Objective: To determine coronavirus disease-2019 vaccination intent and factors influencing the decision among university students.
Method: The analytical cross-sectional study was conducted from 25 January - 25 February 2021 at a state university in Muğla, Turkey, and comprised undergraduate students. Data was collected using a self-designed questionnaire through Google Forms. Factors affecting vaccination intent were identified using multinomial logistic models. Data was analysed using SPSS 22.
Results: Of the 1069 subjects, 629(58.8%) were females and 440(41.2%) were males. The overall mean age of the sample was 21.34±2.99. Overall, 712(66.6%) students were enrolled in health-related fields, and 357(33.4%) were pursuing non-medical degrees. Besides, 578(54.1%) students intended to have the vaccine. While 458(64.3%) of the subjects studying health-related subjects intended to have the vaccine, only 120(33.8%) in other academic streams said they would get vaccinated. Students who had had the disease or had been in contact with someone who had it 102(33%) were more likely to believe that the vaccine was safe. Smoking, having a flu vaccine in the past, and having a coronavirus disease-2019 test were the factors influencing the intent to have the vaccination (p<0.05).
Conclusion: Having had a flu vaccine in the past, social media use, history of, or exposure to, coronavirus disease-2019 and enrolment in health-related programme of studies were the factors influencing the vaccination intent of the students.
Keywords: COVID-19, COVID-19 vaccine, Vaccine intent, University student, Public health. (JPMA 73: 785; 2023)
Submission completion date: 08-03-2022 - Acceptance date: 19-10-2022
The coronavirus disease-2019 (COVID-19) pandemic is a global public health problem. The increasing number of cases necessitated the development of safe and effective vaccines for the virus as part of a sustainable strategy to control the pandemic. Vaccines are one of the most powerful public health tools for fighting infectious diseases. It has been claimed that a 60-70% herd immunity, which would end the pandemic, can only be achieved with vaccinations.1 While COVID-19 vaccination programmes continue, a lack of large cohorts in vaccine studies, and a lack of data with regard to serious adverse effects, together with speculations about their effects and protective capacities, have had a negative effect on confidence in COVID-19 vaccines.2 Barello et al.3 reported that university students have an insufficient or basic level of information about COVID-19, and also 86.1% students intended to have the COVID-19 vaccine, while the remaining 13.9% were not sure. Similarly, in another study, 50.6% students said they would get vaccinated, 29.8% said they would not, and 19.3% were undecided.4
University students are known to make a significant contribution towards increasing public awareness about vaccine uptake and, thus, towards preventing future pandemics. The current study was planned to determine COVID-19 vaccination intent and factors influencing the decision among university students.
Subjects and Methods
The analytical, cross-sectional knowledge-attitude-practice (KAP) study was conducted from 25 January - 25 February 2021 at a state university in Muğla, Turkey. After approval from the institutional ethics review committee, the sample size was calculated using the formula5
Where p and q were 0.5, effect size (d) 0.25, type I error (𝛼) 0.05, z value 1.9616. It was calculated with 95% confidence interval (CI) and 50% proportion of population.
The sample was raised using purposive sampling technique from among undergraduate students enrolled in various departments at the university. Data was collected online using a self-designed questionnaire through Google Forms. The questionnaires were pilot-tested on 99 students who were studying at locations other than the central campus. The power of the test was calculated by G*Power 3.1, and it was 0.9861.6
For the main study, data was collected aftertaking informed consent from the subjects. Those who did not volunteer to participate were excluded, and so were invalid questionnaires.
The questionnaire had two sections. The first was related to personal factors, including information, such as gender, where the participants lived, and the academic department. The second section was related to the particpants’ general health, and of their families, COVID-19 status, and their views on getting vaccinated.
Data was analysed using SPSS 22 and STATA 16. Descriptive statistics, including mean, standard deviations, frequencies, percentages, and 95% CI were used to express data as appropriate. Chi-square test and multinomial logistic model (MLM) were also used. Factors affecting the intent to be vaccinated were determined using MLM. Two-tailed p<0.05 was considered statistically significant.
Of the 1069 subjects, 629(58.8%) were females and 440(41.2%) were males. The mean age of the sample was 21.34+/-2.99. Overall, 712(66.6%) students were enrolled in health-related fields, and 357(33.4%) were pursuing non-medical degrees. Regarding the level of protection offered by vaccines at large, 349(32.6%) subjects were unsure, while 469(43.9%) were hesitant about the efficacy of COVID-19 vaccine compared to 321(30%) participants who had confidence in COVID-19 vaccine. Besides, 578(54.1%) students intended to have the vaccine. While 458(64.3%) of the subjects studying health-related subjects intended to have the vaccine, only 120(33.8%) in other academic streams said they would get vaccinated (p<0.05) (Table 1).
The majority of the students 908(84.9%) believed that healthcare workers should be vaccinated, and that the vaccination process should be carried out hospitals and primary care practices. The overall knowledge about COVID-19 protective measures, including the vaccine, and the choices of the subjects were noted in detail (Table 2).
