The COVID-19 pandemic caused by the SARS-CoV-2 virus has resulted in a significant loss of human lives worldwide and posed an unparalleled global health threat (1). The virus is contagious, spreads easily through contact and droplets. Prevention methods like distancing, hygiene, masks, and vaccines are crucial for control (2). As of June 2024, there have been over 884 million COVID-19 cases globally, with over 7 million deaths (3) and a total of 13,595,583,125 vaccine doses have been administered globally (4). While new infections slowed in Africa, the WHO African region reported over 8 million cases and 200,000 deaths (5). In Ethiopia, between January 2020 and November 2023, there were over 500,000 confirmed cases and over 7,500 deaths (6).

COVID-19 vaccines have proven highly effective in preventing symptomatic illness, with studies showing up to 95% effectiveness (7). Ethiopia began vaccinations on March 13, 2021, but as of May 27, 2023, only 59 people per 100 had received at least one dose, falling short of the global average of 74% (8). Vaccine hesitancy, the reluctance to get vaccinated despite availability, complex issue with many contributing factors. These factors range from demographics and political views to concerns about safety, lack of awareness, cultural beliefs, and socioeconomic considerations (9, 10).

COVID-19 vaccine hesitancy is a major hurdle, particularly in sub-Saharan Africa, where rates range from 14% in Ethiopia to a high of 65% in Tanzania. Several factors contribute to this hesitancy, including a history of unequal treatment in global health research, complex social and cultural beliefs, inadequate community engagement, and a general distrust in authorities (10–12).

Additionally, political influences, religious views, and a low perceived risk of contracting COVID-19 further hinder vaccine uptake in the region (13). Ethiopia faces a significant challenge in COVID-19 vaccination due to vaccine hesitancy, ranging from 14% to 69% across geographic divides, and this hesitancy stems from a combination of factors, including young age, female gender, rural residence, and limited access to information (14). To combat COVID-19 vaccine hesitancy and promote equitable access in Ethiopia, a multi-pronged approach is crucial. This includes developing culturally relevant educational materials, engaging trusted voices like religious leaders and community members, and addressing vaccine safety concerns through clear communication (15). Moreover, targeted outreach to populations with higher levels of hesitancy is crucial. Meaningful community engagement involving scientific experts plays a key role in building trust and countering misinformation (16). Additionally, addressing underlying factors contributing to hesitancy is key. Socio demographic factors like age, gender, and location, along with personal beliefs and access to accurate information, all play a role (10, 17). Vaccine hesitancy is a major hurdle to achieving equitable access to COVID-19 vaccines in Ethiopia (18–20, 15, 21). Thus, this scoping review aimed to investigates factors contributing to hesitancy and potential mitigation strategies by understanding these barriers, researchers can design interventions that promote vaccine acceptance, particularly among vulnerable populations. Increased focus on Africa-based research and development, improved stakeholder communication, and ensuring universal trust in vaccines are all crucial aspects of a multifaceted approach to achieving vaccine equity in low- and middle-income countries.

A systematic search identified 1,924 studies on COVID-19 vaccine hesitancy and mitigation strategies in Ethiopia. After removing duplicates (n = 804), 1,120 articles underwent title and abstract screening. We excluded 1,031 irrelevant studies and another 55 during full-text review (non-peer-reviewed, editorials, protocols, not on hesitancy or Ethiopia, or unavailable full text). The final analysis included 34 relevant studies. See the PRISMA flow diagram (Figure. 1) for details.

This review provides a mapping of important studies and results on COVID-19 vaccine hesitancy and predictors in Ethiopia. It also explores strategies to encourage more people to get vaccinated fairly and on-time. The quality assessment of the included studies revealed that 27 studies were rated as high quality, 7 as moderate quality, and none as poor quality based on the JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies. The majority of the research papers included were cross-sectional and examined a variety of population groups. The analysis is based on data from over 18,151 participants across all regions of Ethiopia. The magnitude of vaccine hesitancy ranged from 19.1% (12) in Addis Ababa to 69.7% to Oromia (4). Majority (58.8%) of the included studies reported vaccine hesitancy rates lower than 50%. The highest levels of vaccination hesitancy shown in several of the included studies contrasted with research conducted in other locations, such as Europe and the Americas (17, 69), China (87) Kuwait (77), and the United Kingdom (88). This may be a direct result of disparities in vaccine access, and awareness of vaccine information between countries and region in the country. Studies showed that, people in middle- or high-income groups are more likely to get vaccinated (89), and inadequate financial considerations as barriers to vaccination acceptance (90). Even while many African governments provide free vaccinations to their citizens, the reluctance of resource- constrained communities may indicate a misunderstanding about who bears the cost. Similarly, the financial burden on such communities is likely to extend beyond the vaccine itself, including transportation to vaccination centers that may not be nearby, childcare fees, and other hurdles.

