Background: The Coronavirus disease-2019 (COVID-19) vaccines were rolled out in many countries; however, sub-optimal COVID-19 vaccine uptake remains a major public health concern globally. This study aimed at assessing the factors that affected the uptake, hesitancy, and resistance of the COVID-19 vaccine among university undergraduate students in Malawi, a least developed country in Africa.

Methods: A descriptive cross-sectional study design was conducted using an online semi-structured questionnaire. A total of 343 University undergraduate students in Blantyre participated in this study after obtaining ethical clearance. Data was exported from Survey Monkey to Microsoft Excel version-21 for cleaning and was analysed using SPSS version-29. Descriptive statistics, including percentages, were performed to define the sample characteristics. Pearson Chi-square and Fisher's exact test were performed to identify significant relationships between vaccine uptake and demographics. A 95% confidence interval was set, and a p-value of < 0.05 was considered statistically significant.

Results: Of the 343 participants, 43% were vaccinated. Among the vaccinated, the majority (47.3%, n = 69/146) received Johnson & Johnson vaccine followed by AstraZeneca (46.6%, n = 68/146). The commonly reported reason for vaccine acceptance was 'to protect me against getting COVID-19' (49%); whereas vaccine hesitancy was attributed to 'lack of knowledge (34%), and concerns about vaccine safety (25%).

Conclusions: This study found that adequate knowledge about benefits and safety of COVID-19 vaccine could potentially increase uptake. Lack of credible information or misinformation contributed to vaccine hesitancy. The findings provide insights for design of strategies to increase future vaccine uptake and reduce determinants of vaccine hesitancy. To reduce vaccination hesitancy in any population with or without higher education, we recommend that institutions entrusted with vaccine management must optimise health messaging, and reduce mis-information and dis-information.