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COVID-19 vaccine uptake in Zimbabwe and Sierra Leone: an application of Health Belief Model constructs

Abstract

Introduction

While African countries, in general, experienced a milder COVID-19 impact compared to Western nations, they faced challenges with vaccine uptake. Specifically, Zimbabwe and Sierra Leone saw vaccine acceptance rates below global averages. This research delves into the underlying factors that influenced these disparities in vaccine acceptance in these two countries, using the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) as guiding frameworks.

Methods

This study utilized data from a cross-sectional survey encompassing 2,312 participants from areas where the Africa Christian Health Associations Platform (ACHAP) operates in Zimbabwe and Sierra Leone. The survey assessed respondents' views in line with core HBM and TPB constructs, in addition to their levels of vaccine acceptance. We then employed adjusted logistic regression models to investigate the correlation between health behavior change theory constructs and vaccine uptake, taking into account variables like gender, age, education, and country of residence.

Results

Several associations were identified, including high vaccine uptake correlated with a heightened perceived threat of COVID-19 (OR鈥=鈥2.674; p鈥<鈥.001), recognized benefits of vaccination (OR鈥=鈥1.482; p鈥<鈥.001), stronger perceived behavior control (OR鈥=鈥2.189; p鈥<鈥.001), and fewer perceived barriers to vaccination (OR鈥=鈥0.173; p鈥&濒迟;鈥.001). Conversely, low vaccine uptake was linked to diminished perceived threats (OR鈥=鈥0.540; p鈥<鈥.001), fewer perceived benefits (OR鈥=鈥0.762; p鈥<鈥.001), weaker perceived behavior control (OR鈥=鈥0.429; p鈥<鈥.001), and heightened perceptions of barriers (OR鈥=鈥2.001; p鈥&濒迟;鈥.001).

Conclusion

Results underscore the significance and utility of theoretical constructs in understanding variations in vaccine uptake levels. They highlight the importance of relying on well-established theories to grasp decision-making mechanisms and to shape suggestions for behavior modification. Consequently, to boost vaccine acceptance, public health campaigns should focus on reshaping risk perceptions, addressing obstacles, emphasizing the advantages of getting vaccinated, and fostering a sense of self-efficacy within target communities.

Peer Review reports

Introduction

The COVID-19 pandemic caused by SARS-CoV-2 has had a devastating effect globally. As of early March 2023, when Johns Hopkins University stopped compiling and reporting on global COVID-19 data, the total confirmed cases exceeded 676 million, with at least 6.8 million deaths worldwide [4]. It is noted that additional analyses and modeling have shown a significant excess mortality worldwide due to COVID, meaning deaths totals have been greater in many regions than what has generally been reported [24]. Despite faring better than other continents, Africa also suffered greatly from the COVID-19 pandemic. The World Health Organization (WHO) African Region reported more than 8.9 million cases and 174,243 deaths as of May 2, 2023 [23]. Zimbabwe and Sierra Leone are two Sub-Saharan nations impacted by the pandemic. Zimbabwe has experienced 264,276 cases and 5,671 COVID-19 deaths while in Sierra Leone there have been a total of 7,760 confirmed cases logged and 126 COVID-19 deaths recorded [4]. Both nations have prioritized the distribution of COVID-19 vaccinations to those 12听years of age and older (age of eligibility). Among the approximately 15.5 million people living in Zimbabwe, 11,239,749 are eligible to receive the vaccine. As of July 18, 2023, 7,332,243 had received at least one dose (65.2% of those eligible) and 5,420,528 had been fully vaccinated (48.7% of those eligible) [2]. In Sierra Leone, home to 8.42 million people, 4,977,483 are eligible to receive the vaccine. As of July 18, 2023, 4,693,903 had received at least one dose (94.3% of those eligible) and 3,846,767 had been fully vaccinated (77.3% of those eligible) [2].

