COVID-19 vaccines will become available in Democratic Republic of Congo soon. Understanding communities’ responses to the forthcoming COVID-19 vaccines is important. We was conducted an analytical cross-sectional study online in 26 provinces of the Democratic Republic of Congo during the period from January to March 2021. A total of 11971 responses were included; mean age of respondents was 35.1±10.4 years; 79.4% were males; 90.5% had university school education and 55.4% has a high socioeconomic level. A frequency of poor perception of covid-19 vaccination is 75.6%. In a multivariable regression model, age between 46-55 years, 36-45 years and 26-35 years (aOR=1.54, CI: 1.27-1.87, aOR=1.70 CI: 1.35-2.13 and aOR =3.40, CI: 2.78–4.17, respectively), None profession and liberal profession (aOR=1.75, CI: 1.49-3.34 and aOR=2.52, CI: 1.89-3.34, respectively), moderate and low socioeconomic level (aOR=3.06, CI: 2.64-3.56 and aOR=5.89, CI: 4.11-8.38, respectively), Low and very low risk of infection with COVID-19 (aOR=1.67, CI: 1.07-1.97 and OR=2.66, CI: 1.36-3.04, respectively; Moderate, low and very low risk of getting sick if you are infected (aOR=1.49, CI: 2.08-2.98, aOR=2.97 CI: 2.45-3.59 and aOR=3.89, CI: 3.11-4.82, respectively) were associated with a poor perception COVID-19 vaccination. In conclusion, the frequency of misperception in the Congolese population is high. It is associated with the poor perception of the disease and the socio-demographic characteristics of individuals.

Keywords: COVID-19, perception, covid-19 vaccination, determinants

Since the start of the pandemic, several surveys have been conducted in the population of world and in the Democratic Republic of Congo (DRC) to know the intention of people to receive a vaccine or not against the 2019 coronavirus disease (COVID-19).^1,2 The analysis of its surveys, although they target a fairly homogeneous group of the population (older adults aged eighteen years), nevertheless provides useful information regarding the attitudes of the Congolese population towards vaccines against COVID-19.^3,4 The acceptability of this vaccination in certain groups of the population who might be targeted first.⁵ Overall, we note that a majority of Congolese express the intention to receive a vaccine against COVID-19.⁶ We observed, however, a downward trend in favorable intentions in a more diminished environment. The fear of side effects and the poor perceived effectiveness of vaccines are the main reasons for not intending to be vaccinated against COVID-19 as reported in several studies carried out around the world.^7–15 A number of participants spoke of the futilities of vaccination in the face of the pandemic.³ To induce motivations for resorting to vaccination, the personal protection conferred by a vaccine against COVID-19 is cited in certain studies.^12–15 In the same vein, studies showing the perception of COVID-19 vaccination in the DRC have not yet been carried out. We considered that Covid-19 could be perceived as a social fact unrelated to the medical causes and that the effectiveness of the vaccine was often questioned because it does not necessarily meet the expectations of population in terms of health. This study, therefore wants to show how the Congolese perceive vaccination against COVID-19 on the one hand and on the other hand to research the socio-demographic factors associated with the poor perception of vaccination against covid-19.

Study setting and design

An analytical cross-sectional study was conducted online in 26 provinces of the DRC during the period from January to March 2021. The study population consisted of the inhabitants of the DRC. Anyone who was at least 18 years old and freely agreed in writing or orally to participate in the study was included. Congolese living abroad or people with a known mental disorder were not included in these surveys. Respondents who did not answer two-thirds of the questionnaire questions during the survey were excluded from the study. Systematic probability sampling-The sample size is calculated from Fisher's formula: $n\ge \frac{Z^2*\left(p\right)*\left(1-p\right)}{d^2}$  where n=Sample size, z=1.96 (confidence coefficient), p=previous prevalence, d=0.05 (margin of error or range of imprecision reflecting the degree of absolute precision desired). Because of the probable non-responding subjects, 10% of the number calculated at the height should be added. We have been estimated that the frequency of poor perception about COVID-19 vaccination is 50%, as mentioned in the literature, in the absence of a prevalence of such a documented in the country. The sample size thus calculated was $n\ge \frac{{1.96}^{2 }*0.50*0.50}{{\left(0.05\right)}^2}$ =384. By including the 10% of non-respondents, we obtained 422 people to question. Assuming that 422 people must answer the questionnaire in each province, the sample was multiplied by 26, which gives a size of 10,972 people.

