Lack of influence of social media on vaccine decision-making by university students in Ireland

ABSTRACT

Vaccine hesitancy is a complex, context-specific issue that negatively impacts vaccine uptake. During the COVID-19 pandemic, vaccine mis- and dis-information on social media negatively impacted on COVID-19 vaccine acceptance. University students’ beliefs and behaviors surrounding vaccine decision-making is less studied, but this population is important in disease transmission, vaccine uptake and effectiveness. Here, we surveyed students in a third-level Irish university, in September 2022, when pandemic restrictions had been removed, to primarily determine if their use of, and influence by, mainstream and social media correlated with their willingness to receive a COVID-19 vaccine or any vaccine. We analyzed 151 responses and found no significant correlation between students’ willingness to receive either a COVID-19 vaccine or any vaccine and their use of social media. There were significant links between vaccine acceptance and a range of factors, namely accommodation type, social media behaviors, perceived exposure to vaccine mis- or dis-information and previous vaccine uptake. This study provides a preliminary insight into drivers of university student COVID-19 and general vaccine willingness. It provides initial data, in the context of post-pandemic restrictions, to support further development of interventions to enhance vaccine uptake in third-level students in Ireland.

KEYWORDS:

• Vaccine hesitancy
• COVID-19
• social media
• university students
• survey

Introduction

Vaccine hesitancy negatively impacts on rates of vaccination, and it was identified by the World Health Organization (WHO) as a top 10 global threat to public health in 2019. Vaccine hesitancy is defined as a delay in acceptance or refusal of a vaccine despite the availability of vaccine services.^1,2 It is a complex, multi-faceted issue that is context-dependent and exists on a spectrum.^1,3 Common factors that affect vaccine hesitancy include societal duty, personal choice, perceived risks of disease and/or the vaccine and access to vaccines.^2,3 Notably, factors affecting vaccine hesitancy are fluid and change over time and can be vaccine specific.^2,3 Hesitancy can result in individuals searching for more information about vaccines, assessing their perceived risks and benefits of becoming vaccinated and/or seeking out secondary opinions from trustworthy or less trustworthy sources. Vaccine misinformation and disinformation is defined as either unintentionally or intentionally, respectively, providing misleading information about vaccines and vaccination.⁴ The spread of vaccine misinformation and disinformation has occurred at least since the 18^th century, for smallpox vaccination. The impact of the internet and social media on vaccine attitudes and behaviors was recognized before the COVID-19 pandemic.^5–7 The impact of specific social media platforms on the general public’s vaccine acceptance, from 2020 to 2021, during the COVID-19 pandemic and prior to extensive vaccine deployment, has also been documented in a number of countries, including the UK and Ireland^8–11 and has been reviewed in a global context.¹²

University students, usually young adults between the ages of 18–24, are in charge of their own health decisions for the first time in their life, and these young adults can also have a sense of invulnerability.^13–16 Young adults’ and university students’ lifestyles can put them at high risk to contract and spread infectious diseases.^17–20 Furthermore, unlike young children, older adults and individuals with co-morbidities, healthy university students are generally at low risk of developing moderate or serious disease for most pathogens.^14,15 These factors may influence university students’ vaccine decision-making process. University students rely upon the advice of medical professionals and family members regarding their decision to be vaccinated.^{15–17–20–24} Recent studies indicate that university students are less likely to accept recommended vaccinations, such as HPV or the yearly influenza vaccine, due to worries about the safety of the recommended vaccine or the associated inconvenience with getting vaccines.^15,19,21 This could have implications on the uptake of future COVID-19 booster vaccinations and other routine vaccines. High levels of adherence to infection control preventive behaviors by third-level students in an Irish university were documented during a period of national lockdown restrictions and easing of these restrictions.¹⁹ At that time, approximately 65% of these students were vaccine acceptors.¹⁹ Of interest, this study suggested that living in student accommodation compared to living at home decreased the likelihood of vaccine uptake.¹⁹ However, this study did not interrogate the impact of social media on students’ vaccine acceptance. Little, if any, research has been done on the effects of social media on vaccine hesitancy in university students in a post-pandemic lockdown time in Ireland. As COVID-19 vaccines are approved for use and COVID-19 boosters are recommended, it is timely to assess the attitudes of university students toward vaccines, as this provides a post-pandemic baseline for future research. The primary aim of this study was to determine if social media significantly impacts on university students’ vaccine confidence and vaccine uptake in an Irish university, at a time when pandemic restrictions had been removed and pre-pandemic university life had resumed. We examined if the environment in which the student lives while at university has an impact on their vaccine confidence, as a comparison with the situation during lockdown restrictions in Ireland.¹⁹ Further, we investigate whether differences in students’ previous vaccine history have an impact on their vaccine confidence. This understanding aims to provide initial insights that could support tailored public health interventions for young adults enrolled in universities in Ireland.

