The coronavirus SARS-CoV-2 (COVID-19), has drastically impacted countries globally. Its spread and severity have been influenced by factors such as resource allocation, availability of tests, strength of existing health systems, effective risk communication, adherence to recommended preventive measures, and vaccine acceptance or hesitancy (1–4). Low-and middle-income countries (LMICs) have faced economic challenges, increased pressure on health systems and difficulties in securing and distributing COVID-19 vaccines (5). As vaccination remains a critical strategy for reducing severe illness and death, and for controlling the pandemic, many studies have examined vaccine access and uptake across various populations (1, 6–10). However, it is essential to consider the country-specific context when analyzing the factors contributing to vaccine acceptance and hesitancy. In Mozambique, there is limited research on the predictors of the COVID-19 vaccination uptake and the factors influencing individuals’ willingness to be vaccinated.

Mozambique’s first case of COVID-19 was confirmed on March 22, 2020, and the President of Mozambique declared a state of emergency in response to the pandemic on April 20, 2020 (11). The situation escalated to a state of public calamity on September 7, 2020 (11). The Government of Mozambique announced its vaccination strategy on March 5, 2021, which included a target of vaccinating 16.8 million Mozambicans (11). As of June 2023, about 34.9 million doses of COVID-19 vaccines had been administered in Mozambique, with about 63% of the population being fully vaccinated. About 233,417 confirmed COVID-19 cases and 2,243 deaths due to COVID-19 had been reported in Mozambique (12).

Vaccine acceptance is commonly discussed throughout the literature relating to vaccine uptake (1, 2, 6, 8, 13–16). Acceptance rates can vary based on trust in vaccines and the institutions administering them, and the spread of misinformation (5). To reduce the public health burden of COVID-19, acceptance must be translated into uptake- a complex process influenced by factors such as access, health system capacity, and infrastructure (5, 13).

Studies have documented a wide range of COVID-19 vaccine acceptance across and within sub-Saharan African countries, with low rate of 7% in a 2021 study in southeast Nigeria and high rate of 98% in a 2021 phone survey study in Ethiopia (1, 15, 17–19). A 2021 narrative review further found vaccine acceptance rates ranging from 50% in Zimbabwe to 92% in Ethiopia (18). Commonly reasons given for COVID-19 vaccine acceptance included personal and family protection against COVID-19 infection (20).

Vaccine hesitancy has emerged as a major global challenge in efforts to control the COVID-19 pandemic (1, 10, 18). The World Health Organization (WHO) defines vaccine hesitancy as a “delay in acceptance or refusal of vaccination despite availability of vaccination services” (21). Individuals who are vaccine-hesitant may delay vaccination, accept some vaccines but not others, or refuse vaccines altogether (1, 2). Research consistently shows that women are more likely to be vaccine-hesitant than men (1, 7, 22–25). Common reasons for COVID-19 vaccine hesitancy included concerns about the vaccine’s novelty and safety, fear of potential side effects, and general vaccine avoidance (1, 2, 10). In sub-Saharan Africa, mistrust of authorities involved in COVID-19 vaccine development and distribution – such as vaccine manufacturers and pharmaceutical companies- has also contributed to vaccine hesitancy (1, 16, 24).

In Mozambique, a study conducted in March 2021, before the availability of COVID-19 vaccines, reported that 65% of the general population and 87% of healthcare workers surveyed expressed willingness to take the COVID-19 vaccine if it was available (8). Another study, conducted in Mozambique between September 2020 and March 2021, reported fluctuations in vaccine acceptance over time, with acceptance significantly associated with levels of institutional trust (26). Since then, the COVID-19 situation in Mozambique has evolved with vaccines becoming more widely available, which could affect perceived vaccine acceptability and factors related to uptake. Understanding these factors is critical to inform strategies to improve vaccine coverage and address gender-specific barriers. This study aims to determine the COVID-19 vaccine uptake, hesitancy, and associated factors among women of reproductive age in Mozambique.

The RaMMPS study, conducted between March–July 2022, demonstrated that mobile phone surveys are a feasible approach to quickly collect data to assess the impact of COVID-19 pandemic on vaccine uptake among women of reproductive age in Mozambique. COVID-19 vaccination coverage was high (77.2%) among studied women ages 15–49. This estimate was slightly lower than findings from a national study, which reported a vaccination coverage of 93% among adults over 18 years as of May 2022 (41). Additionally, among vaccinated women in the RaMMPS study, 64.5% reported receiving two doses. The COVID-19 vaccination rate of the general population, which was defined as the “total number of people who received all doses prescribed by the initial vaccination protocol, divided by the total population of Mozambique,” was estimated at 46% as of May 2022 (41). These findings suggest that overall the vaccination coverage in Mozambique is relatively high compared to many other sub-Saharan African countries (12).

Among unvaccinated women in the RaMMPS study, 88% reported being likely to take the COVID-19 vaccine if it was offered to them. This finding was higher compared to a 2021 study in Mozambique that revealed that 71% of participants indicated they would take the vaccine, with significant sociodemographic differences across subpopulations (8). This reflects a high level of vaccine acceptance, especially given that women are generally more likely to be vaccine-hesitant than men (1, 7, 20, 22, 24). Concerns about vaccine safety and effectiveness were among the primary reasons for reluctance among women unwilling to be vaccinated. Similar concerns have been reported in other studies in sub-Saharan Africa, including in Uganda, Zimbabwe, Tanzania, Ethiopia, Nigeria, Uganda, Malawi and Burkina Faso (1, 15, 16, 20, 24).