The two most significant reasons for not getting vaccinated were the possibility of side effects 399(37.3%), and lack of knowledge about the body’s potential reaction to the vaccine 363(34.0%).
Willingness to be vaccinated against COVID-19 varied in line with respondents’ characteristics. Smoking, having a flu vaccine in the past, and having a COVID-19 test were the factors influencing the intent to have the vaccination (p<0.05). Students who had had the disease or had been in contact with someone who had it were more likely to believe that the vaccine was safe 102(33%) (Table 3).
The students used social media as a source of information about COVID-19 (p<0.05). Female students were more concerned about having relevant information than male students (p<0.05), but were more hesitant about having the COVID-19 vaccine than male students (p<0.05).
MLM showed that having had a flu vaccine in the past, social media use, a history of COVID-19 and education in medical/nursing schools were the factors influencing the students’ intent to get vaccinated (Table 4).
The current study had participants with chronic diseases and those who smoked. One study demonstrated a correlation between severe COVID-19 infection and diabetes mellitus (DM).7 In another study, active smokers were found to be at almost twice the risk of COVID-19 disease.8 Given the negative effects of smoking and tobacco use on the severity of COVID-19, ensuring that university students are aware of these issues will contribute to the prevention of many chronic diseases and to the fight against COVID-19.
The main protective measures against COVID-19 among the current students were mask usage, handwashing, social distancing, hand sanitisers, dietary supplements, goggles, and face shields. These findings may indicate that students who felt at risk were more careful about following the protective measures, whereas those who did not feel at risk were more relaxed about such protective measures. The most frequently used protective measures against
COVID-19 are masks, social distancing, avoiding crowded spaces, handwashing and vaccination.9 Compliance with the recommended protective measures is important.
Although the percentage of students who had confidence in the COVID-19 vaccines was reasonably high, those who were undecided in this regard were even more in numbers. It was observed that people's confidence and trust in COVID-19 vaccination, and their intent to get vaccinated, varied depending on whether they had had COVID-19 or had been in contact with a COVID-19 patient. Vaccination hesitancy is associated with a decrease in acceptance of COVID-19 vaccines.10 It is believed that widespread vaccine hesitancy due to concerns over a vaccine’s safety and effectiveness jeopardises the process of achieving herd immunity. The fact that the participants were not willing to have the vaccine or were unsure about having the vaccine showed that they needed more information.4 It is important to convince people who are not sure about the safety of the vaccine to have the vaccine, and information about the potential side effects and safety profile of the vaccine should be provided to these people to reduce the level of hesitancy.11 The current study showed that some students were afraid of the unknown. Social media plays a significant role in the spread of fear and hesitancy about the COVID-19 vaccine. Information campaigns that stress the social benefits of vaccination and collaboration among public officials are important strategies to decrease hesitancy and increase willingness to have the vaccine.11
Also, strategic public health approaches are needed to reduce fear and encourage healthy behaviour.
Having had a flu vaccine in the past, social media usage, history of COVID-19 and education in medical/nursing schools were the main factors influencing vaccination intent in the current study. One study found that vaccine rejection and hesitancy were significantly correlated with female gender, age, low education level, adverse reactions to previous vaccines, and having no specific chronic condition.12 According to another study, people who did not have university degrees were more inclined to accept the vaccine.13 In another study, the factors affecting vaccination intent were gender, marrital status, risk perception, having had a flu vaccine in the past, believing in the efficacy of COVID-19 vaccines, following doctors' recommendations, the convenience of vaccine procedures and the price of the vaccine.14 Based on the results of a logistic regression analysis, another study demonstrated that gender, being married, higher risk perception, having had a flu vaccine in the past, believing in the efficacy of COVID-19 vaccines, and following doctors' recommendations could increase acceptance of the need to be vaccinated.15
The reasons cited in literature regarding vaccine hesitancy include the fact that the vaccine is ‘new’, potential side effects, lack of trust in the vaccine’s efficiency and safety, believing that the disease poses no threat to them, that the vaccine is dangerous for health, that the vaccine is not effective, that long-term side-effects of the vaccine are not known, that the vaccine is harmful, that they suffer from allergies, that there are not enough studies about the safety of the vaccine, not wanting to risk long-term health, the fear of the unknown, that more data and evidence are needed, and various conspiracy theories. 4,11,15-17
In the current study the students believed that healthcare workers, people with chronic diseases and people who are aged >65 years should be vaccinated. Healthcare workers have priority in COVID-19 vaccination programmes.18
The current study has limitations in terms of sample orientation. Besides, data was collected using a self-administered online survey, which may allow for subjectivity although it is the most appropriate method that matches the study design.
Further qualitative and quantitative studies will contribute significantly to medical literature.
Having had a flu vaccine in the past, social media use, history of, or exposure to, COVID-19 and enrolment in health-related programme of studies were found to be the factors influencing the vaccination intent of the students.
Acknowledgement: We are grateful to all the study participants.
Conflict of Interest: None.
Source of Funding: None.
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