metadata: authors: 0: author: Wollburg,Philip Randolph
1: author: Markhof,Yannick Valentin
2: author: Kanyanda,Shelton Sofiel Elisa
3: author: Zezza,Alberto
count: Africa
docna: 0: docna: The Evolution of COVID-19 Vaccine Hesitancy
            in Sub-Saharan Africa : Evidence from Panel Survey Data
docty: Policy Research Working Paper
abstracts: cdata!: COVID-19 vaccination rates in
            Sub-Saharan Africa lag behind other world regions, with just
            over 20 percent of the population in Sub-Saharan Africa
            fully vaccinated. To reach widespread coverage, high
            willingness to get vaccinated for COVID-19 among the
            population is considered an important prerequisite. Drawing
            on two years of panel survey data, this paper studies the
            dynamics of vaccine acceptance, its correlates, and reasons
            for hesitancy over time. The data come from multiple rounds
            of national High-Frequency Phone Surveys in five countries
            in East and West Africa (Burkina Faso, Ethiopia, Malawi,
            Nigeria, and Uganda), covering the period between 2020 and
            2022. The surveys are cross-country comparable and draw
            their samples from nationally representative sampling
            frames. The paper finds that COVID-19 vaccine acceptance has
            been high throughout the study period (68 to 98 percent).
            However, acceptance levels were lower in 2022 than in 2020
            in three countries (Burkina Faso, Malawi, and Nigeria) and
            higher in one country (Uganda). Moreover, individuals are
            observed to change their stated vaccine attitudes between
            survey rounds, to a limited extent in some countries
            (Ethiopia) and more frequently in others (Burkina Faso,
            Malawi, Nigeria, and Uganda). Vaccine hesitancy is higher in
            richer households and among those residing in urban areas,
            women, and the better educated. Conversely, hesitancy is
            lower in larger households and among heads of the household.
            The main reasons for hesitancy are concerns about side
            effects of the vaccine, its safety and efficacy, as well as
            assessments of COVID-19 risk, although these reasons
            fluctuate over time. The findings suggest that vaccine
            hesitancy is not the primary obstacle to reaching greater
            vaccine coverage in Sub-Saharan Africa. Instead, low
            coverage rates may be related to access and delivery
            barriers as well as supply shortages. Nevertheless, vaccine
            attitudes appear malleable so that continued efforts are
            needed to retain high levels of vaccine acceptance.
display_title: The Evolution of COVID-19 Vaccine
            Hesitancy in Sub-Saharan Africa : Evidence from Panel Survey Data
listing_relative_url: /research/2023/01/33977765/evolution-covid-19-vaccine-hesitancy-sub-saharan-africa-evidence-panel-survey-data
topicv3: Health Emergencies m1326557 2165,Immunizations m1327505 1459,Public Health m1327519 635,Household Surveys m1504071 2761,Coronavirus (COVID-19) m1939478 4828
publishtoextweb_dt: 2023-01-12T00:00:00Z
dois: 10.1596/1813-9450-10275
origu: Off of Sr VP Dev Econ/Chief Econ (DECVP)
author_keys: 0: author_key: 1464872
1: author_key: 1974294
2: author_key: 805742
3: author_key: 635976
model_extractions: Policy Research Working Paper 10275 The Evolution of COVID-19 Vaccine Hesitancy in Sub-Saharan Africa Evidence from Panel Survey Data _Philip Wollburg Yannick Markhof Shelton Kanyanda Alberto Zezza_ Development Economics Development Data Group January 2023
Policy Research Working Paper 10275

# **Abstract**

COVID-19 vaccination rates in Sub-Saharan Africa lag behind other world regions, with just over 20 percent of the population in Sub-Saharan Africa fully vaccinated. To reach widespread coverage, high willingness to get vaccinated for COVID-19 among the population is considered an important prerequisite. Drawing on two years of panel survey data, this paper studies the dynamics of vaccine acceptance, its correlates, and reasons for hesitancy over time. The data come from multiple rounds of national High-Frequency Phone Surveys in five countries in East and West Africa (Burkina Faso, Ethiopia, Malawi, Nigeria, and Uganda), covering the period between 2020 and 2022. The surveys are cross-country comparable and draw their samples from nationally representative sampling frames. The paper finds that COVID-19 vaccine acceptance has been high throughout the study period (68 to 98 percent). However, acceptance levels were lower in 2022 than in 2020 in three countries (Burkina Faso, Malawi, and Nigeria) and higher in one country (Uganda). Moreover, individuals are observed to change their stated vaccine attitudes between survey rounds, to a limited extent in some countries (Ethiopia) and more frequently in others (Burkina Faso, Malawi, Nigeria, and Uganda). Vaccine hesitancy is higher in richer households and among those residing in urban areas, women, and the better educated. Conversely, hesitancy is lower in larger households and among heads of the household. The main reasons for hesitancy are concerns about side effects of the vaccine, its safety and efficacy, as well as assessments of COVID-19 risk, although these reasons fluctuate over time. The findings suggest that vaccine hesitancy is not the primary obstacle to reaching greater vaccine coverage in Sub-Saharan Africa. Instead, low coverage rates may be related to access and delivery barriers as well as supply shortages. Nevertheless, vaccine attitudes appear malleable so that continued efforts are needed to retain high levels of vaccine acceptance.

