The COVID-19 pandemic resulted globally in more than 769 million cases and 6.9 million deaths.1 Nigeria reported 256,028 confirmed cases and 3,143 confirmed deaths due to COVID-19 disease.2 The rapid spread of COVID-19 and associated mortality, especially among the elderly and people with comorbidities spurred efforts to develop vaccines for controlling the epidemic. Conventional vaccine development from the preclinical phase to licensing could take an average of over 10 years.3 However, epidemics in the last decade have accelerated the development of novel platforms that have shortened the time for vaccine sequencing from years to weeks.4 Leveraging these platforms and multisectoral collaborations, several vaccines were rapidly produced and approved for distribution to curb the scourge of the COVID-19 pandemic.

Within the first year of the COVID-19 pandemic, Janssen completed phase 3 trial of a potential COVID-19 vaccine5, and multiple options became globally available with greater access to vaccines in the developed countries compared to other nations.6 With availability of effective vaccines, overcoming hesitancy assumed priority. Vaccine hesitancy defined as delay in the acceptance or complete refusal of vaccines despite the availability of vaccines has been identified as one of the top 10 global public health problems.7 It is complex phenomenon that is influenced by factors such as age, culture, socio-economic status, and trust in the healthcare system.89

The World Health Organization SAGE working group identified three barriers to vaccine uptake known as the 3C’s: Confidence/lack of confidence (in vaccines and lack of trust in the system that delivers them), complacency, (when perceived risks of vaccine-preventable diseases are low or when vaccination is considered secondary to other responsibilities at a given point in time) and convenience (which denotes the extent to which physical availability, affordability, and access to information and other immunization services exist).10 Research estimates suggest that herd immunity to COVID-19 would require more than 60% of the population to be vaccinated or infected naturally.11

As of June 18, 2022, only 13% of Nigerians had completed all recommended COVID-19 vaccines despite the widespread availability of the vaccines12 This fell significantly short of the goal of vaccinating 40% of the population by December 2021. Suboptimal uptake of vaccines is not uncommon in Nigeria due to vaccine unavailability, lack of confidence in vaccines or complacency factors.13

This study is designed to identify the predictors of COVID-19 vaccine hesitancy in the seven states of North-Central, Nigeria.

The study recorded a total of 1,999 survey entries, of which 13 did not consent to participate in the survey, yielding a response rate of 99.3%. We excluded 557 responses for not meeting the inclusion criteria. Thus, the final sample size for this study was 1,429. Out of the 1,429 responses included in the study analysis, 1,008 (70.5%) were willing to accept or had received at least one dose of the COVID-19 vaccine while 421 (29.5%) were unvaccinated and hesitant as shown in Figure 1.

The COVID-19 pandemic resulted in significant disruption in the health and livelihoods globally. Despite the evidence that vaccines offer viable protection against the disease, achieving universal acceptance remains an uphill task. Nigeria has reported challenges with the uptake of several vaccines in different parts of the country including vaccines that were aimed at the prevention of infant mortality 10111718. In this study, 29.5% of the respondents in the North-Central region were unwilling to receive the COVID-19 vaccine. A similar study in Southwest Nigeria reported a vaccine hesitancy rate of 25.5%,15 and an African survey of 34 countries reported a hesitancy rate of 37% among the general population.16

On a global level, vaccine hesitancy rates above 50% have been reported in China, Malaysia, Australia, Pakistan and Italy. 8171819 Some sociodemographic factors such as education, religion and income were found to be significantly associated with vaccine hesitancy in our study. this shows that the lack of post-secondary education was associated with a 51% higher risk of hesitancy. Our findings are consistent with other studies that have established the value of education in influencing health-seeking behaviours.20 Reliable sources of such information such as educational and health institutions are important in shaping knowledge and attitudes that increase uptake of vaccines, and other health-seeking activities such as social distancing, usage of masks and other proven health interventions that prevent the spread of the COVID-19 virus. Half of the hesitant respondents indicated reliance on social media and friends or family as their trusted sources of information about the COVID-19 vaccine. These sources are often prone to information biases, particularly during a period of massive anti-vaccine campaigns and misinformation. The study also found that higher household income above the national minimum wage with respondents that earning significantly above the minimum demonstrating a 42% reduction in risk. This is consistent with the likelihood of attainment of post-secondary education among higher-earning respondents.