The data was collected from a questionnaire designed using a Gmail link which should be sent to a correspondent by WhatsApp whose number we had. Whoever receives it should send it to other people he knows and so on. The questionnaire was put online and could be taught by anyone in the DRC, the links and the QR-code allowing access to the survey were distributed to correspondents by WhatsApp of the people who made part of the participants therefore relied mainly on the "snowball" effect after validation of consent, access to the questionnaire did not require identification and the responses were completely anonymous. The principal investigator was responsible for the data collected via a confidentiality email. The variables of interest were made up of the socio-demographic and economic characteristics of the respondents, including: sex, age, marital status, religion, level of education, family composition, socioeconomic level of households, and monthly income were considered. Then the variables specific to vaccination (knowledge and perception of vaccines, past experiences and behaviors on the vaccine, knowledge and assessment of risks related to COVID-19and acceptance of the COVID-19 vaccination). The poor perception was defined in any individual who considered that the COVID-19 vaccination was as an excuse to exterminate the African population, as a badge to bring the population to join the lodge. It is also defined as does not actually work to prevent COVID-19 and to be able to be infected by COVID-19 by getting vaccinated.

Data processing and analyses

The data collected was then transferred to SPSS for Windows version 21 for processing and analysis. Categorical variables were presented as absolute and relative frequency, quantitative variables were summarized by measures of central tendency and dispersion. The mean and its standard deviation were reported for variables with a normal distribution. Comparison of proportions was performed using Pearson's Chi-square or Fischer's exact test. Student's t test made it possible to compare the means. The factors determining the poor perception of the covid-19 vaccination were examined in a bivariate model and were included in the logistic regression models when they were associated with the dependent variable in multivariate analysis. Variables not contributing significantly (P≥0.05) were gradually excluded to obtain the final models. The calculated adjusted ORs were used to estimate the degree of association between the dependent variables and the independent variables. The p-value <0.05 was the threshold of statistical significance.

Ethical considerations

The study protocol was approved by the National Health Ethics Committee of the DRC under Approval No.239/CNES/BN/PMMF/2021. Data were collected online anonymously and were only available to study investigators using passwords.

Perception on the vaccine

This figure indicates a frequency of 75.6% of the misperception on vaccination against covid-19 in the Congolese population (Figure 1).

Figure 1 Frequency of poor and good perception of covid-19.

Different types of perception on the COVID-19-Vaccination

In the Congolese population, 66.5% fear that the COVID-19 vaccine does not really work to prevent COVID-19, 49.9% fear that after vaccination, they will get infected with COVID-19, 49.7% fear that the COVID-19 vaccine is being used as an excuse to exterminate the African population and 43.2% perceive the covid-19 vaccine to be used as a badge to bring the population to join the lodge (Figure 2). The mean age of the respondents was 35.1±10.4 years, it is significantly lower among those with poor perception of the vaccine (p<0.001). Men were more numerous sex ratio of 3M/ 1F, the majority were of higher or university level (90.7%), civil servant in 39.3%, low socioeconomic level in 25.8% and high in 55.4%, Catholic religion (41.9%), married in 41.9% and living in Kinshasa in 65.2%. the comparison of the socio-demographic characteristics of respondents with good perception and bad perception were statistically different (p <0.05) (Table 1). This table indicates that knowledge about routine vaccines, about the risks of transmission of covid-19 were significantly higher among respondents with a good perception than those with a poor perception (p <0.05) (Table 2).

Figure 2 Different types of perception of the vaccine against covid-19 by the Congolese population.

In a multivariable regression model, age between 46-55 years, 36-45 years and 26-35 years (aOR=1.54, CI: 1.27-1.87, aOR =1.70 CI: 1.35-2.13 and aOR=3.40, CI: 2.78–4.17, respectively), None profession and liberal profession (aOR=1.75, CI: 1.49-3.34 and aOR=2.52, CI: 1.89-3.34, respectively), moderate and low socioeconomic level (aOR=3.06, CI: 2.64-3.56 and aOR =5.89, CI: 4.11-8.38, respectively), Low and very low risk of infection with covid-19 (OR=1.67, CI: 1.07-1.97 and OR=2.66, CI: 1.36-3.04, respectively; Moderate, low and very low risk of getting sick if you are infected (aOR=1.49, CI: 2.08-2.98, aOR=2.97 CI: 2.45-3.59 and aOR =3.89, CI: 3.11-4.82, respectively) were associated with a poor perception covid-19 vaccination (Table 3).

