Factors Influencing the Intention and Uptake of COVID-19 Vaccines on the African Continent: A Scoping Review

The COVID-19 pandemic is a severe concern worldwide, particularly in Africa. Vaccines are crucial in the fight against the COVID-19 pandemic. This scoping review examined existing literature from 2020 to 2022 on individual, interpersonal, and structural barriers and facilitators to COVID-19 vaccination within Africa to facilitate more informed health promotion interventions to improve vaccine uptake. This review was conducted using Arksey and O’Malley’s five-stage methodological framework. A comprehensive search was undertaken from 2021 to 2022 using six electronic databases: EBSCOhost, PubMed, Web of Science, ProQuest, WorldCat Discovery, and Google Scholar. Data was collected, charted into themes, and summarized using a standard data extraction sheet in Microsoft Excel. A total of forty (n = 40) published academic articles were reviewed, with many conducted in Nigeria (n = 10), followed by Ethiopia (n = 5) and Ghana (n = 4) and the rest elsewhere in Africa. Thematic narratives were used to report data into six themes: attitudes and perceptions about COVID-19 vaccines, intention to uptake COVID-19 vaccines; factors and barriers associated with COVID-19 vaccine uptake; socio-demographic determinants affecting the intention and uptake; and information sources for COVID-19 vaccines. The intention for uptake ranged from 25% to 80.9%, resulting in a suboptimal uptake intention rate (54.2%) on the African continent. Factors that promoted vaccine acceptance included confidence in the COVID-19 vaccines and the desire to protect people. Age, education, and gender were the most common factors significantly associated with vaccine acceptance. Most studies revealed that considerable barriers to vaccine uptake exist in Africa. Concerns about potential side effects, vaccine ineffectiveness, a perceived lack of information, and inaccessibility were among the individual, interpersonal, and structural barriers to COVID-19 vaccine uptake. The unwillingness to receive the COVID-19 vaccine was strongly correlated with being female. Mass and social media were the main sources of information regarding COVID-19 vaccines. To encourage vaccine uptake, governments should pay attention to refuting misinformation through integrated community-based approaches, such as creating messages that convey more than just information.


Introduction
The novel coronavirus 2019, termed COVID-19, is a highly transmissible and pathogenic viral infection caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1][2][3], and COVID-19 vaccines are seen as an effective public health tool in mitigating the spread of SARS-CoV-2. The COVID-19 pandemic has raised many direct and indirect health problems [3]. Although most people experience upper respiratory tract and pulmonary symptoms, those with severe COVID-19 may also experience widespread small and large vessel thrombosis, microvascular injury, cardiac conduction abnormalities, neurologic conducted via the remaining two electronic databases (ProQuest and WorldCat Discovery) from 25 October 2022 to 8 November 2022. The following restrictions were placed on all four databases to produce the relevant studies needed for this scoping review. Studies were searched from 2020 to 2022 and published in English and in peer-reviewed journals.

Study Selection
After conducting a complete title and abstract screening in the databases mentioned above, studies were screened using the Population-Concept-Context (PCC) framework to establish their eligibility for this review. The researcher excluded all studies that did not answer the review's research query: published research on psychosocial and contextual factors influencing intention and uptake of COVID-19 vaccines in Africa.
Furthermore, the inclusion and exclusion criteria guided the selection of full-text studies to determine which studies were most appropriate to include in this review. The researcher focused on quantitative, qualitative, and mixed-methods academic/published journals (peer-reviewed journals) published in English between 2020 and 2022 on attitudes, beliefs, barriers, factors, facilitators, perceptions, acceptance, intentions, concerns, uptake, and hesitancy toward COVID-19 vaccines on the African continent among the general population. The researcher excluded gray literature (i.e., unpublished journals, reports, documents, conference papers, memoranda, theses, letters, and protocols), summaries, and other reviews. Additional exclusions included studies that focused solely on populations other than the general population (e.g., HCWs, high-risk populations, university students, and academics).