According to the Strategic Advisory Group of Experts on Immunization (SAGE), vaccine hesitancy refers to a refusal or delay in acceptance of a vaccine despite its availability (McDonald, 2015). Vaccine hesitancy generally stems from factors related to complacency, convenience, and/or confidence (McDonald, 2015). Complacency may stem from a low perception of the disease risk, subsequently rendering the view that vaccination is unnecessary or of insufficient value when calculating a benefit-risk assessment. Confidence is an indicator of how effective the vaccine is in preventing infection with the disease. Concerning confidence, the rapid development of COVID-19 vaccines appears to have exacerbated vaccine anxiety and hesitancy around the globe, including in many African nations [21]. In Zimbabwe, vaccine misinformation has been a challenge since at least 2010, when religious teachings emphasizing prayers and holy water over the use of medicine and a perception that vaccines were not safe for children combined to discourage vaccine uptake and were associated with a measles outbreak in the country [13]. Recent studies have concluded that vaccine messaging from some religious organizations has impacted Zimbabweans' decisions to refuse the vaccine and has increased vaccine hesitancy generally [5, 11]. Early efforts to promote and administer COVID-19 vaccines in Sierra Leone were challenging due to concerns about vaccines generally and distrust of the healthcare system specifically [6], which may explain why vaccination rates in Sierra Leone were initially lower than most developing nations [11]. Health workers identified that while many community members actually valued vaccines and considered them important, fears related to vaccine side-effects increased hesitancy [6]. However, the primary sources of mistrust identified by Enria et al. [6] included poor treatment and discrimination of rural community members by healthcare workers based on appearance, education, and social standing. Additionally, community members reported a history of having to pay for vaccine cards and services which they believed to be free under Sierra Leone鈥檚 Free Healthcare Initiative. In actuality, these vaccine services were often not covered, a misunderstanding stemming from poor communication which led community members to believe that the health system was corrupt.

Theoretical constructs related to behavior change are beneficial in understanding, analyzing, and predicting the acceptance of health-promoting behaviors like immunizations and vaccinations. The Health Belief Model (HBM) is a value expectancy theory postulating that an individual鈥檚 desire to prevent an illness (value) and one鈥檚 belief that a specific health action available would prevent or ameliorate illness (expectancy) is predictive of specific health behaviors [16]. Key constructs of the HBM include perceived susceptibility, or an individual鈥檚 subjective perception of her risk of contracting a health condition, and perceived severity, an individual鈥檚 opinion of how serious a condition and its symptoms or health consequences would be if contracted or infected [20]. The combination of perceived severity and susceptibility equates to an individual鈥檚 perceived threat. The HBM theorizes that for behavior change or action to occur, individuals must feel threatened by their current choices and the subsequent expected outcomes. The HBM also includes the constructs of perceived benefits and perceived barriers of action, which also impact health behavior change efforts. Perceived benefits highlight what can be expected, typically the positive effects of a specific action [20]. Perceived barriers refer to the tangible and psychological costs of the health-promoting action. Other behavior change models likewise include perceptions as key constructs capable of predicting behavior. For example, perceived behavioral control, a construct of the Theory of Planned Behavior (TPB) represents an individual鈥檚 perception of either the ease or difficulty of performing or completing a specific action [1]. While accurately perceiving both benefits and barriers requires the gaining of new knowledge or correcting existing misinformation [20], perceived behavior control is increased when barriers are lowered either through increasing access to necessary resources or the development of new skills needed to complete the action (Azjen, 1991). Both the HBM and the TPB have been used as a theoretical framework for predicting the uptake of numerous health-promoting behaviors, including COVID-19 vaccine uptake intentions [10, 15, 19, 22, 26]. Hossain et al. [10] found the TPB to be the best theoretical model for explaining COVID-19 vaccine hesitancy among a study sample of adults in Bangladesh. Wong et al. [22] found HBM constructs to predict potential COVID-19 vaccine acceptance in an online cross-sectional survey completed by a large sample of Malaysians. Zampetakis and Melas [26] similarly supported HBM constructs in predicting COVID-19 vaccine uptake among a study sample of online cross-sectional respondents in Greece.

