Misinformation and COVID-19 vaccine uptake hesitancy among frontline workers in Tanzania: Do demographic variables matter?

ABSTRACT

Although COVID-19 vaccination has been widely considered as an important remedy to confront COVID-19, people remain hesitant to take it. The objective of this study was to assess the moderation effects of demographic characteristics on the relationship between forms of misinformation and COVID-19 vaccine uptake hesitancy among frontline workers in Dar es Salaam and Dodoma, Tanzania. Using a sample of 200 respondents, it assessed the differences in ratings on misinformation regarding COVID-19 vaccine based on respondents’ demographics. The study used a Five-point Likert scale questionnaire distributed through snowball sampling to frontline workers from Dar es Salaam and Dodoma regions. Data was analyzed using binary logistic regression. It was found that the forms of misinformation revealed were manipulated imposters, satire, fabricated contents and false contents with their connection, which they influenced COVID-19 hesitancy significantly. With exception of age, that significantly moderated hesitancy, this study uncovers that, sex and education level moderated insignificantly in predicting those who are misinformed; misinformed individuals are not any less educated or not based on one’s sex, different than individuals who are informed. The study informs policy makers on devising appropriate strategies to promote COVID-19 vaccination uptake among the different contextual demographic variables. Promotion of information, media and health literacy to the general public should be considered to deter spreading of vaccine-related misinformation.

KEYWORDS:

• Misinformation
• COVID-19 vaccine
• vaccine uptake
• vaccine uptake hesitancy
• frontline workers
• Tanzania
• demographic variables
• age
• gender
• education

Introduction

While the COVID-19 pandemic has hit the world in an imaginable way one would never think about, misinformation related to the problem in different media is evidenced to have a death-and-life threatening consequence amidst a pandemic.^1–5 This is because inaccurate or misinformation or exaggerated information can generate health anxiety amid an infectious disease pandemic.^1,3,4 Misinformation can be on the disease itself, how it spreads, cure against it, technologies used against COVID-19, and other aspects related to vaccination^1,6–9 including concerns about safety, side effects, and effectiveness of the vaccine.^10–12

While the ground strategy followed by most countries around the world was to reduce the transmissibility of the disease, often by non-pharmaceutical interventions (NPIs), including enforcing masks policy, hands sanitization, social distancing, travel restrictions, schools’ closures, and partial or complete lockdowns,¹³ the most promising strategy to confine the pandemic and providing hope to reduce the mortality and morbidity rates remained within the capacity of medical technology.¹⁴ Such medical technology includes effective, safe, and affordable antiviral agents and vaccines.¹⁴ While as of December 2020, there were no antiviral drugs that had been approved that were specifically developed against COVID-19,¹⁵ the World Health Organization (WHO) approved vaccines as effective interventions that can reduce the high burden of diseases globally.¹⁴

Yet, despite widespread recognition that COVID-19 is a critical issue to people all around the globe, and that getting vaccinated prevents severe illness, hospitalizations, and death^16–18 many remain unwilling to be vaccinated or are choosing to delay vaccination.¹⁹ Watson et al.²⁰ add that, although COVID-19 vaccines are globally accepted as the remedy that saved over 14.4 million COVID-19-related deaths between December 2020 and December 2021 alone,²⁰ they are still not universally accepted till today.²¹ Brown et al.²² observed among others that the speed of COVID-19 vaccine development was a central concern contributing to hesitancy in acceptance leading to uncertainties regarding the safety of the vaccine. Vaccine hesitancy, defined as a delay in acceptance or refusal of vaccination despite availability of vaccination services²³ remains one among top ten global health threats.^24,25 For example, a survey of eleven OECD countries in December 2020 found that on average, only 66% of the population would accept vaccination.²⁶ Studies further show that in Europe and the United States,^27,28 Asia;^29–31 Africa^32–34 including Tanzania in particular^2–35–37 remained hesitant to COVID-19 vaccination.

Misinformation is not a new phenomenon in health.³⁸ Scannell et al³⁸ observe that health innovations and discoveries have been misrepresented and surrounded by myth and conspiracy throughout history. It was the same during the measles era, linking mumps, and rubella vaccine to autism.^38,39 Studies^{1,6–11,40,41} indicate that higher exposure to misinformation led to higher levels of negative attitudes toward the COVID-19 vaccine. Skepticisms such as vaccine will contain microchip; vaccine will cause infertility; vaccine will change deoxyribonucleic acid or DNA; vaccine will control the mind⁴² or vaccine will cause blood clotting and eventual death⁴³ and so on remain. Consequently, vaccine hesitancy continues to have a negative influence on vaccine attitudes and behaviors due ever-growing exposure to vaccine misinformation.⁴¹ The disappointing global vaccine uptake hesitancy rates and the uncertainty caused the COVID-19 pandemic are still troubling health practitioners and puzzling researchers.