Charting Data
A standardized data extraction sheet in Microsoft Excel was used to collate and chart the data into themes and summarize studies and reports. The following headings were used to extract detailed information for the included studies: authors and year of publication; study setting, i.e., country and data collection period; and methodology. The methodology section consisted of study characteristics, i.e., study design, population target, and sample size.
Due to the heterogeneity of studies, a narrative synthesis approach was used to collect, synthesize, and map the literature [23]. The following categories were used to categorize the studies: (1) attitudes and perceptions towards COVID-19 vaccines; (2) intention to take the COVID-19 vaccines; (3) reasons for acceptance or non-acceptance; (4) determinants affecting the vaccine-related outcome; and (5) information sources for COVID-19 vaccines. The researcher applied thematic narratives to report all data [24].

Reporting the Results
In the initial search, 395 studies were identified from database searches: EBSCOhost (n = 247), PubMed (n = 53), Web of Science (n = 43), ProQuest (n = 26), WorldCat Discovery (n = 13), and Google Scholar (n = 13). After removing duplicates with EndNote (V.X9), 274 studies were screened by title and abstract to find those that met the initial screening criteria. One hundred and sixty (n = 160) studies were excluded because they were irrelevant to the research question, leaving 114 studies for full-text review. Following the inclusion and exclusion assessment criteria, studies were further excluded because they did not address research questions (n = 11), a summary of studies (n = 1), focusing only on VH (n = 1), non-peer-reviewed articles (n = 7), not applicable population targets (n = 38), and research reports and documents (n = 16), resulting in 40 published articles for the final analysis. The PRISMA flow diagram below illustrates the selection process in Figure 1.
to the research question, leaving 114 studies for full-text review. Following the inclusion and exclusion assessment criteria, studies were further excluded because they did not address research questions (n = 11), a summary of studies (n = 1), focusing only on VH (n = 1), non-peer-reviewed articles (n = 7), not applicable population targets (n = 38), and research reports and documents (n = 16), resulting in 40 published articles for the final analysis. The PRISMA flow diagram below illustrates the selection process in Figure 1.

Study Design of Included Studies
Many studies (n = 37) that were conducted used a quantitative research approach. Of those studies, (n = 33) adopted a cross-sectional design. Two studies (n = 2) adopted a qualitative research approach, and one (n = 1) applied a mixed-methods research approach.  [27] conducted a multinational study to assess potential VH on the African continent. They surveyed 13 countries, including Liberia, South Africa, Malawi, Sudan, Tanzania, Morocco, Nigeria, Egypt, Rwanda, Ghana, Kenya, the DRC, and Cameroon. The current review provides a nuanced approach compared to other reviews, which goes beyond identifying COVID-19 vaccine acceptance and VH. This review explores various drivers and barriers affecting COVID-19 vaccine acceptance, intention, and hesitancy among the general population on the African continent rather than focusing on Sub-Saharan Africa.

Participant Characteristics
The general adult population (aged ≥ 18 years) (n = 30) made up most of the study sample, while the general population comprised (n = 10). Three studies by Elhadi et al. [28]; Gunawardhana et al. [29]; and Toure et al. [30] focused on the general population, including HCWs (n = 2) and pregnant women (n = 1). However, these sub-populations were not considered due to the abovementioned exclusion criteria. Only the general population sample was used. The sample sizes for the current review ranged from 14 to 11,971 respondents. Male respondents ranged from 15% to 91.7%, while female respondents ranged from 8.3% to 100%. Additional baseline characteristics of the selected studies are listed in Table 2.

Results Pertaining to the Research Questions
The findings of the six themes are discussed in this section. See Table 3. for the predictors of COVID-19 vaccine uptake among the general population in Africa.