Methods

This study was conducted over a one-month period from the 19^th of September 2022 to the 19^th of October 2022 in an Irish university: University College Cork (UCC). The university consists of four colleges: the College of Arts, Celtic Studies and Social Sciences (CACSS), the College of Business and Law (CoBL), the College of Medicine and Health (CoMH) and the College of Science, Engineering, and Food Science (SEFS). The survey was written in Qualtrics Experience Management and set to collect responses anonymously. The study was approved by the UCC Social Research Ethics Committee (Application Reference 2022–099). The questions were reviewed by experts in the vaccine field for clarity, relevance, and checked for potentially leading or biased questions. We also confirmed that the survey could be completed in the expected timeframe. The survey was emailed to all UCC students on the start date and 2 weeks into the survey collection period. The survey, which was completed online, provided anonymous responses to encourage honest answers about respondents’ vaccination history, beliefs, and vaccination status (the full survey is in Supplementary Information). Respondents were informed of the confidentiality and anonymity of the survey. Informed consent was elicited from respondents before accessing the survey. Respondents, who were required to be aged 18 years or older, were allowed to withdraw at any point during the survey. All answers were closed-answer, multiple-choice questions. An ‘Other’ option was provided for respondents to provide answers if their response was not provided as a multiple-choice option. A ‘Prefer not to say’ option was provided if respondents were uncomfortable answering any questions. Surveys that were not answered up to question 16, or at least 59% completed, were removed from the analysis. The survey was set to prevent multiple responses from the same user and to detect bot responses.

Responses for vaccine willingness were given on a scale of 1 to 5 and pooled post-hoc as follows: answers of “1 – Extremely unwilling” were categorized as vaccine resistant; answers of “2 – Unwilling” and “3 – Neutral” were categorized as vaccine hesitant; answers of “4 – Willing” and “5 – Extremely willing” were categorized as vaccine acceptors. The survey data was analyzed in Qualtrics Stats iQ and RStudio and graphed using the ggplot2 package. Chi-squared tests were performed in Qualtrics using a Cramér’s V effect size interpretation, with p-values <.05 considered significant. The pooled vaccine acceptance groups were used as the key variable for each relationship that we tested.

Results

Demographics

A total of 196 survey responses were collected from students enrolled at University College Cork, Ireland (UCC). The Qualtrics ReCAPTCHA function identified two potential bot responses, which were excluded from the analysis. Following the removal of incomplete surveys and respondents who did not answer “yes” to consent to the survey, 151 responses were analyzed (Table 1). The majority of the respondents were female (70%). This gender distribution is slightly higher than the distribution within the UCC student population (60%) and above the average across all higher education institutes in Ireland (54%) in the 2021/2022 enrollment period.²⁵ The highest proportion of respondents were aged between 22 and 25 years old (41%). One-third of respondents were at least 26 years old; this is above the common age range of university students (between 18 and 25). This student cohort may be more independent of their health and vaccine decisions. The proportion of those enrolled in a bachelor’s degree program (54%) is similar to the UCC and to the national average (62%).²⁵ Thus, this cohort of respondents, although limited in number, is representative of the student demographic in UCC and, except for gender, in Ireland.

Table 1. Demographics of collected responses (n = 151).

Demographic	%
Gender
Female	70
Male	28
Non-binary	2
Age range
18–21	26
22–25	41
26–31	13
32+	20
UCC College
CACSS	32
SEFS	27
CoMH	20
CoBL	8
Prefer not to say	12
Degree level
Bachelors	54
Masters	17
PhD	19
Prefer not to say	10

We quantified vaccine uptake in UCC students by asking whether they had received the COVID-19 vaccine, their annual influenza vaccine, their recommended childhood vaccines, and their recommended adolescent vaccines. Over 90% of students had received their COVID-19, childhood and adolescent vaccines, and 38% of students received their annual influenza vaccine (Table 2). This level of COVID-19 vaccine uptake contrasts with other university student research conducted in 2020–2021 {Tavolacci, 2021,¹³ COVID-19 vaccine acceptance`, hesitancy`, and resistancy among university students in France} {Patelarou, 2021,²² Factors influencing nursing students’ intention to accept COVID-19 vaccination: A pooled analysis of seven European countries}. Interestingly, 6% of respondents did not know whether they had received their recommended adolescent vaccines (Table 2).

