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COVID-19 Vaccine Acceptance and Associated Factors Among College Students in Dessie City, Northeastern Ethiopia

Background The COVID-19 vaccine is regarded as an effective measure for reducing the pandemic’s impact. But, COVID-19 disease burden reduction efforts are being affected by the rising vaccine resistance. Objective To assess the COVID-19 vaccine acceptance and associated factors among college students in Dessie city, Northeastern Ethiopia. Methods An institutional-based cross-sectional study was carried out among college students in Dessie town from July 1–20, 2021. The association between independent and dependent variables was assessed by binary logistic regression analysis using crude odds ratio and adjusted odds ratio. Variables having p values of less than 0.05 at the 95% confidence interval were regarded as potential determinants of COVID-19 vaccine acceptance. Results A total of 422 college students participated in the study with a response rate of 95.6%. More than half 226 (56.2%) of the participants had willingness to accept COVID-19 vaccine. Respondents who had history of chronic medical illness (AOR: 4.340, 95% CI: 1.166, 16.149), training on COVID-19 vaccine (AOR: 4.755, 95% CI: 2.606, 6.674), history of regular vaccine uptake (AOR: 2.534, 95% CI: 1.412, 4.549), perception of COVID-19 severity (AOR: 4.109, 95% CI: 2.190, 7.710), perception that COVID-19 can be prevented by vaccine (AOR: 2.420, 95% CI: 1.160, 5.049), and development of herd immunity against COVID-19 vaccines (AOR: 2.566, 95% CI: 1.431, 4.599) were factors significantly associated with COVID-19 vaccine acceptance. Conclusion The acceptance of COVID-19 vaccine among college students was low. The history of chronic medical illness, training on COVID-19 vaccine, history of vaccine uptake, perception that COVID-19 can be prevented by vaccine, perception of herd immunity development against COVID-19, and severity of COVID 19 infection were factors significantly associated with the acceptance of COVID-19 vaccine. Hence, it is necessary to promote COVID-19 vaccination among college students through health education and vaccine outreach.


Introduction
The global pandemic of Coronavirus Disease 19  continues to impose enormous burdens on morbidity and mortality. 1-3 COVID-19 is a fatal viral disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus strain that has spread all over the world and has become a serious public health problem. 4 On March 11,

Inclusion and Exclusion Criteria
The study involved all college students who volunteered to take part. Students who were unable to answer because of a serious sickness or another personal reason, however, were not included in the study.

Sample Size Determination and Sampling Technique
Using the single population proportion formula, the sample size was calculated as 384 with the assumptions of Zα/2 at 95% CI = 1.96, an estimate of the proportion (p) of 50%, and a margin of error (d) of 5%. The study's final sample size, after accounting for non-response rates of 10%, was 422. Five colleges out of a total of 12 were initially chosen using a simple random sampling technique. The number of participants from each chosen college was then distributed proportionally based on the enrollment at each college at the time the data were collected. Then, using a lottery system, departments were chosen at random. Each department provided a list of every student in the chosen departments. The study participants were selected using a simple random sampling technique using the lists of the students from their registrar offices' as a sampling frame.

Operational Definitions
Vaccine acceptance is defined as the willingness of the study participants to receive the COVID-19 vaccine. The participants were then asked if they would be interested in receiving the COVID-19 vaccine, with the options being Yes or No. Yes responses received a score of "1", and No responses received a score of "0." 36

Data Collection and Quality Assurances
The data was collected using a structured questionnaire adapted from previous published papers [23][24][25][26][27]29,30,34,[37][38][39][40][41] and contextualized according to the study setting. The questionnaire consists of socio-demographic characteristics of the participants, socio-political perception and attitude towards COVID-19 vaccine, and willingness towards the acceptance of COVID-19 vaccine. The questionnaire was initially written in English, then translated into the local language (Amharic) for the purpose of gathering data, and finally retranslated back into English to ensure consistency. The validity of the questionnaire was pre-tested using 5% of the study sample size. The feedback from pre-test was used for the amendment of the questionnaire, including avoiding of repeated questions, less irrelevant questions, and unclear questions. Data collectors and supervisors received training on the purpose of the study and the questionnaire's components. Four nursing professionals administered the interviewer, while two MSc. public health experts provided oversight. To reduce data entering errors, double data entry was used. There were no missing records. Data cleaning was then done before statistical analysis.

