Dimensions of Vaccination Attitudes in Nigeria: A Study of the Impacts of COVID-19 Vaccine Risk Perception and Acceptance

Nigeria has been affected by the COVID-19 pandemic, and vaccination is a key strategy. However, the country faces vaccination hesitancy, poor risk perception


Introduction
The COVID-19 pandemic has global repercussions. Since there is no permanent virus treatment, vaccination is needed. 1 Vaccination is a significant public health intervention that prevents virus spread and saves lives. [2][3][4] COVID-19 vaccines have been successfully developed and distributed across countries, but Nigeria's vaccination attitudes are concerns. This condition is because many Nigerians are skeptical about the vaccination, believing it could have unintended health consequences now or in the near future; thus, they have negative attitudes toward the COVID-19 vaccine. 5 Understanding the impact of COVID-19 vaccine acceptability and risk perceptions on various dimensions of vaccination attitudes in Nigeria is crucial for developing effective specific vaccination promotion strategies.
People's attitudes toward the COVID-19 vaccine may be negative or positive. Positive COVID-19 vaccination attitudes, however, may increase immunization rates. In accordance with the conceptualization of the Vaccination Attitude Examination (VAX) Scale by Martin and Petrie, 6 the dimensions of COVID-19 vaccination attitudes are described as mistrust of vaccine benefits, worries about unforeseen future effects, concerns about commercial profiteering, and preference for natural immunity. Positivity in these dimensions may motivate an individual to receive the COVID-19 vaccine. It is generally assumed that a person's attitude toward an object affects their behavior. Thus, the COVID-19 vaccination attitude may predict vaccine uptake.
Negative COVID-19 vaccination attitudes in Nigeria are a public health concern; these negative feelings may have stymied COVID-19 vaccinations. Investigations conducted among various Nigerian demographic groups have revealed negative sentiments against COVID-19 vaccinations. [7][8] All of this indicates apprehension about taking COVID-19 vaccines in Nigeria.
On the contrary, the vaccination attitude in the United States was positive. Baack, et al., 9 noted that nearly half of the country's adults were fully vaccinated. It lends credence to the conclusion made in a systematic review that vaccination acceptance rates generally varied considerably from one country to the other. 10 However, individuals' attitudes toward COVID-19 immunization may be influenced by their impression of the probable hazards involved with the vaccine. Thus, COVID-19 vaccine risk perception is relevant for shaping vaccination attitudes. Several health behavior theories rely on risk perception, including the health belief model and protective motivation theory. 11,12 Darker and Phillips defines risk perception as the belief about possible harm or loss. 13 Risk perception is crucial to the success of public health intervention programs. Low perception of COVID-19 vaccine health risks may be linked to positive views on vaccination. The COVID-19 vaccination risk perceptions are the perceived dangers of receiving the vaccine. These risk perceptions may include the likelihood and consequences of an un known COVID-19 vaccine outcome. Several studies in Nigeria have shown high, moderate, or negative risk perceptions of COVID-19 vaccinations in various groups. 7,14-16 Thus, risk perception may be required for protective measures such as COVID-19 vaccinations. Oyekale argued that reducing people's perceptions of risk and vulnerability is necessary for Nigerians to accept CO-VID-19 vaccination. 17 This shows how risk perception affects vaccine attitudes in Nigeria. Low-risk perceptions of COVID-19 vaccinations may, therefore, increase Nigerian vaccine uptake.
Along with risk perceptions, vaccine acceptance may affect attitudes toward vaccination. Acceptance of the COVID-19 vaccine is a willingness to get immunizations. COVID-19 vaccination uptake is crucial for preventing virus spread. 18 People must accept the vaccination before getting it. However, studies have observed low to moderate acceptance rates of the COVID-19 vaccine across regions and demographics in Nigeria. 14,[19][20][21] Although low or non-acceptance of COVID-19 vaccines in Nigeria has been connected to conspiracy theories, misinformation, and potential vaccine side effects. 22 Oyekale stated that to lower the frequency of the virus in Nigeria, and the COVID-19 vaccine must be accepted across the country. 15 Thus, the acceptability of the COVID-19 vaccine is necessary for creating vaccination attitudes and should not be overlooked in Nigerian studies. COVID-19 vaccines have been studied extensively across regions in Nigeria. For example, in the Southern Nigeria, Adetayo, Sanni, and Aborisade found a correlation between high COVID-19 vaccine acceptance and positive sentiments toward the vaccine. 23 In the Northern Nigeria, skepticism about the vaccine's efficacy, distrust in authority, rumors, and conspiracy theories were re-sponsible for low COVID-19 vaccination acceptance. 24 This study aimed to fill a gap in the literature by comparing COVID-19 vaccine acceptability to various dimensions of vaccination attitudes in Nigeria. Examining Nigerian vaccination attitudes and potential influencing factors is crucial. The findings could help stakeholders, policymakers, and public health professionals understand how to increase COVID-19 vaccination rates in the country and the myths that need to be addressed to ensure willingness to take the vaccines. Consequently, the study aimed to determine the direct and interactive impacts of COVID-19 vaccine risk perception and acceptance on vaccination attitudes in Nigeria.

