Covid-19 vaccine uptake and its associated factors among rural households in The Gambia: a community-based cross-sectional study

Background: The Covid-19 pandemic has affected the globe in all spheres of human life: physical health, mental health, economic burden, and social lives. Population-based vaccination is considered one of the core global response strategies for the containment of Covid-19 across regions, including developing countries. The study aimed to determine the prevalence of Covid 19 vaccine uptake and the factors associated with it among rural dwellers in the North Bank Region (NBR) of The Gambia. Methods: A community-based cross-sectional study design was used in the NBR from 1 st to 10 th October 2021. The study was carried out among 504 rural households across districts in the NBR through a multistage sampling procedure. Structured interviews were used to generate data for this study. Chi-square/Fisher exact tests, as well as logistic regression analysis, were used to examine the associations, with statistical significance set at a p-value <0.05 and the computed adjusted odds ratio (aOR) set at a 95% confidence interval (CI).


Introduction
The severe acute respiratory syndrome coronavirus -2 (SARS-CoV-2) causing coronavirus disease (Covid-19) had its first case reported from Wuhan, China, on December 31, 2019 [1] .Subsequently, Covid-19 was declared by the World Health Organization (WHO) as a global Public Health Emergency on the 11th day of March 2020, and the pandemic has continued to be a health issue of global concern since then due to its virulent status [2] .The Covid-19 pandemics have affected the globe in all spheres of human life: physical and mental health, economic burden, and social lives [3] .Globally, more than 221 million confirmed cases of Covid-19 were reported; nearly 5 million people died, and more than 5 billion doses of Covid-19 vaccines were administered as of the 8 th day of September 2021.Compared to other WHO regions, the African region has the least number of confirmed cases, about 6 million cases [4] .
The Gambia registered its first case of Covid-19 on March 16, 2020.Since then, the country has registered nearly 10

Population
The study was carried out among rural households in the North Bank East Region in each selected district.The participants in the study were people aged 18 years and above living in the region.

Inclusion and exclusion criteria
Participants included in this study were rural household members aged at least 18 years old, physically and mentally healthy, and currently residing in the region.Non-residents such as guests and visitors and seriously ill persons (chronically ill persons in the household) were excluded from the study.

Sample size determination
A Cochran formula was used to determine the study's sample size with a marginal error of 0.05%, a confidence interval of 95%, a probability value of 0.5, and a prevalence precision of 50%.The total sample size calculated was n=385, with a 10% non-response rate adding up to a sample of 424 participants.To improve the power of the study, a total sample of 504 respondents was included in the study.
Sampling procedure A multistage sampling procedure was used to select study respondents.Firstly, four villages were selected from each district using a simple random sampling method.Secondly, 15 households from each village were included in the study through a systematic sampling procedure using the taxpayers' list from the village heads.Thirdly, at the household level, two respondents were selected through a simple random sampling method for the interview.In a household with more than two eligible respondents, a simple random sampling method was used to select a respondent.

Study variables
The dependent variable of the study was the uptake of the Covid-19 vaccination.This was classified as received the Covid-19 vaccine, coded as "Yes," and did not receive the Covid-

Data analysis
The study data were analyzed using IBM SPSS version 26, and the general information of participants was presented in frequencies and percentages.Covid-19 vaccination prevalence was calculated using the vaccinated and eligible populations in the study.Bivariate analyses such as the Pearson chi-square/Fisher exact test were conducted for categorical independent variables.Variables with a p-value ≤0.15 were introduced into a logistic regression model to examine the association between study variables, with statistical significance set at a p-value <0.05 and the computed adjusted odds ratio (aOR) set at a 95% Confidence Interval (CI).

Ethical Considerations
Ethical clearance was sought from the Gambia College Research and Consultancy unit for the approval of the study.
Before the study, consultations were held with regional authorities such as the Regional Governor, District Chiefs, Local Government Authorities, and the Regional Health Directorate of the North Bank East Region.Both written and verbal consent was sought from study participants during data collection.

Results
Socio-demographic characteristics The study constituted 504 participants with a 98.5% response rate.The total number of female respondents accounted for 61%, and 57% were below 34 years of age, with a mean age of 34 and a standard deviation of 14. Mandinka accounted for 49% of the ethnicity, 98% were Muslims, and 59% were married.About 32% had no formal education, and only 3% attained a university education.One-third of the respondents were farmers, less than 5% were non-Gambians, and nearly 84% earned less than $100 in a month.Conversely, nearly 70% used social media, and 11% were currently smoking at the time of the study.About 17% claimed to have been tested for Covid-19, up to 44% had travelled outside the country, and only 8% had had contact with Covid-19 patients.Other variables found to be significant at a p-value <0.05 were gender, ethnicity, educational level, monthly income, cigarette smoking, having been tested for Covid-19, and having travelled outside the country.As shown in Figure 1, Covid-19 vaccination uptake was 44%.Out of these, 87% received Johnson's, while 13% received AstraZeneca vaccines.

