Hassen et al.

BMC Public Health (2022) 22:1142

https://doi.org/10.1186/s12889-022-13485-2

RESEARCH Open Access

Understanding determinants of COVID‑19

vaccine hesitancy; an emphasis on the role
of religious affiliation and individual’s reliance
on traditional remedy
Hanna Defar Hassen1*†, Mengistu Welde2† and Mesay Moges Menebo3†

Abstract
Background: The damage COVID-19 has caused interms of mortalities, economic breakdown and social disruption is
immense. The COVID-19 vaccine has been one of the efficient prevention strategies so far in preventing the pandemic.
However, the publics’ hesitancy towards vaccines has enormously affected this task. With emerging research findings
indicating that a substantial proportion of adults are hesitant about a vaccine for COVID-19, important work that identi-
fies and describes vaccine hesitant individuals is required to begin to understand and address this problem.
Objective: This study assessed public attitude towards COVID-19 Vaccine and identified important factors that lead
to its hesitancy.
Methods: A web and paper-based cross-sectional survey study was conducted from July 31 to August 12, 2021. The
study participants are staffs and students at Jimma University. A total of 358 participants were selected using stratified
simple random sampling and requested to fill a survey questionnaire. Binomial logistic regression analysis was done
to identify factors associated with COVID-19 vaccine hesitancy.
Results: Half of the participants were found to be hesitant to COVID-19 vaccine. The odds of becoming vaccine
hesitant among middle income was two times more than those with lower income (AOR 2.17, 95% CI 1.05–4.5). Fur-
thermore, respondent’s extent of exposure was associated with vaccine hesitancy with the odds of becoming vaccine
hesitant among those whose source of COVID-19 information is from four media sources (Social Media, Mass Media,
Health care worker and Friends/family/Neighbor) being 74% lower (AOR .26, 95% CI .09–.69) than those with one
media source. Concern towards vaccine side effect, vaccine effectiveness and having the belief to treat COVID-19 with
traditional remedies were found to increase the odds of becoming vaccine hesitant by 31%, 42% and 37% respec-
tively. Moreover, the association between side-effect concern and vaccine hesitancy was moderated by participant’s
religious affiliation.
Keywords: COVID-19, Vaccine hesitancy

Introduction
†
Hanna Defar Hassen, Mengistu Welde and Mesay Moges Menebo The global and national damage COVID-19 has caused
contributed equally to this work.
interms of mortalities, economic breakdown and social
*Correspondence: hannadefh@gmail.com disruption is immense. Until this day, it left 3.9 million
1
School of Medicine, Faculty of Medical Sciences, Institute of Health, Jimma people dead [1], almost 25% of COVID-19 patients with
University, Jimma, Ethiopia long term symptoms and organ damages, and 40,000
Full list of author information is available at the end of the article

© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
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Hassen et al. BMC Public Health (2022) 22:1142 Page 2 of 11