Although Tanzania geared toward vaccination after a team of health experts handed in their report on COVID-19 vaccine’s safety, and efficacy to President Samia Suluhu, a heated debate continued partly emanating from prior and ongoing misinformation.^35-37 Masele & Daud,² documented that even after vaccine approval by regulatory agencies in Tanzania vaccine uptake hesitancy remained critical among frontline workers and other vulnerable populations in the country. While vaccine hesitancy is not a new phenomenon globally and in Tanzania, an understanding of the relationship between misinformation and vaccination hesitancy in the COVID-19 pandemic context, is new that poses a new urgency to investigate about the phenomenon.

While vaccine hesitancy, among frontline workers, remains an important threat to successful rollout of vaccines,²¹ and that misinformation was revealed to significantly uptake hesitancy among frontline workers in Tanzania,⁴⁴ assessment of means to increase COVID-19 vaccination acceptability to this group is important in order to save their lives. Yet, according to scholars^21,45 vaccine hesitancy is complex, heterogeneous and context-specific, varying across time, places, and disease type. Interestingly, Greenspan⁴⁶ observes that even demographic differences such as sex, age, education level, or income can moderate the relationship between misinformation and certain adoption uptake, with the assumption that some people are naturally more inclined to believe misinformation. Similarly, studies^27,29,31,47 assert that demographic variables such as age, gender and education have significant moderation effect between misinformation on COVID-19 vaccine uptake hesitancy. The results of chi-square tests by Ruiz and Bell⁴⁸ found significant relationship between demographic variables and vaccine acceptance. A nation-wide survey in the USA revealed that intention for COVID-19 vaccination was higher among men, older people and college educated adults.⁴⁸ The analysis by the Harvard Kennedy School Misinformation Review,⁴⁹ reveals that gender, age, and education have a statistically significant but relatively small effect on whether people feel vulnerable to misinformation.

Yet, existing literature^47,50 had remained inconclusive on how demographic factors such as age, gender, income, and education level may contribute to rumor and or misinformation acceptance that in turn influences hesitancy behavior toward COVID-19 vaccine uptake. Understanding the moderation influence of misinformation on the vaccination uptake hesitancy in the fight against the pandemic in the context of Tanzania is of significant importance to fill the existing knowledge gap. It is for this reason, this study of its own kind was formulated to investigate the extent to which demographic variables moderate the influence of misinformation on COVID-19 vaccine uptake hesitancy among frontline workers in Tanzania.

Specifically, the study seeks to assess the influence of forms of misinformation on COVID-19 vaccine uptake hesitancy among frontline workers; assesses the demographic characteristics associated with the willingness to take COVID vaccine; and, it assesses the differences in ratings on misinformation regarding COVID-19 vaccine based on respondents’ demographics.

Literature review

Social judgment theory

Social judgment theory by Carolyn Sherif, Muzafer Sherif, and Carl Hovlan in 1960s^51,52 focuses on people’s values or issues within their latitude of acceptance.^38,53 The theory posits that persuasive messages are usually judged against an individuals’ existing position (anchor attitude).⁴⁷ If the new message falls into the latitude of acceptance, then it will be perceived as closer than it is to the anchor attitude.^53,54 According to Pan et al.,⁴⁷ messages that are consistent with one’s beliefs will be evaluated and processed more fluently. Accordingly, individuals are more likely to accept these messages as truthful. Messages which are not consistent with individuals’ preexisting beliefs can cause cognitive dissonance and are more difficult to accept.⁵⁵ In the context of health misinformation, individuals are more likely to believe a piece of new information if it is compatible and congruent with their preexisting beliefs. On the one hand, some people hold skeptical views when it comes to health-related information or misinformation. On the other hand, other people are more receptive and are more likely to accept what they were told.

