1 Covid-19 Vaccine Hesitancy and Its Predictors among Diabetic Patients on

2 Follow-Up at Public Hospitals in Nekemte Town, Western Ethiopia

3 Aberash Olani Kuta 1, 2, and Nagasa Dida 1, 3*

4 Affiliation
1
5 Department of Public Health, Faculty of Health Science and Technology, Rift Valley
6 University, Ambo Campus, Ambo, Ethiopia
2
7 Student Services Unit, Wollega University, Nekemte Ethiopia
3
8 Department of Public Health, Medicine and Health Science College, Ambo University,
9 Ambo, Ethiopia

10 E-mail Addresses:
11  Nagasa Dida: [email protected]; B.O.Box: 19; Mobile: +251913174508
12  Aberash Olani Kuta: [email protected]
13
14 * Corresponding author

15 Abstract
16 Background: Understanding and addressing the concerns of vaccine-hesitant individuals,
17 including those with chronic diseases, is key to increasing vaccine acceptance and uptake.
18 However, in Ethiopia, there is limited evidence on the COVID-19 vaccine hesitancy and
19 predictor variables among diabetic patients. Hence, the study aimed to assess Covid-19
20 Vaccine Hesitancy and Predictor variables among Diabetic Patients on Follow-Up at Public
21 Hospitals in Nekemte Town, Western Ethiopia.
22 Method: Facility based cross sectional study was conducted among 422 diabetic patients
23 attending public hospitals at Nekemte Town, Western Ethiopia between January, to February,
24 2023. Study participants were recruited by systematic random sampling. The data were collected
25 interviewee administered pre-tested structured survey questioner. The collected data were
26 entered and cleaned using Epi-Data software 4.6 version. The cleaned data were analyzed using
27 SPSS. 25.0 Statical software. Descriptive statistics like frequency, mean and percentage, and
28 binary logistic regression was applied to identify independent predictors of Covid-19 vaccine
29 hesitancy and association between variables were declared at p-value of 0.05.

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30 Result: The overall magnitude of COVID-19 vaccine hesitancy was 15.2% (95% CI: 11.6-18.7).
31 The top three listed reasons for the COVID-19 vaccine hesitancy were: negative information
32 about the vaccine (32.90%), lack of enough information (21.80%), and vaccine safety concern
33 (19.40%). The hesitancy of the COVID-19 vaccination uptake among diabetes patients was
34 independently influenced by age between 40-49 (Adjusted Odd Ratio [AOR] = 4.52(1.04-
35 19.66)), having vaccine awareness (AOR = 0.029(0.001-0.86)), having a great deal of trust on
36 vaccine development (AOR = 0.028(0.002-0.52)), and a fear amount trust (AOR=
37 0.05(0.003-0.79)) on the vaccine preparation, vaccinated for COVID-19 (AOR = 0.13(0.04-
38 0.51)), perceived exposure to COVID-19 infection after having the vaccine as strongly
39 agree/agree (AOR = 0.03(0.01-0.17))and neither agree nor disagree (AOR = 0.07(0.02-0.30)).
40 Conclusion: COVID-19 vaccine hesitancy among diabetic patients was relatively low. The
41 identified independent predictors were age, vaccine awareness, COVID-19 vaccination history,
42 awareness on vaccine preparation and exposure status to COVID-19 infection. The relevant
43 agency should focus on efforts to translating these high levels of vaccine acceptance into actual
44 uptake, through targeting identifying predictor variables and vaccine availability for a high-risk
45 diabetes patient.
46
47 Key words: COVID-19, Vaccine hesitancy, Diabetic, Nekemte, Ethiopia
48

49 Introduction
50 COVID 19 contributed significant public and economic problem worldwide. The existing control
51 measures and vaccine did not able to stop disease transmission, hospitalization and death tone
52 associated with this disease. As of 2 July 2023, the pandemic had caused more than 767 million
53 cases and 6.9 million deaths globally, making it one of the deadliest infectious diseases in the
54 history As a result, Ethiopia has launched COVID-19 vaccination campaign on 16 November
55 2021, targeting people aged 12 years and above [1].
56 Vaccines are one of the greatest accomplishments in the history of public health. They have
57 indisputably contributed to a decline in sickness and death from numerous infectious diseases.
58 However, the vaccines hesitancy is determined to be a major threat to the impact of vaccination
59 in the prevention of infection, hospitalization and mortality from the COVID-19 [2, 3]. The
60 existing studies documented the COVID-19 vaccine uptake is suboptimal among people with