This paper is a product of the Development Data Group, Development Economics. It is part of a larger effort by the World Bank to provide open access to its research and make a contribution to development policy discussions around the world. Policy Research Working Papers are also posted on the Web at http://www.worldbank.org/prwp. The authors may be contacted at pwollburg@worldbank.org.

_The Policy Research Working Paper Series disseminates the findings of work in progress to encourage the exchange of ideas about development issues. An objective of the series is to get the findings out quickly, even if the presentations are less than fully polished. The papers carry the names of the authors and should be cited accordingly. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily represent the views of the International Bank for Reconstruction and Development/World Bank and its affiliated organizations, or those of the Executive Directors of the World Bank or the governments they represent._ Produced by the Research Support Team
# **<mark>The Evolution of COVID-19 Vaccine Hesitancy in Sub-Saharan Africa: Evidence from Panel Survey Data</mark>**

Philip Wollburg*, Yannick Markhof*<sup>^</sup> , Shelton Kanyanda*, Alberto Zezza*<sup>1</sup>

## **JEL codes: I14, I18, I100, O55**

## **Keywords: COVID-19, vaccination, Africa, vaccine hesitancy**

> 1 * World Bank, Development Economics Data Group. ^ UNU-MERIT, United Nations University. This paper received funding support from the World Bank Research Support Budget grant “Understanding and estimating COVID-19 vaccination attitudes, uptake, and barriers in Sub-Saharan Africa” and the Global Financing Facility. The authors are grateful for support in collecting the data by the country teams: Marco Tiberti for Burkina Faso; Wilbert Drazi Vundru for Malawi; Asmelash Haile Tsegay and Manex Bule Yonis for Ethiopia; Akiko Sagesaka, Amparo Palacios-Lopez, Ivette Contreras Gonzalez, and Gbemisola Oseni for Nigeria; and Giulia Ponzini and Frederic Cochinard for Uganda. We are also grateful for support by Alemayehu Ambel, Talip Kilic, and Gero Carletto.
# **Background**

On December 8, 2020, the first COVID-19 vaccine outside a clinical trial was administered. **[1]** Two years onwards, the COVID-19 vaccine drive has become the largest vaccination effort in history and has reached over 5.4 billion people globally. **[2, 3]** Challenges for COVID-19 vaccination campaigns differ from past vaccination efforts. Instead of taking years or even decades of development, the first COVID-19 vaccines achieved emergency approval within less than a year of the first recorded cases of the disease. **[4, 5]** Such rapid development has given rise to concerns among members of the public regarding the safety of COVID-19 vaccines and has led to additional scrutiny. **[6]** Following the availability of COVID-19 vaccines, the severity of the pandemic that ensued over the course of 2020 has also put time pressure on the rollout of vaccination campaigns, has led to supply shortages and resulted in vastly heterogeneous availability of COVID-19 vaccines across the globe. **[7]** Consequently, many low- and middle-income countries that lack the ability to produce vaccines of their own have relied on donations of vaccine doses from vaccine-producing countries and face infrastructural challenges in the rollout of their vaccination campaigns. Some of these challenges have still not been completely overcome 2 years after. **[8]** A region that has been of particular concern in the quest for global COVID-19 vaccine coverage has been Sub-Saharan Africa. Sub-Saharan Africa is the world’s poorest region. Here, capacity to develop or procure COVID-19 vaccines is lowest and structural barriers that complicate vaccine delivery are pervasive. As a result, COVID-19 vaccine coverage in Sub-Saharan Africa is trailing other regions. **[9]** Furthermore, SubSaharan Africa is a data-scarce environment with typically little robust information on issues such as vaccine acceptance or barriers of access that can inform the rollout of vaccination campaigns. Yet, SubSaharan Africa is home to over 1.16 billion people, about 15% of the world’s population. This makes it a systemically important region in the global effort to contain COVID-19 and end the pandemic.

The special status of COVID-19 vaccination campaigns in Sub-Saharan Africa has created the need for research to fill knowledge gaps around the effective mass delivery of COVID-19 vaccinations in the region. **[8–12]** In an effort to fill this gap, the World Bank supported a series of cross-country comparable high-frequency phone surveys (HFPS) in early 2020 that collect recurring information on vaccine hesitancy, uptake, barriers of access and information transmission in the context of COVID-19 vaccines in SubSaharan Africa.