An increased understanding of the attitudes related to COVID-19 vaccine acceptance and hesitancy is a priority in Zimbabwe and Sierra Leone. Mundagowa et al. [14] used an online survey to examine vaccine hesitancy in Zimbabwe. Approximately half (49%) said they would accept the COVID-19 vaccines. Vaccine hesitancy among this sample was related to two HBM constructs. First, perceived benefits 鈥 how protective would the vaccine be? Three-fourths (76%) of the study sample expressed concerns about vaccine effectiveness. Second, perceived costs 鈥 how large would vaccination's tangible and/or psychological costs be? More than half (55%) of Zimbabweans in the study expressed concerns related to vaccine safety. Indeed, low perceived severity of COVID-19 infection was associated with low vaccine uptake, as more than half of respondents who had previously contracted COVID-19 indicated that their infection was not severe or that they had not experienced severe symptoms due to infection. Before vaccine availability, Sheku et al. [18] reported that 20% of respondents to an online survey administered in Sierra Leone would reject the COVID-19 vaccines. In a similar online survey, Faye et al. [7] found that 50% of respondents in Sierra Leone accepted COVID-19 vaccines, while 61% reported feeling at risk of getting infected with the virus. The strongest predictors of vaccine acceptance were perceived effectiveness and perceived safety of the vaccines. Demographic variables such as sex, rural/urban residence, and educational attainment were not significant factors associated with COVID-19 vaccine intentions in the study [7].

Further exploring theoretical constructs related to perceptions that can influence COVID-19 vaccination, namely perceived threat, perceived benefits, perceived barriers, and perceived behavioral control, is crucial in understanding COVID-19 vaccine uptake. This study aimed to use these perceptions as a framework to explore factors associated with both high COVID-19 vaccine uptake and low vaccine uptake in Zimbabwe and Sierra Leone.

Methods

Design

Data for this study came from a cross-sectional survey conducted simultaneously in Zimbabwe and Sierra Leone during July and August of 2022. Data collection was part of the Africa Christian Health Associations Platform (ACHAP) CoV-FaB project (鈥淧romoting COVID-19 Vaccine Equity through Faith-Based Networks in Africa鈥), which aimed to understand COVID-19 attitudes and predictors of vaccine acceptance in both Zimbabwe and Sierra Leone to increase uptake in project communities. In both countries, assessments were conducted face-to-face using a questionnaire instrument designed by ACHAP with the agreement of global consortium partners, IMA World Health and Internews, and in-country implementing partners, the Zimbabwe Association of Church-Related Hospitals (ZACH) and the Christian Health Association of Sierra Leone (CHASL). The selection of Zimbabwe and Sierra Leone as study locations was based on their selection as CoV-FaB project countries and the willingness of ZACH and CHASL to engage in collaborative efforts.

Sample

Participants in this study were selected from key institutions and groups engaged with the CoV-FaB project. They included government and non-government organizations, faith-based organizations including faith leaders, community members, health institutions, and journalist networks. Respondents were invited by ACHAP leadership via email announcement of a meeting place where surveys would take place. Respondents came from within the CoV-FaB project catchment area to reflect national stratifications from each country. Specifically, national distributions of gender and urban/rural living were mirrored because both characteristics could influence vaccine hesitancy.

ACHAP applied stratified national samples for conducting structured interviews. In Zimbabwe, 1,154 respondents were surveyed, with 374 from Mutoko, 385 from Uzumba-Maramba-Pfungwe (UMP), and 395 from Chikomba districts. In Sierra Leone, 1,149 responses were collected, with 623 respondents from Western Area Urban district and 526 respondents from Western Area Rural district. While ACHAP made significant efforts to ensure that stratified sampling reflected the geographic distributions of the population, resulting in a study sample designed to mirror these distributions, the sample ultimately comprised individuals who were willing to participate, making it a convenience sample. Consequently, the total sample of 2,303 respondents may not be fully representative of the populations in Zimbabwe and Sierra Leone.

