Assessment of Vaccine Hesitancy to a COVID-19 Vaccine in Cameroonian Adults and Its Global Implication

Since the outbreak of COVID-19 in December 2019, no global consensus treatment has been developed and generally accepted for the disease. However, eradicating the disease will require a safe and efficacious vaccine. In order to prepare for the eventual development of a safe and efficacious COVID-19 vaccine and to enhance its uptake, it is imperative to assess vaccine hesitancy in Cameroonians. After obtaining ethical clearance from the Institutional Review Board of the University of Buea, a questionnaire was administered (May–August 2020) to consenting adults either online or in person. A qualitative thematic analysis was done to analyze the participants’ answers to the open questions. A deductive approach was used, that is, the codes and patterns according to the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Working Group Matrix of Determinants of vaccine hesitancy. The number of consenting adult Cameroonians who completed the questionnaire were 2512 (Two thousand five hundred and twelve). Vaccine hesitancy to a COVID-19 vaccine was 84.6% in Cameroonians. Using the WHO recommended Matrix of Determinant of Vaccine hesitancy, the most prominent determinants observed in this study were: Communication and Media Environment, Perception of pharmaceutical industry, Reliability and/or source of vaccine and cost. Most Cameroonians agree that even though there are benefits of a clinical trial, they will prefer it should be done out of the continent and involving African scientists for eventual acceptance and uptake. The concerns of safety, efficacy and confidence has to be addressed using a Public Engagement approach if a COVID-19 vaccine has to be administered successfully in Africa or Cameroon specifically. Since this study was carried out following WHO standards, its result can be compared to those of other studies carried out in different cultural settings using similar standards.


Introduction
As of 17th August 2020, Cameroon had registered 18,599 cases of COVID-19 with 16,540 recoveries and 406 deaths. This gives a recovery rate of 88.9% and a with an overall death rate of 2.1% [1]. However, recent trends show that new cases of infection continue to emerge despite the control measures put in place by the World Health Organization (WHO) and the Ministry of Public Health in Cameroon. It is becoming evident that an efficacious vaccine would be required to put COVID-19 under control and eventually eradicate it. There are currently 138 candidate vaccines in preclinical evaluation and 29 candidate vaccines in clinical evaluation making a total of 167 vaccine candidates under development [2]. However, three COVID-19 vaccines have been developed but only the Comirnaty COVID-19 mRNA vaccine has received WHO Emergency Use Listing Procedure/Prequalification (WHO EUL/PQ) authorization. This made the Pfizer/BioNTech vaccine the first to receive emergency validation from the WHO since the outbreak began a year ago [3]. Hence, in dure/Prequalification (WHO EUL/PQ) authorization. This made the Pfizer/BioNTech vaccine the first to receive emergency validation from the WHO since the outbreak began a year ago [3]. Hence, in order to be able to use these vaccines to eradicate the disease, reluctance to accept them by the population has to be reduced to the barest minimum.
Vaccine hesitancy (VH) has been defined as "a delay in acceptance or refusal of vaccines despite availability of vaccine services" according to the World Health Organization (WHO) Strategic Advisory Group of Experts (SAGE) Working Group on VH [4]. VH has become the focus of growing concern and attention worldwide, despite overwhelming evidence of the importance of vaccines [5]. This is increasingly affecting the rate at which immunization regimes are effectively implemented. Since 2014, the number of countries reporting VH has been on a steady rise [6]. Only 14 countries out of 194 (about 7%) reported no VH according to a WHO/UNICEF Joint Reporting Form data from 2015-2017 [6], although an even lower number of seven (07) countries was reported in 2017 [7]. Research shows that VH is rising, resulting in alarming figures on disease outbreaks reported globally. This led the WHO to announce that, as of 2019, VH is one of the top ten threats to global health ( Figure 1) [8]. Apparently, there is no single cause of VH because many factors come into play. Important drivers of VH include: perception that vaccines are not beneficial, pain and needle fear, concern about the safety of vaccines or distrust of the pharmaceutical industry in the implementation of vaccination programs [9][10][11]. "Fake news" or negative information about vaccination online and in social media is also an important cause of VH. In fact, many studies have shown that the equivocal nature of anti-vaccination information on the Internet contributes to an increase in VH [12][13][14][15]. Another frequently identified cause of VH is lack of knowledge about vaccines [16,17]. As a matter of fact, socioeconomic status and education are related to vaccine acceptance but not in the same way as they are related to health conditions or adherence to public health recommendations. On the contrary, increased VH has been associated with both high and low socioeconomic status as well as high and low education, highlighting the complex array of interrelated factors at play [10].
It has been shown that vaccine behaviors are complex, like most health behaviors and knowledge is only one of many determinants of vaccination decisions [9,18,19]. The three Cs model (confidence, complacency and convenience) indicates three key interrelated causes of VH [4]. With the advent of the COVID-19 pandemic and with the numerous Apparently, there is no single cause of VH because many factors come into play. Important drivers of VH include: perception that vaccines are not beneficial, pain and needle fear, concern about the safety of vaccines or distrust of the pharmaceutical industry in the implementation of vaccination programs [9][10][11]. "Fake news" or negative information about vaccination online and in social media is also an important cause of VH. In fact, many studies have shown that the equivocal nature of anti-vaccination information on the Internet contributes to an increase in VH [12][13][14][15]. Another frequently identified cause of VH is lack of knowledge about vaccines [16,17]. As a matter of fact, socioeconomic status and education are related to vaccine acceptance but not in the same way as they are related to health conditions or adherence to public health recommendations. On the contrary, increased VH has been associated with both high and low socioeconomic status as well as high and low education, highlighting the complex array of interrelated factors at play [10].
It has been shown that vaccine behaviors are complex, like most health behaviors and knowledge is only one of many determinants of vaccination decisions [9,18,19]. The three Cs model (confidence, complacency and convenience) indicates three key interrelated causes of VH [4]. With the advent of the COVID-19 pandemic and with the numerous vaccine candidates under development, it is imperative that an eventual efficacious vaccine should have an excellent uptake worldwide and Cameroon specifically. Here we try to identify the prevalence and determinants of a COVID-19 vaccine VH in Cameroonians.

