key: cord-0983871-y6ugso2p
authors: Silva, Jessica; Bratberg, Jeffrey; Lemay, Virginia
title: COVID-19 and Influenza Vaccine Hesitancy Among College Students
date: 2021-05-21
journal: J Am Pharm Assoc (2003)
DOI: 10.1016/j.japh.2021.05.009
sha: d958123f8e04d0a57ddff2af4dadda4ce30c34cb
doc_id: 983871
cord_uid: y6ugso2p

Background Successful vaccination against coronavirus 2019 (COVID-19) is an essential component of achieving community immunity to bring the COVID-19 pandemic to an end. Vaccine hesitancy, identified as a top threat to global health by the World Health Organization, is a significant barrier to vaccine uptake. With COVID-19 vaccination programs in effect since December 2020, it is critical that vaccination barriers are proactively identified. With limited information surrounding college students’ perspectives on COVID-19 vaccines, outreach measures will play a pivotal role in vaccine uptake in this population. Development of informative, cohort-driven vaccination campaigns requires proactive assessment of factors influencing vaccine hesitancy, access, and uptake. Objectives The primary objective of this study was to investigate the spectrum of vaccine hesitancy among college students at the University of Rhode Island (URI). The secondary objective was to identify differences in COVID-19 and influenza vaccine hesitancy rates in this population. Methods A 22-item, IRB-approved, anonymous questionnaire was developed to survey URI students who voluntarily attended two joint University Health Services and College of Pharmacy influenza vaccination clinics in November 2020. Results A total of 237 vaccination clinic participants consented and responded to at least one question on the survey. Once available to their respective priority group, 92% are very/somewhat likely to receive a COVID-19 vaccine and 50% will receive a COVID-19 vaccine as soon as possible. Only 3% of participants stated they would never receive a COVID-19 vaccine. The top three reported COVID-19 vaccine-related concerns were safety (37%), effectiveness (24%), and limited information (16%). When asked if COVID-19 vaccines and influenza vaccines should be mandated, 85% and 83%, respectively, were in favor. Conclusion Understanding the spectrum of vaccine hesitancy is critical in achieving COVID-19 community immunity thresholds. URI students are willing to be vaccinated against COVID-19 provided that the vaccines are proven safe and efficacious.

likelihood from 74% in April to 56% in December 2020 and cohort analyses (women vs men, black vs 1 white individuals, 65 years and older vs 18 to 49 years, and those with a bachelor's degree vs a high 2 school education or less) showed a larger decline in COVID-19 vaccination likelihood among women, 3 black individuals, individuals 18-49 years, and those with a high school education or less. 11 Such results 4 further supported the need for systematic vaccine hesitancy assessments to improve COVID-19 5 vaccination rates. 6

With limited information surrounding college students' perspectives on COVID-19 vaccines, 7 carefully crafted outreach measures will play a pivotal role in vaccine uptake in this population. A recent 8

New York Times survey indicates that college campuses account for at least 397,000 SARS-CoV-2 cases in 9 the United States; however, it is likely that a substantial number of un-tested students may have 10 unknowingly contributed to asymptomatic viral transmission. 12 Although younger, healthier people, like 11 college students, were not an initial priority group for vaccination, counties with universities and 12 colleges that returned to in-person instruction in the Fall of 2020 experienced relatively higher incidence 13 rates in COVID-19 cases than counties without these institutions due to community spread. 13,14 14 Therefore, in addition to emphasis on physical distancing, mask wearing, and gathering limits, 15 development of informative, cohort-driven vaccination campaigns on college campuses will ensure not 16 only students are protected, but also people at risk of severe disease, hospitalization, and death in their 17 communities. 18

The primary objective of this study was to investigate the spectrum of vaccine hesitancy among 20 college students at the University of Rhode Island (URI). The secondary objective was to identify 21 differences in COVID-19 and influenza vaccine hesitancy rates in this population. 22

Study design, population, and setting 24 This descriptive, cross-sectional survey study was approved by the URI Institutional Review 1 Board (IRB) as exempt research. URI Health Services and the College of Pharmacy organized two, no-cost 2 influenza vaccination clinics staffed by volunteers and students from both. To promote the clinics, URI 3