Procedure

Participants were recruited from the communities within the catchment areas of ZACH and CHASL member facilities. Participants were invited to participate in the face-to-face questionnaire. They were asked to acknowledge their interest and willingness by providing their contact information and scheduling a meeting date with the data collection team. Enumerators contracted by ZACH in Zimbabwe and CHASL in Sierra Leone collected the data. Enumerators traveled to respondents鈥 homes, obtained written informed consent, and completed the 20-min questionnaire. Respondents were assured that their participation was voluntary. Inclusion criteria included being 18听years of age or older and the ability to speak English. Enumerators entered data into smartphones and uploaded the data into a central database. Ethical clearance for publication of study鈥檚 data was approved by the Brigham Young University Institutional Review Board (IRB2023-026). Researchers adhered to the ethical principles outlined in the Declaration of Helsinki by ensuring their autonomy and collecting informed consent from all participants, safeguarding their confidentiality by securing all data on password protected devices, and prioritizing their well-being throughout the research process.

Measurement

The questionnaire instrument used in this study was constructed collaboratively and included inputs from ACHAP, IMA World Health, Internews, and in-country partners ZACH and CHASL. The instrument was adapted from the US Centers for Disease Control and Prevention鈥檚 Rapid Community Assessment guidelines for community surveys. The instrument was constructed in English, and specific items were pilot-tested in focus groups conducted in Zimbabwe and Sierra Leone. The instrument was then revised in accordance with the feedback, and all partners agreed upon a final version. The questionnaire included five sections, including demographics, items measuring COVID-19 vaccination (e.g., vaccination status, vaccine refusal, etc.), and key theoretical constructs from the HBM and TPB related to perceptions.

Demographic items included sex, age, level of education obtained, and information about pre-existing medical conditions. COVID-19 vaccination items included whether the respondent had been vaccinated and whether they have ever refused the COVID-19 vaccine. A variable representing high vaccine uptake was constructed that included respondents who had been vaccinated and who never had at any point refused the vaccine. A separate variable was constructed to represent low vaccine uptake and consisted of respondents who had not been vaccinated and who had previously refused the vaccine. High vaccine uptake and low vaccine uptake were distinct categories, and respondents could not be classified under both.

Variables representing the HBM and TPB included perceived threat, perceived benefits, perceived barriers, and perceived behavior control. Perceived susceptibility and perceived severity were combined to represent perceived threat (to one鈥檚 health). A measure of perceived susceptibility included respondents who reported being 鈥榲ery concerned鈥 about contracting COVID-19 at work and outside (e.g., grocery store, etc.). Respondents who reported 鈥榶es鈥 to personally knowing someone in their family, group of friends, or community networks who became seriously ill or died because of COVID-19 and those who were very concerned about infecting family or friends with COVID-19 were coded a 鈥榶es鈥 on perceived severity. The perceived threat was computed by combining perceived susceptibility and perceived severity. It included high (yes to both), medium (yes to one of two), and low (no to both) threat. Perceived benefits was a scaled variable (Cronbach鈥檚 alpha coefficient鈥=鈥0.62) and was computed by summing positive statements about getting vaccinated (protect my health, protect the health of family/friends, protect the health of co-workers, protect the health of the community, to resume travel). A single item represented perceived barriers and included respondents who said they would have difficulty getting the vaccine. Perceived behavior control can represent an overall or global assessment of the extent to which an individual can navigate circumstances to, in this case, get vaccinated. In this study, individuals were coded as 鈥榶es鈥 on perceived behavior control if they said it would be very easy for them to get the vaccine for themselves.

Analysis

STATA 17 (College Station, Texas) was used for all analyses. Data were cleaned before analysis. Frequency statistics were computed to describe the study sample. Chi-square test statistics were computed to compare differences in HBM and TPB variables between Zimbabwe and Sierra Leone. Multivariate logistic regression analysis was used to explore the HBM and TPB factors associated with high vaccine uptake and low vaccine uptake. All models controlled for sex, age, level of education obtained, and country.

Results

Female respondents accounted for just over half of the sample (52.9%), with more female respondents in Zimbabwe (57.0%) than in Sierra Leone (48.9%) (see Table听1). Approximately half (50.3%) of all respondents were between 25 and 49听years of age, with Zimbabwe鈥檚 age distribution trending slightly older and Sierra Leone鈥檚 slightly younger. Most respondents in Zimbabwe (67.0%) and Sierra Leone (51.9%) had a secondary education, with Sierra Leone having a higher percentage of respondents having completed tertiary education, 27.6%, compared to 7.8% in Zimbabwe. Most respondents identified themselves as community members (68.2%), followed by 鈥渙ther鈥 (13.9%) and community leaders (8.5%). A total of 43.8% of participants had received at least one dose of a COVID-19 vaccine, including more than half of Zimbabweans (55.6%) and 32% of Sierra Leonians.