Inscribed in Pastorium logic, vaccination against covid-19 underlines a separation between modern and scientific knowledge; and local and lay knowledge. From a WHO and public health perspective, vaccination against covid-19 is a safe and cost-effective way to effectively combat covid-19 and the incidence of mortality associated with it. Aiming at the eradication of covid-19, the objectives and principles of vaccination are based on a global vision in the population. For public health, vaccination is an essential component of human rights and a responsibility of the population, making mass campaigns legitimate. People find it difficult to adhere to these principles because they go beyond the idea of ​​contributing to the health of the population. The principles defended during vaccinations against covid-19 may even be in opposition to the expectations of the population. The logical conflicts lie in the perception of the covid-19 vaccine¹⁶ conveyed by the altruistic aspect of the vaccination acts. In this study, the population feared vaccination against covid-19 as a mean of reducing the African population (50%). Furthermore the rumors around the COVID-19 vaccination notably used as a badge to bring the population to join the lodge (43%), as a means of introducing covid-19 into the population (50%) and as a means that will not go not act to reduce contamination (67%). This conception of introducing or contaminating the population is due to the circulation of the virus. According to the Congolese population, COVID-19 is a disease imported from outside. By vaccinating the population, they are still infecting COVID-19. Instead of protecting themselves, the population will fall sicker.

Like modern medicine, the population's knowledge of covid-19 constitutes an important collection of advice and measures to be taken, based on the experiences of healthcare professionals. This study has shown that vaccination against covid-19 does not meet the expectations of the population in terms of prevention because it relies above all on other objectives such as eradication, which constitutes a long-term action, which the population cannot therefore perceive directly. Vaccination must above all meet a need for "optimal healing"¹⁷ requiring the interaction of local knowledge and the characteristics of the population to be vaccinated. It is fitting to underline in this study the importance of awareness and information in the eyes of the population to be vaccinated, and to reassure them about the effects of vaccines and dispel rumors. However, the messages disseminated to the population through social networks and stories do not seem to contribute to the knowledge of the population about the covid-19 vaccine. It is therefore important to improve the information systems concerning vaccination against covid-19. This task falls primarily to community workers who are in-charge of mass immunizations should provide insight about benefits of vaccination.^18,19

The search for health care of the population depends essentially on the perception of its importance.²⁰ Several factors explain the poor perception of the vaccine against covid-19. With regard to this misperception, the related factors were mainly the young age of the population, the lack of profession and the liberal profession, the socioeconomic level of the population and the misperception of covid-19 itself. All of these factors are certainly related to the lack of adequate information about the covid-19 vaccine. Several studies have shown that belonging to a high socioeconomic level is associated with a good perception of the Covid-19 vaccine.^21–29 Older people have a good conception of the fact that they are more exposed to the disease and therefore they are more aware of perceiving vaccination as a lifesaving age.²² Surprisingly the unemployed and self-employed people are likely to perceive the wrong way for receiving the covid-19 vaccine. This is a problem because since the majority of them have a low socioeconomic level, think that the disease does not exist, they are not exposed. They are therefore the vector of disease transmission. A study carried out in Canada has shown that the poor dissemination and lack of information of the population about this vaccine are the factors linked to this poor perception.²⁸

Certain limitations must be recognized in this study. First, our respondents are not representative of the general population in each province where the survey was conducted. Only people with an Internet connection were able to participate in the study. As the level of education of our workers was higher than that of the general population, we speculate that the reluctance of the general population to immunize may even be greater. Self-reports can lead to recall bias and influence our results. The cross-sectional nature of this investigation precludes us from drawing causal inferences.

The regression model revealed that there was an association between socio-demographic factors, perception of covid-19 disease, and the poor perception of the COVID-19 vaccination. It clearly emerges from the important results for a poor perception on the existence and the risk of contamination of the COVID-19 as well as to eradicate this bad perception. The health authorities should concentrate on the aspects related to the disease. This could be especially important in encouraging COVID-19 vaccination uptake in the later stages of the epidemic, as people are not likely to be well informed about the disease, and have bad conceptions. The elimination these misunderstandings and concerns will likely increase the intention to be vaccinated for the next campaign the DRC would organize.

All authors contributed to data analysis, drafting or revising the article, have agreed on the journal to which the article will be submitted, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

We thank all who participated in the study.

The authors declare no conflict of interest.