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61 chronic medical conditions including DM who are at increased risk of complications and
62 mortality associated with SARS-CoV-2 infection. Some recent studies have also reported the
63 magnitude of vaccine hesitancy varying from 3.0% to 76.4%, indicating variabilities across
64 different countries and between different time points [2–4]. Moreover, myths and conspiracy
65 theories on vaccinations have been spreading and can easily be accepted and affect vaccine
66 acceptance. This may cause people to be reluctant towards vaccination, which has been
67 demonstrated by a study in Nigeria by a low vaccine acceptability rate [5]. Furthermore, the
68 WHO listed vaccine hesitancy as one of the ten global threats to public health [6].
69 A vaccine hesitancy is caused by complex, context specific factors that vary across time, place,
70 and different vaccines, and is influenced by issues such as complacency, efficacy, safety,
71 convenience, price, confidence, and sociodemographic contexts [5, 7]. It is also related to
72 misinformation and conspiracy theories which are often spread online, including through social
73 [5, 7].
74 In African countries the tendency toward acceptance of COVID-19 vaccine reaches from 81.6%
75 in South Africa to 65.2% in Nigeria [4, 8]). In Ethiopia, the vaccine hesitancy range between
76 19.1%- 60.3%% were documented in the studies conducted in different part of the country. Such
77 variation in willingness to accept a COVID-19 vaccine may result in difference in vaccine
78 coverage and delay global control of the pandemic [9-11].
79 Therefore, it is imperative to understand vaccine hesitancy and its predictors among high-risk
80 population like DM patient to design strategies to overcome the vaccine hesitancy. First,
81 unravelling the specific fears and doubts of the DM patient with a medical condition that
82 increases the risk of infection and complications from COVID-19 can be helpful. This
83 understanding can then assist government and other concerned officials in designing policies and
84 strategies to adequately address the problem; Diabetic Mellitus diseased year – the period for
85 which the patients diagnosed for diabetic mellitus; overall health – When patients are asked
86 about their "perceived condition" of their "overall health status," they are expressing their
87 personal view of their general health and well-being.

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 88 Methods

89 Study design, and setting

90 A facility-based cross-sectional study was conducted between January to February, 2023, at
91 public hospitals providing diabetic follow-up services in Nekemte Town, Western Ethiopia.
92 Nekemte town is located in the Western part of the Oromia region 331 km away from country’s
93 capital, Addis Ababa, and astronomical location at 9º 04’ North Latitude and 36º 30’ East
94 Longitude. The data from Nekemte Town Health Office showed that the town has four public
95 health institutions, namely Nekemte Referral Hospital, Wollega University Referral Hospital,
96 Bake Jama Health Center, and Cheleleki Health Center. Also, the town has more than fifteen
97 private and NGO health facilities. From these health facilities in Nekemte Town, the two public
98 hospitals, Nekemte Referral Hospital, and Wollega University Referral Hospital provides follow-
99 up services for diabetic patients residing in Nekemte Town and its surrounding communities.
100 The study was conducted in the two public hospitals providing follow-up services for diabetic
101 patients [12].

102 Source and study Population

103 All diabetic patients on follow-up attending public hospitals in Nekemte Town were considered
104 as source populations. All randomly selected diabetic patients (Type I and II) who were
105 attending diabetic clinic of public hospitals in Nekemte Town during the study period was the
106 study population. Eligible participants were known type 1 or 2 diabetic mellitus patients who
107 visited the diabetic centers for follow-up and age older than 18 years were used for inclusion
108 criteria and women with gestational diabetic mellitus was excluded.

109 Sample size determination and sampling technique

110 A single population proportion formula was used to determine the sample size. The sample size
111 was calculated by taking proportion of 50 %. Marginal error between sample size and population
112 parameter of 5% (d=0.05), and 95% confidence level (Z=1.96), and 10% non-response rate was
113 considered. So, the final sample size was 422.

114 All known DM patients visited the study hospitals for follow-up were taken into consideration.
115 Systematic random sampling was used to select the study participants. The sampling interval was
116 calculated by dividing the total number of DM patients on follow-up as counted from the

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117 registries by the calculated sample size. Evidence from the study of hospitals shows there are
118 3200 DM patients on the follow-up in Nekemte Referral Hospital and 208 at Wollega University.
119 The sample interval (k) of the study is 8 (3408/422). The first candidate for the study was
120 selected by simple random sampling from the first 8 (k) patients who arrived at the diabetic
121 clinic on the first day of data collection and who met the eligibility criteria. The study subject
122 selection continues in every eight intervals until the desired sample size is attained. The sample
123 size was distributed between the study facilities based on proportion size of the study population.