Attitudes and Perceptions Regarding COVID-19 Vaccines among People in Africa
In this review, a total of eighteen studies (n = 18) reported on attitudes or perceptions regarding COVID-19 vaccines in Africa. Six of those studies (n = 6) found that the participants were hesitant toward the vaccine [29,32,37,39,44,60]. Furthermore, of the 18 studies, three studies each reported a positive [28,48,53] or a negative [31,55,59] attitude toward the vaccine. While the qualitative study by Chauke et al. [38] reported opposing attitudes among respondents regarding the COVID-19 vaccines.
Two of the 18 studies reported a positive perception [34,46] of the vaccine, while five of the 18 studies reported an overall negative perception [26,30,48,53,56] of the vaccine. According to the findings, two studies were diametrically opposed regarding attitudes and perceptions toward the vaccine. The study among the general adult populations by James et al. [48] in Nigeria and Mesesle [53] in Ethiopia discovered an overall positive attitude toward the vaccine. However, respondents also expressed a negative perception of the COVID-19 vaccine. The relationship between attitude and behavior is not always consistent [65,66], with behaviors being influenced by attitudes and various other factors impacting one's decision or willingness to uptake vaccines [67,68].
Vaccines 2023, 11, x FOR PEER REVIEW 20 of 30 COVID-19 vaccine but revealed mixed feelings among the young population. Some young people considered it necessary to take the vaccine to mitigate the effects of the pandemic. Others, on the other hand, believe that the vaccine should only be used as a last resort because it negatively affects their genetic makeup, including their reproductive system. Furthermore, these participants believed that, once vaccinated, their daily activities would be monitored through a microchip in the COVID-19 vaccine. According to the study by Bono et al. [25], the average intention rate was 42.2%, with wide ranges between 22.6% and 65.4%. Uganda was reported to have the highest intention for uptake among the five African countries. On the other hand, Benin was found to have the lowest intention for uptake. Ahiakpa et al. [26] reported on 17 African countries with an average intention rate of 59% to uptake the COVID-19 vaccine, while 22% of participants refused to take the COVID-19 vaccine regardless of the directive given by their governments, and 19% were undecided on taking the vaccine. The continent-wide cross-sectional study by Anjorin et al. [27] assessed the willingness to accept the COVID-19 vaccine. The average acceptance rate was 63%, and they agreed to accept the vaccine as soon as possible. Liberia reported the highest intention rate of 84%, while the lowest intention rate of 33% was reported in Cameroon.          Negative perception

Non-acceptance: Effectiveness concerns
Safety concerns Subscribing to misinformation or conspiracies  Over the thirty (n = 30) studies, the intention for uptake ranged from 25% to 80.9%. Only nine studies (n = 9) reported a lower-than-average rate (i.e., below 50%). In comparison, twenty-one studies (n = 21) illustrate an intention rate of 50% or higher (see Table 2. for a detailed intention rate). The country with the lowest intention rate was reported as Egypt (25%), by Omar and Hani [59]. In contrast, the country with the highest intention rate was reported as Nigeria (80.9%) by Adedeji-Adenola et al. [34]. The average intention rate to uptake the COVID-19 vaccines among the included studies was 54.2%, resulting in a suboptimal uptake rate on the African continent.
The qualitative study conducted in South Africa by Chauke et al. [38] among 14 youth participants (aged 18-35 years) did not statistically report the intention to accept the COVID-19 vaccine but revealed mixed feelings among the young population. Some young people considered it necessary to take the vaccine to mitigate the effects of the pandemic. Others, on the other hand, believe that the vaccine should only be used as a last resort because it negatively affects their genetic makeup, including their reproductive system. Furthermore, these participants believed that, once vaccinated, their daily activities would be monitored through a microchip in the COVID-19 vaccine.
According to the study by Bono et al. [25], the average intention rate was 42.2%, with wide ranges between 22.6% and 65.4%. Uganda was reported to have the highest intention for uptake among the five African countries. On the other hand, Benin was found to have the lowest intention for uptake. Ahiakpa et al. [26] reported on 17 African countries with an average intention rate of 59% to uptake the COVID-19 vaccine, while 22% of participants refused to take the COVID-19 vaccine regardless of the directive given by their governments, and 19% were undecided on taking the vaccine. The continent-wide cross-sectional study by Anjorin et al. [27] assessed the willingness to accept the COVID-19 vaccine. The average acceptance rate was 63%, and they agreed to accept the vaccine as soon as possible. Liberia reported the highest intention rate of 84%, while the lowest intention rate of 33% was reported in Cameroon.