The influence of misinformation on COVID-19 vaccine uptake hesitancy

A number of studies have already advanced that misinformation such as manipulation, misleading, fabrication, imposter content, satire, with false^56,57 plays a big role in misinformation. This is because misinformation is often “preferred” to true information and often shared more than true news⁵⁸ and such that individuals retain false beliefs even after being corrected.^59–61 And in fact, it matters little whether the source is formal (such as TVs, radio and newspapers) or informal (suh as WhatsApp, family and friends’ religious leaders, Facebook, Youtube, twitter and the like).²

With informal sources like social media are characterized by user generated content that allows anyone with access to the internet to share inf ormation related to COVID-19 including vaccination related information^62–64 thus generating unnecessary health anxiety amid the pandemic. Formal sources can also be censored for some reasons including managing potential crises, keeping the economy alive or attempts not to lose political positions make them not credible.⁶⁵ It is therefore important that before one relies on certain information for COVID-19 vaccination decision, to scrutinize about the author/source, the time the material was published, the purpose of a source, how that source can be proved, and what type of audience is this source aimed at. The study by Masele and Daud² observed that there is significant influence of COVID-19 sources misinformation (MI) on vaccination hesitancy uptake (VUH) at p < .001. Misinformation that brings suspicion on safety, efficacy and pharmaceutical quality of the vaccine in question and the information given by the dependable sources influenced vaccination uptake hesitancy. This study thus had its 1^st hypothesis H1: COVID-19 Vaccine Misinformation significantly influences COVID-19 vaccine uptake hesitancy.

The effect of age in moderating the relationship between misinformation and COVID-19 uptake hesitancy

Studies associate age to influence the strength of relation between misinformation and uptake of an invention.^46,47 In fact, studies assert that, out of three demographic categories, age has the greatest effect on the acceptance of fake news, compared to the other two; education and gender. Age’s direct effect on the acceptance of fake news is 0.102.³⁰ A study by Park⁶⁶ regarding political news argued that young people are more receptive and react more emotionally to negative political news on twitter. A study by Afzal et al.²⁷ on the impact of demographic factors on early COVID-19 vaccine hesitancy among health care workers in New York city public hospitals revealed that age significantly associated with vaccine hesitancy and vaccine refusal (p < .001) for all groups). The youngest age group (18–24) was the least likely to be vaccinated, and the most likely to be hesitant or refuse vaccination as compared to groups above 65 years.²⁷ Yet, hesitancy among the other age ranges was not substantially different in magnitude.

On contrary, a study by Bapaye and Bapaye³¹ that analyzed 1137 responses from WhatsApp users in India revealed that users aged over 65 years had the highest vulnerability to misinformation as compared to their counter parts in the age group 19–25 years who had significantly lower vulnerability than those aged over 25 years (p < .05). The argument is in line with what the Harvard Kennedy School Misinformation Review⁴⁹ reveals that younger people, those between 15–29, are most concerned about encountering false information online, with concern decreasing with age. Similarly, Mahmud et al.²⁹ found significant relationship between age group willingness to get the vaccine (χ² = 43.680, df = 2, p < .001). The percentage of respondents who were above 40 years and willing to take vaccine was significantly higher than those who were below 40 years old (>40 years vs <40 years, 81.0% vs 43.6%). A significant proportion of participants under 40 years’ group (42.6%) was unsure about taking COVID-19 vaccine. While age has been primarily associated to sharing fake news, evidence is mixed,^67,68 limited to developed countries’ population and involving mostly social media, and not taking into account the whole possible comprehensive set of sources of information that influence COVID-19 vaccine uptake hesitancy.

This study thus hypothesized as H2: Age positively moderates the relationship between misinformation and COVID-19 vaccine uptake hesitancy.

Effect of gender in moderating the relationship between misinformation and COVID-19 uptake hesitancy

Another demographic variable that is documented to moderate the relationship between misinformation and uptake of an invention. The findings by Afzal et al.²⁷ indicate that gender was significantly associated with vaccination status, with men being more likely than women to be vaccinated (87% vs. 77%). Their survey also demonstrated that COVID-19 vaccine hesitancy was higher among women when compared to men.²⁷ A study by Mahmud et al.²⁹ on the relationship between participants’ demographic characteristics and their willingness to take COVID-19 vaccine revealed that there was a significant relationship between gender and vaccine acceptance (χ² = 6.724, df = 2, p < .05). The percentage of males (56.2%) willing to take vaccines was higher than that of female respondents (42.8%). In the same way, a high ratio of females was not willing (male vs female, 12.4% vs 15.9%) or unsure (male vs female, 31.4% vs 41.4%) about taking the vaccine. A study by Hossain et al.,⁶⁹ indicates that female students, having inadequate knowledge, and negative perceptions and attitudes toward the vaccine were susceptible to vaccine hesitancy and resistance. The observation is similar to Kricorian et al.,¹² who found that females were more likely (59.2%) to believe that the COVID-19 vaccine is unsafe. However, Rampersad and Althiyabi,³⁰ observed an indirect effect of gender of 0.009 which is positive but weak. While the literature presents mixed results on the moderation effect of gender in the relationship, and that the findings are mostly from developed countries with those from developing and Tanzania in particular missing, this study presents its third hypothesis as H3: Gender positively moderates the relationship between misinformation and COVID-19 vaccine uptake hesitancy.

