Pairwise and three-country comparisons of high and low COVID-19 vaccination rates in 12 African countries: a mixed-method study protocol

Introduction: The COVID-19 pandemic has highlighted significant disparities in vaccine uptake across sub-Saharan Africa, yet research exploring the regional and country-specific factors influencing these rates remains limited. Understanding these factors is crucial for developing targeted regional and global public health interventions to improve vaccination uptake and strengthen pandemic preparedness. This study aims to fill a critical knowledge gap by assessing the factors influencing vaccination rates across sub-Saharan Africa at the operational, systemic and socio-political levels. Methods and analysis: The study will employ a comparative case study design across 12 African countries to examine context-specific factors influencing pandemic vaccine preparedness. The 12 selected countries (Angola, Botswana, Burundi, Cameroon, Côte d'Ivoire, Malawi, Namibia, Nigeria, Rwanda, Senegal, South Africa and Uganda) will be categorised by vaccination rate (high, moderate or low). The study will integrate quantitative and qualitative data to provide comprehensive insights. Quantitative data, including COVID-19, macroeconomic, health system and governance indicators, will be sourced from reputable online portals, such as the WHO, the World Bank and Our World in Data. Qualitative data will be collected through key informant interviews with experts across participating African countries, except Angola. Due to delays in obtaining ethics approval in Angola, no primary data collection including key informant interviews will be conducted in Angola unless ethics approval is obtained. Angola will therefore be included through a secondary data approach, drawing on publicly available reports, published literature and relevant case studies. All qualitative data will be analysed using thematic analysis, and quantitative data will be analysed using descriptive methods. Ethics and dissemination: Ethics approval was obtained from Western University’s Health Sciences Research Ethics Board (126398) and relevant bodies in the 11 participating countries. Findings will be shared through reports to public health authorities, policy briefs and presentations at academic conferences and peer-reviewed publications.