children parentless [2]. Economic wise, it became a rea- among Republicans [14]. In another study conducted
son for export activities to be plummeted by 46% [3], among 2032 Sub-Saharan African participants, about
and 43% of businesses worldwide to be closed [4] bring- 7.3% of them believed that 5G technology was behind
ing significant amount of employees to an economic cri- the COVID-19 pandemic [15]. Besides conspiracy theo-
sis. With people’s movement impeded, It has also caused ries, other health and socioeconomic variables also play
experiences of depression and anxiety to surge by 25% significant role in predicting COVID-19 vaccine hesi-
[5], and major social activities like the Olympic to be tancy. For example, COVID-19 vaccine hesitancy is most
postponed. expressed by people who are less educated [16], racial
So far, there are 19 COVID-19 vaccines approved for and ethnic minority [17], less incomed [18], women
use by at least one national regulatory authority [6] that [19], pregnant, city dwellers, and those suffering from
are 50% to 95% effective in preventing the pandemic [7, an underlying chronic health problem [20]. A number of
8]. Despite the occurrence of new variants being reported psychological constructs have also been explored in rela-
repeatedly, health authorities and vaccine manufacturers tion to COVID-19 vaccine hesitancy. For example, indi-
assure that the already-in-market vaccines still offer pro- viduals who are -religious [21], politically conservative
tection against most variants currently spreading [9]. This [22]and have an anti-government view [23] were shown
implies that vaccination programs have so far been the to be vaccine hesitant. Moreover, individuals who are
most successful strategy against COVID-19 pandemic. more—self-interested, distrustful of experts and author-
Hesitancy towards the COVID-19 vaccine however ity figures (i.e. scientists, health care professionals, the
severely impacted the prevalence of vaccination pro- state), in favor of authoritarian political views has more
grams and consequently contributed to the burden vaccine hesitant attitudes. Furthermore, societal disaffec-
COVID-19 has endangered. For example, in a study tion, intolerance of migrants, impulsivity in ones thinking
conducted by the imperial college of London, it is fore- style, characteristics of disagreeability, emotional unsta-
casted that high numbers of people refusing or delaying bility, less conscientiousness, conviction that one’s lives
a vaccine could increase the mortality rate by up to eight are primarily under own control [20]—were shown to
times compared with ideal vaccination uptake [10]. In a influence vaccine hesitancy (see Fig. 1).
similar study, it was also indicated that countries with Though an extensive and thorough investigation of dif-
broad populations refusing or delaying a COVID-19 vac- ferent driving factors to COVID-19 vaccine hesitancy
cine could face death rates that are as much as nine times were reported, but the literature still misses some impor-
higher than in other populations. tant factors that might predict COVID-19 vaccine hesi-
With emerging research findings indicating that a sub- tancy behaviors. First is individuals’ extreme reliance on
stantial proportion of adults (especially in regions like traditional remedies. Especially in the African and Asian
Africa or the conservative section of the USA) are hesi- region, traditional remedies are considered to be a major
tant about a vaccine for COVID-19 [11, 12], important source of treating illnesses [24]. In some cases as a first
work is required to begin to understand and address this line of treatment [25]. As a result of this, individuals tend
problem. It has been documented in large part over the to underestimate or reject the complete use of modern
years that vaccine hesitancy is a result of an inter-indi- medicine. Even in extreme cases, individuals tend to
vidual difference for example in personality, socio-eco- develop a disbelief to contrary modern medicine if they
nomic status, demography and beliefs. The importance think there is a traditional remedy to replace it. Though
of identifying, describing, and understanding vaccine we yet do not sufficiently know whether this also be the
hesitant individuals as a key preparatory step for vaccine case to COVID-19 vaccine, but it was previously docu-
development is further emphasized by the World Health mented that people who use traditional, complementary
Organization’s (WHO, 2014) Strategic Advisory Group of and alternative medicine were found to be more vaccine
Experts (SAGE) on Immunization [13]. It is imperative, hesitant [26].
therefore, that an effort is made to understand the multi- Second, it was previously shown that the more peo-
ple characteristics that define and distinguish those who ple are religious, the more they tend to be COVID-19
are hesitant to a vaccine for COVID-19 from those who vaccine hesitant [21]. But how useful are such pieces of
are accepting. information for a country where most of its population
In most of the cases, COVID-19 vaccine hesitancy is considered to be highly religious (e.g. 95% religious
is a result of belief in conspiracy theories. For example, in Indonesia) or very unreligious (e.g. 12% religious
from a poll of 1,640 people in the US, 28% of Americans in France) [27]. For example, can we extrapolate from
believe that Bill Gates wants to use vaccines to implant this finding to predict that the majority of the Indone-
microchips in people—with the figure rising to 44% sian (vs French) population is vaccine hesitant (vs non-
hesitant) since the population is majorly religious (vs
Hassen et al. BMC Public Health (2022) 22:1142 Page 3 of 11

Fig. 1 A review of Socio-demographic and Psychological factors that predict public’s attitude towards COVID-19 vaccine

