptake of COVID-19 Vaccination Through Requirement and Incentive Programs [Internet]. Washington (DC): National Academies Press; 2022 [cited 2024 Sep 1]. 21 p. https://doi.org/10.17226/26545 Purchase or subscription required to access full text. Google Scholar


29. Sulub SA, Mohamed MA. Determinants of COVID-19 Vaccine Uptake and Acceptability in the Horn of Africa: Evidence from Somaliland. Vaccines [Internet]. 2022 Jul 4 [cited 2024 Sep 1];10(7):1076. https://doi.org/10.3390/vaccines10071076 PubMed | Google Scholar


30. Syan SK, Gohari MR, Levitt EE, Belisario K, Gillard J, DeJesus J, MacKillop J. COVID-19 Vaccine Perceptions and Differences by Sex, Age, and Education in 1,367 Community Adults in Ontario. Front Public Health [Internet]. 2021 Sep 22 [cited 2024 Sep 1];9:719665. https://doi.org/10.3389/fpubh.2021.719665 PubMed | Google Scholar


31. Toshkov D. Explaining the gender gap in COVID-19 vaccination attitudes . Eur J Public Health [Internet]. 2023 May 13 [cited 2024 Sep 1];33(3):490-5. https://doi.org/10.1093/eurpub/ckad052 PubMed | Google Scholar


32. Nery N, Ticona JPA, Cardoso CW, Prates APPB, Vieira HCA, Salvador De Almeida A, Souza MMDS, Borba Dos Reis O, Pellizzaro M, Portilho MM, Rosa Da Anunciação R, Victoriano R, Oliveira Dos Anjos R, Argibay HD, Carmo Lima DO, Mesquita IL, Conceição WM, Santana PM, Oliveira EC, Santana PSN, Brodskyn CI, Mothé Fraga DB, Solcà MDS, Reis MG, Costa F, Ribeiro GS. COVID-19 vaccine hesitancy and associated factors according to sex: A population-based survey in Salvador, Brazil . PLoS One [Internet]. 2022 Jan 21 [cited 2024 Sep 1];17(1):e0262649. https://doi.org/10.1371/journal.pone.0262649 PubMed | Google Scholar