This review found that women in Ethiopia were more hesitant to get vaccinated than men, leading to lower vaccination rates among women. This finding aligns with a broader review of vaccine hesitancy in Africa, which reported that men were generally more likely to be (69) accepting of the COVID-19 vaccine (75). This finding also aligns with a Canadian study on COVID-19 vaccines, where women were more hesitant than men (91). Another study found low COVID-19 vaccine acceptance among women with primary education and unemployed women (81). This aligns with a global study on immunization attitudes, which reported that unemployed women were more likely to have concerns about vaccine safety and effectiveness (85). One possible explanation for the lower vaccine acceptance among some women might be persistent misconception of COVID-19 vaccines can cause fertility problems or birth defect (92).

This misconception has caused many young women of childbearing age to hesitate about vaccination and not to consider being vaccinated. In fact, a systematic review of a sample of 703,004 pregnant women globally revealed a lower rate of vaccination among them than among the rest of the population (93).

Similarly, the results of this review showed that low education level was a factor associated with vaccine acceptance and marginally associated with high vaccine hesitancy. This finding is consistent with other studies conducted elsewhere (77, 94, 58, 95). Education plays a significant role; in a Canadian study, individuals with less than a high school education showed lower adjusted odds of wanting to vaccinate themselves against COVID-19 compared to their counterparts (96). Furthermore, Black Americans with lower educational attainment are more hesitant to accept a COVID-19 vaccine (97). A study conducted in Latin America and the Caribbean disclosed similar findings but added that lower education influences vaccine hesitancy due to the general distrust in vaccines and the robustness of conspiracy beliefs across individuals with lower education levels (98). People with lower education levels and places with higher poverty rates (99, 100), such as sub-Saharan Africa (SSA), Latin America and the Caribbean rural regions, are more likely to be skeptical of vaccines and hold conspiracy theories. In these places, health promotion initiatives lack proper coverage, increasing the danger of misinformation and hence raising resistance to immunization and community mitigation strategies. It is vital to reinforce and tailor communication techniques to these demographics.

Tailored communication improves relevance; trust, and behavioral response, ultimately enhancing public health outcomes, for example messages targeting women should consider gender roles, health literacy, and caregiving responsibilities. Community-based communication, peer networks, and maternal health platforms can be effective channels (101). Content should be accessible, empathetic, and culturally sensitive. For rural communities, leveraging trusted local leaders (e.g., religious or community figures), radio broadcasts, and mobile health units is recommended due to limited internet access and health infrastructure (102).

Visual aids and local language translations also enhance message comprehension.

Healthcare workers respond well to evidence-based, concise, and actionable information delivered via professional platforms (e.g., WhatsApp groups, clinical bulletins, or in-service training). Peer-to-peer knowledge sharing and continuous medical education can also reinforce trust and uptake (102). Additionally, this review indicated that individuals living in rural areas were more reluctant to be vaccinated. Vaccination intentions would be lower in rural areas because of the low burden of the pandemic. Similarly, these findings might be explained by the idea of a certain innate immunity, by low exposure to information, or by their poor living standards compared to other parts of the nation. This finding differs from a study in Senegal, where vaccine hesitancy and refusal were linked to living in large cities (103). Significant differences in the likelihood of immunization in more rural areas may indicate other considerations that must be addressed when planning for COVID-19 vaccination implementation.

According to recent research, indigenous dwellers and those who live in rural areas are less likely to take preventive measures like wearing masks, but are more comfortable engaging in activities that require more social interaction. Given our findings, these behaviors could have severe effects for less densely populated, conservative societies s that may be resistant to present and future preventive interventions (104).

The herd immunity threshold for the virus that causes COVID-19, SARs- CoV-2, is predicted to be 55% to 82% (103), and achieving it will necessitate coordinated efforts across the country and across all administrative areas. In preparation for their involvement in COVID-19 vaccine administration, pharmacists and other providers must consider the importance of personal and community beliefs in influencing medical recommendations and subsequent actions taken to prevent the spread of infectious diseases across all regions of the country.