Table 2. Respondent COVID-19, influenza, childhood and adolescent vaccine uptake (n = 151).

	Yes (%)	No (%)	I Don’t Know (%)	Prefer not to say (%)
COVID-19 Vaccine	95	5	0	<1
Influenza Vaccine	38	62	0	<1
Recommended Childhood Vaccines	95	5	0	<1
Recommended Adolescent Vaccines	93	<1	6	0

When asked about their willingness to consent to receive the COVID-19 vaccine, 83% (n = 125) of respondents were vaccine acceptors, 12% (n = 18) were vaccine hesitant and 5% (n = 8) were vaccine resistant (Figure 1a). When asked about their willingness to receive any vaccine, 82% (n = 123) of respondents were vaccine acceptors, 16% (n = 24) were vaccine hesitant, and 2% (n = 3) were vaccine resistant (Figure 1b). There were more vaccine hesitant respondents for any vaccine compared to COVID-19 vaccines and a larger percentage of vaccine-resistant respondents for COVID-19 vaccines than for any vaccine.

Figure 1. Respondents’ attitudes toward willingness to receive vaccines. a) Number of responses recorded for willingness to consent to COVID-19 vaccine after pooling responses. b) Number of responses recorded for willingness to consent to any vaccine after pooling responses. Classification was performed post-hoc as described. Percentages displayed over the bars are the total percent of the responses categorized as vaccine acceptors, vaccine hesitants, and vaccine resistants.

Social media habits and willingness to be vaccinated

The primary objective of this study was to determine if social media use impacted on UCC students’ vaccine confidence. We first determined respondents’ social media habits. The most common social media platform selected was Instagram (43%), followed by TikTok (23%). Twitter and Facebook accounted for 12% and 7% of responses, respectively (Table S1_Supplementary Information). Responses in the ‘Other’ category included social media platforms such as Tumblr, Reddit, and Snapchat. The highest proportion of students (33%) estimated they spent 6–10 h on social media (Table S1).

We evaluated how often UCC students perceived that they were exposed to either vaccine advocacy messaging and mis- or dis-information. Students were provided definitions for vaccine advocacy messaging, mis- or dis-information in the question. We predefined “frequently” as exposure more than 4 times per month, “commonly” as exposure 3–4 times per month, “moderately” as exposure 2 times per month, “uncommonly” as exposure once per month, and “rarely” as exposure less than once per month. The highest response (32%) indicated that they saw vaccine advocacy commonly, while the lowest response (6%) said they saw vaccine advocacy messaging rarely (Table S1). When asked about their exposure to vaccine misinformation or disinformation, the highest response (26%) reported that they saw it moderately often (Table S1). Overall, there was a mix of responses toward the frequency of exposure to both advocacy and mis- and dis-information.

We next compared respondents’ reported exposure to advocacy messaging or mis- and dis-information to their willingness to be vaccinated against COVID-19 and to be vaccinated with any vaccine (Figure 2). Visibility of vaccine advocacy messaging was similar across the three cohorts. However, the COVID-19 vaccine hesitant group had the highest proportion of respondents who indicated that they saw advocacy with moderate frequency (33%). The COVID-19 vaccine hesitant group had the highest proportion of respondents indicating that they saw vaccine mis- and dis-information with rare frequency (50%) (Figure 2c). Similar levels of responses were observed with respect to the frequency of seeing advocacy for any vaccine across the cohorts (Figure 2b,d). Higher proportions in the vaccine hesitant group reported seeing mis- and dis-information rarely (29%) and uncommonly (13%) compared to vaccine acceptors (19% for rarely, 4% for uncommon). Overall, there are little differences between the frequency of perceived exposure to vaccine advocacy messaging and the willingness to be vaccinated against COVID-19 or with any vaccine; however, a higher proportion of the vaccine hesitant group reported rarely seeing mis- and dis-information compared to vaccine acceptors.