Table 1 Demographics of study participants in Zimbabwe and Sierra Leone

High vaccine uptake was greater among Zimbabwe respondents, at 45.6%, compared to 19.5% in Sierra Leone (Table听2), where they also reported a greater percentage of low vaccine uptake at 48.7% (27.0% in Zimbabwe). When comparing theory variables across the two countries, there are noticeable differences. Perceived susceptibility and perceived severity combine to form a variable called perceived threat (to one鈥檚 health). Perceived threat is significantly lower in Sierra Leone compared to Zimbabwe. Respondents in Sierra Leone reported higher perceived barriers to vaccination (41.0% to 20.1%). By contrast, in Zimbabwe, respondents reported higher perceptions of the benefits of vaccination (50.8% to 35.8%). Zimbabwe respondents also reported higher perceived behavior control, 60.2%, compared to 38.6% in Sierra Leone.

Table 2 Theoretical constructs reported by study participants in Zimbabwe and Sierra Leone

Adjusted regression models explored the HBM and TPB variables and the association with high and low vaccine uptake. Each model controlled for sex, age, education, and the respondent鈥檚 country. In the model considering high vaccine uptake (Table听3), all theory variables were significant and in the expected direction. Compared to a low perceived threat, both medium (OR鈥=鈥2.142; p鈥<鈥0.001) and high perceived threat were positively related to high vaccine uptake (OR鈥=鈥2.674; p鈥<鈥0.001). Perceived barriers was negatively associated with high vaccine uptake (OR鈥=鈥0.173; p鈥<鈥0.001), such that higher perceived barriers was associated with decreased odds of vaccine uptake. Perceived benefits (OR鈥=鈥1.482; p鈥<鈥0.001) of getting vaccinated and perceived behavior control (OR鈥=鈥2.189; p鈥<鈥0.001) were both associated with increased odds of high vaccine uptake.

Table 3 Adjusted logistic regression comparing theory-based factors (HBM and TPB) with high vaccine uptake among study participants in Zimbabwe and Sierra Leone

In the adjusted model exploring the relationship between the theory variables and low vaccine uptake (Table听4), medium perceived threat (OR鈥=鈥0.439; p鈥<鈥0.001) and high perceived threat (OR鈥=鈥0.54; p鈥<鈥0.001) were both negatively associated with low vaccine uptake; increases in perceived threat was related to decreased odds that respondents reported low vaccine uptake. Perceived barriers was positively related to increased odds of reporting low vaccine uptake (OR鈥=鈥2.001; p鈥<鈥0.001). Perceived benefits of vaccination and perceived behavior control were both negatively related (OR鈥=鈥0.762; p鈥<鈥0.001; OR鈥=鈥0.429; p鈥<鈥0.001, respectively), such that increases in both were related to decreased odds of also reporting low vaccine uptake.

Table 4 Adjusted logistic regression comparing theory-based factors (HBM and TPB) with low vaccine uptake among study participants in Zimbabwe and Sierra Leone

Discussion

The purpose of this study was to use HBM and TPB constructs related to perceptions as a framework to explore factors associated with both high COVID-19 vaccine uptake and low vaccine uptake in Zimbabwe and Sierra Leone. Nearly all findings from the current study detailing vaccine uptake in these two countries support the tested theoretical constructs. Further exploring constructs related to perceptions, namely perceived threat, perceived benefits, perceived barriers, and perceived behavioral control, that can influence COVID-19 vaccination is crucial in understanding vaccine uptake and hesitancy.

