ABSTRACT
Background: COVID-19 vaccine uptake has been suboptimal in many lowincome countries. In Malawi, as of end-2022, just over 3.1 million adults have been fully vaccinated, representing ~21% of the adult population. We sought to identify correlates of COVID-19 vaccination among adults in Malawi to inform evidence-based policies and programs. Method(s): A survey was administered among adult (aged >=18) clients at 32 health facilities across Malawi (May-June 2022). We asked about COVID-19 vaccination history and about hypothesized correlates per the WHO Behavioural and Social Drivers of Vaccination model: what people think and feel, social processes, and practical issues. We assessed correlations between these and vaccination status, adjusting for age, HIV status, sex, educational attainment, household wealth, and urban-rural classification using multivariable logistic regression. Result(s): Surveys were conducted with 837 people, median age 39 (IQR 30-49), 56% female, 51% living with HIV and on ART. 33% were up-to-date on COVID-19 vaccination per Malawi guidelines (1 dose for J&J;2 doses of AstraZeneca or Pfizer vaccines), 61% were unvaccinated, and 6% were overdue for a second dose, with no difference by HIV status, religion, or urban-rural classification. Up-to-date individuals were older than those who were not (45 vs 38 years, p< 0.001). The strongest correlates of up-to-date vaccination were believing the vaccine is important and safe, believing vaccination's benefits outweigh its risks, and perceiving social support for vaccination (Table). Of 510 unvaccinated respondents, 54% had been offered the vaccine;the most commonly reported reasons for being unvaccinated were concerns about vaccine side effects (56%) and access-related barriers, such as travel time or cost (19%). Among the unvaccinated, 54% were eager or willing to be vaccinated, 29% were ambivalent, and 18% were opposed. Those opposed were less concerned about COVID-19 infection, did not feel the vaccine is important, and were less confident in the vaccine's safety. Conclusion(s): Up-to-date COVID-19 vaccination status was associated with positive attitudes about its importance and safety and perceiving provaccination social norms. Concerns about vaccine side effects were common, but over half of unvaccinated respondents were willing to get vaccinated. Disseminating messages about vaccine safety and ensuring local availability of the vaccine may help address concerns and access barriers, and thus help increase COVID-19 vaccination in Malawi.