Figure 2. The frequency of exposure to vaccine advocacy messaging or vaccine misinformation or disinformation within each willingness group. Respondent exposure to (a) vaccine advocacy messaging and (b) vaccine misinformation or disinformation and their willingness to receive a COVID-19 vaccine. Respondent exposure to (c) vaccine advocacy messaging and (d) misinformation and disinformation and their willingness to receive any vaccine. N = number of respondents in group.

We then assessed whether there was a relationship between a student’s main social media platform and their willingness to be vaccinated. In at least one study of third-level students, during COVID-19, Facebook users had a more negative attitude to vaccination compared to Twitter users.²³ Here, there is a similar diversity of use of social media platforms between vaccine acceptors, vaccine hesitants and potentially, in vaccine-resistant groups (Figure 3a,b). We were also interested in understanding their behavior toward vaccination beliefs that do not conform to their beliefs, that is, if students’ self-selecting online communities of like-minded individuals associated with their vaccine decision-making. When asked if respondents would unfollow someone on social media because of their vaccination status or beliefs, 54% of respondents who were COVID-19 vaccine acceptors replied “yes”, whereas 11% of COVID-19 vaccine hesitant respondents and 13% of respondents who were COVID-19 vaccine resistant replied “yes” (Figure 3c). For vaccination with any vaccine, this number reduced slightly to 52% of any vaccine acceptors replying “yes”, while it increased to 25% of any vaccine hesitant respondents and 33% of any vaccine-resistant respondents who replied “yes” (Figure 3d). The vaccine hesitant cohort was more similar to vaccine resistant compared to vaccine accepting individuals in this parameter.

Figure 3. Frequency of respondents’ social media habits and their willingness to be vaccinated. a) Respondents’ attitudes toward the COVID-19 vaccine and their main social media platform. b) Respondents’ willingness to be vaccinated toward any vaccine and their main social media platform. c) Respondents’ attitudes toward the COVID-19 vaccine and their willingness to continue to follow a social media account with alternative vaccination beliefs. (d) Respondents’ attitudes toward general vaccines and their behavior toward alternative vaccination beliefs. N = number of respondents in group.

We next assessed if there was a relationship between students’ use of mainstream media and their attitudes toward the COVID-19 vaccine and any vaccines. We determined whether students were watching or listening to live news broadcasts on mainstream media, namely, television and/or radio (Table S2). Responses were evenly split between respondents who do and do not watch (54% and 46% respectively) and listen to live radio broadcasts (49% and 51%, respectively). The most watched TV news is from the national broadcaster, RTÉ (61%). The highest proportion of those who listen to the radio listen to a local radio station (41%). For students who did not listen to radio news or watch TV news broadcasts (n = 58), their main source of gathering news was social media (58%) (Table S2). Responses in the ‘Other’ category included online news sources and mobile news apps, podcasts, and having no interest in the news. For live TV news broadcasts, there was little to no difference across the three cohorts with respect to the proportions who do and do not watch TV news (Figure 4a). For live radio news broadcasts, 50% of COVID-19 vaccine acceptors, 61% of COVID-19 vaccine hesitant and 75% of COVID-19 vaccine resistant do not listen to live radio news broadcasts (Figure 4c).

Figure 4. Proportion of respondents’ interaction with live news broadcasts, their main source of news outside of TV or news broadcasts and their attitudes toward vaccines. a) Respondent live TV news broadcast interaction and their feelings toward the COVID-19 vaccines. b) Respondent live TV news broadcast interaction and their feelings toward general vaccines. c) Respondent live radio news broadcast interaction and their feelings toward the COVID-19 vaccines. d) Respondent live radio news broadcast interaction and their feelings toward general vaccines. e) Respondent attitudes toward the COVID-19 vaccine and their main source of news if they do not watch or listen to live broadcasts. f) Respondent attitudes toward general vaccines and their main source of news if they do not watch or listen to live broadcasts. N = number of respondents in group.

We further examined the 58 respondents who did not listen to radio news or watch TV news broadcasts. Social media is the predominant news source for all cohorts (Figure 4e,f). Students in the COVID-19 vaccine hesitant and resistant groups only used social media or “other” as their main source of news, however, the cohort sizes are small (Figure 4e). Vaccine acceptors had a more diverse source of news (Figure 4e). A similar result was found in the Any Vaccine groups (Figure 4f).