All theoretical constructs related to perceptions included in the current study were strongly supported by study results. Higher levels of perceived threat, perceived benefits, and perceived behavioral control should each theoretically predict higher vaccine uptake and higher actual vaccine acceptance. Compared to Sierra Leoneans, Zimbabweans in the current study perceived COVID to be a greater threat as measured by perceived severity of infection and perceived susceptibility to infection. Similarly, participants from Zimbabwe perceived COVID-19 vaccines to be of greater benefit than Sierra Leoneans and perceived that they could also easily get vaccinated if desired. Finally, lower perceived barriers reported by Zimbabweans are also predictive of higher vaccine uptake. In total, each of these HBM and TPB study measures accurately predicted higher rates of vaccine uptake by Zimbabwean participants in this study.

The perceived threat of COVID-19 varied greatly between participants from Zimbabwe and Sierra Leone. More than half of Sierra Leoneans perceived COVID to be of 鈥榣ow鈥 threat, and just 3% considered COVID a 鈥榟igh鈥 threat. Low perceptions of COVID-19鈥檚 threat in Sierra Leone are not necessarily misperceptions. While it must be noted that underreporting of both COVID morbidity and mortality has been problematic worldwide, across nearly three years of the pandemic in Sierra Leone there have been a total of 7,760 cases and 126 deaths, equating to a case-fatality ratio (CFR) of 1.62%. By comparison, in just over two years of the Western Africa Epidemic of Ebola in Guinea, Liberia, and Sierra Leone, there were 28,610 cases and 11,308 deaths, including approximately 4,000 deaths in Sierra Leone. Ebola鈥檚 CFR during this epidemic was 39.5% [9]. All preventable deaths are tragic, and mortality rates are only one measure of a disease鈥檚 devastating impact on society, but it would be understandable if the Sierra Leoneans in the current study perceived the threat of COVID-19 to be lower given their country鈥檚 recent catastrophic experience with Ebola.

Of note, and as predicted by the theoretical constructs examined, the current study found that vaccine confidence was more than twice as high in Zimbabwe than in Sierra Leone. Sheku et al. [18] surveyed Sierra Leoneans to better understand general COVID-19 vaccine hesitancy. The authors found three primary concerns among their study sample: 1) safety and efficacy given these vaccines鈥 rapid development and approval,2) distrust of the government and healthcare system; and 3) disbelief in the reality of the COVID-19 pandemic [18]. The spread of misinformation in Sierra Leone regarding the legitimacy of the virus and the safety of the COVID-19 vaccine likely increased vaccine hesitancy throughout the country. Some healthcare workers in Sierra Leone, including physicians, nurses, and medical students, also remained hesitant [25]. Such reports help explain the comparatively low level of vaccine uptake among Sierra Leoneans in the current study.

Nearly half of the current study鈥檚 participants in Zimbabwe were found to have high vaccine uptake. Furthermore, higher vaccine uptake among Zimbabweans in this study is consistent with higher numbers of participants from Zimbabwe reporting that they had received at least one dose of a COVID-19 vaccine. These findings are remarkably consistent with the reporting from Mundagowa et al. [14] who noted that prior to COVID-19 vaccine availability, exactly half (50%) of Zimbabweans surveyed indicated they would accept the vaccine. It should again be noted that while vaccine uptake and receiving at least one dose of a COVID-19 vaccine were both higher among Zimbabweans in the current study, national COVID-19 vaccination rates are nearly 35% higher in Sierra Leone (94.3% of those eligible) than in Zimbabwe (65.2% of those eligible) [2]. In this case, the current study sample may not be representative of either country as a whole.