unreligious)? No, the recent vaccine-hesitancy preva- Materials and methods

lence findings does not confirm this prediction [28, 29]. Study setting
This raises a need to study hesitancy against a more The study was conducted at Jimma University (JU), the
deeper classification of individuals than religiosity. For largest and comprehensive public research university in
example, it is seemingly assumed that classifying indi- Ethiopia located in the Jimma zone-Southwestern region
viduals interms of their religious affiliations (denomi- of Ethiopia. The university operates four campuses and
nations) instead of their religiosity is more precise in educates more than 43,000 students in 56 undergraduate
showing a more meaningful inter-individual difference and 103 postgraduate programs in regular, summer and
than religiosity does [30]. For example, both a Method- distance education programs.
ist and an Evangelical score the same on religiosity, but
as a result of their specific affiliations each end up show- Study design, participants and sampling
ing different behaviors. The source population for this study are all individu-
In this work, we investigated how individuals’ reliance als who are staffs or students at Jimma University. Indi-
on traditional remedies for treating COVID-19 com- viduals aged ≥ 18 years and who are staffs or students at
promises individuals’ willingness of taking COVID-19 Jimma University were included in this study. Individuals
vaccine. Moreover, we investigated how affiliation to dif- who are already vaccinated for COVID-19 vaccine were
ferent Christianity denominations (e.g. being an Ortho- excluded.1
dox Christian versus Protestant Christian) differently
associate with vaccine hesitancy. While doing this, we
also made an effort to partial out the effect of other key
1
variables that are previously investigated to relate with Inclusion and Exclusion decision was made based on participants responses
for questions on the first section of the Survey (Age, Vaccination Status and
COVID-19 vaccine hesitancy. Consent). Participants aged > 18 and those who mentioned they are not vac-
cinated were allowed to proceed with the main survey.
Hassen et al. BMC Public Health (2022) 22:1142 Page 4 of 11

Stratified simple random sampling technique was uncomfortable to answer. Questions for political affilia-
used to select study participants. First, stratification tion and race received small number of responses in the
was done based on the faculty of staffs and students. pretest implying participant discomfort on responding
Nine study faculties were identified. Then, four facul- to these questions. The main study therefore avoided to
ties were selected using lottery method and the sample include these questions. Moreover, we used the pretest
was proportionally allocated. Finally, study participants responses to test the consistency of the translation. Par-
were selected randomly and requested to fill the survey ticipants in the pretest pilot study filled both the Eng-
questionnaire. lish and Amharic Questionnaire. The analysis of their
responses on the two scales was highly correlated (r > 0.9)
Sample size calculation implying the consistency of the questionnaire translation.
Single population proportion formula was used to cal- Questions under ‘Attitude and knowledge to COVID-
culate the sample size with the following assumptions: P 19 vaccine’ measured individual’s level of understanding,
(62.3%, the average proportion of intention to take vac- extent of information, level of concern and overall atti-
cine among three Ethiopian towns [31]),d (the permissi- tude on topics related to COVID-19 vaccine. For exam-
ble Margin of error 5%) and Zα/2 corresponding to 95% ple, it covered topics like COVID-19 vaccine efficacy,
confidence level. safety, side-effect and complications. It also measured
preference to traditional remedies than COVID-19 vac-
cine. Measures were adopted and modified from previous
(Z a/2 )2 ∗ p(1 − p) (1.96)2 0.37 ∗ 0.62 literatures [32, 33]. The questions measured the extent
n= = = 340
d 2 0.052 of how strongly or weakly participants approve or dis-
approve 12 item statements made about the topics: for
Assuming a potential non-response rate of 5%, we
example, ‘I believe I can prevent or treat COVID-19 with
increased the calculated sample size by 5%. The total
traditional remedies than the COVID-19 vaccine’, ‘I do
number of individuals approached to attain desired sam-
not have enough information regarding COVID-19 vac-
ple were therefore 358 (340 + 5%*340).
cine’, ‘ I have concern with COVID-19 vaccine side effects’,
‘I believe that the COVID-19 vaccine is not safe’, ‘I have
Data collection tool, quality control, and procedure
concerns on COVID-19 vaccine due to religious reasons’.
The data was collected using both web-based and paper-
Participants were asked to approve the statements on a
based questionnaire.2 The web-based questionnaire was
five points likert scale with 1 being ‘strongly disagree’ and
prepared on an online platform named Qualtrics and
5 being ‘strongly agree’.
the survey link was distributed to targets through mail.
We operationally defined COVID-19 vaccine hesitancy
The questionnaire involved structured and self-adminis-
as a delay in acceptance or refusal of vaccines despite
tered questions. The questionnaire was prepared both in
availability of vaccine services. Measure is adopted
English and Amharic formats and participants filled the
from a previous literature [34]. Hesitancy was meas-
questionnaire with the language of their convenience.
ured by asking participants how willing they would be
The questionnaire tool consisted questions that meas-
to get a COVID-19 vaccine if it is freely offered to them.
ured socio-demographic characteristics, media exposure,
Response options include “definitely not willing,” “prob-
attitude and knowledge about COVID-19 and COVID-
ably not willing,” “not sure,” “probably willing,” and “defi-
19 vaccine, and COVID-19 vaccine hesitancy. Automatic
nitely willing.” For the primary outcome, responses into
and default attention check questions were included on
“willing” (definitely or probably willing) or “not willing”
the web-based version of the questionnaire to moni-
(all other responses) were dichotomized.
tor and control participants who tried to fill the survey
Participants were asked to indicate which religion they
questionnaire randomly. In addition, participant’s dura-
belong to out of four affiliations; ‘Orthodox Christian’,
tion of survey filling time was recorded so as to reject
‘Catholic Christian’, ‘Protestant Christian’, and ‘Muslim’
replies that spend less time than the mean duration of the
with the possibility of selecting ‘Others’ if they do not
majority of participants. The data collection instrument
belong to one of these.
was pre-tested on Jimma University Medical Faculty stu-
The study was conducted after receiving ethi-
dents (on 2% of the sample size).
cal approval from Jimma University Ethical Review
The pretest helped identify questions that create mis-
Board (IRBJU/20/2021). Permission letter was obtained
understanding and questions where participants are
from Jimma University Institute of Health Ethical
Review Board before data collection was started. Writ-
2
We first tried to reach staffs and students at the 4 faculties through a non- ten informed consent was obtained from all participants
targeted institutional based mail. Since the turnout of the online collection after explaining the study’s purpose, risks, and benefits.
wasn’t effective, we switched to paper-based collection with a data collector.
Hassen et al. BMC Public Health (2022) 22:1142 Page 5 of 11