Factors Associated with COVID-19 Vaccine Uptake
Various factors that promoted the intention for vaccine uptake were reported in thirteen studies (n = 13). Across the 13 studies these were grouped as confidence in the COVID-19 vaccine [28,32,39,42,44] and the desire to protect others, e.g., family, community members, and vulnerable people [32,35,38,63]. A less common reason was that the acceptance of the vaccine is a public responsibility [32]. In addition, other reasons relate to being better informed about COVID-19 i.e., having an awareness of the possible side effects of the COVID-19 vaccine [32]; increased COVID-19 vaccine education [35]. Further reasons were observing others receive the COVID-19 vaccine; having free access to the COVID-19 vaccine [35]; receiving a vaccine certificate [35]; prior diagnosis of COVID-19 [26]; having a positive perception of the COVID-19 vaccine [26]; returning to normalcy by opening up the economy [38]; COVID-19 vaccine from an African country [29,49]; COVID-19 vaccine from a Muslim country [49]; having access to media [54]; having a high perceived susceptibility of contracting COVID [60]; the presence of comorbidities [63]; COVID-19 vaccines being recommended by HCWs and for self-protection [63].
According to findings from Afrifa-Anane et al. [35], a qualitative study in Ghana among women revealed two themes i.e., interpersonal and structural factors, that promoted vaccine acceptance. The desire to protect oneself and one's family is to get vaccinated against COVID-19, and seeing others get the COVID-19 vaccine was the main interpersonal factor that facilitated the uptake of the COVID-19 vaccine among respondents. While the structural facilitators included being educated about COVID-19 vaccines and the vaccine being free of charge, receiving a vaccination certificate and giving souvenirs to vaccinated people facilitated COVID-19 vaccine uptake. In this instance, a vaccination certificate or passport is required to access social services (such as banks), employment, and international travel.
Individual, interpersonal, and structural barriers to COVID-19 vaccine uptake were identified [35] among Ghanaian women. Individual barriers to COVID-19 vaccine uptake included tight work schedules, vaccine effectiveness, and being pregnant. Subscribing to misinformation or conspiracy theories about COVID-19 emerged as an interpersonal barrier to COVID-19 vaccine uptake. Vaccine-related misconceptions include the idea that being injected with COVID-19 vaccines will affect one's reproductive system, such as causing barrenness in women and impotence in men. Furthermore, vaccines are made to make people foolish and are intended to kill the African population. The structural barriers identified were long queues at vaccination centers, accompanied by vaccine shortages and proximity to a vaccination center.
According to Jabessa and Bekele [47], Ethiopian rural residents reported a statistically positive relationship between socio-demographic characteristics and vaccine uptake, which is inconsistent with the other studies (n = 19) included in this review. Having a low perception of the use of vaccination; being unemployed, having a low level of acceptance of COVID-19 vaccines, being unwilling to test for COVID, and having an extremely low (illiterate) education level were significant predictors for uptake.
Four studies (n = 4) reported on participants who received their information from religious and traditional leaders [26,27,29,41], from governments and governmental officials, i.e., politicians [27,29,30,62] and participants receiving their information from the internet [28,31,62,63], which included sites such as the Centers for Disease Control and Prevention (CDC), the Nigeria Centre for Disease Control (NCDC), and the World Health Organization (WHO).