Living environment and vaccine attitudes

We wished to determine if a student’s living environment influences a student’s vaccine acceptance. We focussed on the type of accommodation as a key environmental influence. Students who live in rented accommodation, private student accommodation, or UCC-owned student accommodation are predominantly surrounded by other university students, for an increased length of time compared to students who live at home, who likely interact with their family members more than those in rented accommodation. The highest proportion of students live at home (48%), followed by renting private accommodation from a landlord (33%) (Table S3). For this study, we differentiated accommodation rented from private companies from accommodation rented from UCC. Public health interventions may be more accessible in UCC student accommodation, for example, from the UCC Student Health Services than the private rented accommodation. With respect to willingness to be vaccinated, similar proportions of COVID-19 vaccine and any vaccine acceptors, hesitants and resistants live at home (Figure 5). The vaccine hesitant cohorts had the most diverse accommodation status (Figure 5).

Figure 5. Proportion of respondents’ accommodation type and their attitudes toward vaccines. a) Respondents’ attitudes toward COVID-19 vaccines and their accommodation while living at UCC. b) Respondents’ attitudes toward general vaccines and their accommodation while living at UCC. N = number of respondents in group.

With respect to being a regular close contact of individuals who are known to be most susceptible to poor outcomes due to infectious diseases, the most frequently reported close contact was the elderly (42%) followed by immunocompromised people (26%) (Table S3). About a quarter of respondents (22%) had no close contacts in high-risk groups (Table S3). For the purpose of this study, these groups were not defined as COVID-19 susceptible close contacts in the survey question.

Previous vaccine history and vaccine attitudes

We were interested in previous annual influenza vaccine uptake history and its relationship to willingness to be vaccinated against either COVID-19 or with any vaccine. Within the COVID-19 vaccine acceptors, 45% of respondents received an annual influenza vaccination (Figure 6a). This dropped to 5% with the COVID-19 vaccine hesitant group, while none of the COVID-19 vaccine-resistant group received a seasonal influenza vaccine (Figure 6a). Similar proportions were observed when respondents were classified to acceptor, hesitant or resistant to receive any vaccine, although a higher frequency (15%) of any vaccine hesitant respondents, compared to COVID-19 vaccine hesitants (5%), received their annual influenza vaccination (Figure 6b).

Figure 6. Proportion of respondents’ yearly influenza vaccination uptake and their behavior toward influenza vaccinations. a) Respondent influenza vaccine uptake and their willingness to accept a COVID-19 vaccine. b) Respondent yearly influenza vaccine uptake and their willingness to accept a general vaccine. N = number of respondents in group.

Respondents were asked to indicate the biggest contributors to their willingness and hesitancy to be vaccinated, and they could select multiple reasons for both questions. Approximately one-third of respondents (31%) said the main reason for willingness to get vaccinated, not specific to COVID-19, was to contribute to a public health initiative, followed by having friends or family in high-risk groups (Table 3). Responses in the “Other” category (8%) included vaccines being required for travel, while 7% of respondents selected a provided answer and gave an alternative response in the “Other” category (Table S4). With respect to vaccine hesitancy, “Other” reasons were reported most frequently (29%), followed by fear of needles (19%). Allergies to ingredients, distrust of medical professionals and advice from family and friends were the next most common reasons for hesitancy (Table 3). When asked about their reasons for hesitancy, respondents provided free-form answers that included lack of trust in the vaccine, worries about long-term side effects, or thinking vaccines to be irrelevant (Table S4).

Table 3. Frequency of reasons either for or against receiving any vaccination. Respondents were allowed to select multiple options (n = 151).

Contributing Factor	%
Reasons to Receive Vaccines
Contribute to a public health initiative	31
Friends and family in a high-risk group	25
Required for work	13
Reminders from GP/health system	11
Other	8
In a high-risk group	7
Anecdotes and/or advice from family and friends	5
Reasons to be Vaccine Hesitant
Other	29
Fear of needles and injection	19
Allergies to vaccine ingredients	15
Distrust of medical professionals	13
Anecdotes and/or advice from family and friends	11
Inconvenient access to a doctor or pharmacist	9
Religious beliefs	1
Prefer not to say	5

Statistical associations between willingness to be vaccinated and student behaviours and environment