Ethical Statement
Ethical clearance for this study was obtained from the Institutional Review Board of the Faculty of Science, University of Buea; Ref: 2020/1220-06/UB/SG/IRB/FHS. After explaining the purpose of the study and consent obtained (either written or verbal), a questionnaire was administered either in person or online using Google Forms.

Statistical Analysis
Data was analyzed using Microsoft excel and ReCal2 0.1 (Alpha). IBM SPSS Statistics 20 (IBM Corporation, Chicago, IL, USA) was used to calculate the 95% confidence interval and the significant differences amongst the 21 Items of the Matrix of Determinants of VH. p < 0.05 was considered statistically significant.

Demographic Information
The number of Cameroonians gave their consent and filled a questionnaire was 2512 (Two thousand five hundred and twelve). Of the 2512 participants, 2086 (83%) were residing in the national territory while 426 (17%) were living in the diaspora (Figure 2A). Participants from all the ten regions of Cameroon took part in this study. Most of them worked in the education sector and the least were working at home ( Figure 2B). They were made up of more females 1378 (54.9%) than males 1134 (45.1%) ( Figure 2C) and were mostly of the age group 18-25 years ( Figure 2D).

Ethical Statement
Ethical clearance for this study was obtained from the Institutional Review Board of the Faculty of Science, University of Buea; Ref: 2020/1220-06/UB/SG/IRB/FHS. After explaining the purpose of the study and consent obtained (either written or verbal), a questionnaire was administered either in person or online using Google Forms.

Statistical Analysis
Data was analyzed using Microsoft excel and ReCal2 0.1 (Alpha). IBM SPSS Statistics 20 (IBM Corporation, Chicago, IL, USA) was used to calculate the 95% confidence interval and the significant differences amongst the 21 Items of the Matrix of Determinants of VH. p < 0.05 was considered statistically significant.