Discussion
The success of Africa's extensive COVID-19 pandemic vaccination program [69] depends on high vaccination rates. As a result, vaccination uptake and acceptance are critical in the fight against COVID-19 [70]. To increase vaccine acceptance, it is necessary to understand the factors that influence vaccine intention and uptake of COVID-19 vaccines in order to inform interventions in this regard.
Forty published academic journal articles were reviewed to gain a more in-depth and nuanced understanding of how various factors, such as psychosocial and contextual factors, influence COVID-19 vaccine uptake intentions and behaviors among people in Four studies (n = 4) reported on participants who received their information from religious and traditional leaders [26,27,29,41], from governments and governmental officials, i.e., politicians [27,29,30,62] and participants receiving their information from the internet [28,31,62,63], which included sites such as the Centers for Disease Control and Prevention (CDC), the Nigeria Centre for Disease Control (NCDC), and the World Health Organization (WHO).

Discussion
The success of Africa's extensive COVID-19 pandemic vaccination program [69] depends on high vaccination rates. As a result, vaccination uptake and acceptance are critical in the fight against COVID-19 [70]. To increase vaccine acceptance, it is necessary to understand the factors that influence vaccine intention and uptake of COVID-19 vaccines in order to inform interventions in this regard.
Forty published academic journal articles were reviewed to gain a more in-depth and nuanced understanding of how various factors, such as psychosocial and contextual factors, influence COVID-19 vaccine uptake intentions and behaviors among people in Africa. Most of the studies included in this review were quantitative cross-sectional studies conducted in Nigeria. The findings of this review revealed a varied response in people's perceptions and attitudes regarding COVID-19 vaccines. There was a general hesitancy regarding the uptake of COVID-19 vaccines; only 54.2% of studies reported a higher-than-average intention to uptake the COVID-19 vaccines.
The most frequently cited demographic factors influencing COVID-19 determinants of vaccine intention and uptake in this review were the respondents' age, education, and gender. Men and older adults aged 30 years and older are more likely to accept the vaccine, similar to a study conducted in Slovenia by Petravi et al. [71], who reported that being male and middle-aged was associated with better vaccine uptake. This may stem from beliefs about being at higher risk of contracting COVID-19 and the higher severity of the illness. Therefore, vaccination is likely to be accepted by those who perceive themselves as being at a higher risk of contracting COVID-19 [46,72,73].
The low intention rate is due to the rapid development of COVID-19 vaccines, concerns about the vaccines' safety and effectiveness, and mainly reports on the adverse side effects [37,72,74]. This is exacerbated by misinformation, which has fostered distrust in government officials, regulatory agencies, and pharmaceutical companies [25,74,75]. The fact that social media was reported as a source of information regarding COVID-19 and vaccines explains the role of misinformation and conspiracy theories in VH. Furthermore, the dissonance between holding opposing views, i.e., messages from significant others i.e., government and HCW, as well as social media, is likely to create barriers to the uptake of preventative measures [76]. Health communication messages should therefore be directed toward countering fake news regarding COVID-19 to enhance acceptance of COVID-19 vaccines.
Numerous significant barriers to COVID-19 vaccine uptake in Africa have been identified, particularly around distrust in vaccines, safety concerns, and vaccine effectiveness [77]. A history of medical experimentation has caused significant mistrust of Western medicine in Africa [78]. The mistrust of Western medicine fuelled by socio-political issues, which are founded on historical and contemporary racism, has also eroded vaccine trust [79,80]. The findings by Josiah and Kantaris [50] in Nigeria and Gunawardhana et al. [29] in Cameroon showed acceptance of COVID-19 vaccines when obtained from an African country rather than Western or European countries. This seems to be a clear call for African countries to play a more active role in vaccine development and distribution [81]. In a context of distrust, negative experiences with vaccine safety are likely to impact uptake and further raise questions about vaccine effectiveness. In the early 2000s, HIV vaccine trials were abruptly halted in South Africa due to many recipients developing increased susceptibility to infectious diseases [78]. Trust in science and scientists is strongly correlated with vaccine confidence [82]. Therefore, confidence in vaccines is expressed as trust in individual vaccines and/or trust in the health care systems [83] and trust in the government [84]. The ability to comprehend and believe in the safety and effectiveness of vaccinations is a critical predictor of intention and vaccination uptake [85] and is important to counteract widespread misinformation [84].
Mohamud et al. [55] in Somalia reported that 73.8% of participants refused to vaccinate their children against COVID-19 once they became eligible for immunization. Religious and traditional leaders impact the general population's intention to vaccinate, according to a study by Afrifa-Anane et al. [35] among women in Ghana. Respondents mentioned that some pastors advised their congregations not to accept the COVID-19 vaccine because it is demonic. Rather than taking these vaccines, pastors provided them with spiritual guidance to help protect them from COVID-19. The study conducted by Elhadi et al. [28] in Libya found that the death of a loved one from COVID-19 significantly decreased the likelihood of COVID-19 vaccine uptake. According to Jabessa and Bekele [47], findings revealed that a low education level, a low level of perception about the usefulness of vaccine, a low-income category, being unemployed, an older age, and an unwillingness to test for COVID-19 were predictors of willingness to receive the COVID-19 vaccine among residents of southwestern Ethiopia. Further qualitative studies are required to explore this phenomenon. Attitudes and behaviors are not always completely aligned. An individual's behavior can be influenced by a combination of beliefs, perceptions, environmental needs, and self-preservation [86].
Most studies emphasize the importance of stakeholders educating and raising the level of awareness among the general public about COVID-19 vaccines with consideration of cultural orientations e.g., collectivism, to foster social responsibility for COVID-19 prevention, including vaccination prosociality, which has been found to be a significant positive predictor of COVID-19 vaccination intention [87]. Therefore, efforts are necessary to combat the effects of misinformation by providing easily accessible information to the general public through multiple platforms, including mainstream and social media.

