https://orcid.org/0000-0003-1186-0543
ABSTRACT
This study determines factors related to the intention to vaccinate against COVID-19 for health science students in Ho Chi Minh City (HCMC), using both the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB) model. A cross-sectional survey was considered in April 2021, using a self-administered questionnaire to all health sciences students of the University of Medicine and Pharmacy in Ho Chi Minh City (UMP), Vietnam. The multiple regression was performed to specify the predictable factors of willingness to get a future COVID-19 vaccination.
A total of 854 students completed the survey, whose vaccination acceptance was 77.1%. Predictors of intention to receive a COVID-19 vaccination included year of education, knowledge, and the HBM and TPB variables including the perceived benefits, cues to action, perceived behavioral control, and positive attitudes toward the vaccine (all p < .05). The main reasons for hesitancy included being afraid of the side effects (73.0%), vaccine safety (65.3%), and the process of new vaccine development (53.6%). The study examined students’ intention toward COVID-19 vaccine and related factors to notify university administrators and policymakers. The findings showed the acceptability of vaccines had differences within the education year of students, besides, knowledge, perception of benefits, cues to action, behavioral control, and attitudes toward the vaccine were positive predictive factors. These may be useful for developing health education messages to promoting vaccination acceptability for students who had hesitancy of a new vaccine and in broader groups.
Introduction
The Coronavirus disease-2019 (COVID-19) pandemic is considered a global challenge due to the impact across all aspects of living, especially healthcare facilities.Citation1 As of 12 June 2021, the World Health Organization (WHO) reported, cumulatively, over 174 million confirmed cases with SARS-CoV-2 resulting in over 3.7 million deaths worldwide.Citation2 The South-East Asia region has recorded increasing cases of COVID-19, with about 33.3 million cases and over 447,938 deaths. Vietnam faces the fourth wave of COVID-19 with the number of cases increasing daily.Citation3 Clinical manifestations of COVID-19 occurs ranging from asymptomatic infections from mild to severe including fever, dry cough, tiredness, difficulty breathing or shortness of breath, chest pain, and so on.Citation4 The mean incubation period was 5.2 days and a range from 0 to 24 days before illness onset.Citation5 In terms of treatment, there is no specific antiviral medication for COVID-19, the main treatment are symptomatic and supportive. Consequently, it is necessary to comply with preventive measures like washing hands regularly, wearing face masks, social distancing, limit gatherings, lockdowns and so on. However, the attempts to loosen these precautious behaviors have led to exponential growth in cases in several countries.Citation6 Moreover, there has been the rapid emergence of the new variant of SARS-CoV-2 that spreads more easily and is seen as causing more severe symptoms.Citation7 At present, immunization appears to be one of the most cost-effective preventive interventions to control this crisis, especially noting the current effective vaccines that have been developed and approved for vaccination.Citation8,Citation9 Notably, several vaccine candidates, such as Pfizer-BioNTech, Moderna, and AstraZeneca showed high efficacy.Citation10 In Vietnam, a total of 1,187,607 vaccine doses have been administered thanks to the COVAX Facility.Citation2 The vaccination process has started with priority groups, including people who participate in the fight against COVID-19, such as healthcare workers, security personnel, frontline workers, and patients at higher risk of infection.Citation11 Besides, the Government is currently focused on efforts to supply equivalent vaccines to achieved herd immunity through large-scale vaccination strategies. According to Shaffer et al the predicted vaccine coverage to gain COVID-19 herd immunity ranges from 55% to 82%.Citation12 However, the percentage of the population to be vaccinated will also depend on the individual’s willingness to receive a vaccination against COVID-19. Vaccine hesitancy is one of the top 10 threats to global health, especially in the context of the emerging COVID-19 and its vaccines. The reluctance or refusal to vaccinate threatens progress in tackling diseases.Citation9 The conceptual framework including the health belief model (HBM) and the theory of planned behavior (TPB) has been proposed as the theoretical guideline to explain the factors influencing the health behavior in public health research.Citation13,Citation14 Previous studies showed that a number of students were hesitant to get vaccinated such as medical students in Uganda (37.3%),Citation15 Egyptian (64%),Citation16 the USA (23%).Citation17 In Vietnam, Health science students would be mobilized and supported healthcare workers against COVID-19, making them a vulnerable group and a priority for vaccination. Also, they are an important force for health education in communities. Therefore, it is essential to investigate the acceptability of students toward COVID-19 vaccination and associated factors by integrating the HBM and TPB model to establish effective interventions to gain vaccination coverage.