Health Services sent university-wide email messages with the location, dates, and times of the clinics on 4 the morning of the first clinic (Monday, November 9, 2020, 4-7 pm) and on November 12, 2020 prior to 5 the Monday, November 16, 2020, 10am-1pm clinic. These emails included links to the online Qualtrics® 6 (Provo, UT) survey as a URL and QR code. At the clinics, identical QR code survey links were accessible to 7 clinic participants on the back of vaccine consent forms. Volunteers encouraged participants to 8 complete the five-minute survey while waiting in line to get vaccinated and while being observed post-9 vaccination. Any student, 18 years or older, enrolled at URI who voluntarily attended the Health Services 10 and College of Pharmacy influenza vaccination clinic was eligible to complete the survey. Although 11 certain cohorts of students (e.g. nursing, pharmacy) are required to receive the influenza vaccine for 12 clinical experiences, influenza vaccination is not mandated by the University. There were no incentives 13 for survey completion. Survey responses were anonymous and only accessible by the researchers. 14

Participants reviewed a consent document and provided informed consent prior to proceeding 16 with the questionnaire. Demographics collected included age, gender, ethnicity, area of residence, 17 medical history, and current employment. The remaining 16 multiple-choice questions assessed 18 participants' vaccination preferences, level of concern if they became sick with influenza or COVID- 19, 19 willingness to receive influenza and COVID-19 vaccines, perceived benefits and concerns with influenza 20 and COVID-19 vaccines, and vaccine mandate preferences. Influenza vaccines were utilized as a 21 comparator to assess if vaccine hesitancy rates differed among students when compared to novel 22 COVID-19 vaccine(s). Participants could only select one response, with the exception of two "select all 23 that apply" demographic questions, and responded to likelihood questions using a four-point Likert 1 scale. 2 Survey completion took less than 5 minutes for the 22-item questionnaire. Participants could 3 exit the survey at any time and only completed responses were recorded upon survey submission. 4

Recorded responses securely stored within Qualtrics® (Provo, UT) were accessed by study researchers 5 for data analysis. Demographic data was summarized using descriptive statistics and proportions. For 6

Likert survey questions assessing concern surrounding influenza and COVID-19 illness, influenza and 7 COVID-19 vaccine mandates, and benefits of receiving influenza and COVID-19 vaccines, Mann-Whitney 8 U tests were performed among cohorts to identify if responses were impacted by demographics such as 9 age (18-19 vs 20-29 years), gender (participants who identify as female vs male), ethnicity (participants 10 who identify as white vs non-white), and occupation (healthcare professional vs non-healthcare 11 professional); p<0.05 indicates significance. To compare survey question differences between influenza 12 vaccinations and COVID-19 vaccinations, chi-square tests of independence were used. All statistical 13 analyses were performed using IBM corporation, SPSS version 26 (Armonk, NY). Of note, to assist with 14 ease of readability in tables, Likert-scale responses were consolidated into similar groupings (e.g. 15 very/somewhat likely and very/somewhat unlikely). 16

A total of 534 students attended the university-wide influenza clinics. Of those participants, 300 18 accessed the Qualtrics survey (56%) and 237 consented and responded to at least one survey question, 19 of whom greater than 94% responded to all survey questions. Demographic information (eTable 1) 20 collected at the end of the survey indicated 97% (n=230) of the participants were 18 to 29 years old, 21 65% (n=155) identified as female, and a majority identified as white or Caucasian, 84% (n=199). 22

Reported results are based upon those that responded to at least one survey question. 23

Survey questions assessed vaccination preferences as well as vaccine hesitancy factors related 1 to influenza and COVID-19 vaccination. A comparison of survey question differences between influenza 2 and COVID-19 vaccinations is found in Table 1 . When asked if they were concerned about getting sick, 3 significantly more participants were more concerned about COVID-19 illness than influenza. Females 4 reported increased concern surrounding COVID-19 (p=0.025); however, participants who did not identify 5 as white were more concerned about influenza (p=0.031). More students were motivated to receive the 6 influenza vaccine to prevent physician visits (p=0.03) and to protect themselves (p<0.001), whereas 7 students were more motivated to receive the COVID-19 vaccine to reduce viral spread (p=0.004). 8

Consistent with previously published vaccine hesitancy survey data, the top three reported COVID-19 9

vaccine-related concerns were safety (37%), effectiveness (24%), and limited information (16%). 2,15,16 10

Students were more concerned about limited access to and safety of COVID-19 vaccines, while a 11 majority of students, indicated no concern to receiving the influenza vaccine. Survey takers were in 12 favor of mandatory influenza and COVID-19 vaccinations by a margin of 6:1. Participants who identified 13 as female (p=0.011), non-white (p=0.039), and a healthcare worker (p=0.032) were more likely to 14 support influenza vaccine mandates compared to their counterparts. COVID-19 vaccine mandate 15 preferences were not statistically different among the analyzed cohorts. 16