Moreover, participants were assured the participation is COVID-19 information is from four media sources (Social
entirely voluntary and personal information is not dis- Media, Mass Media, Health care worker and Friends/fam-
closed to third parties. The right to withdraw from the ily/Neighbor) is 74% lower (AOR 0.26, 95% CI 0.09–0.69)
study was respected for participants. than those with one media source. In addition, for respond-
ents who reported death of a family member with COVID-
Statistical analyses 19, the odds of becoming vaccine hesitant is seven times
Data was exported from Qualtrics to the Statistical Pack- (AOR 6.9, 95% CI 1.8–26.4) more than those who does not
age for Social Science (SPSS) version 28.0 for analy- have similar experience.
sis. Frequency, percentage and mean was computed for Respondent’s attitude and knowledge about COVID-
descriptive statistics. The association between the inde- 19 and COVID-19 vaccine was also associated with vac-
pendent and dependent variables was analyzed using the cine hesitancy (See Table 4). For example, respondents
binomial logistic regression model. Bivariate analysis was who have concern with COVID-19 vaccine side effects
done to select candidates for multivariate at p < 0.05. The and respondents who believe that the COVID-19 vaccine
adjusted model was run including all the sociodemo- is not effective have a 31% and 42% increase in the odds
graphic, health condition and knowledge/attitude vari- of becoming vaccine hesitant respectively than respond-
ables as independent variable. The fitness of the model ents who have less of those concerns. In the contrary,
was checked with Hosmer and Lemeshow (HL) test val- respondents who claimed that they do not have enough
ues. When running all the variables together as predictor, information regarding COVID-19 vaccine and respond-
HL value is significant implying poor fit (χ2 (1,8) = 11.81, ents who believe that all COVID-19 vaccines in general
p = 0.044). However, removal of all nonsignificant vari- are useful in controlling the COVID-19 pandemic have a
ables from the adjusted analysis and rerunning the model 24% and 33% decrease in the odds of becoming COVID-
yields a strong fit ( χ2 (1,8) = 2.5, p = 0.96)). 19 vaccine hesitant respectively.