Methods
Participants and survey design
A cross-sectional survey was considered in April 2021 by using a self-administered questionnaire that was sent to all the first to sixth-year health sciences students who were studying Medicine, Preventive medicine and public health at the University of Medicine and Pharmacy in Ho Chi Minh City (UMP) in Southern Vietnam. Exclusion criteria included instances where data was not included in any items in TPB and HBM scales. All respondents were informed about the aims of the study and informed consent was given before participating.
Data collection
The structured questionnaire was designed including four sections: (1) the demographics of respondents; (2) the 10 items toward COVID-19 knowledge;Citation18 (3) the 12-items HBM scale that was validated in our previous study, with Cronbach’s alfa of 0.76Citation19 and the 12-items TPB scale that was used in the prior study of Myers LB toward swine flu vaccine using a 5-option scales ranging from strongly disagree to strongly agreeCitation20 and only one for evaluating the intention to receive a future COVID-19 vaccination. The questionnaire was followed by a pilot test among 20 students of the first-year study to give their opinions toward comprehensibility.Citation21 It took around 15 minutes to complete each.
Statistical methods
The knowledge items were classified into correct and incorrect, with one point for each correct answer. A mean score of total knowledge was calculated, which ranged between 0 (with no correct answer) and 10 (for all correct answers), with higher scores representing higher/good knowledge. Each item of both the HBM and TPB scale was applied on the 5-point Likert scale, with one score anchored at strongly disagree and five scores for strongly agree. The mean score of each item and domain of the HBM and TPB scales were computed separately. For assessing vaccination intention, responses of being “absolutely certain,” “very likely,” or “somewhat likely” were marked as a positive vaccination intention, and responses of being “not likely” or “none” were determined as unwillingness to receive a vaccination.
Statistical analysis was performed using STATA 14 software. The reliability of the HBM and TPB scale was done using Cronbach’s α test, the descriptive analyses displayed the frequencies (percentages) and mean scores (standard deviations) of the responses. The Chi-square test or t-tests that were based on the characteristics of the examined variables, was done in the univariate analysis to determine a relationship between the dependent variable (intent to get vaccinated) and independent variables (demographics of participants, knowledge, and both TPB and HBM scales). The multiple regression was only performed for the independent variables that were identified in the univariate analyses at significant levels of <.05. Odds ratios (OR) with 95% confidence intervals (95% CI) were calculated separately for variables of demographics, knowledge, and each domain of both HBM and TPB scale, the p-value of < .05 was considered as statistically significant difference.
Ethical considerations
All participants in the study agreed and signed a consent inform before answering the questionnaire. The study was approved by the Ethics Council, University of Medicine and Pharmacy at Ho Chi Minh City, Vietnam (protocol number 27/UMP-BOARD), which permitted us to perform on all high-risk subjects with COVID-19 including people with chronic illness, health science students.
Results
Demographics and intention to get a vaccine against COVID-19
Of the study population, a total of 854 first to sixth-year students (82.1% of invited participants) finished and returned the questionnaire, whose mean age was 22.1 ± 2.5 years, most of them were female (63.0%), and of no religion (80.4%). The sources of COVID-19 information were mainly via social media (88.5%) and television (76.6%). The rate of vaccination acceptance was 77.1%. There was a significant association between vaccination intention and demographic including age, year of education, and source of COVID-19 information (p < .05). However, there were no significant differences between vaccination intention and gender, religion, and specialty ().