Effect of education in moderating the relationship between misinformation and COVID-19 uptake hesitancy

Generally, it is considered the more educated a person is, the more likely that person would critically evaluate certain information before accepting it. A study by Afzal et al.²⁷ observed that the more educated a person, the more likely they would be vaccinated, with the exception of those with “high school education” for which the numbers were too small to be meaningful. Interestingly, among those who were not vaccinated, 24% of respondents with a high school diploma or GED were more likely to be hesitant than refusers. Yet those with college education, associate’s degree, or a bachelor’s degree, all had higher rates of refusal than the high school or GED individuals, even though their overall vaccination rates were higher. The survey by Afzal et al.²⁷ demonstrated that education level was significantly associated with vaccine hesitancy and refusal (p-value < .001). COVID-19 vaccine hesitancy was higher among participants with college degrees compared to those without a degree.²⁷ A study by Mahmud et al.²⁹ found a significant relationship between respondents’ educational qualification and their vaccination intention. It was evident from the past findings that the higher the educational level, the higher the percentage of willingness to take COVID vaccine (school (14.3%) vs college (36.9%) vs bachelor’s (45.8%) vs postgraduate (73.6&). Further, participants with low education levels were more unsure about taking the vaccine than those who had high academic degrees (school (47.6%) vs college (46.2%) vs bachelor’s (39.6%) vs postgraduate (20.0%), Rampersad and Althiyabi³⁰ assessment on the effect of education showed a negative effect and therefore they inferred that education negatively influences the acceptance of fake news related to vaccination. This means that as education increases, the acceptance of fake news will be reduced.³⁰ Impliedly, information literacy skills can help people identify misinformation about vaccination. This study thus hypothesizes that H4: Education level positively moderates the relationship between misinformation and COVID-19 vaccine uptake hesitancy.

Literature gap and conceptual model

The literature review of the moderation effect of demographic variables (age, sex and education) on the relationship between misinformation and COVID-19 vaccine uptake hesitancy has revealed contradicting and inconclusive results which triggers for further investigation in the Tanzanian context. The review has observed that age is significantly associated acceptance of fake news and consequently associated with vaccine hesitancy and vaccine refusal.^27,30 They are both outside Tanzania but also from developing countries which are contextually different from Tanzania. Contradicting results with gender was also shown. Some^12,27,29,69 indicated gender to be significantly associated with vaccination status, while others (Rampersad & Althiyabi),³⁰ observed an indirect positive but weak effect of gender. Education wise, some review indicates that education is significantly associated with vaccine hesitancy and refusal,^12,27,29,69 while others³⁰ showed a negative effect. Such results from both gender and education not only show contrasting results but also they are conducted outside Tanzania and from developed countries; which are contextually different from Tanzania. Thus, since vaccine hesitancy is complex, heterogeneous and context-specific, varying across time, places, and disease type, conducting this study in the context of Tanzania was considered important in order to fill the existing knowledge gap.

This study has conceptualized as presented in Figure 1 that misinformation relating to COVID-19 vaccine uptake influences vaccine uptake hesitancy, and the relationship is moderated by demographic variables.

Figure 1. Conceptual model.

Methodology

This study was conducted in Dar es Salaam and Dodoma, Tanzania. Dar es Salaam is not only the most populated city in Tanzania but also a business city hosting more frontline workers as compared to other cities² while Dodoma, a national capital of Tanzania, is located in central Tanzania. This study refers frontline workers to include, but not limited to, healthcare workers, protective service workers (police and EMTs), cashiers in grocery and general merchandise stores, production and food processing workers, janitors and maintenance workers, agricultural workers, truck drivers,⁷⁰ priests and church elders, teachers and instructors.