Results Traditional remedies and COVID‑19 vaccine hesitancy

Sociodemographic Characteristics of Respondents 30% (N = 105) of respondents agree that they can effec-
A total of 338 participants were included in the current tively prevent or treat COVID-19 with traditional rem-
study, with a 94.4% response rate. More than 75% of edies better than the COVID-19 vaccine. Consequently,
respondents are in the age group of 18–29. Almost two- such belief leads to a 37% increase in the odds of becom-
third (62.7%) of the respondents were males, three-fourth ing vaccine hesitant (AOR 1.37, 95% CI 1.0–1.7).
(67.8%) single, and more than half (63.9%) with a first
degree. The overall vaccine hesitancy rate is 50%. Par- Religion and COVID‑19 vaccine hesitancy
ticularly, respondents with—age between 18 and 29, male Participant’s distribution is diverse interms of religious
and single, have a degree, Orthodox Christian, have more composition. Orthodox Christian (39%; n = 132) and
than 4 family members, and have a middle income—were Protestant Christian (34%; n = 116) represent 75% of
found to be more hesitant to COVID-19 vaccine (See participants while those with Muslim affiliation account
Table 1). for 18% (n = 61). Vaccine hesitancy does not vary among
Associated Factors for vaccine hesitancy the religious groups. However, the increase in the odds
On bivariate analysis, vaccine hesitancy has statistically of becoming vaccine hesitant is not dependent on con-
significant associations with respondents’ -attitude and cern with COVID-19 side effects equally for all religious
knowledge towards COVID-19 and COVID-19 vaccine, groups. For example, being concerned with COVID-
media exposure, monthly income and whether their family 19 side effects is not associated with vaccine hesitancy
member has recently died with COVID-19 (See Tables 2, for Orthodox Christian participants but for Protestant
3, 4). Regarding association with socioeconomic factors, the Christian and Muslim participants (See Fig. 2).
odds of becoming vaccine hesitant among middle income
(monthly salary between 1000 to 5500 ETB3) is two times Discussion
(AOR 2.17, 95% CI 1.05–4.5) more than those with a lower Vaccine hesitancy is currently under-studied in devel-
income (monthly salary of less than 1000 ETB; See Table 2). oping countries [35]. It was found that half of the study
Furthermore, respondent’s extent of media exposure was population in this study are hesitant to vaccine. This
associated with vaccine hesitancy (See Table 3). The odds prevalence is approximately similar to findings from
of becoming vaccine hesitant among those whose source of other regional cities in Ethiopia like Sodo town (> 50%)
and Gondor (44%) but way bigger than reported in
the capital city Addis Ababa (19%). The magnitude of
3
ETB = Ethiopian Birr. 1,000 ETB is equivalent to 19.46 USD as of 01.05.2022. vaccine hesitancy increased as moving away from the
Hassen et al. BMC Public Health (2022) 22:1142 Page 6 of 11

Table 1 Sociodemographic characteristics of participants (n = 338)

Vaccine hesitancy Total [338]

No Yes
N [169] N [169]

Age 18-29 125 (74) 133 (78.7) 258 (76.3)

30-39 31 (18.3) 22 (13.0) 53 (15.7)
40-49 9(5.3) 7 (4.1 16 (4.7)
50-59 1(0.6) 5 (3.0) 6 (1.8)
60 and above 3 (1.8) 2(1.2) 5 (1.5)
Gender Male 105 (62.1) 107 (63.3) 212 (62.7)
Female 64 (37.9) 62 (36.7) 126 (37.3)
Marital Status Single 114 (67.5) 115 (68.0) 229 (67.8)
Married 52 (30.8) 47 (27.8) 99 (29.3)
Divorced 2 (1.2) 6 (3.6) 8 (2.4)
Widowed 1 (0.6) 1(0.6) 2 (0.6)
Educational level No formal education 2 (1.2) 3 (1.8) 5 (1.5)
Elementary school 0 (0.0) 6(3.6) 6 (1.8)
High school 7 (4.1) 10(5.9) 17 (5.0)
Diploma 31 (18.3) 37(21.9) 68 (20.1)
Degree 112 (66.3) 104 (61.5) 216 (63.9)
Masters 11 (6.5) 3 (1.8) 14 (4.1)
Doctorate degree 6 (3.6) 6 (3.6) 12 (3.6)
Religion Orthodox Christian 63 (37.3) 69 (40.8) 132 (39.1)
Catholic Christian 3(1.8) 4 (2.4) 7 (2.1)
Protestant Christian 68(40.2) 48 (28.4) 116 (34.3)
Muslim 28(16.6) 33 (19.5) 61 (18.0)
Others 7 (4.1) 15 (8.9) 22 (6.5)
Family members 0 (Living alone) 23 (13.6) 25 (14.8) 48 (14.2)
1 5 (3.0) 17 (10.1) 22 (6.5)
2 18 (10.7) 18 (10.7) 36 (10.7)
3 20 (11.8) 17 (10.1) 37 (10.9)
4 35 (20.7) 29 (17.2) 64 (18.9)
More than 4 68 (40.2) 63 (37.3) 131 (38.8)
Monthly income Less than 1000 ETB 45 (26.6) 47 (27.8) 92 (27.2)
From 1000 to 5500 ETB 62 (36.7) 77 (45.6) 139 (41.1)
From 5500 to 6900 ETB 38 (22.5) 20 (11.8) 58 (17.2)
6900 and above 24 (14.2) 25 (14.8) 49 (14.5)