Table 1. Demographics and COVID-19 vaccine acceptance (N = 854)
Knowledge, HBM, and TPB variables and intention to get a vaccine against COVID-19
The univariate analyses displayed the relationship between knowledge, HBM and TPB constructs and the intention to get vaccinated against COVID-19 (). There was a significant difference between knowledge scores and vaccination intention (p < .05). For the HBM model, the findings showed there was a significant relationship between vaccination intention and the perceived susceptibility and severity of COVID-19, benefits of vaccination, and cues to action (all p < .05). Also, there was a significant correlation between vaccination intention and the TPB constructs, including the attitude, subjective norms, PBC, and self-efficacy (all p < .001).
Table 2. Univariate analyses between HBM and TPB variables and the intention to get vaccinated against COVID-19 (N = 854)
Factors correlating intention to get a vaccine against COVID-19
The results of the multiple regression found that years of education, knowledge, some domains of HBM and TPB were related to vaccination intention, accordingly, participants who were the third to fifth-year students were more likely to intend to get a COVID-19 vaccination compared to those who were in their first-year of study (p < .05). Respondents who showed the higher the mean knowledge scores were, the higher the probability of vaccination intention. (OR 1.2, 95% CI 1.01–1.38, p < .05). For the HBM constructs, participants were more likely to receive a vaccination if they had a higher level of perceived benefits (OR 2.6, 95% CI 1.83–3.59, p < .001) and of cues to action (OR 2.7, 95% CI 1.72–4.13, p < .001). Regarding the TPB variables, students had higher vaccination intention if they had a higher level of a positive attitude (OR 1.4, 95% CI 1.01–1.92, p < .05) and of PBC (OR 2.9, 95% CI 2.04–3.99, p < .001) ().
Table 3. The multiple regression analysis of factors associated with intention to get vaccinated against COVID-19 (N = 854)
Reasons for COVID-19 vaccine hesitancy
Among participants who were unwilling to get a COVID-19 vaccine, the main reasons found that being afraid of the side effects (73.0%), a desire to delay and follow-up on the safety of the vaccine (65.3%) and afraid of the process of new vaccine development (53.6%). The under a half rate of students reported that they have a plan to use other preventive measures (43.9%), afraid of needles (27.6%), the vaccine could lead to illness (21.9%), afraid of the expensive vaccination costs (18.4%), not considered themselves in the high-risk group (18.4%), do not trust the government (10.2%), and vaccines are not effective (7.7%) ().
Table 4. Reasons for COVID-19 vaccine hesitancy (n = 196)
Discussion
To the best of our knowledge, this is the first study to examine the acceptance and associated factors toward the COVID-19 vaccine among health science students who could be mobilized in responding to the current pandemic that cases continue to increase in Vietnam. The Government is focused on their efforts to supply equivalent vaccines to help control the pandemic. The success of a vaccine strategy will depend on the rate of uptake of the vaccine among the population. As a result, investigating the intention to get a COVID-19 vaccination, as well as factors that influence a person to accept or be hesitant to receive the vaccination is essential to enhance vaccination uptake in the community, especially the students who are in the priority group to assist healthcare workers.