A semi-structured questionnaire was used to a sample of 200 respondents, 100 being from Dar es Salaam and other 100 from Dodoma. According to Anthoine et al.⁷¹ sample sizes of 200 to 300 respondents provide an acceptable margin of error, and it is thus considered as fair enough to translate into reliable results. A snowball sampling was used to pick the respondents. A respondent was given a questionnaire when he/she falls under frontline workers grouping. The questionnaire consisted of three parts. The first part included participants’ demographic information, i.e. gender, age, educational level and their current region of residency. The second part of the questionnaire contained data about COVID-19 and vaccine acceptance. Response options were “yes,” “no” and “not sure” for questions on previous vaccination and whether they will be taking the COVID-19 vaccine in future. The third part of the questionnaire consisted of list of misinformation about COVID-19, drawn from earlier studies. In this study, the term “misinformation” refers to all kinds of fraudulent information, false claims, fake news, rumors and active manipulation of vaccine information with dubious intentions. Participants were asked to indicate their level of agreement or disagreement regarding vaccine-related misinformation using a Five-point Likert scale from 1 – “Strongly disagree” to 5 – “Strongly agree.” To ensure that the study adheres to required ethics, the participants provided their informed consent to participate in this study.

Cronbach’s alpha coefficient was used for assessing the internal consistency of the Likert scale items used in this study. A Cronbach alpha of more than 0.7 computed from a pilot study data conducted to sample of 20 to sort any ambiguity from the questionnaire implied that the instrument was reliable.

Frequency and percentage were used to describe frontline workers’ demographic characteristics- region of residence, age, sex and education level. Descriptive statistics were obtained for respondents’ demographics, level of agreement with COVID-related misinformation and the strategies to be adopted. The computation of outcome variable was done through creating percentage of total scores of items on COVID-19 Vaccine uptake hesitancy among respondents from Dar es Salaam and Dodoma region in Tanzania. The computed percentage scores were categorized using blooms cut point,^72,73 as Low COVID-19 Vaccine uptake hesitancy (0 = Low COVID-19 Vaccine uptake hesitancy) if less than 50% score and High COVID-19 Vaccine uptake hesitancy (1 = High COVID-19 Vaccine uptake hesitancy) if equal to 50% or above.

The predictor variables selected for this study are frontline workers’ COVID-19 Vaccine misinformation (measured by Manipulated imposter, satire and fabricated content, False content and their connection). Dimension reduction factor analysis was done with principle component method were employed to generate COVID-19 Vaccine misinformation variables (Q1 = Manipulated imposter, satire and fabricated content and Q2 = False content with their connection). The moderating variables were the frontline workers’ demographic characteristics, - age, gender and education level.

Binary logistic regression model was used to determine moderation effect of frontline workers’ demographic characteristics between frontline workers’ COVID-19 vaccination misinformation on COVID-19 Vaccine uptake hesitancy. Logistic regression was more preferred because, the measurement scale of vaccination uptake hesitancy utilized in the study was binary, consisting of only “yes” and “no” categorical responses. Besides, logistic regression does not rely on assumptions of normality for the predictor variables or the errors and it allows the selection effect to vary nonlinearly. In the process of fitting models, potential identified predictors were tested with crude odd ratio analysis and also all variables which were significance (p < .05) at crude model was taken for adjusted model analysis.

Chi-square tests were conducted to compare vaccine acceptance proportions across various demographic groups. For further analysis, participants’ responses on the willing to take the COVID vaccine were divided dichotomously as either a positive (“yes” response) or a negative (“no” and “not sure” response) to indicate the extent of vaccine hesitancy. A binary logistic regression model was used to analyze the vaccine hesitancy by demographic groups. Hosmer – Lemeshow goodness-of-fit test was used to determine the model fit of the data.⁷⁴ Additionally, nonparametric Mann – Whitney and Kruskal – Wallis tests were conducted to find out the significance of difference in respondents’ assessment,⁷⁵ on vaccine-related misinformation in terms of their demographic characteristics. Finally, the ratings on COVID-19 misinformation items were summed to compute the total misinformation score to examine the possible correlation between the extent of vaccine hesitancy and the total score.

Study findings

This study had sought to assess the forms of COVID-19 vaccination misinformation faced by frontline workers in Dar es Salaam and Dodoma; and assess the demographic characteristics associated with the willingness to take COVID vaccine and their moderation effects on the influence of COVID-19 vaccination misinformation and COVID-19 vaccine uptake hesitancy. The findings are presented basing on the study objectives.