Data Processing and Analysis
Data cleaning and analysis were carried out using the Statistical Package for Social Science (SPSS) version 25.0 after being exported from the Epi-Data software version 4.6. The study's findings were represented using descriptive statistics. The association between independent variables and the willingness to accept COVID-19 vaccine was determined using a binary logistic regression analysis at 95% CI. Binary logistic regression with a 95% CI was used to analyze the data using bivariable analysis (COR, or crude odds ratio), as well as multivariable analysis (AOR, or adjusted odds ratio). Variables from the bivariable analysis that had p-values under 0.25 were kept for the multivariable analysis. Then, in a multivariate analysis, the variables were selected as significant predictors of college students' willingness to accept the COVID-19 vaccine at a 95% CI when the p-value was less than 0.05. Using the standard error at the threshold value of −2 to +2, the presence of multicollinearity among the study's independent variables was examined for each variable, but none of them revealed it. Additionally, the Hosmer-Lemeshow test was used to determine the model's fitness, and we discovered a fit model with a p-value of 0.894 which was fit to run further statistical analysis.

Ethical Consideration
The study was carried out in accordance with the Helsinki Declaration. The ethical clearance was obtained from College of Medicine and Health Sciences, Wollo University. Higher officials of the chosen college granted permission for the study to be carried out. All participants were told of the study's purpose and goals before participating, and participation was anonymous. Each study participant provided their written consent. Those who did not want to participate have the option of being excluded from the study. The data collection was done in compliance with the COVID-19 preventative strategies that were advised.

Socio-Demographic Characteristics of the Respondents
In the current study, 422 college students participated in the study with a response rate of 95.6%. More than one-third 163 (40.5%) of the participants were males and less than half 186 (46.3%) of the participants were in the age range of 18-20 years. More than three fourth of the respondents 316 (78.6%) were single. Besides, lower than half 188 (46.8%) of the respondents were attending health science fields. Furthermore, only 27 (6.5%) of the participants had faced one or more chronic medical illness conditions and 35 (8.7%) had history of COVID-19 infection. On the other hand, slightly more than half, 212 (52.7%) of the study participants took training about COVID-19 vaccine. The current finding also revealed that about half 199 (49.5%) of the respondents used health insurance and 214 (51.9%) of the participants knew anyone diagnosed with COVID-19. Regarding the sources of information about COVID-19 vaccine, majority 345 (85.8%) of the respondents used peers as a source of information followed by mass-media such as (TV and radio) 243 (60.4%) ( Table 1).

Perception and Attitude Towards COVID-19 Vaccine
The finding of the present study revealed that three-fifth 244 (60.7%) of the participants perceived that COVID-19 infection is severe for human beings. On the other hand, more than two-thirds 281 (69.9%) of the participants agreed that the infection of COVID-19 can be prevented by vaccination. Besides, nearly three-quarter 298 (74.1%) of the respondents trust the government of Ethiopia towards the current COVID-19 vaccination. Additionally, near two-thirds 265 (65.9%) of the respondents perceived that the vaccine of COVID-19 infection is safe, while 278 (69.2%) perceived the vaccine is effective against the disease causing virus. Finally, this study pointed that more than half 226 (56.2%) of the participants had a willingness to accept of COVID-19 vaccine (Table 2).