capital city. A hypothesis for this variation in vaccine previously represented as the flagship bearer of false
hesitancy across regions might have arised from inad- information. Many previous studies [36] shown the sus-
equate information access about COVID-19 vaccine ceptibility of social media in propagating unverified and
in smaller than bigger cities. Giving support to this scientifically unproven information about legit health
hypothesis, a negative association was found between services including COVID-19 vaccine, contributing to
the frequency of media exposure and vaccine hesitancy. the prevalence of hesitancy. In our study, we document
It was found that the more information access an indi- that vaccine hesitancy does not depend much on the
vidual has about COVID-19 vaccine from a variety of type of the media but on the variety. This might imply
media sources (Social Media, Mass Media, Health care that all media sources can be vulnerable to false infor-
worker and Friends/family/Neighbor) than a single mation and to creating hesitancy. Therefore, a recom-
media source (one of the four), the odds of becoming mendable form of intervention in this regard is to use
vaccine hesitant decreased by 74%. Social media was mix of media sources.
Hassen et al. BMC Public Health (2022) 22:1142 Page 7 of 11

Table 2 Sociodemographic factors associated with vaccine hesitancy of study participants (n = 338)
COR5 (95% CI) P-value AOR6 (95% CI) P-value

Age 18–29 .57

30–39 .67 (.36–1.2) .185 .89 (.36 -2.2) .82
40–49 .73 (.26–2.0) .546 .87 (.19 -4.04) .86
50–59 4.7 (.54 -40.7) .160 5.9 (.29 -122) .25
60 and above .63 (.1 -3.8) .612 .08 (.00–10.1) .32
Gender Male
Female .95 (.61 -1.47) .82 .74 (.39 -1.4) .36
Marital Status Single .38
Married .89 (.56 -1.43) .65 .69 (.31 -1.5) .38
Divorced 2.97 (.59–15.0) .19 3.8 (.38 -37.2) .25
Widowed .99 (.06–16.0) .99 .09 (.0 -70.6) .48
Educational level No formal education .68
Elementary school .99 .99
High school .95 (.12–7.2) .96 2.47 (.01 – 603) .75
Diploma .79 (.12–5.1) .81 1.00 (.00 – 4) 1.0
Degree .62 (.10–3.7) .60 .95 (.00 -26) .98
Masters .18 (.02 -1.6) .13 .34 (.00–11) .71
Doctorate degree .67 (.08 -5.5) .71 1.57 (.00 – 4) .87
Religion Orthodox Christian
Catholic Christian 1.22 (1.2-.26) .80 .46 (.04 -4.9) .52
Protestant Christian .65 (.65-.39) .09 .86 (.43 -1.7) .68
Muslim 1.07 (1.0-.58) .81 1.96 (.88 -4.3) .10
Others 1.95 (1.9 -.75) .17 2.16 (.56 -8.2) .26
Family members 0 (Living alone)
1 3.1 (.9 -9.8) .05 3.54 (.78 -16) .10
2 .92 (.38 -2.1) .85 .51 (.15 -1.76) .29
3 .78 (.33 – 1.8) .58 .51 ( .14 -1.7) .29
4 .76 (.36–1.6) .48 .73 (.25 -2.1) .57
More than 4 .85 (.4 -1.6) .64 .66 (.25 -1.7) .39
Monthly income Less than 1000 ETB
From 1000 to 5500 ETB 1.18 (.7 – 2.0) .52 2.17 (1.05–4.5) .04*
From 5500 to 6900 ETB .50 (.25—.99) .05 .52 (.19 -1.4) .19
6900 and above .99 (.49 -1.9) .99 1.94 (.67 -5.5) .22
Media exposure Exposed to 1 source
Exposed to 2 sources .92 (.53–1.59) .76 .63 (.29–1.3) .23
Exposed to 3 sources 1.16 (.56 -2.43) .68 1.1 (.4 -2.9) .84
Exposed to 4 sources .51 (.26 – 1.02) .06 .26 (.09 -.69) .01**
*(p < 0.05), **(p < 0.01)