Demographic Information
The number of Cameroonians gave their consent and filled a questionnaire was 2512 (Two thousand five hundred and twelve). Of the 2512 participants, 2086 (83%) were residing in the national territory while 426 (17%) were living in the diaspora (Figure 2A). Participants from all the ten regions of Cameroon took part in this study. Most of them worked in the education sector and the least were working at home ( Figure 2B). They were made up of more females 1378 (54.9%) than males 1134 (45.1%) ( Figure 2C) and were mostly of the age group 18-25 years ( Figure 2D).

Vaccine Hesitancy to a COVID-19 Vaccine
The number of the study participants who said they will need more information, do not know or will not take a COVID-19 vaccine stood at 2124 giving a VH prevalence of Vaccines 2021, 9, 175 6 of 14 84.6% (95% CI 83.1-85.9%). Those who said they will either need more information or they do not know or will refuse the vaccine were grouped into the vaccine hesitancy category.

Qualitative Thematic Analysis (QTA)
Table 2 presents the inter-rater reliability measures computed for each item of the MxDt. It shows the degree of agreement between the two researchers in coding the data. Except for Item 6 (which was not mentioned), no other Item had a score below 0.9 indicating the high level of agreement between the two. The large sample size of the study also created a condition to have a more frequent repetition of these items by the responders, hence the high degree of agreement. Additionally, item 6 was not mentioned once by either researcher, while those statements labelled "not codable" reflected comments that were not specific and ideas outside the matrix. The coding guide is found in Appendix B. This item was frequently raised by participants to explain the reluctance to accept a COVID-19 vaccines (p < 0.001, when compared to Item 19 (Table 3)). Of particular interest here, is the role of Internet and the emergent role of social media such as Facebook, where it is known that sharing of anecdotal experiences, anti-vaccines campaigns and science denigrating content proliferate. This issue appears to be raised across the narratives of both COVID-19 vaccine hesitant and non-hesitant participants: participant 30 "Facebook", participant 439 "confusing information circulating on social media" participant 2033 "antivaccine campaigns saying Africans should not accept a COVID-19 vaccine", participant 984 "I've seen on TV that Africans don't need a COVID-19 vaccine since there are herbal cures for the disease".

Item 7 "Perception of the Pharmaceutical Industry"
The issue of conflicts of interests and the respect for ethics by the pharmaceutical industry was raised by mostly COVID-19 vaccine hesitant individuals (p < 0.001, when compared to the non-hesitant group (Table 3)). They believed financial gains by these companies superseded the public health interest of the population. A few examples illustrate these negative attitudes:

•
Participant 2285 stated, "I don't think these companies really care about our health". • Participant 438 opined "Vaccine companies will send suboptimal vaccines to Africa", • Participant 2421 affirmed, "They take advantage of the political system to come and test vaccines and other products in Africa that they would not otherwise test in their own country and hence they will not respect standard ethical procedures".

Item 18 "Reliability and/or Source of Vaccine"
This item was present in an overwhelming majority (86.1%) of the statements (p < 0.001, when compared to Item 19 (Table 3)). They worried about the quality of the vaccine distributed or sent to Africa in general and Cameroon specifically.

•
Participant 942 replied "why would they label drugs and vaccines for human use as "Not for use in USA and EU?" • Participant 1985 wondered, "the vaccine sent to Africa will be of poor standards", • Participant 1469 declared, "I will only accept a COVID-19 vaccine from a reliable organization that has been tested and proven effective".

Item 20 "Cost"
Cost was also present in the majority of the statements 56% (p < 0.001, when compared to Item 19 (Table 3)) saying a COVID-19 vaccine should be made free for everyone while some people said it should be made free only to kids, the elderly, people with comorbidities and those working in hospitals.
The other items that showed up prominently among the responders include; Item 10 Knowledge/awareness (p < 0.001), Item 14 Risk/benefits (epidemiological and scientific evidence) (p < 0.001) and Item 16 Mode of administration (p < 0.001), All Items were compared to Item 19 since it is the item that appeared the least number of times (non-zero number) amongst the statements.

Proposed Venue of a Clinical Trial
When asked where they think a COVID-19 vaccine clinical trial should take place, most Cameroonians proposed that it should be done in Europe (p < 0.001) with a small fraction saying it should be carried out where the vaccine was developed or where the disease is most prevalent ( Figure 3A). Participant 398 proposed, "In Europe since they were hit hard by the pandemic," participant 1212 "First trial in the country that manufactures/discovers the vaccine".