Respondents of the Islamic faith had a 32% lower risk of hesitancy compared to the Christians. The impact of faith on health and social behaviours is very profound in Nigeria. Many adopt mannerisms or practices that conform to the teachings of religious leaders or community leaders. The notable anti-vaccine messaging that emanated from some prominent Christian leaders at the beginning of the pandemic may have contributed to vaccine hesitancy among some members of the faith.21 The majority of religious and community leaders supported COVID-19 vaccination efforts but over two-thirds of hesitant persons were unswayed by the support of their religious or community leaders to accept the vaccine.

Our study identified a combination of confidence, convenience, and complacency factors as influencers of vaccine hesitancy. Nearly half of the vaccine-hesitant respondents cited a lack of confidence in the safety and side effect profile of the vaccines as the reasons for their unwillingness to be vaccinated. Other studies have documented similar findings. 2224 More than two-thirds of respondents expressed a lack of trust in both the government of Nigeria and pharmaceutical companies to deliver the vaccine with the sole purpose of improving quality of life. Similar attitudes to vaccines have been demonstrated with the polio vaccination drive where citizens in Northern Nigeria perceived the vaccines to contain compounds with sterilization properties that will prevent childbearing.13 The unprecedented speed in the development of COVID-19 vaccines and perceived inequalities in vaccine distribution contributed in fuelling vaccine hesitancy. The Oxford/AstraZeneca vaccine that was initially delivered to Nigeria through COVID-19 Vaccines Global Access (COVAX) initiative was perceived as inferior to the Moderna and Pfizer vaccines that were available in the high income countries. These findings are consistent with the findings of Lar son et al.23 that a lack of trust in the healthcare system, government, and economic systems has a profound effect on vaccine acceptance. Nomhwange, et al., (2022) similarly reported that the COVID-19 vaccine hesitancy was attributed to uncertainties about the safety of the vaccine, and the negative information that was circulated about COVID-19 vaccines on social media26.

Complacency factors were demonstrated by those who expressed that the COVID infection was not real, the vaccine was not required and those who felt the use of universal precautions and personal protective equipment were adequate to address the epidemic. This may be potentiated by the high risk of misinformation among hesitant respondents as more than 50% of them relied on sources that are prone to biases such as social media, friends, and others for information about the vaccine. Examples of pervasive misinformation about the COVID-19 vaccine include rumours of the vaccine as a means of inoculating tracking chips into humans, the COVID-19 epidemic is a punishment from God, the illness is an effect of 5G technology deployment, while some believed it was just the regular flu.25

Convenience factors were expressed by more than a third of the respondents who indicated that distance from homes to vaccination centres, the perceived waiting time required to complete the vaccination, and the process of vaccination were unfavourable for them. These factors are likely associated with the cost of transportation or the opportunity costs of vaccination over other activities of priority such as work.

This study provides a perspective on the COVID-19 vaccine hesitancy in a large region of Nigeria. Though similar studies have been conducted in other states or regions of the country, this adds to the body of knowledge about the magnitude of vaccine hesitancy and the factors that drive them in a large region of Northern Nigeria. We acknowledge some limitations of the study which may have affected the generalizability of its findings. This includes online survey methodology with possible selection and response biases. Participants were those with access to internet, computers or smartphones. In addition, the inferences from this study relate to the COVID-19 vaccine and may not apply to vaccines for other diseases.

This study's findings reaffirm vaccine hesitancy as a threat to COVID-19 prevention efforts in the North Central region of Nigeria. It enhances our understanding of the predictors of vaccine hesitancy and the reasons why people refuse to be vaccinated with the COVID-19 vaccine. The study found that vaccine hesitancy is a complex problem that is linked with multiple social determinants of health as lower educational attainment and Christian faith were found to be predictors of vaccine hesitancy. Confidence, Complacency and Convenience factors were expressed by respondents as concerns about side effects, doubt about the existence of COVID-19 and the time required to receive the vaccines were the most prominent reasons for unwillingness to receive the vaccine. The study highlights the importance of leveraging trusted sources of information, such as healthcare workers and social media, to disseminate accurate and timely information about COVID-19 and the vaccine. To protect the public health of communities, targeted interventions are required to increase vaccine acceptance by cultivating trust in vaccines, disseminating accurate information, and engaging with community stakeholders including religious groups.

The study was funded by Georgetown University Medical Center, Dean of Research. However, the funder did not play any role in the research.