Discussion
The approval and acceptance of the Covid-19 vaccine have been a relief across the globe, with optimism to control this pandemic [21] .However, the coronavirus vaccination has been deemed safe and reliable, but the vaccination issue has sparked controversies and caused vaccine hesitancy and even denial in some instances [22] .To avert the effects of This study found that the Covid-19 vaccination uptake among respondents was 44% lower than the targets for herd immunity 75% to 85% declared by WHO.Compared to other studies, the uptake was higher than in a study in Iraq, India, and Jordan, and lower than that of Kuwait and Southern Ethiopia [23][24][25] [26] .The socio-demographic status dynamics could closely influence the variation in vaccination prevalence across various studies [27][28] [29] .The current study revealed a higher uptake of Covid 19 vaccination (20.8%) among the younger generation (18 -33 years) and the lowest (3.6%) among those 66 years old and above.Thus, the vaccination uptake decreases with an increase in age.These findings were conformity to a study done in Kuwait, where vaccine acceptability was highest within the 21 -24 age group and lowest among the 50 -64 age group [25] .
The Covid 19 vaccination uptake was higher in females (29%) than in males.The vaccine uptake among females may be attributed to the long-standing phenomenon that health-related matters in The Gambia were seen as women's preoccupation.Furthermore, women are basically responsible for attending vaccination clinics for their children thus are more responsive to health care services uptake.Thus, gender has been predicted as a factor in the uptake of the Covid-19 vaccine in this study.This finding is invariable with a study in Ethiopia where males were more willing to take the vaccination than females [26] .More than half of those who received the Covid-19 vaccination were married, and approximately a quarter of these recipients were single.Consequently, married respondents were 72% more likely to take the Covid-19 vaccination, and single respondents were 88% more likely to receive vaccination against the widow.
Additionally, the educational level was found to be an associated factor for Covid-19 vaccination among respondents.The majority of those who received the vaccination were respondents who did not receive any formal education.
Consequently, respondents who do not have formal education and those who attained senior secondary education were 3 and 4 times more likely to receive the Covid-19 vaccines than those with a university education.These findings were also documented in some other studies [28][30] [31] .The acceptance of vaccination may be associated with regulations regarding vaccination status being a requirement in some public offices and schools.The vaccination strategy of the EPI has deployed vaccination teams to institutions and communities to vaccinate people voluntarily.
The study findings also revealed an association between the monthly income of the respondents and the acceptance of Covid-19 vaccination.Respondents whose average monthly incomes were less than D1000 ($20), D5000 ($100), and D10,000 ($200) were 74%, 87%, and 90% less likely to receive the Covid-19 vaccination as against those whose incomes were more than D10,000 ($200).Thus, the vaccination rate reduces with an increase in monthly income among respondents.Ultimately, the confirmation of respondents' Covid-19 status was also a factor associated with vaccination uptake, as those who did the test were 23% more likely to take vaccines.These findings were similar to other studies in Nigeria [29] , Malaysia [27] , and Thailand [22] .However, travel history was positively associated with vaccination uptake, as travellers were 58% more likely to take the Covid-19 vaccination than non-travellers.Consequently, respondents who had contact with Covid-19 patients were 41% more likely to be vaccinated.The international requirement for Covid-19 vaccination evidence may drive many travellers to accept the vaccine [21] .
The findings of our study revealed respondents who do not take up the Covid 19 vaccines was mainly based on the reason that the fear of adverse events after taking the Covid vaccine.Our findings are similar to another research conducted on Covid 19 vaccine acceptance in Ethiopia where fear of adverse effects of Covid 19 vaccine (21.2%) is among the major reasons for not taking Covid 19 vaccine [32] .

Strengths and limitations
The large sample size ensured statistical sufficiency with low tendencies for recall bias, since the data was collected when the vaccination process was near completion and respondents had fresh memories of their vaccine utilization, with a high retentivity of vaccination cards.Interviews were conducted face to face with a reduced tendency of avoiding ambiguity.
However, the study could not claim a causal relationship across study variables owing to the study design.

Conclusion
The study revealed a low Covid-19 vaccine uptake in the region, with associated factors such as gender, ethnicity, educational level, monthly income, cigarette smoking, Covid-19 testing, and a history of travel outside the county.To meet the target for herd immunity to Covid-19 in The Gambia, the health ministry should continue to engage people to accept the utilization of the vaccine.Furthermore, social and political commitment is also required in the drive to increase vaccine uptake across the country.Target-specific messaging for the population should be developed in local languages, with intensified communication strategies across media outlets such as radio and television in The Gambia.

Figure 1 .
Figure 1.Prevalence of Covid-19 vaccine Uptake vaccine hesitancy among Gambians, the Expanded Programme of Immunization (EPI) in The Gambia has conducted numerous training sessions for health workers as vaccinators and community sensitizations were conducted to allay the fears and infodemics.The EPI unit provided training for vaccinators on WHO guidelines ranging from Covid-19 vaccinations, storage, handling, delivery, and waste management of Covid-19 vaccines, Adverse Events Following Immunization monitoring, vaccine recording and monitoring, and the communication and organization of vaccination sessions.This study, being the first of its kind in the country and known for high immunization coverage among children less than five years old, will help the Ministry of Health and partners strategies the way forward in improving Covid-19 vaccination and any other mass vaccination campaigns in the country.
19vaccine, coded as "No".The study's independent variables were socio-demographic factors such as age, gender, religion, marital status, and educational level attained.