Proposed Venue of a Clinical Trial
When asked where they think a COVID-19 vaccine clinical trial should take place, most Cameroonians proposed that it should be done in Europe (p < 0.001) with a small fraction saying it should be carried out where the vaccine was developed or where the disease is most prevalent ( Figure 3A). Participant 398 proposed, "In Europe since they were hit hard by the pandemic," participant 1212 "First trial in the country that manufactures/discovers the vaccine".

Involving Cameroonian Scientists
On the idea of involving Cameroonian scientists in the development of a COVID-19 vaccine, an overwhelming majority (p < 0.001) suggested that Cameroonian scientists should be involved. However, while some said they should be involved right from conception, others said they should be on board if they possess the skills and knowledge to do so. Some also said Cameroon should develop its own capacity to develop and produce a COVID-19 vaccine ( Figure 3B). Participant 722 "Cameroonian scientists should be involved from conception", Participant 884 "why not develop our own capacity to develop and produce a COVID-19 vaccine"

Involving Cameroonian Scientists
On the idea of involving Cameroonian scientists in the development of a COVID-19 vaccine, an overwhelming majority (p < 0.001) suggested that Cameroonian scientists should be involved. However, while some said they should be involved right from conception, others said they should be on board if they possess the skills and knowledge to do so. Some also said Cameroon should develop its own capacity to develop and produce a COVID-19 vaccine ( Figure 3B). Participant 722 "Cameroonian scientists should be involved from conception", Participant 884 "why not develop our own capacity to develop and produce a COVID-19 vaccine"

Discussion
Since the first diagnosed case of COVID-19 in December 2019, the number of new infections and fatalities continue to rise in some countries leading to a pandemic that is yet to be put under control. The World Health Organization (WHO) is yet to confirm and endorse a treatment of the disease and it is now a general consensus that the spread of the disease can be stopped by strict application of the barrier measures while eradicating the disease will require a vaccine. However, for the approved vaccines to achieve its intended goal, VH has to be reduced to under 30%-25%. It is therefore imperative to assess VH and its determinants locally in order to strategize and achieve significant vaccine acceptance. Here we report the first results of VH among Cameroonians using WHO SAGE recommendations.
It has been shown that a major source of access to health-related information is the Internet [28] and Social media in particular [29]. This has also been used by activists to carry out campaigns against the scientific institutions [30]. Studying the Internet content has also shown that future public health interventions need not only focus on the benefits of COVID-19 vaccination but, more so, on understanding the type of doubts around COVID-19 VH issue in order to enhance communication strategies [31].
Another item of the Matrix of Determinant of VH that came up strongly in this study is "Reliability and/or source of vaccine". This shows the level of confidence and trust issues Cameroonians will have with a COVID-19 vaccine. Comments from participants show that they are really concerned about who is producing the vaccine and what will be the true intention of administering these vaccines to Cameroonians.
The next most frequent item raised by the participants was "Perception of pharmaceutical industry". This seems to be expected giving the fact that pharmaceutical industries will be directly involved in producing and distributing a COVID-19 vaccine. From the comments of the participants, there seems to be a deep mistrust of pharmaceutical industries, especially those in the Western countries and in China. Respondents have the impression that the companies are interested only in making profit instead of thinking of the health of the population. It has been shown that people turn to be worried about risks produced by people or institutions they do not trust [31].
This study shows that Cameroonians will like Cameroonians or African scientists to be involved in the development of a COVID-19 vaccine. This again has to do with the level of trust they have in foreign institutions and pharmaceutical companies when it comes to a COVID-19 vaccine. The assumption here is that seeing one of theirs in the research team developing a vaccine will increase confidence.
It is well known that travelling abroad broadens your horizon and makes you more knowledgeable [32] and so Cameroonians at home will usually turn to their relatives/friends in the diaspora for pieces of advice on critical issues. Hence, it was imperative to access VH of a COVID-19 vaccine in this set of Cameroonians. The opinions expressed by them followed the same trend as those back at home even though the tone was more objective and had less conspiracy-like tone. The issues raised were that of safety, efficacy and confidence.
Involving African scientists in general and Cameroonian scientists specifically, in the development of a COVID-19 vaccine will greatly enhance its uptake. This could be achieved by empowering these scientists through capacity building, infrastructure and funds to carry independent research in a consortium.
As concerns carrying out clinical trials, Cameroonians, especially those in the diaspora agreed that there are many benefits for such to be carried out in Cameroon including; infrastructure, capacity building, attracting foreign investments, instilling research culture and inspiring young people to become scientists. However, it was emphasized that this can only be achieved if the trials are carried out to the highest standards and respecting WHO recommended rules and regulations for a human clinical trial. This fear could be reflected in the fact that most of the Cameroonian respondents at home suggested that a COVID-19 vaccine clinical trial should be done either in Europe, where the vaccine was developed or where the disease is most prevalent.
The high prevalence of VH in Cameroon is worrisome and indicates a low appetite to have the vaccine and hence a low COVID-19 vaccine uptake. Therefore, a lot of measures have to be put in place to reduce the VH value to around 30% in order to achieve herd immunity to COVID-19 infection in Cameroonians.
Our projection is that the observations seen in the present study reflects the scenario one will encounter in other sub-Saharan countries. With the use of the WHO recommendations in assessing VH in a population, the results of the present study can be compared to that of other studies using the same approach in different geographical and cultural settings around the world.
Hence, community/public engagement will be the ultimate approach to significantly increase vaccine acceptance to a COVID-19 vaccine in Africans in general and Cameroonians specifically.