Chi-squared tests were performed to determine the dependence between the variables and respondents’ willingness to be vaccinated with a COVID-19 or any vaccine, using all five vaccine willingness categories. Willingness to receive COVID-19 vaccines is significantly related to perceived exposure to vaccine misinformation or disinformation, behavior toward alternative vaccine beliefs, yearly influenza virus vaccine uptake and accommodation type (Table 4). COVID-19 vaccine acceptors were less likely to see vaccine mis- or dis-information frequently, more likely to unfollow someone on social media with discordant vaccine beliefs, more likely to receive their yearly influenza vaccination and more likely to live at home. Willingness to receive any vaccine is significantly related to behavior toward vaccine beliefs and type of accommodation (Table 4). Acceptors of any vaccine were more likely to unfollow someone with discordant vaccine beliefs on social media and more likely to live at home. Notably, no other significant associations were found (Table 4).

Table 4. Results of Chi-squared tests performed for the question “what is your willingness to be vaccinated with any vaccine?” or “what is your willingness to be vaccinated with the COVID-19 vaccines?” performed prior to post-hoc grouping. p-values <.05 were considered statistically significant. ‘*’ = p < .05, ‘**’ = p < .01, ‘***’ = p < .001.

Variable	COVID-19 Vaccination	ANY VACCINE
	p-value	p-value
Gender	.110	.419
Age range	.832	.482
UCC College	.06	.220
Degree level	.602	.841
Year of degree programme	.825	.824
Exposure to vaccine advocacy messaging	.196	.384
Exposure to vaccine misinformation or disinformation	.003 **	.207
Main social media platform	.909	.838
Weekly hours on social media	.654	.976
Behaviour toward vaccine beliefs	.0004 ***	.008 **
Yearly influenza virus vaccine uptake	.029*	.065
Vaccination with childhood vaccines	.780	.682
Vaccination with adolescent vaccines	.645	.134
Accommodation	.0003 ***	.0102 *
Watch live news broadcasts	.951	.471
TV channel	.285	.872
Listen to live radio news broadcasts	.420	.168
Radio station	.497	.438
Alternative news source	.868	.995

Discussion

Vaccine hesitancy is a dynamic issue that public health bodies continue to address. University students generally lead active lives with ample opportunities to contract and transmit SARS-CoV-2 but typically only experience mild disease, and they therefore can act as a reservoir for the virus.^{14–15-17–18-20–26-28} Additionally, university students tend to be open-minded and willing to develop new habits and behaviors.^24,26,29,30 For some university students, they will have less, if any, experience of making decisions about their own healthcare. It is therefore important to understand what factors impact their decision to accept a vaccine so that vaccine uptake can be optimized for their health and for broader public health benefits. Here, we primarily aimed to study what impact mainstream media, social media, behaviors and environment have on university students’ vaccine confidence in an Irish university context in 2022, when pandemic restrictions had ceased and COVID-19 vaccines were widely deployed and used. Our research provides new insights into previous studies conducted on the UK/Irish general public’s COVID-19 vaccine confidence, in 2020, at the start of the pandemic and before any vaccine was authorized¹⁰ and university students’ risk perceptions and behaviors during a period of Irish national lockdown restrictions and easing of these restrictions (2021) in Ireland.¹⁹ We demonstrate that the majority of students were accepting of a COVID-19 vaccine and of any vaccine. Two environmental factors correlated with willingness to accept a COVID-19 vaccine: more diverse frequency of exposure to vaccine mis- or dis-information and accommodation type (living at home). Furthermore, two behaviors correlated with willingness to accept a COVID-19 vaccine: social media behavior (i.e., un-following accounts with discordant views) and receiving annual influenza vaccination. No other demographic, environmental or behavioral parameter correlated with willingness to be vaccinated. These findings were derived from a small sample size (151 students), in this initial, unvalidated survey. Identification of these factors provides a post-pandemic initial baseline of university students’ attitudes to vaccination that could support further research to identify tailored interventions to further increase vaccine acceptance in a university student population.

We identified that most students use social media, predominantly Instagram and TikTok, and about half of all students use social media as their primary news source. Identifying the predominant social media platform in future, validated surveys should permit the focussing of public health messaging to these platforms to increase the visibility of vaccine advocacy compared to traditional mainstream media. During the COVID-19 pandemic, several EU-based governments and their Departments/Ministries of Health initiated social media-based public health and science communication campaigns to target a range of barriers to vaccine uptake.³¹ For example, the Government of Ireland established a network of expert Young Science Communicators to communicate with young people with respect to COVID-19 public health guidelines, vaccines and to address any common myths circulating about the virus.³² Other online initiatives have been developed by other EU and UK organizations.³¹ While the success of these initiatives remains to be evaluated, they are examples of targeted interventions to a demographic that primarily use social media, such as university students, as outlined here.