Lack of sufficient information, misinformation and poor attitude regarding vaccine safety were some of the other factors associated with vaccine hesitancy. This was consistent with studies conducted in different regions of Africa (15, 93, 58, 105), Europe and America (106, 107). When it comes to the fear of adverse effects, the influence of disinformation, particularly on social media platforms, was noted in practically every research setting. Social media has a significant capacity to mediate the spread of disinformation in anti-vaccine efforts (108). Some studies (40, 72) identified social media and, to a lesser extent, traditional media as the primary sources of erroneous information dissemination. Interestingly, despite being medical students, 91% of the respondents in Kanyike and colleagues' study (108), reported getting knowledge about COVID-19 via social media rather than health specialists. Misinformation on social media exacerbated their vaccine hesitation, despite the fact that they perceived an elevated risk as a result of their engagement in COVID-19 health interventions. As these findings demonstrate, social media has enormous power in effectively disseminating information and influencing health-seeking behaviors. These influences must be central to national programs addressing vaccination reluctance. It would entail modifying the content of campaigns to appeal to individuals more strongly than the misinformation that they so readily accept. Educational strategies emphasizing vaccine safety and efficacy have been identified in the literature as an important need to overcome misinformation and enhance compliance rates (109). As Zewude and Zikarge (42) established, vaccine hesitancy can be driven by public reaction to specific vaccines. The underlying principles in these interventions should be customized to reflect the various concerns about certain vaccines. These teaching campaigns could have a greater impact if they were targeted at those individuals identified as being most anxious about vaccination. This highlights the importance of collaboration among public health organizations, healthcare professionals, and media platforms to ensure accurate information, and to deliver programs that enhance attitudes and health literacy empowering the target population to make informed decisions.

Low perceived risk of getting COVID-19, distrust in science and vaccine safety, and doubts about the vaccine's effectiveness were also among the most important factors identified by this review. People who believed vaccination wouldn't protect them or might even harm their health were more likely to be hesitant or refuse the vaccine. A number of studies indicate that worries about the safety and effectiveness of vaccines seem to play a significant role in vaccine intention (110–112). Studies emphasized the need for targeting mistrust of vaccine manufacturers and the belief that COVID-19 vaccinations will be used as targets to damage Africa (72, 73, 111, 113). Respondents were skeptical since the pharmaceutical companies were foreign and scientists from their home nations were not engaged in producing the vaccines. Further longitudinal investigations will be required to supplement the findings of this research, given the advanced stages of vaccination campaigns in many countries. In order to establish equitable widespread vaccination campaigns related to COVID-19. Therefore, good communication regarding safety and efficacy and more transparency about vaccine development and distribution, including financial aspects, should be the made a cornerstone of all other measures efforts to ensure equitable and widespread vaccination campaigns especially related to COVID-19. In addition cultural beliefs, particularly the reliance on traditional medicine, significantly influence vaccine hesitancy in Ethiopia. Traditional healers are often regarded as trusted health authorities, and many communities favor herbal and spiritual remedies over biomedical interventions, which can foster skepticism toward vaccines especially when introduced without culturally sensitive engagement (114). Mistrust in the formal health system and the perceived efficacy of traditional practices further contribute to low vaccine uptake (115). To address these challenges, policy makers' public health campaigns should collaborate with traditional healers and religious leaders to foster community trust, deliver culturally appropriate messaging, and create inclusive dialogue platforms. Utilizing local languages and storytelling can also enhance message comprehension in rural and low-literacy settings (114). Respecting cultural frameworks while promoting evidence-based practices is essential to improving vaccine acceptance and immunization coverage.

The strengths of this study include being the first to consolidate studies and key factors of COVID-19 vaccine hesitancy and its mitigation strategies in Ethiopia, aiding targeted intervention programs. The analysis provides insight into the most significant contributors to vaccine hesitancy in the country. This indicates a predominance of high-quality research in the evaluation of COVID-19 vaccine hesitancy in Ethiopia. Additionally, the strength of the study on COVID-19 vaccine acceptance in Ethiopia is the inclusion of many articles with large sample sizes, providing a comprehensive overview. However, a limitation is the lack of studies from some regions of the country such as Tigray, Afar and Somali. Additionally, there was potential selection bias due to the inclusion of only published articles but this is but this does not affect the generalizability of the study due to the high quality of the article and the adequate sample size.

This scoping review highlights key factors driving COVID-19 vaccine hesitancy in Ethiopia, including younger age, rural residence, low educational attainment, female gender, and individual concerns related to vaccine safety, side effects, and perceived risk. Religious and cultural beliefs further influence vaccination decisions, underscoring the need for context-specific strategies. To effectively address these challenges, policymakers should engage trusted community figures such as religious leaders and elders and implement culturally appropriate communication efforts. Recommended actions include launching targeted media campaigns via local radio and social media to dispel misinformation, training healthcare workers in risk communication and community engagement, and collaborating with grassroots organizations to deliver tailored messages to high-risk groups, particularly women, youth, and rural populations. These integrated efforts can enhance vaccine confidence and promote equitable access to immunization across the country.