Factors Associated with the Acceptance of COVID-19 Vaccine
According to a multivariable logistic regression analysis, history of chronic medical illness, training on COVID-19 vaccine, history of regular vaccine uptake, perception of COVID-19 severity, perception that COVID-19 can be prevented by vaccine, and the development of herd immunity against COVID-19 vaccines were all factors that were significantly associated with willingness to accept COVID-19 vaccine among college students in Dessie, Northeastern Ethiopia. The current finding revealed that participants who had a history of chronic medical illness were four times more likely to accept COVID-19 vaccine (AOR: 4.340, 95% CI: 1.166, 16.149) than those who did not have chronic medical illness. Participants who had training on COVID-19 vaccine were four times more likely to accept COVID-19 vaccine (AOR: 4.755, 95% CI: 2.606, 6.674) than those who did not take training on COVID-19 vaccine. Besides, participants who had history of regular vaccine uptake were two times more likely to accept COVID-19 vaccine (AOR: 2.534, 95% CI: 1.412, 4.549) than those who did not have a history of vaccine uptake. Participants who perceived that COVID-19 is severe infection were four times more likely to accept COVID-19 vaccine (AOR: 4.109, 95% CI: 2.190, 7.710) than the corresponding groups who perceived COVID-19 is not severe infection. In addition, participants who perceived that COVID-19 can be prevented by vaccine were two times more likely to accept COVID-19 vaccine (AOR: 2.420, 95% CI: 1.160, 5.049) than the corresponding groups who perceived COVID-19 cannot be prevented by vaccine. Moreover, participants who perceived as they did not develop herd immunity against COVID-19 were two times more likely to accept COVID-19 vaccine (AOR: 2.566, 95% CI: 1.431, 4.599) than the corresponding groups (Table 3).

Discussion
An institutional-based cross-sectional study design was implemented among college students in Dessie city, Northeastern Ethiopia from July 10-30, 2021. The study was aimed to assess the acceptance and determinant factors of COVID-19 vaccine among college students of Dessie city Northeastern Ethiopia. The urgency for vaccination is growing by the day, with increasing numbers of cases and reports of the virus variants across the world. 24 For many years, vaccinations have been regarded as the most effective way to combat infectious diseases that spread quickly, including COVID-19. 2,13 The effectiveness of this method will be determined by the rate of vaccination acceptance, which is based on a risk-benefit analysis. 1,39 However, vaccine hesitancy and misinformation are obstacles to establishing high coverage and community immunity against COVID-19 infection. 1,13 Vaccinations have long been seen to be the most effective way to combat quickly spreading infectious diseases. 13 The COVID-19 vaccine is widely recognized as the most promising method for containing or ending the pandemic. 1 The finding of the present study revealed that more than half, 226 (56.2%) 95% CI: 51.5; 60.9% of the participants were willing to accept COVID-19 vaccine. Near to half 176 (43.8%) 95% CI: 39.1; 48.5 of the respondents were either refused or hesitated to receive COVID-19 vaccine. This finding matched the findings of studies in France (58.1%), 40 USA (53%), 37 USA (52.8%), 33 Nigeria (55.5%), 41 UAE (56.3%), 42 Libya (60.9%), 13 and Algeria (53.51%). 24 The current finding was lower than the study conducted in Italy (86.1%), 43 Canada (77.8%), 44 16 countries (69.2%), 45 Italy (91.9%), 46 and Ethiopia (69.3%). 36 However, this finding is higher than the study conducted in Gonder, Ethiopia (34.2%). 34 In our study, less than 75% of participants were willing to get the COVID-19 vaccination, which is the minimum rate needed to achieve herd immunity and halt the coronavirus outbreak. 41 The novelty of COVID-19 disease may be the cause of the poor prevalence of vaccination uptake. Possible reasons for this finding include widespread pandemic conspiracy theories and a psychological need to comprehend numerous pandemic-related occurrences. As a result, particularly in LMIC nations, there may be mistrust and unfavorable perceptions about the vaccine, a lack of faith in the current healthcare system, and information shortages. 38 When a safe and effective vaccine is offered for free or at a low cost, the acceptance of the COVID-19 vaccine can rise. 47  History of chronic medical illness condition, training towards COVID-19 vaccine, previous history of vaccine uptake, and concern of becoming infected with COVID-19, perception of herd immunity development against COVID-19 and severity of COVID-19 infection were factors significantly associated with the acceptance of COVID-19 vaccine among the participants of the current study. The pandemic of COVID-19 affects all groups of the population. However, literature has revealed that individuals with a history of chronic medical illness conditions are highly vulnerable to developing severe risk of morbidity and mortality due to COVID-19 infection. 9,38 The problem is highly severe in developing countries due to the shift of the planned resource budget from routine management of chronic illness disease to the ongoing COVID-19 cases. 14 This finding revealed that respondents with a history of chronic medical illness were 4.340 times more likely to accept COVID-19 vaccine than the corresponding groups which was supported by studies conducted in Jordan, 48 Bangladesh, 49 Italy, 46 Mozambique, 50 and Ethiopia. 51,52 The perception of becoming infected by COVID-19 is an important factor that may motivate individuals to take vaccine against COVID-19. 50 The finding of the current study revealed that individuals with the concern of being infected by COVID-19 were 4.109 times more likely to accept the COVID-19 vaccine than the corresponding groups which was supported by the studies conducted in Mozambique, 50 Uganda, 53 and Nigeria. 41 According to literature, knowledge contributes to the judgment on the vaccination concept. 12 The finding of the current study revealed that individuals who took training on COVID-19 vaccine were 4.755 times more likely to accept COVID-19 vaccine than the corresponding groups. This finding is in agreement with the study conducted in Ethiopia. 38 Participants who had a history of vaccination reluctancy for their children were considerably less likely to take the COVID-19 vaccine. This finding revealed that respondents with a previous history of vaccine uptake were two times more likely to accept COVID-19 vaccine (AOR: 2.534, 95% CI: 1.412, 4.549) than their corresponding groups which was in line with the study conducted in Uganda, 53 Switzerland, 54 New Jersey, 33 and Jordan. 55