A student’s willingness to be vaccinated against COVID-19 significantly associated with their behavior toward people with differing vaccine status and/or beliefs. To our knowledge, this has not previously been described. Vaccine acceptors were significantly more likely to unfollow someone based on their vaccine status and/or beliefs than vaccine hesitant or resistant students. This pattern is also apparent in a student’s willingness to be vaccinated with any vaccine. These trends support the idea of social media platform aggregation and self-selection, whereby individuals are more likely to join like-minded communities.^12,33 Overall, these results suggest that vaccine hesitant students do not unfollow discordant views. This behavior may be due to their hesitancy and lack of defined opinion. Trusted sources of accurate vaccine information can be easily lost in the vast amount of mis- and dis-information and can be difficult for a person to critically evaluate.^6,34 We identified that a higher proportion of the COVID-19 vaccine hesitant group reported to rarely see mis- and dis-information compared to the vaccine acceptor or resistant groups. This indicates that vaccine hesitant students may not be able to discriminate between vaccine advocacy and mis- and dis-information. This could be due to a number of factors. Vaccine hesitant individuals may accept mis- and disinformation as truth. Alternatively, they may not wish, or be able, to discern the accuracy of vaccine information, mis- and dis-information. Therefore, our finding could indicate a need to support students to better identify vaccine mis- or dis-information. Vaccine hesitant individuals tend to be seeking further information about vaccinations and may not self-select and unfollow discordant views due to this pattern of behavior^35,36 Previous research of vaccine hesitant students, in the USA, demonstrated that students were more likely to accept a vaccine when they have improved knowledge of the vaccine-preventable disease and knew people who have been affected by the disease.³⁰ In a 2021 study of Irish university students, during the pandemic, knowledge of COVID-19 disease predicted with significant confidence, vaccine acceptance.¹⁹ Education courses on how to evaluate vaccine messaging and determine if it is accurate or misleading have also been developed to address this issue.³⁰ Such approaches may be of value in other university cohorts.

The decision to be vaccinated was independent of both a student’s main social media platform and the number of reported estimated hours a student spends on social media per week. This result proves that our initial hypothesis and that social media would impact a student’s willingness to be vaccinated, is false. Students are making their decision to be vaccinated based on multiple sources of information, not just social media. This finding contrasts with research examining COVID-19 vaccine acceptance in a UK and Irish public cohort early in the pandemic (2020).¹⁰ This survey demonstrated that vaccine hesitant and resistant individuals were more likely to trust information from social media compared to vaccine acceptors.¹⁰ It also differs from surveys of Lebanese university students in 2021²³ and a 2021 German study, where students were found to be significantly less likely to receive the COVID-19 vaccine when their primary source of information was YouTube.²¹ All of these studies were conducted when pandemic lockdown restrictions were in place and when COVID-19 vaccinations were still being rolled out on a large scale. In contrast, our study was conducted when Irish society and university business had returned to pre-pandemic function. Further research, within the same context, is needed to determine, with a greater level of confidence, if social media has a similar or different impact on the third level student compared to the general population during non-pandemic periods.

Possible interventions for the physical environmental factors include an increased amount of public health messaging in shared student accommodation. We found that a student’s COVID-19 and any vaccine uptake had a significant association with their accommodation type. COVID-19 vaccine-resistant individuals were significantly more likely to live in private, landlord-rented accommodation, and less likely to live at home, than vaccine acceptors and vaccine hesitants. This agrees with a university student survey in Ireland that primarily assessed risk behavior during the pandemic.¹⁹ The environment in which a student lives affects their exposure to information and attitudes. It can also impact on their interaction with close contacts in high-risk groups. In our study nearly one-third (31%) of students reported their main reason for being vaccinated in general as contributing to a public health campaign. This is similar to previous findings in Ireland which demonstrated that students were more likely to be vaccinated against COVID-19 based on the health and safety of elderly or immunocompromised family members.¹⁹ Unanticipated reasons for vaccine hesitancy were identified in our study. Access, previous illness with COVID-19 and safety concerns was provided in our survey as ‘Other’ answers when students were asked why they were hesitant to be vaccinated (Table S4). We based the list of responses on concerns commonly reported in the literature, but the high rate of ‘Other’ answers indicates that UCC students’ concerns are not the same as ones commonly reported in the literature.^{3–11–13–16–18,19-22,23-37} Based on our finding, it will be important to further focus on developing and implementing vaccine uptake interventions for students who live outside their family home and to be cognizant of less reported reasons for hesitancy.

