COVID-19 vaccine hesitancy among reproductive-age women in Ethiopia: a spatial and multilevel analysis
Although vaccines are becoming increasingly accessible, hesitancy is still a public health concern, particularly in reproductive-age women in Ethiopia. However, evidence regarding geographic distribution and determinants of COVID-19 vaccine hesitancy remains limited. This study addresses these gaps by examining geographic patterns and factors associated with COVID-19 vaccine hesitancy in reproductive-age women. Data from 7,663 (weighted) reproductive-age women were analyzed using the nationally representative survey dataset (the 2021 PMA-ET), collected through the stratified cluster sampling method. Multilevel logistic regression was fitted to account for cluster-level (enumeration area) clustering of COVID-19 vaccine hesitancy. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were applied to determine statistical significance. To assess the local geographic pattern of vaccine hesitancy was conducted using SaTScan (Bernoulli model, purely spatial). COVID-19 vaccine hesitancy was reported in 27.91% of reproductive-age women (95% CI: 26.92%-28.92%). It was significantly higher among women aged 40 to 44 (AOR = 1.38, 95% CI: 1.05 – 1.82), 45 to 49 (AOR = 1.49, 95% CI: 1.11 – 1.99), with primary education (AOR = 1.38), no education (AOR = 2.06), and never married (AOR = 1.39). Conversely, the lower wealth quintile was associated with reduced hesitancy (AOR = 0.77). The primary cluster was centered at 9.148990°N, 40.048298°E with a radius of 152.28 km covering southern Amhara, southern Afar, central Oromia, and Addis Ababa. Vaccine hesitancy remains high among reproductive-age women in Ethiopia (27.9%), and it is higher among older, less educated, and unmarried women. These findings highlight the need for targeted strategies in these groups before the rollout of any new vaccine. While the COVID-19 crisis has dropped, the geographic clustering identified in this study may be continue as epicenters of hesitancy for future vaccine rollouts, including the nationally planned rollouts for hepatitis B birth dose, malaria, and cholera in Ethiopia. Therefore, conducting targeted surveillance over these high histant areas may help to proactively mitigate localized resistance during upcoming immunization campaigns.