124 Data collection tool and techniques

125 The data was collected using a pretested structure questionnaire with closed-ended questions.
126 The questionnaire is adapted from different relevant previous studies in the area [2, 4, 10] that
127 adapted and modified to suit the current study. The questionnaire was prepared in English and
128 translated to Afan Oromo by professional translators. The Afan Oromo questionnaires was then
129 back translated to ensure that the original and translated questionnaires was check for similar in
130 terms of content, clarity, and meaning. The back-translation to English was compared with the
131 original questionnaire to ensure consistence of the questionnaires. The contents of the
132 questionnaire were validated by pretest in the field. Data were collected using interviewer
133 administered pretested questionnaire by nurse working in diabetic clinic of the health facility

134 Data quality control and management

135 To ensure the quality of data the following measures were undertaken. Validity of the
136 questionnaire was maintained by pretested questionnaires 5% (21) of study population at Bako
137 Hospital, Western Ethiopia. During the pre-test, the acceptability and applicability of the
138 procedures and tools was evaluated. Training was given to data collectors on the objective of the
139 study, data collection process and relevance of the study prior to data collection. The completed
140 questionnaire was cross checked daily for inconsistencies. Throughout the course of the data
141 collection, the data collectors were supervised at each site by the principal investigator. The data
142 was checked for completeness on site and before data entry.
143 Operational definition: In this study, COVID-19 Vaccine hesitancy – A condition in which the
144 study subject who refuse or fail to complete the vaccine despite availability of vaccination
145 services; Diabetic Patients on Follow-Up – is known Diabetic Mellitus patients of any type who
146 has a regular follow-up at diabetic clinic with the health care provider.

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147 Data management and Analysis
148 The collected data was entered and cleaned using Epi-Data software 4.6 version. The cleaned
149 data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20.0
150 statically software. Descriptive statistics, including frequencies and proportions were used to
151 summarize the study variables; quantitative variables are presented as mean and standard
152 deviation. The crude odds ratio (COR) was obtained using a binary logistic regression model,
153 with COVID-19 vaccine hesitancy as the dependent variable and baseline characteristics as
154 independent variables. Variables with a P-values of <0.05 in the bi-variable logistic regression
155 analysis were entered in the multivariable logistic regression analysis to control the possible
156 effect of confounders. The adjusted odds ratio (AOR) with a 95 % confidence interval was
157 estimated to assess the strength of association, and a p value of <0.05 was used to declare
158 independent variable to be the statistical significance determinate of COVID-19 hesitancy in the
159 multivariable analysis.

160 Ethical considerations

161 The ethical issue was approved by the Research and Ethical Review Committee of Rift Valley
162 University with reference number RVU/AC/978/3/14. All administrative bodies communicated
163 and obtained permission in a hierarchical manner. Then after verbal consent was sought by
164 explaining the goals and methods of the study and their right to withdraw from participation at
165 any time prior to the interview. One-page consent letter outlining the study's overall objective
166 and confidentiality as no identifiers were used was attached to the cover page of each
167 questionnaire. The study had no procedure that would have an impact on the study subjects and
168 the data would only be used for only research purpose.