Strengths and Limitations
Although this study adopted an inclusive approach, many articles were quantitative and cross-sectional, which means that further in-depth qualitative research is needed to better understand the factors influencing the intention and uptake of COVID-19 vaccines on the African continent. Only peer-reviewed studies published in English were considered for this review.

Conclusions
As COVID-19 becomes endemic in many African countries, the uptake of COVID-19 vaccines is one key way to achieve immunity and mitigate the negative impact of COVID-19. Vaccines are the most effective prevention method against severe COVID-19 complications and hospitalization. Most of the studies reviewed reported significant barriers to COVID-19 vaccine uptake, resulting in suboptimal intention rates. It is also noted that social media has exacerbated the effects of misinformation and conspiracy theories, resulting in divided communities where some support and others oppose COVID-19 vaccines.
Therefore, improving general health literacy and knowledge regarding COVID-19 vaccines among African populations is critical. It is now up to various stakeholders and policymakers to take effective action to provide tailored health promotion interventions with consideration of the personal, social, and contextual factors influencing vaccine acceptance and thus address the pandemic's adverse health and socio-economic consequences.
This paper calls on the relevant stakeholders to train and create opportunities for Community Healthcare Workers (CHWs) and Health Promotion Practitioners (HPPs) to engage with the public through information, education, and communication platforms to improve vaccine literacy in general and for COVID-19 vaccines, as well as cultivate positive beliefs and attitudes towards COVID-19 vaccines. Greater awareness of social responsibility in protecting oneself, loved ones, and the vulnerable in communities may augur well for increased uptake of vaccines. However, COVID-19 vaccination uptake in the African context will hinge greatly on building trust between the general population, scientists, the health care system, and governments.
Author Contributions: D.N., the first author, was responsible for the conceptualization and design of this research paper. He gathered data for the study, conducted data analysis, and authored the article. He was supervised by professor A.M.-W., who also gathered data for the study, conducted data analysis, and reviewed and provided constructive feedback. K.G. reviewed various drafts of the paper and provided feedback to the senior author. The review forms part of the research requirement for the degree of Master of Social Science in Health Promotion. All authors have read and agreed to the published version of the manuscript.

Conflicts of Interest:
The authors declare no conflict of interest.