DovePress
The vaccine hesitancy affects both the person who refuses to take the vaccine and the entire population, posing a significant challenge to reaching the threshold for conferring COVID-19 herd immunity. 12 This study revealed that participants who perceived as they did not develop herd immunity against COVID-19 were two times more likely to accept COVID-19 vaccine (AOR: 2.566, 95% CI: 1.431, 4.599) than the corresponding groups, which was in line with the study conducted in Uganda. 56 The strongest predictors of vaccine acceptance included confidence in vaccine safety or effectiveness, worrying about COVID-19, belief in the importance of vaccines to their own country, compliance to mask guidelines, trust of public health agencies/health science, as well as attitudes towards routine vaccines. 1 Our study revealed that participants who perceived that COVID-19 is severe infection were four times more likely to accept COVID-19 vaccine (AOR: 4.109, 95% CI: 2.190, 7.710) than the corresponding groups. This is consistent with the findings of Saudi Arabia. 57 According to the literature, women were also more likely than men to state that the vaccine was too new that they were fearful of side effects and that they had a medical contraindication to the vaccine. 38 However, in our study, it was not statistically significant.

Limitation of the Study
This study has several restrictions. In the beginning, self-administered interviews were used to get the data. The result is flawed by a cross-sectional study design, as is common. In these reports, a longitudinal research might be of utmost value. Additionally, the students who made up the sample are not all population-representative.

Conclusion
In general, the acceptances of COVID-19 vaccine among college students were low which was lower than the vaccination level required for the development of herd immunity. History of chronic medical illness condition, training on COVID-19 vaccine, previous history of vaccine uptake, and concern of becoming infected with COVID-19, perception of herd immunity development against COVID-19 and severity of COVID 19 infection were factors significantly associated with the acceptance of COVID-19 vaccine. Hence, it is necessary to promote COVID-19 vaccination among college students through health education and vaccine outreach. Healthcare practitioners should continuously promote awareness of the COVID-19 vaccine's significance, safety, and efficacy, with a focus on populations with a higher risk of contracting the disease. Public health authorities must implement systematic measures to lower vaccination reluctance levels and increase vaccine uptake.

Data Sharing Statement
The corresponding authors will provide the datasets used and/or analyzed during the current work upon reasonable request.