Firstly, the findings revealed that the acceptance was relatively high (77.1%). This result was higher than other previous studies on medical students in Uganda (37.3%),Citation15 Egyptian (64%),Citation16 the USA (52.5%),Citation22 France (58.0%),Citation23 but lower than studies in China (78.9% and 94.73%).Citation24,Citation25 A possible explanation for this might be that the discrepancy of the time of the survey and our survey conducted in the context Vietnam begin implementing immunization for priority groups including the healthcare force.Citation11 It is possible, therefore, that there is a discrepancy in the impact of COVID-19 around the world, which could directly affect an individual’s risk perception toward COVID-19 and undermine their decision to be vaccinated. However, this finding was lower than a survey among high-risk people which was recorded as 84%.Citation26 This result may be explained by the different levels of education. This study found that knowledge found that was associated with vaccination intention (OR 1.2, 95% CI 1.01–1.38, p < .05). These results are in line with those of Robinson E. et al, which showed that the education level was consistently associated with the willingness to get vaccinated.Citation27 However, Kricorian et al found that people who were less educated believed the vaccination is safe and they were likely to get the vaccine.Citation28
Second, we found that over one-fifth of students were hesitant about the vaccine. The main reasons reported include being afraid of the side effects (73%), follow-up the safety of the vaccine (65.3%), and being afraid of the process of new vaccine development (53.6%). This also accords with earlier observations, which showed that vaccination hesitancy is influenced by several factors, such as fear of adverse side effects and vaccine safety, perceived ineffectiveness of vaccine.Citation29 This may indicate the interventions that should be implemented to convince a remarkable proportion of college students that expressed hesitancy toward the vaccine.
Third, the majority of students received information toward COVID-19 via social media (88.5%). Social media are the major platforms that people could seek information and discuss COVID-19.Citation30,Citation31 In accordance with the Luo S’ results that increasing social media exposures and peer discussions could enhance students’ perceived information sufficiency, which leads to a rise in their vaccination intention.Citation32 However, social media was recorded as the major source of negative information about vaccination. The spread of mis- and disinformation through the social media platforms, such as conspiracy theories, exaggerated side effects, and down-graded vaccine efficacy may increase vaccine hesitancy.Citation33,Citation34 Therefore, communication campaigns need to be organized via social media sources, with censored information, which focuses on enhancing the knowledge and attitude toward COVID-19, and the benefits of the vaccine, as well as encourage students to share positive thoughts and experiences with others, which contributes to promoting vaccination acceptance.
At last but not least, we used theoretical models, including HBM and TPB, based on this research, provide greater insight into the factors that influence the willingness to get a COVID-19 vaccine of students. HBM and TPB models were used widely as the theoretical framework to describe why an individual accepts the changes in health-related behaviors such as vaccination. To reduce the limitations of the models, over the past several years, researchers improved them by using an integrated model which was a combination of factors in different models together to explain and predict the health-related behavior.Citation35 Therefore, our study has combined both models, with hoping to have a full report of the predictable results, this is the novelty and contribution of the study. Findings in this study indicate that there were associations between HBM, TPB constructs, and vaccination intention including perceived benefits, cues to action, a positive attitude and PBC. These results seem to be consistent with Myer et al.Citation36 Wong LP et al.Citation37 Also, a previous study showed that higher vaccination intention were mostly associated with belief in the benefits of the vaccine, trust in institutions, perceived effectiveness of the vaccine, influence of social environment, protection of patients and perceived healthcare professionals’ duty.Citation38
This study has some limitations. First, this is a cross-sectional study, thus the relationship between intention and factors could not be examined. Second, the vaccine is not yet available for the entire population, so and vaccine decisions are multifactorial, which can change over time. Third, it should be considered the generalization of this research results to a broader population because this study was limited to the students in one university in Vietnam.
Conclusion
As the COVID-19 pandemic is still happening with many new variations, all health care staff can be mobilized to participate in anti-pandemic including health science students. Besides taking preventive measures at all times, they need to be fully vaccinated with the COVID-19 vaccination. The study provides evidence that the acceptability of vaccines had differences within the education year of students, besides, knowledge, perception of benefits, cues to action, behavioral control, and attitudes toward the vaccine were positive predictive factors. These may be useful for university administrators and policy makers to develop health education messages to promoting vaccination acceptability for students who had hesitancy of a new vaccine and in broader groups.
Acknowledgments
We wish to acknowledge the cooperation and support of students at the University of Medicine and Pharmacy at HCMC for the time and effort that they devoted to the study.
Data availability
The data used to support this study are available from the first author upon request.
Disclosure Statement
No potential conflicts of interest were disclosed.
Additional information
Funding
References
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