Method
This cross-sectional study involved 1,026 participants completed structured questionnaires from 2 to 30 April, 2021. Data were collected from four geopolitical zones in Nigeria (Southwest, South, Southeast, and North Central) using a convenient sampling method to sample locations and participants from classrooms, workshops, and offices. Overall, 1,500 questionnaires were distributed, and 1,196 were return ed, with a response rate of 79.7%. However, 1,026 properly completed questionnaires were used for the data analysis in the study. Copies were distributed to the consented participants at various locations, including schools, offices, and workshops. Participants gave verbal consent before completing the questionnaire and were assured of the anonymity and confidentiality of their responses since no form of identification was required. The questionnaires were distributed and 10 trained study assistants followed basic COVID-19 prevention protocols, including wearing face masks, keeping their distance, and using hand sanitizers. This study's inclusion criteria were 1) the participant was 18 or older, 2) a Nigerian resident, 3) could read and answer questionnaire items, and 4) had not received COVID-19 vaccines. These instructions were at the top of the questionnaire. The questionnaires consisted of questions regarding participants' age, sex, occupation, education, religion, marital status, ethnic group, and residence, along with vaccination attitude, COVID-19 vaccine acceptance, and risk perception scales.
The COVID-19 vaccine risk perception data was assessed using a questionnaire consisting of two questions devised based on the literature and explicitly designed for this study. The participants were asked, "Getting the CO-VID-19 vaccine can result in short-term health problems for me" and "Getting the COVID-19 vaccine can result in long-term health problems for me." Responses to these items were on a 7-point Likert scale, as follows: Not at All (1), Very Little (2), Little (3), Somewhat (4), Much (5), Very Much (6), and A Great Deal (7). A higher score reflected a greater COVID-19 vaccine risk perception. Participants with scores above the mean (M = 5.72) were regarded as high in COVID-19 vaccine risk perception, while those below the mean were regarded as low. The data on COVID-19 vaccine acceptance was assessed using a single item devised based on the literature and designed specifically for this study. Participants were asked on one statement, "Whenever I am approached to take the CO-VID-19 vaccine, I will accept it without hesitation." Responses were made using a 5-point Likert scale, where strongly disagree was scored (1), disagree (2), undecided (3), agree (4), and strongly agree (5). A higher score indicated a higher acceptance of the COVID-19 vaccine. Participants with scores above the mean (M = 2.62) were regarded as high in acceptance, while those below the mean were regarded as low in acceptance.
While, the COVID-19 vaccination attitude data was assessed using Martin and Petrie's 12-item VAX Scale and adapted to assess COVID-19 vaccination attitudes. 6 The VAX Scale examines general views regarding vaccines. However, "COVID-19" was added to each of the 12 sentences to represent this study's topic. Samples of the items include "I will feel safe after being vaccinated against CO-VID-19" and "Authorities promote COVID-19 vaccination for financial gain, not for people's health." The VAX Scale has four dimensions: 1) mistrust of vaccine benefits, 2) worries about unforeseen future effects, 3) concerns about commercial profiteering, and 4) preference for natural immunity. 6 Responses were assessed on a 5-point Likert scale from strongly disagree (scored 1) to strongly agree (scored 5). However, items 1, 2, and 3 of the VAX Scale were reversed-scored. A higher score indicated a more negative attitude toward the COVID-19 vaccination. Cronbach's alphas previously reported in studies ranged from 0.77 to 0.93. 6,23 The free version of statistical analysis software for social science was used to analyze the collected data. The demo graph ics of the individuals were described using descriptive statistics, such as mean, standard deviation, percentages, and frequency distribution. The inferential statistics of multivariate analysis of variance (MANOVA) were used to determine the independent and joint influence of COVID-19 vaccine risk perception and acceptance on the dimensions of COVID-19 vaccination attitude for the study objectives. This study accepted a p-value of <0.05 as a statistical significance level. This study obtained a Cronbach's alpha of 0.75 for the VAX Scale and a Cronbach's alpha of 0.73 for the COVID-19 risk perception scale in a sample of 1,026. Thus, the scale was reliable and valid.