The remaining questions (Table 2) for high-risk individuals based on age and comorbidities, so it remains to be seen if reducing cases 6 among the transmitting population is as effective a strategy. Our survey results indicate that college 7 students are aware of the critical importance of COVID-19 vaccination, with nearly 80% significantly 8 motivated to receive vaccination to protect others and reduce viral transmission as shown in Table 1 . 9

With over 90% of our surveyed college students likely to receive the COVID-19 vaccine once available to 10 them, in any location, campus-wide vaccination programs are well poised to lead to a reduction in 11 transmission rates. 12

Successful campus-wide vaccination programs require a multifaceted approach in collaboration 13 with local healthcare professionals and institutional healthcare programs, such as College of Pharmacy 14 faculty and students. A major barrier to address, particularly in this population, is prevalent 15 misinformation on internet and social media platforms. Our survey data revealed college students are 16 much more likely to receive a vaccination when recommended by a physician or pharmacist; however, 17 access to vaccine positive messages and reliable resources may be challenging. Research on social media 18 disproportionately promoting vaccine hesitancy indicates that anti-vaccine content incites more user 19 engagement with anti-vaccine tweets more likely to be re-tweeted by 4.13 fold. 19 With nearly 60% of 20 our college students receiving COVID-19 related information from such platforms, it is critical that 21 experts at higher education institutions and public health departments are utilized to share accurate, 22 reliable vaccine information via platforms preferred by students. Further, most of our college students 23 indicated increased concern regarding vaccine side effects and safety, effectiveness, and limited 24 J o u r n a l P r e -p r o o f information, thus programs should tailor educational messages to these specific concerns. Health 1 information can be difficult to navigate, especially in young adults who have had their healthcare 2 organized and directed by parents and caregivers for most of their lives. Overcoming vaccine hesitancy is 3 not a one-size fits all; however, knowing the audience and their needs is a critical step. Targeting 4 education on vaccine-preventable diseases, immunology, and critical thinking based on student's level 5 of education, delivered through multiple communication channels has been shown to reduce vaccine 6 hesitancy and mitigate vaccine misinformation. 20,21 Given one-third of our students have no preference 7 on where they receive their COVID-19 vaccine, institutional personnel should take this opportunity to 8 increase accessibility through on-campus vaccination clinics. 9

This study has various strengths and limitations. The large sample size allowed researchers to 10 effectively collect and report new information on college student perspectives on influenza and COVID-11 19 vaccines. Also, survey distribution coincided with a surge in COVID-19 cases and imminent EUA of 12 two vaccine candidates, making findings pertinent to the primary objective. However, due to a limited 13 timeframe to submit for and receive IRB approval prior to the first influenza clinic survey questions were 14 not piloted or validated, which may have led to redundant and/or misguided questions. The 15 questionnaire was only provided to URI students and other URI community members who attended 16 influenza clinics with the intention of receiving a vaccination, introducing bias towards vaccine uptake. 17

As discussed, influenza vaccine hesitancy on college campuses negatively impacted past vaccination 18 rates. To counteract this, surveys addressed the need to understand vaccination barriers or hesitancy to 19 enhance educational opportunities. 18 Although vaccine uptake bias may have skewed results, influenza 20 vaccine and COVID-19 vaccine hesitancy factors differ as shown in Tables 1 and 2, which supports the 21 need for institutions to consider such factors when creating educational programs to increase 22 vaccination uptake campus-wide. Study findings are representative of this population and may not be 23 generalizable to a larger sample of college students. Participants were not asked about university 24 affiliation (e.g. student or faculty/staff member) in the demographics, thus it is possible that 1 faculty/staff completed the survey. Additionally, since survey demographics did not ask about prior 2 vaccine knowledge nor field of study, this may have potentially confounded the results. As COVID-19 3 data changes daily, this research was conducted prior to the release of Phase 2/3 efficacy data on 4 currently available COVID-19 vaccines through FDA's EUA which may influence current vaccine hesitancy 5 rates. 6

Understanding the spectrum of vaccine hesitancy on college campuses is a critical step in 8 slowing community spread and achieving COVID-19 immunity thresholds. Published data demonstrate 9

increased COVID-19 incidence and community-wide transmission rates among college populations. 8 What is your biggest concern with the influenza and COVID-19 vaccine(s)? 

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Survey Response % (n)