Strengths of The Study
To our knowledge, this is the first study in Cameroon to ever use the tools developed by the WHO to monitor vaccine hesitancy. It will bring a valuable contribution to public health strategies to enhance vaccine uptake.
The selection of study participants was not biased as people of all age groups, gender, those who regularly see medical providers/those who don't, different economic and educational background took part in the study. The questionnaire was administered online and as well as in person to those who are not literate or do not have access to the internet.
The total number of participants was far larger than the calculated sample size of 385. The number of persons admitted in this study was large enough to permit declarations with 99% confidence level. This also permitted a high Cohen's Kappa score hence preventing disagreement between the coders to weigh more on the score.
With responders from all the ten Regions of Cameroon as well as Cameroonians living out of the country, the data provide a nationally representative result. This is a pilot study whose outcome could be used to properly design and execute a survey to determine VH for other vaccines.

Limitations of The Study
The questions were not pilot-tested as recommended in SAGE's report from 2014 [24]. A pilot test could assist researchers reflect and alter the question sequence accordingly [33].
Some studies used electronic data extraction from the data and then mapped against the Matrix [34], but in the present study we used the deductive thematic analysis to map the statements of participants' answers to matched the SAGE WG MxDt of vaccine hesitancy.
People of the older generation who are more vulnerable to the disease did not respond much to the survey probably due to limited access to online participation. Furthermore, the Cameroonian population is skewed towards the younger population with the result that the 18-25 years' range is truly representative of the overall adult population.

Data Availability Statement:
The data presented in this study are available in the article.

Acknowledgments:
We thank the 2512 participants who took part in this study and Stephanie Perimbie for administrative assistance. We also acknowledge institutional support from African Vaccinology Network (AfVANET; www.afvanet.org), Cameroon Christian University Institute, University of Buea and Michael Gahnyam Gbeugvat Foundation. We would also like to thank the Bill and Melinda Gates foundation for covering the Article Publication Charge.

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

1.
Where do you live?
Institutional Review Board Statement: Ethical clearance for this study was obtained from the Institutional Review Board of the Faculty of Science, University of Buea; Ref: 2020/1220-06/UB/SG/IRB/FHS.

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World 2.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment 7.

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

What type of information from RELIABLE sources would you like to have on COVID-19 vaccines?
‫‬Administration route ‫‬Dosage ‫‬Producer ‫‬Country of origin ‫‬Others: ………………………………………………. 11. Should the COVID-19 vaccine be paid or given free of charge? * ‫‬Only free for children and elders ‫‬Free for everybody ‫‬Only free for health personnel ‫‬Paid for everybody ‫‬I don't know ‫‬Others: ………………………………………………………… 12. Would you agree to receive a COVID-19 vaccine? ‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid information on a COVID-19 vaccine? ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: ………………………….. 14. Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: ………………………….. Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment 7.