Results
The participants were aged 18-69, with a mean age of 26.11 (SD = 9.32). The participants were from all regions in Nigeria and of diverse demographics. Approximately 83.5% of the participants were from the Yoruba region where the study originated. The study participants had a higher representation of those living in urban areas (74.5%). Most participants were students (67.4%), while most had tertiary education (92.7%). Most of the participants were Christians (89.6%), singles (73.9%), and Yoruba (83.5%). Most participants (74.5%) stayed in the country's urban areas.
Specifically, the average age of the 1,026 participants was 26.11 years (SD = 9.32), with 427 (41.6%) male and 599 (58.4%) female. Of the participants, 692 (67.4%) were students, 151 (14.7%) were civil servants, 74 (7.2%) were from the private sector, 74 (7.2%) were self-employed, 12 (1.2%) were retirees, and 23 (2.2%)  Table 2 Table 3, where participants with low acceptance of the COVID-19 vaccine (M = 11.32) reported significantly higher mi-   Similarly, COVID-19 vaccine risk perception and acceptance had an interactive effect on various aspects of vaccination attitudes among the participants. Table 5 shows that participants with a high-risk perception and low acceptance of the COVID-19 vaccination (M = 11.19) indicated significantly more worries about the vaccine's future effects than those with a high-risk perception and high acceptance (M = 10.75), low-risk perception and high acceptance (M = 9.93), and low-risk perception and low acceptance (M = 9.66). Participants with a high-risk perception and low acceptance of the COVID-19 vaccine (M = 10.09) expressed significantly more concern about commercial profiteering than those with a high-risk perception but high acceptance (M = 9.73), low-risk perception and high acceptance (M = 8.78), and low-risk perception and low acceptance (M = 9.20). Furthermore, participants with a high-risk perception and low acceptance of COVID-19 vaccination (M = 9.73) showed significantly higher levels of preference for natural immunity than those with a high-risk perception but high acceptance (M = 8.49), low-risk perception and high acceptance (M = 8.01), and low-risk perception and low acceptance (M = 7.71).

Discussion
Several studies might have shown that certain factors influenced COVID-19 vaccination attitudes in Nigeria. However, the dimensions of COVID-19 vaccination attitudes, risk perception, and acceptance in Nigeria are poorly understood. This study, therefore, examined the direct and interactive effects of COVID-19 vaccine risk perception and acceptance on vaccination attitude dimensions in Nigeria. The findings demonstrated that people's perceptions of the COVID-19 vaccine risk signifi- cantly influenced their attitudes regarding mistrust of vaccine benefits, worries about unforeseen future effects, concerns about commercial profiteering, and preference for natural immunity. Specifically, participants who perceived a high risk of COVID-19 vaccines displayed a high er level of mistrust in the benefits of the vaccine, worried more about unforeseen future effects if they took the vaccine, were more concerned about the possibility of giving it out to make money and had a higher preference for taking natural measures as forms of gaining immunity in the body. These findings were consistent with earlier study that highlighted the importance of COVID-19 vaccine risk perception in fostering favorable attitudes toward the vaccines and the willingness to receive the vaccines among various groups in the Nigerian population. 6,[14][15][16]26 These findings may be related to the unguided or inaccurate information that many Nigerians appear to have received concerning COVID-19 vaccines, as stated in a previous study. 27 It is possibly a significant contributing reason why people have high-risk judgments of immunizations and why they establish negative attitudes toward immunizations.