In this paper, we bring together two years of data and findings from the HFPS across five Sub-Saharan African countries. We focus on COVID-19 vaccine acceptance as a prerequisite for widespread vaccine coverage in the region and a matter of particular concern given the special circumstances of COVID-19 vaccine development. COVID-19 vaccine hesitancy has been the subject of a number of studies across lowand middle-income countries, including in Sub-Saharan Africa, however, there is a lack of longitudinal evidence. **[9–11, 13–17]** Such longitudinal evidence is needed to understand the dynamics of vaccine acceptance in the region with some of the world’s lowest COVID-19 vaccine coverage figures. By virtue of the recurring nature of the HFPS, we are able to study vaccine attitudes and their correlates at the countrylevel and among a panel of individuals over a 2-year time horizon.

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# **Methods**

## **Data**

We use data from High-Frequency Phone Surveys (HFPS) in five countries in Sub-Saharan Africa: Burkina Faso, Ethiopia, Malawi, Nigeria, and Uganda. The surveys were conducted by study countries’ national statistical organizations (NSOs), supported by the World Bank’s Living Standards Measurement Study (LSMS). Since May 2020, the LSMS-supported HFPS have collected cross-country comparable longitudinal data on a wide range of topics, focused on COVID-19 impacts on households and individuals.

Vaccine hesitancy related information was collected from in 2020, 2021, and recently in 2022, depending on the study country. This study uses four rounds of data for Malawi (Oct-Nov 2020, Apr 2021, Feb 2022, Jul-Aug 2022) and Uganda (Oct-Nov 2020, Feb 2021, Sep-Nov 2021, Aug-Sep 2022), three rounds in Burkina Faso (Dec 2020, May-Jun 2021, Apr-May 2022) and Nigeria (Oct 2020, Feb 2021, Dec 2021-Jan 2022), and two rounds of data for Ethiopia (Sep-Oct 2020, Feb 2021).

## **Sampling and sample representativeness**

The HFPS have national coverage and draw their samples from nationally representative samples of households interviewed in pre-pandemic face-to-face surveys of the LSMS-Integrated Survey on Agriculture (LSMS-ISA) series. In the settings at hand, mobile phone coverage is not universal, and the sample selection of phone surveys may not yield samples fully representative of the general population. Phone surveys also experience an extent (albeit limited) of non-response and attrition. The HFPS therefore use recalibrated sampling weights (based on propensity score and post-stratification methods), which mitigate sample selection biases. **[18–20]** In each household, one main respondent over the age of 15 was interviewed, selected to be knowledgeable of the household and its members. This purposive selection has been found to overrepresent certain population groups. **[20]** The sample sizes for each country are shown in Table A1.

## **Survey instrument and variables**

Survey instruments were harmonized across countries while allowing for a degree of contextualization where necessary. In the early rounds, before COVID-19 vaccines were available, vaccine acceptance questions were posed in the hypothetical, asking respondents if they would be willing to get vaccinated if an approved COVID-19 vaccine was available. When vaccines became more widely available, questions were changed to reflect this development, asking respondents if they were planning to be vaccinated. Whenever respondents said they were unsure or unwilling to be vaccinated, the survey enquired about the reasons for their hesitancy or unwillingness.

## **Estimation methods**

Reported estimates are population-weighted means with their 95% confidence intervals where applicable, computed using the recalibrated phone survey weights. To explore how individual and household characteristics correlate with the willingness to get vaccinated, we make use of a multivariate logit regression setup, again using recalibrated phone survey weights.

3
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need to be ongoing and effectively targeted. Lastly, our findings also highlight that vaccine hesitancy is a country-specific phenomenon with at times substantial variation in vaccine attitudes and their dynamics, correlates of hesitancy and hesitancy reasons. Any policy recommendations thus need to take into account the specific country context.

Our study faces the challenges and limitations of phone survey data collection on vaccination. There is some sample selection at the household level due to under-coverage, non-response, and attrition, whose potential impacts however our recalibrated sampling weights limit.[19] The purposive selection of respondents leads to the over-representation of certain population groups and the under-representation of others.[20] Survey data relies on respondent declarations, a method that is vulnerable to respondents’ incentives, misreporting, and misperceptions. Finally, our estimates cover five countries with a population of around 433 million, but they need not be representative of the entire region.

# **Conclusions**

We find overall high rates of vaccine acceptance across our study countries and over a 2-year time horizon, never dipping below 68%. Yet, we notice a decline of several percentage points in the willingness to be vaccinated in three countries from 2020 to 2022, while in one country vaccine acceptance increases. Overall, women, better educated individuals and those living in better-off households are more likely to express vaccine hesitancy, though these differences reduce over time. Vaccine hesitancy is lower in larger households and among heads of the household. Underlying vaccine acceptance and its correlates, there are important country differences. The main reasons for vaccine hesitancy are concerns about side effects and vaccine safety as well as perceptions around COVID-19 risk.

While this is not the only study analyzing COVID-19 vaccine attitudes in Sub-Saharan Africa, there has been lack of longitudinal evidence to assess dynamics over time. This study fills this gap by using panel survey data collected in high-frequency phone surveys over the span of almost two years.

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