Reported vaccine uptake rates were high for childhood, adolescent and COVID-19 vaccines, despite the frequency of students identifying as vaccine hesitant. There was no significant relationship between a student’s COVID-19 or any vaccine acceptance and their childhood and adolescent vaccination status. A positive association between annual influenza virus vaccination and COVID-19 vaccination behavior was identified here, similar to a study of third-level students in Texas.¹⁴ However, a significant correlation was not observed between influenza vaccine uptake and willingness to be vaccinated with any vaccine. This may be due to sample size. In Ireland, there was a large amount of public health messaging from the Health Services Executive (HSE) regarding COVID-19 vaccines, including during lockdown periods, when individuals’ movements were restricted. We postulate that the unusual context of a pandemic resulted in different willingness to receive a COVID-19 vaccine compared to routine vaccination in normal circumstances. For example, social implications of not receiving a COVID-19 vaccine, such as not being permitted to travel or enter public spaces, differ in implications of not being vaccinated with other vaccines. Secondly, while we intended for the statement “any vaccine” to be interpreted as any licensed, clinically available vaccination, students may have perceived it as any vaccine at all, licensed or unlicensed. This could also have caused some students to be wary of the statement and thus, respond differently compared to statement relating to COVID-19 vaccines. Future research to validate this survey will be needed to address this issue. However, these findings further highlight how context can impact on decision-making and/or responding to surveys.

This survey timing and context is a novel aspect of our study. Out of all EU countries, Ireland had the longest lockdown restrictions and closure of public spaces of any kind. Intermittent and variable lockdown measures existed from mid-March 2020 until mid-January 2022.³⁸ This study was conducted in September and October 2022, when students had returned to a normal, in-person university experience following the lifting of COVID-19 restrictions. The COVID-19 vaccines had still Emergency Use Authorisation at that time. The level of anxiety about COVID-19 compared to anticipation about an on-campus academic experience could have influenced students’ responses, again highlighting the influence of context on responses. This study included a range of individuals who had and had not previously experienced university life. This study did not exclude mature students (33%) or students enrolled in postgraduate programs and is composed of the full student body. Notably, vaccine confidence was similar. To our knowledge, all previous studies of university students relating to COVID-19 vaccine acceptance were conducted during the pandemic. As such, we believe that these preliminary results will be of interest to field.

The limitations and caveats of this study are that the number of analyzed responses (n = 151), resulting in a limited sample size. Secondly, an unpiloted and unvalidated survey was used. While we made the survey anonymous, responses could have been affected by social desirability bias. Furthermore, there may be selection and non-response bias. While the intention for this survey was to be distributed to all registered students, only those students who had continued to subscribe to the mailing list received the invitation to partake in this research. The objective of this study was to better understand third-level students’ attitudes to COVID-19 and other vaccines. The survey population is, however, reflective of Irish university demographics We do not believe that these findings are representative of any broader groups, outside of university students, and we do not wish to extrapolate our findings to broader groups without any evidence that this extrapolation is justified.

In summary, our study is novel in its timing; conducted when Irish universities and societies had fully re-opened after pandemic restrictions. Some of our findings, such as accommodation type, reenforce findings from other studies of Irish university students.¹⁹ Furthermore, we uniquely found that there was a significant association between students’ willingness to be vaccinated and behavior on social media, influenza vaccination. This was a small sample size and utilized an unvalidated survey. However, these preliminary findings improve our knowledge of university students‘ attitudes to both COVID-19 and other vaccines. This should underlie further research to tailor public health and vaccine advocacy messaging toward third-level students. The results presented here underlie further research on vaccine attitudes in other third-level institutes and populations.

Acknowledgement

The authors would like to thank all of the survey respondents for their time and input into this research.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary data

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2023.2287279.

Additional information

Funding

This work was not supported by any funding.