169 Result
170 Socio-demography characteristics of study participants
171 In this study, 422 study participants took part in the study with a response rate of 100%. The
172 mean age of the participants was 42.22 (SD+12.55) years. The age of the participants ranged
173 from 18-75 years old. Among the study participants 158(37.4%), 103(24.4%) and 98(23.2%)
174 were age between 30-39, 40-49 and >=50 years old, respectively. Majority of the participants
175 were male 281(66.6%), Oromo ethic group 360(85.3%), protestant religion 271(64.2%), and
176 married 361(85.5%). Most (91.9%) of the study participants attended formal education. Three
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177 hundred twenty-three (76.5%) of the participants were urban dwellers, and about a quarter of
178 respondents reported that their occupation was merchant 102 (24.2%) or government employee
179 116 (27.5%).
180 More than three third 169(40%) of the participants had earn an average monthly income of
181 1000-5000 Ethiopian Birr. More than half (51.9%) of participants had between 3 and 6 family
182 size. The mean family size of a household was 4.52 (SD±2.254). Of the total, three hundred
183 nighty-six (93.8%) study participants took part from Nekemte Referral Hospital, and the rest
184 were from Wollega University Referral Hospital study institution (Table 1).
185 Table 1: Socio-demography characteristics of the diabetic patients attending public hospitals in
186 Nekemte Town, East Wollega Zone, Western Ethiopia, 2023.
Variables Vaccine hesitancy Total,
Yes, N (%) No, N (%) N (%)
Family size <3 25(18.1) 113(81.9) 138(32.7)
3-6 34(15.5) 185(84.5) 219(51.9)
>6 5(7.7) 60(92.3) 65(15.4)
Sex Male 42(14.9) 239(85.1) 281(66.6)
Female 22(15.6) 119(84.4) 141(33.4)
Age 18-29 15(23.8) 48(76.2) 63(14.9)
30-39 21(13.3) 137(86.7) 158(37.4)
40-49 23(22.3) 80(77.7) 103(24.4)
>=50 5(5.1) 93(94.9) 98(23.2)
Ethnicity Oromo 53(14.7) 307(85.3) 360(85.3)
Amhara 6(12.8) 41(87.2) 47(11.1)
Other* 5(33.3) 10(66.7) 15(3.6)
Marital status Single 10(22.7) 34(77.3) 44(10.4)
Married 50(13.9) 311(86.1) 361(85.5)
Window 1(9.1) 10(90.9) 11(2.6)
Divorced 3(50.0) 3(50.0) 6(1.4)
Education No formal education 7(20.6) 27(79.4) 34(8.1)
Elementary 11(12.2) 79(87.8) 90(21.3)
Secondary/high school 19(14.2) 115(85.8) 134(31.8)
College diploma 7(13.5) 45(86.5) 52(12.3)
University level degree 20(17.9) 92(82.1) 112(26.5)

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 Religion Protestant 50(18.5) 221(81.5) 271(64.2)
Orthodox 10(8.1) 114(91.9) 124(29.4)
Muslim 4(14.8) 23(85.2) 27(6.4)
Occupation Unemployed 3(8.6) 32(91.4) 35(8.3)
Farmer 9(11.5) 69(88.5) 78(18.5)
Student 6(25.0) 18(75.0) 24(5.7)
Marchant 14(13.7) 88(86.3) 102(24.2)
Miner 0(0.0) 2(100.0) 2(0.5
Governmental employee 12(10.3) 104(89.7) 116(27.5)
Religious leader 12(75.0) 4(25.0) 16(3.8)
Housewife 3(30.0) 7(70.0) 10(2.4)
Daily laborer 5(12.8) 34(87.2) 39(9.2)
Income per <1000 22(20.2) 87(79.8) 109(25.8)
monthly 1000-5000 28(16.6) 141(83.4) 169(40.0)
(Ethiopia birr) >5000 14(9.7) 130(90.3) 144(34.1)
Address Urban 49(15.2) 274(84.8) 323(76.5)
Rural 15(15.2) 84(84.8) 99(23.5)
Study NRH 62(15.7) 334(84.3) 396(93.8)
institution WURH 2(7.7) 24(92.3) 26(6.2)
187 Key: N = Frequency, % = Percentage, * =Gurage, Tigre, NRH=Nekemte Referral Hospital,
188 WURH=Wollega University Referral Hospital

189 Study participants’ Clinical Characteristics

190 In the study, type-1 DM is the dominant 298 (70.6%) diabetic type. Around half (47.4%) of the
191 study participants were diagnosed to be DM patients in the year between 5-10 years from the
192 time of survey while 109(25%) within last 5 years, and the rest were over 10 years. One hundred
193 three (24.4%) study participants had controlled glucose level (<126 gmd/dl) but around two third
194 (75.6%) of the study participant had higher glucose level despite of they were undergoing the
195 DM treatment follow. Most of the study participants describe their overall health condition as
196 either average 141(33.4%) or good 214(50.7%) (Table 2).
197 Table 2: Clinical characteristics of diabetic patients attending public hospitals in Nekemte
198 Town, East Wollega Zone, Western Ethiopia, 2023.
Variables Vaccine hesitancy Total,