It is however important to be cautious of the accuracy information from a variety of media sources might not
of information pieces in media sources. This is because, help in alleviating COVID-19 vaccine hesitancy if the
use of several media sources precedes information over- sources hold some amount of disinformation.
load, which negatively influences how individuals process Socioeconomic factors like monthly income have been
information. A recent study [37] shown that information shown to associate with COVID-19 vaccine hesitancy in
overload with COVID-19 made participant’s incline to previous literatures. However, a definite direction of rela-
greater heuristic and less systematic processing. Given tionship has not emerged. For example, while Soares [38]
individuals are more susceptible to process information reported no association but several others [39] reported
automatically (vs critically) when exposed to a variety of a negative association where individuals of lower income
media sources, this implies that exposure to COVID-19 reported to be higher in COVID-19 vaccine hesitancy.
Hassen et al. BMC Public Health (2022) 22:1142 Page 8 of 11

Table 3 Health condition factors associated with vaccine hesitancy of study participants (n = 338)
COR (95% CI) P-value AOR (95% CI) P-value

Chronic disease No
Yes 1.70 (.82—3.52) .15 2.3 (.77 -6.7) .14
Perceived healthiness Poor
Fair 1.78 (.1 -30.1) .69 4.5 (.00 -93) .69
Good .69 (.04 – 11.28) .79 .85 (.00 -17) .96
Excellent 1.07 (.06- 17.37) .96 2.8 (.00 -5) .79
Diagnosed with Covid-19 No
Yes .82 (.34–1.96) .66 .45 (.1 -1.9) .29
Tested for Covid-19 No
Yes .85 (.54–1.34) .48 1.3 (.65- 2.49) .47
Family diagnosed with Covid-19 No
Yes .87 (.53–1.45) .61 .58 (.26 -1.3) .18
Family died with Covid-19 No
Yes 1.96 (.81- 4.75) .14 6.9 (1.8 -26.4) .01**
**(p < 0.01)

Table 4 Knowledge and attitude factors associated with vaccine hesitancy of study participants (n = 338)
COR (95% CI) P-value AOR7 (95% CI) P-value

I do not have enough information regarding COVID-19 vaccine .93 (.80–1.06) .27 .76 (.62-.93) .00**
I have concern with COVID-19 vaccine side effects 1.29 (1.07–1.53) .00** 1.31(1.0–1.7) .05*
I believe that the COVID-19 vaccine is not safe 1.42 (1.21 –1.67) .00** 1.23 (.95–1.5) .11
I think that the COVID-19 vaccine is not effective 1.64 (1.37–1.97) .00** 1.42 (1.1 -1.8) .01**
I think that COVID-19 is not any more dangerous 1.09 (.94–1.26) .26 1.13 (.9 -1.4) .29
I have fear of COVID-19 infection .81 (.70-.94) .00** .82 (.66 -1.0) .09
I am against vaccination in general 1.23 (1.03–1.47) .02* 1.1 (.84–1.5) .45
I have concerns on COVID-19 vaccine due to religious reasons 1.16 (1.0–1.34) .04* .99 (.7 -1.2) .93
I have concerns on COVID-19 vaccine due to cultural reasons 1.06 (.91–1.23) .48 .86 (.8 -1.1) .26
I believe I can prevent or treat COVID-19 with traditional remedies than the Covid-19 vaccine 1.32 (1.13–1.54) .00** 1.37 (1.0–1.7) .01**
In general, I am concerned about serious complications of the COVID-19 vaccine 1.07 (.91–1.25) .38 1.0 (.79–1.2) .99
The COVID-19 vaccines, in general, will be useful in controlling the COVID-19 pandemic .66 (.56—.79) .00** .67 (.52-.85) .00**
*(p < 0.05), **(p < 0.01)