The logistic regression analysis, which accounted for within-country variations, provided strong support for the theoretical framework, with all variables from the HBM and the TPB being statistically significant and aligned with expected outcomes. These findings are consistent with previous global studies on COVID-19 vaccine uptake and intentions, reinforcing the validity of these theoretical constructs in understanding vaccine behavior. The perceived threat of COVID-19 morbidity and mortality, a combination of perceived susceptibility and perceived severity, has been the focus of many such studies. In their study of adults in France, Schwarzinger et al. [17] found a strong association between the refusal of COVID-19 vaccines and lower perceived severity of the disease if infected. The authors noted that the benefit-risk assessment of COVID-19 vaccination was perceived as unfavorable, particularly among younger working adults.听Relatedly, a heightened perception of COVID-19 severity, when compared to the seasonal flu, was associated with an increased acceptance of COVID-19 vaccines amongst adults in Italy [3]. Hilverda and Vollmann [8] studied perceptions of COVID-19 among Dutch university students and concluded that heightened perceived severity of COVID-19 was associated with increased concern about the disease and both stronger vaccine intentions and vaccine uptake. Perceived risk of COVID-19 infection among study participants in South Africa, mediated by perceived vaccine efficacy, was found to be associated with intentions to receive the COVID-19 vaccines [12]. Like the current study, Shmueli and colleagues (2021) combined HBM and TPB constructs in their study of Israeli adults. The authors noted perceived severity, perceived benefits, and perceived behavioral control as significant determinants of participants鈥 intention to receive COVID-19 vaccines. These finding from around the globe provide strong support for the use of HBM and.

TPB constructs in the development of interventions to promote uptake in, and acceptance of, COVID-19 vaccines.

The current study鈥檚 findings should be interpreted with several key limitations in mind. First, all study data were gathered via self-report with no inspection of vaccination records. Second, this study used data from, and made comparisons between, two countries with many differences and unique experiences related to disease. Country-specific contextual factors related to recent disease outbreaks and past performance of health systems may help explain the difference in perceptions of COVID-19 among the two countries in the current study. Furthermore, despite the current study鈥檚 large sample size, results are not generalizable to all of Zimbabwe or Sierra Leone and should thus be interpreted with caution. Namely, vaccination percentages found in the current study vary from national vaccine uptake percentages reported elsewhere. Lastly, participants may represent a biased sample as a result of coming from a CoV-FaB catchment area where numerous efforts had been made to engage with the population and where respondents were not actively sought out, but instead willingly volunteered. This could limit the finding鈥檚 generalizability. Despite these limitations, the current study adds to the literature supporting established theoretical constructs from the HBM and TPB while building support for adherence to theory in the development and implementation of public health programming.

Conclusion

This study identified theoretical constructs from both the HBM and the TPB as significant predictors of vaccine uptake among participants in Zimbabwe and Sierra Leone. The findings from this study may inform the design of future public health interventions focused on increasing vaccine uptake generally. More specifically, future efforts to increase the perceived threat of disease outbreaks like COVID-19 and the perceived benefit of accessing appropriate preventative care like COVID vaccines while also increasing an individual鈥檚 perceived behavior control in assuaging such threats through preventative action and minimizing perceived barriers to care or other health-enhancing actions should be public health priorities. Proven theoretical frameworks such as the HBM and TPB can increase public health鈥檚 understanding of both a population鈥檚 response to disease outbreaks as well as inform effective program planning and public health messaging.

Data availability

Data and materials requests can be considered through an inquiry to the corresponding author who will in turn seek approval from the Africa Christian Health Associations Platform and CORUS International.

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Acknowledgements

We appreciate each study participant鈥檚 willingness to participate in this study and recognize their contribution to our understanding of factors that contribute to high and low COVID-19 vaccine uptake.

Funding

Osprey Foundation provided funding for this study.

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Authors and Affiliations

Authors

Contributions

JW and BC did the analysis. RW, SS, JW, BC, ML, and CH contributed to the survey design. SS, AM, and RW contributed to the data collection. SS, AM, MM, RG, JW, BC, CH, RW, ML, HB, and DC all contributed to the manuscript design and preparation.

Corresponding author

Correspondence to Joshua West.

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Ethics approval and consent to participate

Ethical clearance for publication of study鈥檚 data was approved by the Brigham Young University Institutional Review Board (IRB#: IRB2023-026).

Competing interests

The authors declare no competing interests.

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Ssentongo, S., Muhereza, A., Mustapha, M. et al. COVID-19 vaccine uptake in Zimbabwe and Sierra Leone: an application of Health Belief Model constructs. 樱花视频 25, 451 (2025). https://doi.org/10.1186/s12889-025-21610-0

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  • DOI: https://doi.org/10.1186/s12889-025-21610-0

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