We found that the odds of COVID-19 vaccination increased with age, with women aged 40–49 being significantly more likely to be vaccinated compared to those under 20. Our findings were consistent with previous studies conducted in Mozambique (8, 23, 26). Similar age-related patterns in COVID-19 vaccine acceptance have been also observed in studies from Botswana, Zambia, Zimbabwe, Tanzania and the Democratic Republic of Congo (7, 24, 42–44). However, a multi-country study showed that younger age was associated with vaccine acceptance (20). When analyzing these associations, it is important to consider that the COVID-19 vaccination strategy in Mozambique has prioritized older age groups early in the rollout (11), which may have influenced both access and uptake among different age cohorts.

We found that women who had attained secondary education or higher were more likely to be vaccinated than women without formal education. However, there was no significant difference in COVID-19 vaccination coverage between women with only primary education and those with no formal education. The relationship between education level and vaccine acceptance has varied across studies. In some countries, including Botswana, Burkina Faso, Ethiopia, Malawi, Nigeria, Sierra Leone, and Uganda, with lower levels of formal education were associated with higher vaccine acceptance (15, 42). Conversely, other countries including Senegal, Zimbabwe and Kenya have found that higher levels of education was associated with increased acceptance of COVID-19 vaccine (16, 19, 45, 46).

Women’s health behavioral factors related to the use of health facilities during pregnancy increased the likelihood of being vaccinated against COVID-19. Specially, women who delivered at a health facility were significantly more likely to be vaccinated against COVID-19 than those who delivered at home. However, ANC attendance was not significantly associated with COVID-19 vaccine acceptance, likely due to the near-universal ANC coverage observed in our study. This may also be related to Mozambique’s COVID-19 vaccination policy, which excluded pregnant women and individuals under 18 years of age from initial eligibility (26). While some studies have examined COVID-19 vaccine acceptance among pregnant women, including one in Ethiopia that assessed factors influencing uptake among ANC clinic attendees, few have explored the association between birth history factors and COVID-19 vaccine acceptance (47).

Geographic variation in vaccine acceptance was also observed. Women residing in provinces such as Manica and Gaza reported significantly higher levels of COVID-19 vaccine acceptance than women in Cabo Delgado. This may be related to the military conflicts in Cabo Delgado that have led to population displacement and disruption of community and health facilities services (48). Similarly, findings from another 2022 study conducted in the COMSA platform indicated that 65% of women 15–49-year-olds in Nampula and 80% in Maputo (Province and City) were vaccinated against COVID-19 (49). Our findings were also consistent with an early study conducted in Mozambique between September 2020 and March 2021 that revealed that COVID-19 vaccine acceptancy was not significantly associated with women’s place of residence (26). However, evidence from other sub-Saharan African countries is mixed. A multi-country phone survey study reported higher vaccine acceptance in rural areas of Burkina Faso, Ethiopia and Malawi (15), of Madagascar (50) and Bangladesh (6), while other studies have identified rural residence as a factor associated with increased vaccine hesitancy (5, 6, 51). In Kenya, findings from phone-based surveys varied across different rounds of data collection, showing inconsistent patterns in vaccine acceptance between urban and rural populations (45). Accessibility of healthcare infrastructure and vaccination services emerged as key determinants of increased COVID-19 vaccine uptake (6, 15, 50).

Characteristics related to women’s empowerment- measured through mobile phone ownership, access, and participation in healthcare decision-making- were not significantly associated with COVID-19 vaccination in the multivariate regression model. To our knowledge, no prior studies have specially examined the relationship between women’s empowerment and COVID-19 vaccine acceptance in Mozambique or other LMIC settings.

Vaccine hesitancy is influenced by a complex interplay of sociocultural, political, informational, and logistical factors. Trust in health systems, individual knowledge, perceived risks and benefits, cultural norms, and healthcare access can all affect vaccination decisions (1, 8, 19, 52, 53). Our study identified factors linked to higher vaccine uptake such as age group, education, marital status, geographic location, and maternal healthcare use. These insights can guide targeted strategies to that address specific demographic, social geographic characteristics to enhance vaccine acceptance. For future public health emergencies, understanding these drivers of vaccine behavior is critical to designing effective disease prevention campaigns. By strengthening trust, improving access, and targeting communication efforts, health systems can improve immunization rates and better manage outbreaks through inclusive and responsive public health planning.

This study contributes to Mozambique-specific evidence on factors influencing COVID-19 vaccine acceptance and hesitancy among women, while examining other potential factors of influence, including women’s empowerment. It highlights the importance of targeting younger women, those with no formal educated, women delivering outside a health facility, and those residing in conflict-affected provinces, like Cabo Delgado. While ANC attendance was not significantly associated with COVID-19 vaccine acceptance, improving the quality of counseling during ANC services – specially around vaccine safety and effectiveness is critical. However, our findings are limited by potential biases related to phone ownership and social desirability affecting respondents’ willingness to report their vaccination status and factors related to vaccine hesitancy. Further research, including qualitative studies, is recommended to better understand women’s decision-making and strengthen vaccines uptake strategies.