Contrary to these previous findings, it is the middle [40] has led to the ban of the Oxford–AstraZeneca
incomed who are twofold more hesitant than the lower COVID-19 vaccine in many European countries. Second
incomed in this study. It is our speculation that, since confusion that came along with COVID-19 vaccine is the
income was measured with an objective not subjective vulnerability of being reinfected even after being fully vac-
scale, middle incomed participants of this study might cinated. The prevalence of this event is 3 out of 100: out
be regrouped as lower incomed within the income scale of 100 fully vaccinated, three get infected [41]. The conse-
framework of previous studies in developed countries that quences of these two confusions, side-effects and occur-
has reported a negative association between income and rence of infection, is long-range. It does not only prolong
hesitancy. the burden of the pandemic or merely disrupt the global
Immediately after the launch and implementation of vaccine supply chain, but also contribute to more people
the COVID-19 vaccination program, two problems arose becoming concerned about the COVID-19 vaccine. Our
that affected both the scientific community and the global study brought an empirical evidence to this discourse by
public. First are mild to serious COVID-19 vaccine related documenting an association between vaccine hesitancy
side-effects which were reported and widely shared that and individuals concern on COVID-19 vaccine effec-
even led to the ban of some vaccine brands from the mar- tiveness and concern on COVID-19 vaccine side effects
ket. For example, frequent reports of thromboembolism (Table 2). More interestingly, this association does not
Hassen et al. BMC Public Health (2022) 22:1142 Page 9 of 11

Fig. 2 Religious affiliation moderating the relationship between Concern with COVID-19 side effects and Vaccine hesitancy

hold for those with Orthodox Christian affiliation: the of COVID-19 vaccine hesitancy among universities is
magnitude of how concerned this group of participants considerably lower than found in this study. For exam-
are with COVID-19 vaccine side effects does not vary ple, the prevalence is 24% [43] in an Italian university,
their hesitancy on the vaccine (Fig. 2). This might indicate 7.4% in a Czech university [44], 13% in a Qatari education
the presence of other more important predictors of vac- sector population [45]. No similar data is reported from
cine hesitancy in this group of population. African universities than this particular study. If the most
Amidst uncertainty and frustrations both in the pathophys- educated group of the society are hesitant to vaccines to
iology and the management of COVID-19, many, especially this level, then Ethiopian health authorities might need to
in Africa, resorted to home remedies as immediate alterna- devise a strategic communication. A communication that
tive or first line of action [42] to COVID-19. With home rem- leverages on the factors that are presumed to have caused
edies treating mild COVID-19 like symptoms, it is expected the hesitancy. This could involve usage of every avail-
that this further strengthens individuals reliance to traditional able source of media to disseminate legit and accurate
remedies more than on COVID-19 vaccine. As per the extent COVID-19 and COVID-19 vaccine related information.
of our literature search, previous studies overlooked how such Moreover, the communications should involve clinical
reliance on alternative treatments for COVID-19 contributes presentations that document the minimal prevalence of
to the overall tendency to vaccine hesitancy. vaccine side effects globally. Furthermore, communica-
The findings from this study will have practical contri- tion strategies should be able to clearly indicate the value
butions that might help in policy and health intervention of being vaccinated. For example, future campaigns aimed
activities. First, it is alarming that a significant proportion at promoting COVID-19 vaccination intention could craft
of the study population is hesitant to COVID-19 vaccine. messages that depict the significantly reduced extent of
Given that this figure is documented from a sample of an disease severity in those vaccinated than non-vaccinated,
academic institution that involved more than 67% partici- despite there is still a chance of reinfection after full vac-
pants with atleast a first degree, it is daunting to predict cination. Moreover, religious affiliation can also be used
that the figure might even plummet among other mem- as an important characteristics to segment target groups
bers of the society that are less educated. Global figures when running anti-vaccine-hesitancy communications.
Hassen et al. BMC Public Health (2022) 22:1142 Page 10 of 11

Limitations Author details

1
School of Medicine, Faculty of Medical Sciences, Institute of Health, Jimma
Our study should be interpreted within the context of its University, Jimma, Ethiopia. 2 Department of Biomedical Sciences, Faculty
limitations. First, our study population was restricted to of Medical Sciences, Institute of Health, Jimma University, Jimma, Ethiopia.
an educational institution that constitutes individuals with 3
Department of Business and IT, School of Business, University of South-East-
ern Norway, Campus Bø, Notodden, Norway.
atleast high school or above high school educational quali-
fications. This limits the generalizability of our study find- Received: 5 February 2022 Accepted: 16 May 2022
ings to the general population. Second, our study being
cross-sectional in design limits inference of causal relation-
ships between the identified factors and vaccine hesitancy.
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