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 Yes No N (%)
DM diseased year <5 19(17.4) 90(82.6) 109(25.8)
5-10 28(14.0) 172(86.0) 200(47.4)
>10 17(15.0) 96(85.0) 113(26.8)
DM type Type-1 49(16.4) 249(83.6) 298(70.6)
Type-2 15(12.1) 109(87.9) 124(29.4)
Other chronic diseases yes 19(17.9) 87(82.1) 106(25.1)
No 45(14.2) 271(85.8) 316(74.9)
Fasting glucose level (mg/dl) <126 10(9.3) 93(90.3) 103(24.4)
126-200 36(17.2) 173(82.8) 209(49.5)
>200 18(16.4) 92(83.6) 110(26.1)
Overall health Very poor 0(0.0) 16(100.0) 16(3.8)
Poor 6(28.6) 15(71.4 21(5.0)

Average 28(19.9) 113(80.1) 141(33.4)

Good 27(12.6) 187(87.4) 214(50.7)
Very good 3(10.0) 27(90.0) 30(7.1)

199 Key: N = Frequency, % = Percentage, DM = Diabetes Mellitus, mg = milligrams, dl = deciliter

200 COVI-19 Vaccine awareness, source of information and practice

201 In this study, majority 392(92.9%) of study participants had awareness about the COVID-19
202 vaccine. Two-thirds of the study participants reported their primary source of information was
203 Media (Television, Radio, Newspaper), and followed by healthcare provider 109(25.8%). More
204 than half (55.2%) study participants had great deal awareness on COVID-19 vaccine preparation
205 (Table 3).
206 Moreover, the study found, 250(59.2%) of study participants didn’t receive any kind of vaccine
207 in their lifetime. While 1347(82.2%) of study participants report, they support any vaccine.
208 Vaccine hesitancy was higher 60(32.1%) among COVID-19 non- vaccinated study participants.
209 The study also found majority 329 (78.0%) of the study participants were believes COVID-19
210 vaccine either definitely or probably reduce and protect complication from COVID-19 infection
211 (Table 3).
212 Information related to COVID-9 expose and testing revealed, twenty-five (5.9%) study
213 participants had their family had COVID-19 disease, and 17 (4.0%) family member died of
214 COVID-19. Less the one-third 117 (27.7%) of study participants had tested for COVID-19
215 infection. Out of tested study participants seventeen (4%) were found to be positive. Around

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216 two-thirds (64.1%) of respondents also believe they were exposed to COVID-29 infection (Table
217 3).
218 Table 3: Awareness, source of information and practice on COVID-19 vaccine hesitancy among
219 diabetic patients attending public hospitals in Nekemte Town, East Wollega Zone, Western
220 Ethiopia, 2023.
Variable Vaccine hesitancy Total,
Yes No N (%)
COVID-19 Vaccine awareness
Yes 54(13.8) 338(86.2) 392(92.9)
No 10(33.3) 20(66.7) 30(7.1)
Source of information
Media (TV, Radio, Newspaper) 51(17.4) 242(82.6) 293(69.4)
Healthcare provider 8(8.7) 101(92.7) 109(25.8)
Friends & family member 3(30.0) 7(70.0) 10(2.4)
Religious leaders 1(20.0) 4(80.0) 5(1.2)
Social media 1(20.0) 4(80.0) 5(1.2)
Family members have COVID-19
No 59(14.9) 338(85.1) 397(94.1)
Yes 5(20.0) 20(80.0) 25(5.9)
Tested for COVID-19
No 51(16.7) 254(83.3) 305(72.3)
Yes 13(11.1) 104(88.9) 117(27.7)
Tested positive for COVID-19
No 64(15.8) 341(84.2) 405(96.0)
Yes 0(0.0) 17(100.0) 17(4.0)
Close contact with COVID-19 patient
No 59(15.0) 335(85.0) 394(93.4)
Yes 5(17.9) 23(82.1) 28(6.6)
Family died of COVID-19
No 61(15.1) 344(84.9) 405(96.0)
Yes 3(17.6) 14(82.4) 17(4.0)
Received any vaccine in lifetime
No 35(14.0) 215(86.0) 250(59.2)