Forms of misinformation on COVID-19 vaccine uptake hesitancy among frontline workers

The first objective of this study was to identify and profile the forms of misinformation on COVID-19 vaccine uptake hesitancy among frontline workers. The findings indicate that the misinformation forms were in terms of content, perceptions/trust, belief and information asymmetry. After factorization of each form’s indicator items with loading above 0.5 considered fit, a descriptive analysis was done to rank the importance of the misinformation forms from the data collected using a five-point Likert scale (1 – not important at all to 5 – very important). The mean scores for the content, perception/trust, belief and information asymmetry was 4.03, 3.67, 2.55 and 2.52 respectively. As presented in Table 1, it was revealed that manipulated, misleading, fabricated, imposter, satire or false content was the dominant form of misinformation determining COVID-19 vaccine uptake hesitancy mentioned by 161 (80.6%) respondents. This was followed by perception cited by 146 (73%) respondents. The perception was related to the quality, safety and efficacy of the vaccine by the pharmaceutical companies and vaccine manufacturers. The hesitancy was also huge where respondents poorly perceived that the government was not in their favor but because of some pressure from external forces. Belief based on one’s religious philosophy/faith, culture, past memories and event related to vaccines was cited by 102 (51%) respondents. Information asymmetry or feeling to have no enough information on the need for vaccine, its content and efficacy by responsible individuals and the community in general triggered for COVID-19 vaccine uptake hesitancy among frontline workers, reported by 100 (50%) respondents.

Table 1. Factorization and mean scores of forms of misinformation on COVID-19 vaccine uptake hesitancy.

From of misinformation	Indicator statements	Factor loading	N	n (%)	Mean
Content	Manipulated content on COVID-19 vaccine creates significant barriers to intention to vaccination	.878	200	161 (80.5%)	4.03
	Misleading content with skewed facts/information about COVID-19 is a barrier	.798
	Fabricated content about COVID-19 vaccination designed to deceive and do harm is a barrier	794
	Imposter content on COVID-19 genuine sources shared through media	.791
	Satire or parody about COVID-19 posted online and other media	.764
	Visual source captions with false connection to the said content on COVID-19 vaccines	.762
	COVID-19 genuine content shared with false contextual information	.746
Perception & trust	Perception that pharmaceutical companies will not provide safe and effective COVID-19 vaccine	.779	200	146 (73%)	3.67
	Perception that the government is pushed on certain vaccine by COVID-19 vaccine manufacturers	.759
	Poorly convinced on COVID-19 vaccine quality purchased by the government	.748
	Distrust that COVID-19 vaccine is important to protect those that cannot get vaccinated	.731
	Distrust in the government existing during the COVID-19 epidemic creates significant barriers to intention to vaccination	.730
Belief	Religion philosophy/culture recommending against COVID-19 vaccine	.688	200	102 (51%)	2.55
	One’s faith opining that vaccination is not a good thing	.678
	Some memories of the past make my community refuse to accept other kind of vaccine	.609
	Remembering some events in the past discourage one from getting COVID-19 vaccine	.516
Information asymmetry	Community leaders poorly informed on the need to urgently introduce a COVID-19 vaccine	.750	200	100 (50%)	2.52
	Health professional not providing most of information on questions relating to COVID-19 vaccination	.676
	Information on side effects after COVID-19 vaccination not openly discussed by the authorities	.651
	Being not properly informed on the vaccines	.636
	Feeling to have no enough information about COVID-19 vaccine	.610

Demographic characteristics associated with willingness to take COVID-19 vaccine

The respondents’ demographic characteristics used in this study include region of residence, sex, age and education level attained. The respondents’ demographic characteristics presented in Table 2 indicate that 52.4% of respondents were from Dar es Salaam city while 47.6% of respondents were from Dodoma city. The data also indicates that 69.5% of respondents were males while 30.5% were females. Age wise 39.6% of respondents were between 31 and 40 years old, followed by 26.8% aged between 21 and 30 years old, 26.2% aged between 41 and 50 years old and 7.3% who were aged above 50 years old. Education wise, 93.9% of respondents had college/university education level and only 6.1% had secondary education as their highest level of education attainment. Yet with exception of age, there were no significant differences between sex, education level and regions of residences as the p values at χ² of 1.574, 0.233, and 0.05 was p = .233, .745 and .875 respectively. With age, there were significant differences in the hesitancy level between respondents age at χ2 of 9.351 and p value of .024, suggesting that younger frontline workers were more hesitant to COVID-19 vaccination compared to the relatively older counterparts. It can further be observed that about 55% with high hesitancy were from age group below 50 years, with about 70.8% of high hesitant groups being from 31 and 40 years of age.

Table 2. Demographic characteristics of frontline workers on COVID-19 vaccine uptake hesitancy.