Lawal, et al. Dimensions of Vaccination Attitudes in Nigeria: A Study of the Impacts of COVID-19 Vaccine Risk Perception and Acceptance
This study found that COVID-19 acceptance significantly influenced Nigerian vaccination attitudes regarding mistrust of vaccine benefits, concerns about its commercial profiteering, and preference for natural immunity. In other words, vaccination attitudes regarding mistrust of vaccine benefits, its commercial purpose, and preference for natural immunity over vaccination were a function of low acceptance of the vaccines in Nigeria. These findings were consistent with those of other studies that demonstrated a link between acceptance of the CO-VID-19 vaccine and attitudes held by various groups within the Nigerian community. 15,22 These findings may be ascribed to a lack of awareness of the benefits of immunizing against COVID-19, negative information, or concerns linked to safety. To provide evidence in favor of this claim, Nomhwange, et al., observed that reticence toward the COVID-19 vaccination in Nigeria might be attributable to a perceived lack of safety and inadequate information read about the vaccines on social media channels. 28 Interactively, COVID-19 vaccine risk perception and acceptance influenced vaccination attitudes in the areas of worries about the vaccination's future effects, concerns about its commercial profiteering, and preference for natural immunity. In other words, participants perceived as high risk with a low acceptance of COVID-19 vaccines reported negative vaccination attitudes, believing that the vaccines have unforeseen future effects, were for money-making, and could not be effective as natural immunity. These findings were consistent with a study demonstrating that risk perception and acceptance are relevant factors that could have combined influenced the implementation of COVID-19 vaccinations in Nigeria. 16 It demonstrated that several factors might be interactively responsible for various forms of Nigerians' attitudes toward COVID-19 immunization and the process of implementing it. Nevertheless, it is essential to note that the authors utilized a cross-sectional methodology in which the participants were selected at a particular time. As a result, it is possible that the study would not be able to consider all the potential confounding variables that could influence the vaccination attitudes held by the Nigerian public regarding COVID-19.
This study had several limitations. This was a crosssectional study; thus, causal conclusions about the studied variables were limited. As a result, it could not be categorically inferred that risk perception and acceptance caused a change in participants' COVID-19 vaccination attitudes. The participants were limited to those who could read and write; thus, the findings should be evaluat ed in Nigeria's elite community context. The data collection tool was self-reported, meaning participants may have given socially acceptable answers.
Future studies should employ a longitudinal design to overcome the limitations noted above. This design would allow data collection over an extended period, perhaps documenting shifts in COVID-19 vaccination risk perception, acceptability, and attitudes. This should encompass a more varied sample, accounting for a wider variety of demographics that may influence vaccine attitudes. A qualitative study that includes in-depth interviews and focus group discussions may be conducted in future studies to better understand the factors influencing vaccination attitudes. Vaccination attitude is a complex phenomenon that cannot be comprehensively captured through a cross-sectional study alone because of the depth of infor mation it can provide.
In addition, since vaccination attitude is a complex phenomenon, it cannot be comprehensively captured through a cross-sectional study alone. It is possible to gain a more comprehensive understanding of vaccination acceptance by integrating the insights from quantitative study with those gained from qualitative study. This, in turn, can inform the creation of more effective public health interventions and policies. Despite these limitations, the study showed the importance of COVID-19 vaccine risk perception and acceptability in the attitudinal change of Nigerians toward the vaccine.
The COVID-19 pandemic has affected millions of people worldwide and sparked the spread of misinformation and myths about the virus. Not enough effort has been put into dispelling the misconceptions and misunderstandings surrounding this virus. Thus, practice, policies, and educating diverse groups nationwide about CO-VID-19 myths are advocated for public health interven-tion. This step will prevent people from using dangerous preventive measures. Policymakers, medical experts, and researchers working on COVID-19 pandemic challenges will also benefit from this study's findings, revealing that people's attitudes about disease transmission might be negatively influenced by high-risk and low acceptability.
The Nigerian Ministry of Health must be strengthened to counter any misinformation on vaccinations that may reduce acceptability. This will dispel any vaccine skepticism in the public's thinking. These efforts aim to increase awareness and understanding of the virus, its transmission, and the most effective methods for prevention and treatment. Specifically, education programs can provide accurate information, debunk myths, and address people's concerns. Policies, such as mask mandates and vaccination requirements, can encourage safe behavior and reduce the spread of the virus. By promoting the policies and practices mentioned above, Nigeria can work toward a more informed and healthier population regarding COVID-19 vaccinations. In addition, increasing vaccine use in Nigeria should include evidence-based risk communication, risk reduction, and trust-building efforts.

Conclusion
This study reveals that Nigerians have varying opinions about the COVID-19 vaccine and finds that risk perceptions and acceptance of COVID-19 vaccines shape their vaccine attitudes. It shows that high risk and low acceptance of COVID-19 vaccination have direct and interacting negative consequences in Nigeria. According to this study, a decrease in people's perception of the CO-VID-19 vaccine's risk and increased willingness to accept vaccinations will increase the number of Nigerians vaccinated against the virus.

Ethics Approval and Consent to Participate
Ethics and Research Committee of The Department of Psychology,