Post-vaccination confidence in COVID-19 vaccines and associated determinants in post-war context of Tigray, Northern Ethiopia: a mixed-methods study

Abstract

Introduction It is widely recognized that access to and utilization of health services are negatively impacted by war. These effects worsen particularly when combined with pandemics such as COVID-19. Therefore, this study aimed to assess adults' COVID-19 post-vaccination confidence in the conflict-affected region of Tigray, Northern Ethiopia. Methods The study employed a concurrent parallel mixed-methods design, combining a quantitative survey of 1599 adults and six key informant interviews and six focus group discussions. Survey participants were selected using a multistage cluster sampling technique, while qualitative participants were purposively sampled. Quantitative data were collected using a pre-tested, structured questionnaire administered via Open Data Kit (ODK), while qualitative data were gathered through in-depth interviews and FGDs. For analysis, SPSS (version 26) was used for quantitative data, and ATLAS.ti (version 9.0) was used for qualitative data. Multilevel logistic regression analysis was applied to identify factors significantly associated with vaccine confidence and thematic analysis to the qualitative data. Results Although the study was conducted under difficult circumstances, a high response rate of 96.9% was achieved. 46.5% of respondents had good confidence in the COVID-19 vaccine following vaccination. Significant factors associated with confidence included larger family size (AOR = 1.76, 95% CI: 1.12–2.78), mobile phone ownership (AOR = 1.39, 95% CI: 1.09–1.77), household access to electricity (AOR = 1.78, 95% CI: 1.29–2.46), higher perceived susceptibility (AOR = 1.91, 95% CI: 1.49–2.47), and higher perceived severity (AOR = 2.77, 95% CI: 2.16–3.56). Conversely, higher individual perceived barriers (AOR = 0.16, 95% CI: 0.12–0.22) and community-level perceived barriers (AOR = 0.51, 95% CI: 0.33–0.81) were associated with lower confidence. Qualitative analysis further identified four key themes: the need to improve vaccine knowledge, address rumors and misconceptions, develop strategies to enhance vaccine acceptance and uptake, and emphasize the importance of community engagement. Conclusions The study revealed a low level of post-COVID-19 vaccination confidence. It was positively associated with larger family size, awareness of the COVID19 vaccination, access to electric power supply, higher perceived susceptibility, and severity. It was also negatively associated with individual and community perceived barriers. Therefore, we recommend to reducing community-level barriers through technological access (mobile/electricity) which enables information dissemination and using community networks to facilitate trust-building.