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

What type of information from RELIABLE sources would you like to have on COVID-19 vaccines?
‫‬Administration route ‫‬Dosage ‫‬Producer ‫‬Country of origin ‫‬Others: ………………………………………………. 11. Should the COVID-19 vaccine be paid or given free of charge? * ‫‬Only free for children and elders ‫‬Free for everybody ‫‬Only free for health personnel ‫‬Paid for everybody ‫‬I don't know ‫‬Others: ………………………………………………………… 12. Would you agree to receive a COVID-19 vaccine? ‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid information on a COVID-19 vaccine? ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: ………………………….. 14. Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: ………………………….. Town: ……………………………… 3.

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

14.
Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: ………………………….. Acknowledgments: We thank the 2512 participants who took part in this study an Perimbie for administrative assistance. We also acknowledge institutional support Vaccinology Network (AfVANET; www.afvanet.org), Cameroon Christian Univer University of Buea and Michael Gahnyam Gbeugvat Foundation. We would also li Bill and Melinda Gates foundation for covering the Article Publication Charge.

Conflicts of Interest:
The authors declare no conflict of interest.
Where do you live? ‫‬Cameroon ‫‬Rest of the World 2.

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid information on a COVID ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in deve ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid inform ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

14.
Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment 7.

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment 7.

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment 7.

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 va
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

What type of information from RELIABLE sources would you like to have on C
‫‬Administration route ‫‬Dosage ‫‬Producer ‫‬Country of origin ‫‬Others: ……………………………………………….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid information on a C ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

Have you heard information about the COVID-19 vaccines in development?
‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 va
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Where would you like that a covid19 vaccine trial be carried out?
‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid information on a ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working envi ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environme

8.
Have you heard information about the COVID-19 vaccine ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Inte ‫‬My surroundings ‫‬Others: ….
11. Should the COVID-19 vaccine be paid or given free of cha ‫‬Only free for children and elders ‫‬Free for everybody ‫‬Only free for health personnel ‫‬Paid for everybody ‫‬I don ‫‬Others: …………………………………………………………

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all vali ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

14.
Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….

Would you agree to receive a COVID-19 vaccine?
‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

14.
Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….
11. Should the COVID-19 vaccine be paid or given free of charge? * ‫‬Only free for children and elders ‫‬Free for everybody ‫‬Only free for health personnel ‫‬Paid for everybody ‫‬I don't know ‫‬Others: ………………………………………………………… 12. Would you agree to receive a COVID-19 vaccine? ‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know

Through which channel would you like to receive all valid information on a COVID-19 vaccine?
‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

14.
Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..

1.
Where do you live? ‫‬Cameroon ‫‬Rest of the World

Gender:
‫‬ ‫‬Male

6.
Which of the following best describes your working environment? ‫‬Hospital ‫‬Office ‫‬Home ‫‬School ‫‬Outdoor environment

8.
Have you heard information about the COVID-19 vaccines in development? ‫‬Yes ‫‬No ‫‬Others: ….

9.
Where did you hear about this information? ‫‬Social Media ‫‬Government radio TV ‫‬Newspapers ‫‬Internet ‫‬My surroundings ‫‬Others: ….
11. Should the COVID-19 vaccine be paid or given free of charge? * ‫‬Only free for children and elders ‫‬Free for everybody ‫‬Only free for health personnel ‫‬Paid for everybody ‫‬I don't know ‫‬Others: ………………………………………………………… 12. Would you agree to receive a COVID-19 vaccine? ‫‬Yes ‫‬No ‫‬I will need more information ‫‬I don't know 13. Through which channel would you like to receive all valid information on a COVID-19 vaccine ‫‬In a book ‫‬In a newspaper ‫‬On Radio/TV ‫‬Internet/Social media ‫‬Others: …………………………..

14.
Where would you like that a covid19 vaccine trial be carried out? ‫‬In Cameroon ‫‬In another African country ‫‬In Europe ‫‬Others: …………………………..