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 Yes 26(16.1) 135(83.9) 161(38.2)
Unknown 3(27.3) 8(72.7) 11(2.6)
No support any vaccine
Yes 26(40.6) 38(59.4) 64(15.2)
No 34(9.8) 313(90.2) 347(82.2)
Unknown 4(36.4) 7(63.6) 11(2.6)
Vaccinated for COVID-19
Yes 4(1.7) 231(98.3) 235(55.7)
No 60(32.1) 127(67.9) 187(44.3)
Exposed to COVID-19 infection
Strong agree 1(0.6) 171(99.4) 172(40.8)
Agree 4(7.1) 52(92.9) 56(13.3)
Neither agree nor disagree 36(21.7) 130(78.3) 166(39.3)
Disagree 14(82.4) 3(17.6) 17(4.0)
Strongly disagree 9(81.8) 2(18.2) 11(2.6)
Awareness on vaccine preparation
A great deal 6(2.6) 227(97.4) 233(55.2)
A fear amount 7(8.6) 74(91.4) 81(19.2)
No too much 46(45.1) 56(54.9) 102(24.2)
None at all 5(83.3) 1(16.7) 6(1.4)
COVID-19 vaccine reduces and protect from complication
Definitely 2(0.9) 217(99.1) 219(51.9)
Probably 7(10.9) 103(28.8) 110(26.1)
Unsure 22(40.0) 33(60.0) 55(13)
Probably not 23(35.9) 3(0.8) 26(6.2)
Definitely not 10(83.3) 2(16.7) 12(2.8)
221 Key: N = Frequency, % = Percentage
222

223 COVID-19 vaccine hesitancy rate and its reasons

224 The overall magnitude of COVID-19 vaccine hesitancy rate was 15.2% (95% CI: 11.6-18.7)
225 (Figure 2). The vaccine hesitancy rate was 12.10% and 16.40% among type -2 and type 1
226 diabetic patients, respectively. The top listed reasons for the COVID-19 vaccine hesitancy were
227 negative information about the vaccine (32.90%), lack of enough information (21.80%), concern

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228 about vaccine side effects (19.40%), didn’t believe the vaccine work and/or effective (15.4%),
229 didn’t believe COVID-19 is health problem (14.70%), and not at risk of contracting COVID-19
230 (12.80%) (Figure 3).

231 Predictors of Vaccine Hesitancy

232 The study revealed that respondents in the age of 40-49 years old had 4.52 more likely to hesitate
233 COVID-19 vaccination compared to those respondents aged greater than 50 years old (AOR =
234 4.52(1.04-19.66)). The study participants who had COVID-19 vaccine awareness were 0.029
235 times less likely to hesitate COVID-19 vaccine (AOR= 0.029(0.001-0.857)) compared to their
236 counterpart. The odd of having previous COVID-19 vaccine were 0.134 less compared to their
237 counterpart to vaccine hesitancy (AOR =0.134(0.035-0.507)). Also, the study participants who
238 had a great deal (AOR= 0.028(0.002-0.523)) and a fear (AOR= 0.046(0.003-0.791)) trust on
239 vaccine preparation or development were 0.03 and 0.05 times less likely to hesitate to the
240 vaccine comparing to those respondents who had no trust at all. Moreover, respondents who
241 strongly agree and/or agree (AOR = 0.03(0.006-0.17)) and neither agree nor disagree (AOR =
242 0.07(0.02-0.30)) to the perceived COVID-19 infection exposure were 0.03 and 0.07 times less
243 likely to hesitate the vaccine comparing to the stronger disagree and or disagree (Table 4).
244 Table 4: Binary logistic regression analysis result for predictor variables with COVID-19
245 vaccine hesitancy among diabetic patients attending public hospital in Nekemte Town, East
246 Wollega Zone, Western Ethiopia, 2023.
Variables Hesitate, COR (95%CI) P- AOR (95%CI) P-
N (%) value value
Age 18-29 15(23.8) 5.812(1.99- 0.001* 2.002(0.36- 0.43
16.95) 11.17)
30-39 21(13.3) 2.851(1.04-7.83) 0.042* 1.842(0.443- 0.401
7.663)
40-49 23(22.3) 5.35(1.94-14.72) 0.001* 4.516(1.04- 0.045*
19.66)
>=50 5(5.1) 1 1
Occupation Unemployed 3(8.6) 0.64(0 .14-2.89) 0.559 0.19(0.02-1.81) 0.148
Farmer 9(11.5) 0.89(0.28-2.852) 0.840 0.25(0.04-1.75) 0.162
Student 6(25.0) 2.267(0.61-8.46) 0.223 0.87(0.09-8.04) 0.902
Marchant/ 14(13.5) 1.06(0.35-3.16) 0.888 0.37(0.06-2.49) 0.310
miner
Governmental 12(10.3) 0.79(0.26-2.387) 0.669 0.83(0.13-5.25) 0.843