Demographic variables		COVID-19 Vaccine uptake hesitancy
	Total (%)	Low hesitancy	High hesitancy	Chi-square	P-value
Age
Between 21 and 30	44(26.8%)	21(47.7%)	23(52.3%
Between 31 and 40	65(39.6%)	19(29.2%)	46(70.8%)	9.351	.024
Between 41 and 50	43(26.2%)	22(51.2%)	21(48.8%)
Above 50	12(7.3%)	8(66.7%)	4(33.3%)
Gender
Male	114(69.5%)	45(39.5%)	69(60.5%)	1.574	.233
Female	50(30.5%)	25(50%)	25(50%)
Education level
Secondary education	10(6.1%)	5(50.0%)	5(50.0%)	0.233	.745
College/University education	154(93.9%)	65(42.2%)	89(57.8%)

Moderation effects of age, gender and education level on COVID-19 vaccine uptake hesitancy among frontline workers in Dar es Salaam and Dodoma

Binary logistic regression model with unadjusted (Crude odd Ratio) and adjusted (Adjusted Odd ratio) ratio was fitted to determine the moderation effect of frontline workers’ demographic characteristics on the influence of misinformation and COVID-19 uptake hesitancy in Dar-es salaam and Dodoma regions. In unadjusted model, results presented in Table 3 show that only manipulated imposters, satire and fabricated content, false content with their connection moderated by age are significant (p < .05) determinant factors for COVID-19 vaccine uptake hesitancy among frontline workers for Dar es salaam and Dodoma region. Whereas the chance of COVID-19 Vaccine uptake hesitancy for frontline workers aged between 31 and 40 was 2.21 (at 95% CI 0.99,4.91) times higher, 12.8%(at 95% CI 0.376, 2.021) less for age group between 41 and 50, 74.9%(at 95% CI 0.12,1.74) less for age group above 50 consecutively as compared to age group between 21 and 30. Also for unit change in manipulated imposters, satire and fabricated contents resulted to increase of 20% (at 95% CI 1.124, 1.281) odd chance of COVID-19 Vaccine hesitancy. Also, findings indicate that unit change in false content with their connection increased 54.2% (at 95% CI 1.332,1.784) the odd likelihood of COVID-19 vaccine uptake hesitancy in frontline workers. Other variable (gender, education level attained) were not statistically significant (p > .05). Surprisingly, frontline workers attained college/university level were 36.9% (at 95% CI 0.381,4.925) more likely to have COVID-19 vaccine uptake hesitancy compared to those with secondary education level.

Table 3. Crude and adjusted binary logistic regression model to determine the factors of frontline workers on COVID-19 vaccine uptake hesitancy.

Variables	COR at 95% at CI	P-value	AOR at 95% at CI	P-value
Age		.030		.161
Between 21 and 30	Ref
Between 31 and 40	2.211(0.996,4.906)	.051	0.24(0.021,2.695)	.247
Between 41 and 50	.872(0.376,2.021)	.749	1.23(0.176, 8.701)	.835
Above 50	0.251(0.120,0.740)	.049	0.67(0.093, 4.837)	.609
Gender		.21
Male	Ref
Female	0.652(0.334,1.274)	.121	0.62(0.310,1.240)	.177
Educational level attained
Secondary education	Ref
College/University education	1.369(0.381,4.925)	.650
Manipulated imposters, satire and fabricated contents	1.20(1.124, 1.281)	<.001	1.175(1.082,1.276)	<.001
False content with their connection	1.542(1.332,1.784)		1.379(1.169,1.627)	<.001

After adjusting for other variables, manipulated imposters, satire and fabricated contents, age and false content with their connection were significant (p < .05) determinant factors for COVID-19 vaccine uptake hesitancy among frontline workers for Dar es salaam and Dodoma regions. Findings after adjustment of other variables show that 17.5% (at 95% CI 1.082,1.276) increase odd chance of COVID-19 vaccine hesitancy attributed by unit change in manipulated imposters, satire and fabricated contents. Also, for unit shift in false content with their connection resulted to 37.9% (at 95% CI 1.169,1.627) odd chance of COVID-19 vaccine hesitancy for frontline workers (Table 3 summarizes).

Discussion

This study was formulated to assess the influence of forms of misinformation on COVID-19 vaccine uptake hesitancy among frontline workers in Dar es Salaam and Dodoma; assess the demographic characteristics associated with the willingness to take COVID vaccine; and, assess the differences in ratings on misinformation regarding COVID-19 vaccine based on respondents’ demographics.

The forms of misinformation revealed were manipulated imposters, satire, fabricated contents and false contents with their connection. Their influences were significant (p < .05) implying that they are determinant factors for COVID-19 vaccine uptake hesitancy among frontline workers for Dar es salaam and Dodoma region. The findings indicate that for a unit change in manipulated imposters, satire and fabricated contents resulted to increase of 20% odd chance of COVID-19 Vaccine hesitancy. Furthermore, a unit change in false content with their connection increased by 54.2% odd likelihood of COVID-19 vaccine uptake hesitancy in frontline workers. The moderation effects of demographic variables (gender and education level attained) with exception of age, on the relationship between forms of misinformation (manipulated imposters, satire, fabricated contents and false contents with their connection) and COVID-19 vaccine uptake hesitancy were not statistically significant (p > .05).