1. Boseley S, Oltermann. P. Covid-19 vaccine candidate is 90% effective, says manufacturer. The Guardian. 2020.
2. Baum MA, Ognyanova K, Chwe H. The state of the nation: A 50-state survey report 14: Misinformation and vaccine acceptance. The COVID-19 Consortium for Understanding the Public’s Policy Preferences across States 2020.
3. Ratzan V, Palayew SC, Gostin A, et al. A global survey of potential acceptance of a COVID-19 vaccine. Nature Medicine. 2020;27;1–4.
4.  Roozenbeek J, Schneider CR, Dryhurst S, et al.  Susceptibility to misinformation about COVID-19 around the world. Royal Society Open Science. 2020;7(10):201199.
5.  The Royal Society & the British Academy. COVID-19 vaccine deployment: Behaviour, ethics, misinformation and policy strategies. 2020.
6. Partnership for Evidence-Based COVID-19 Response (PERC). Responding to COVID-19 in Africa: Using Data to Find a Balance (Part II). 2020.
7. Tyson A, Johnson C, Funk C. US Public Now Divided Over Whether To Get COVID-19 Vaccine. Pew Research Center Science & Society. 2020.
8.  Loomba S, Figueiredo A de, Piatek SJ, et al. Measuring the Impact of Exposure to COVID-19 Vaccine Misinformation on Vaccine Intent in the UK and US. Med Rxiv. 2020.
9. Johns Hopkins Center for Communication Programs. KAP COVID Global View. Johns Hopkins Center for Communication Programs 2020.
10.  McGinty, M, Gyenes N. A dangerous misinfodemic spreads alongside the SARS-COV-2 pandemic. Harvard Kennedy School (HKS) Misinformation Review. 2020;1(3).
11. Meedan. Misinfodemic Report: COVID-19 in Emerging Economies. Meedan. 2020.
12. van der Linden S, Roozenbeek J, Compton J. Inoculating Against Fake News About COVID-19. Frontiers in Psychology 2020;11.
13.  Bhopal S, Nielsen M. Vaccine hesitancy in low- and middle-income countries: Potential implications for the COVID-19 response. Archives of Disease in Childhood. 2020;106(2):1–3.
14. Dubé E, Laberge C, Guay M, et al. Vaccine hesitancy: an overview. Human Vaccines & Immunotherapeutics. 2013;9(8):1763–1773.
15.  Dubé E, Vivion M, MacDonald NE. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: Influence, impact and implications. Expert Review of Vaccines. 2015;14(1):99–117.
16. MAUSS M. Essai sur le don: Forme et raison de l’échange dans les sociétés archaïques. In: M. MAUSS, editor. Sociologie et Anthropologie, Paris, Presses universitaires de France. 1973. p. 149–279.
17. CREUSAT L. Gestion traditionnelle de la maladie et politiques de santé en Afrique du Sud. Clermont-Ferrand, Presses universitaires Blaise Pascal. 2000.
18. Dube E, Vivion M, Valderrama A, et al. Attitudes et croyances des sagesfemmes québécoises sur la vaccination. Santé Publique. 2013;1(25):35–43.
19. Massé R., Désy M. Lay people’s interpretation of ethical values related to mass vaccination; the case of A(H1N1) vaccination campaign in the province of Quebec (French Canada). Health Expectations. 2014;17(6):876–887.
20. Neumann-Böhme S, Varghese NE, Sabat I, et al. Once we have it, will we use it? A European survey on willingness to be vaccinated against COVID-19. Eur J Health Econ. 2020;21(7):977–982.
21. Edmund Mugabi Bukenya. Acceptance and Risk Perception of COVID-19 Vaccine in Uganda: A Cross Sectional Study in Western Uganda. Vaccine. 2021.
22. Ditekemena JD, Nkamba DM,  Mutwadi A, et al.   COVID-19 Vaccine Acceptance in the Democratic Republic of Congo: A Cross Sectional Survey. Vaccine. 2021;9(2):153.
23. European Centre for Disease Prevention and Control. Vaccine Hesitancy among Healthcare Workers and Their Patients in Europe: A Qualitative Study (Technical Report). ECDC. 2020. p. 1–33.
24. Programme Elargie de Vaccination, République Démocratique du Congo. Impact du Covid-19 Sur la Vaccination en RD Congo; Rapport du dialogue Multipartite, PEV RDC: Kinshasa, Congo, 2020.
25.  Democratic Republic of Congo. Mics snapshot. Minister of Heath DRC. Kinshasa. 2019.
26. Wilson SL, Wiysonge C. Social media and vaccine hesitancy. BMJ Glob Health. 2020;5:e004206.
27. Democratic Republic of Congo. National Task Force. COVID-19 et Essais de Vaccin en RDC: “Jamais les Congolais ne seront utilisés comme cobayes”. Pour le Professeur Muyembe. 2020.
28. Verger P, Scronias D, Dauby N, et al. Attitudes of healthcare workers towards COVID-19 vaccination: A survey in France and French-speaking parts of Belgium and Canada, 2020. Eurosurveillance. 2021;26:2002047.
29. Spassiani I, Gubian L, Palù G, et al. Vaccination Criteria Based on Factors Influencing COVID-19 Diffusion an Mortality. Vaccines. 2020;8(4):766.