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 employee
Religious 12(75.0) 20.40(0.69- <0.001 5.93(0.50-70.22) 0.158
leader 88.75) *
Housewife 3(30.0) 2.91(0.56-15.12) 0.203 2.22(0.17-28.34) 0.540
Daily laborer 5(12.8) 1 1
Income per <1000 22(20.2) 2.35(1.14-4.84) 0.021* 1.373(0.33-5.73) 0.663
monthly (Ethiopia 1000-5000 28(16.6) 1.84(0.930-3.66) 0.080 1.65(0.48-5.67) 0.427
birr) >5000 14(9.7) 1 1
Source of Media (TV, 51(17.4) 0.58(0.18-1.89 0.366 0.71(0.10-5.27) 0.74
information Radio,
Newspaper)
Healthcare 8(8.7) 0.22(0.06-0.842) 0.027* 0.81(0.10-6.83) 0.85
provider
Other ** 4(26.7) 1 1
Having COVID- Yes 54(13.8) 0.32(0.14-0.72) 0.006* 0.029(0.00-0.86) 0.040*
19 Vaccine No 10(33.3) 1
awareness
No support any Yes 26(40.6) 1.197(0.32-4.51) 0.790 1.33(0.24-7.30) 0.747
vaccine No 34(9.8) 0.19(0.05-0.68) 0.011* 0.364(0.07-1.87) 0.226
Unsure 4(36.4%) 1
Vaccinated for Yes 4(1.7) 0.04(0.01-0.10) <0.001 0.13(0.035-0.51) 0.003*
COVID-19 *
No 60(32.1) 1

Exposed to Strong 5 (2.2) 0.01(0.00-0.02) <0.001 0.031(0.01-0.17) <0.001

COVID-19 agree/agree * *
infection Neither agree 36 (21.7) 0.06(0.02-0.17) <0.001 0.071(0.02-0.30) <0.001
nor disagree * *
Disagree/ 23 (82.1)
Strongly
disagree
Trust on vaccine A great deal 6(2.6) 0.01(0.00-0.05) <0.001 0.03(0.00-0.52) 0.017*
preparation *
process A fear amount 7(8.6) 0.019(0.00-0.19) 0.001* 0.05(0.00-0.79) 0.034*
No too much 46(45.1) 0.164(0.02-1.46) 0.105 0.14(0.01-1.99) 0.147
None at all 5(83.3) 1
247 N = Frequency, % = Percentage, * = Statistically significant, COR = Crude odd ratio, 95% CI = 95% confident
248 interval, 1=reference, and AOR = Adjusted odd ratio, **=Friends & family member, religious leaders, social
249 media (FB, Whatup, Twitter etc)

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250 Discussion
251 Vaccination against COVID-19 can significantly reduce the risk of COVID-19 diseases,
252 complications, and hospitalization in patients with chronic diseases including diabetes. The
253 existing evidence showed that to stop the spread of the COVID-19 pandemic and to develop herd
254 immunity, 60–70% of society should be vaccinated [13]. Therefore, the highest acceptance of the
255 COVID-19 vaccine has a greater role to control the worldwide COVID-19 pandemic. However,
256 its effectiveness is challenged by vaccine hesitancy.
257 In this study the overall magnitude of COVID-19 vaccine hesitancy rate was 15.2% (95% CI:
258 11.6-18.7). This is in line with the study conducted in Italian (14.2%) [14], Woldia, Ethiopia
259 (17.4%) [15], Uganda (15.5%) [16], Malawi (17.3%) [16] but lower than study conducted at
260 Sub-Saharan Africa (26.0%) [17], China (56.4%) [18] and global (24.9%) [19], On the other
261 hand, the magnitude was lower than from findings among the general population in Ethiopia
262 (42.2%) [20]. The discrepancy in these data may be due to sociodemographic characteristics.
263 These difference in vaccine hesitancy rate is also partly explained with COVID-19 vaccine
264 hesitancy is not stable and changing with time. This is well presented in the cohort study done
265 by Aaron et al., 2021 [21, 22] that where COVID-19 vaccine hesitancy was decreased between
266 late 2020 and early 2021, with nearly one-third (32%) of persons who were initially hesitant
267 being vaccinated at follow-up and more than one-third (37%) transitioning from vaccine hesitant
268 into vaccine willing.
269 The reasons for COVID-19 vaccine acceptance and hesitancy remain complex. As new COVID-
270 19 variants emerge, adding further complexity [23], new vaccines come to the market, it will be
271 important to maintain a delicate balance in communicating what is known and acknowledging
272 the uncertainties that remain. In this study, a top reason for a study participant to hesitate to get
273 COVID-19 vaccine was negative information about the vaccine and followed with lack of
274 enough information and fear of vaccine side effect. In support of these, the study found the
275 participants who had vaccine awareness had 0.03 less odd to hesitate. This data confirms
276 evidence already documented on other studies done among diabetic patients and other high-risk
277 populations [24-26]. The evidence further notes the need to avoid spreading falsehoods or using
278 language that could be misinterpreted and could thereby potentially add to vaccine hesitancy as
279 well as increases awareness to increase vaccine uptake.