The results based of the direct influence of demographic variable indicated a significant influence of age on COVID-19 Vaccine uptake hesitancy for frontline workers. The results indicate that frontline workers aged between 31 and 40 was 2.21 times higher, 2.021 less for age group between 41 and 50, and less for age group above 50 consecutively as compared to age group between 21 and 30. This study uncovers that, sex and education level moderated insignificantly in predicting those who are misinformed; misinformed individuals are not any less educated or not based on one’s sex, different than individuals who are informed. This is contrary to findings by Hossain et al.⁶⁹ and Kricorian et al.,¹² who had observed that females having inadequate knowledge were susceptible to vaccine hesitancy and resistance. This is because they could likely believe that the COVID-19 vaccine is unsafe. The findings are in line with what Maffioli and Gonzalez⁷⁶ revealed that socio-demographic and economic indicators play a minor role in predicting those who are misinformed. The findings are slightly different with Pan et al.⁴⁷ who posited that demographic characteristics significantly affect how people respond to health misinformation. The findings also differ from Greenspan⁴⁶ who advances that some people are naturally more inclined to believe misinformation and are influenced by their demographic differences such as sex, age, education level.

Surprisingly, this study found that frontline workers who had attained college/university education level were at 95% CI 0.381,4.925) more likely to have COVID-19 vaccine uptake hesitancy compared to those with secondary education level. The findings can be explained by the fact that, educated people typically have greater digital literacy skills, and are accessible to a number of information sources including online and on social media. So, while they can be assumed to have greater media literacy (the educated) where they don’t have correct information they may be consequently being more vulnerable to misinformation. It may explain why those with secondary education level were likely to have COVID-19 vaccine uptake hesitancy compared to those with higher university college. The findings are in line with Afzal et al.²⁷ and Kricorian et al.,¹² who argue that the more educated a person, the more likely they could be vaccinated, with the exception of those with low education such as “high school” or less whose numbers were too small to be meaningful. The findings are also in line with Mahmud et al.²⁹ who found significant relationship between respondents’ educational qualification and their vaccination intention. Unlike Afzal et al.,²⁷ Mahmud et al.,²⁹ and Kricorian etal.¹² studies, our study found no significant moderation effect with education (p > .05). Accordingly, given the findings with this study, it can be argued that demographic variables can be assumed to be contextual factors rather than universal antecedents of COVID-19 vaccination misinformation adoption.

Conclusion and implications of the study

This study has indicated a significant moderation of age on the relationship between misinformation on COVID-19 Vaccine uptake hesitancy for frontline workers. The study however has found that sex and education level moderated insignificantly in predicting those who are misinformed, meaning that misinformed individuals are not any less educated or not based on one’s sex, different than individuals who are informed. This study has a number of implications practically, policy wise and theoretically. The findings inform influence of misinformation on COVID-19 vaccine hesitancy and the degree they are moderated by the various demographic variables- age, gender and education. The study will also support policy-level planning in devising appropriate strategies to promote COVID-19 vaccination uptake among the different contextual demographic variables. Theoretically, the study posits basing on Social Judgement Theory that since persuasive messages are usually judged against an individuals’ existing position around his/her anchor attitude, promotion of information literacy, media literacy and health literacy skills to the general public should be considered to overcome the strong influence of misinformation. Provision of relevant and timely information in accessible formats can be a deterrent to spreading vaccine-related misinformation.

Limitation of the study

COVID-19 vaccine hesitancy is a complex phenomenon that encompasses a variety of factors. In this study we focused on misinformation as the independent variable and demographic factors as moderators. Nonetheless, this study acknowledges that other factors such as informational, psychological, social and cultural aspects, may have an impact on vaccine hesitancy. Furthermore, vaccine hesitancy can be contagious, so an individual’s social network of friends and family can play a crucial role in their decision to receive or reject the vaccine. Future studies may focus on these factors and theory relationships with misinformation and COVID-19 vaccine uptake hesitancy. Besides, while a sample of 200 was considered adequate, further studies may test a phenomenon with large samples.

Authorship contribution statement

Juma James Masele is the author of the manuscript and the correspondence author.

Ethics approval

All ethical approval procedures were adhered.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was not funded by any supporting body.