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280 Surprisingly, the study revealed having a great deal and/or a fear amount of awareness on the
281 vaccine preparation would lower participants vaccine hesitancy. This is in support of the existing
282 literature [25, 26]. This attribute to the facts that knowledge on the vaccine preparation and
283 studying finding in the clinical trial help high risk individuals like diabetic patients to understand
284 the value of the vaccine, possible side effect and to avoid misinformation.
285 The association between the COVID-19 vaccine hesitancy and socio-demographic variables of
286 the study participants supports the scale’s construct validity. The study results indicated that age
287 between 40-49 was associated with higher likely to vaccine hesitate to compare to older, a
288 finding which aligns with findings from previous studies that found the intention to get
289 vaccinated increases with age [27, 28].
290 In present study found previous COVID-19 vaccination is one of the main independent
291 predictors for COVID-19 vaccine hesitancy where study participants who have previous
292 vaccination history had hesitancy to COVID-19 vaccination with the odd of 0.13. This is in line
293 with existing literature [29, 30]. Perceived risk could also be the predictors of COVID-19
294 vaccine acceptance in the existing literature [28] which is consistent with the results of this
295 study, the higher perceived risk of COVID-19 infection was associated with lower odd of
296 vaccine. This is attributed to participants perceived risk level is a determinate to accept or
297 hesitate a COVID-19 vaccine as one of method to avoid the risk of their own health or the health
298 of their loved ones. The possible explanation for vaccine hesitancy towards COVID-19
299 vaccination could be individuals with a history of vaccinations may have experienced side
300 effects from past vaccinations, leading them to be hesitant about receiving the COVID-19
301 vaccine. Past experiences with vaccine side effects can influence an individual's attitudes and
302 perceptions towards vaccination in general, and these attitudes can persist even when the benefits
303 of vaccination outweigh the risks.
304 Strength and limitation of the study
305 A strength of this study is that it is the first to investigate predictor variables with COVID-19
306 vaccine hesitancy in diabetic patients on follow-up in Ethiopia. Hence, the study gives further
307 insights on the magnitude of COVID-19 vaccines hesitancy and its predictor variables among
308 high-risk diabetic patients in the country. However, our study also had some limitations. First,
309 this study design to measured COVD-19 vaccines hesitancy at a certain point in time that is
310 potentially prone to change with the vaccine availability and level of the problem in the country.

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311 Lastly, as the study was a cross-sectional survey, the causal relationship between predictors and
312 outcome variables could not be determined.

313 Conclusion and recommendation

314 The study confirms that COVID-19 vaccine hesitancy among diabetic patient was relatively low.
315 The hesitancy of the COVID-19 vaccination uptake among diabetes patients was independently
316 influenced by age, vaccine awareness, COVID-19 vaccination history, awareness on vaccine
317 preparation and exposure status to COVID-19 infection. Hence, stakeholders have to focus on
318 efforts to translating these high levels of vaccine acceptance into actual uptake, through ensuing
319 vaccine availability and accessibility vaccine to for a high-risk diabetes patient. Policy makers
320 should design policies to integrate COVID-19 health education in the ongoing diabetic
321 management in the health care system to avoid the ongoing misinformation and conspiracies on
322 the diseases. Behavioral change communication should be promoted about the value of vaccine,
323 the safety, and level of protection of the vaccine for individual with diabetic. In a future study,
324 we recommended larger sample size that employ mixed research methods both qualitative and
325 quantitative approaches to fully capture the COVID-19 vaccines hesitancy in Ethiopia.
326 Acknowledgments
327 The authors would like to acknowledge the Nekemte Referral Hospital and Wollega University
328 Referral Hospital administration for their unreserved support during data collection. The author
329 also grateful for all data collectors, and respondents without whom this research would not have
330 been realized.

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