key: cord-1053867-trhh1ly4
authors: Zhou, Ying; Wang, Yidan; Li, Zheng
title: Intention to get vaccinated against COVID-19 among nursing students: A cross-sectional survey
date: 2021-09-16
journal: Nurse Educ Today
DOI: 10.1016/j.nedt.2021.105152
sha: 355d5b529b0e590211acda9401cf10460135930b
doc_id: 1053867
cord_uid: trhh1ly4

BACKGROUND: As the COVID-19 pandemic continues, safe and effective vaccines with high coverage remain the most effective way of controlling the infection. Therefore, the intention to get vaccinated is a critical issue for nursing students because they will act as health care providers and educators due to their future profession. OBJECTIVES: This study aimed to explore factors associated with COVID-19 vaccination intention among Chinese nursing students. DESIGN: A cross-sectional online survey was used. PARTICIPANTS: A total of 1070 Chinese nursing students participated in this study. METHODS: The study used structured self-administered questionnaires to assess the effects of the following elements; sociodemographic factors, vaccination status, beliefs on general vaccination, beliefs and attitudes towards COVID-19 and COVID-19 vaccination, and COVID-19 vaccination intention. Hierarchical regression analysis was conducted to examine the relationship between these variables and COVID-19 vaccination intention. RESULTS: More than half (51.9%) of nursing students were willing to vaccinate against COVID-19, while 43.4% were uncertain and 4.7% were unwilling to get vaccinated. Increased likelihood of intention to get vaccinated was associated with positive beliefs towards general vaccination and COVID-19 vaccination, perceived less adverse effects following vaccination, the greater impact of COVID-19 on daily life, and less clinical practice experience in healthcare settings. Those hesitant to vaccinate raised concerns about the safety of vaccines, doubted the efficacy, believed that vaccination was unnecessary, or had insufficient information on COVID-19 vaccines. CONCLUSIONS: More efforts are needed to enhance vaccine confidence and increase the vaccination rates against COVID-19 in nursing students by organizing effective educational campaigns and establishing positive vaccination beliefs.

The coronavirus disease 2019 (COVID-19) pandemic has imposed a substantial burden on society and healthcare systems. As of 31 July 2021, the virus had spread to 237 countries or territories, infected over 196 million people, and caused over 4 million deaths worldwide J o u r n a l P r e -p r o o f (WHO, 2021) . The development and implementation of vaccines are critical to controlling the spread of COVID-19. There is a worldwide effort to develop effective vaccines against . As of late July 2021, there are 135 vaccines in clinical trials with 392 in various stages of development. Currently, 21 COVID-19 vaccines have been approved for marketing worldwide. Among these vaccines, Sinovac and Sinopharm produced by China have been listed for World Health Organization (WHO) Emergency Use Listing (Shrotri et al., 2021) .

However, successful vaccination programs depend not only on efficacious vaccines but also on high vaccine coverage. Consequently, strategies to increase the uptake of vaccines are vital to prevent infection (Dror et al., 2020; Le et al., 2020) .

Accumulating evidence suggests healthcare professionals are priority targets for COVID-19 vaccines because they are at a higher risk of infection (Chirico et al., 2020) .

Nurses and nursing students are the most vulnerable group of healthcare professionals since they provide direct care to patients (Jackson et al., 2020) . They have been at the front line during the COVID-19 pandemic. Compared to nurses, nursing students have less clinical experience and weaker protective techniques, and therefore more susceptible to infection.

Additionally, nursing students are important since they act as care providers and health educators due to their future profession (Patelarou et al., 2021) . Therefore, more vaccination efforts should be directed towards nursing students to protect them from infection.

Numerous studies have investigated the COVID-19 vaccination intention among different populations (Sallam, 2021; Tavolacci et al., 2021) . A systematic review of COVID-19 vaccine acceptance rates worldwide included 60 surveys from 33 different J o u r n a l P r e -p r o o f countries (Sallam, 2021) . The study populations included the general public (47/60), healthcare workers (8/60), parents/guardians (3/60), and university students (2/60). The review suggested that most studies focused on the general population. Additionally, preliminary studies have shown that the vaccination intention of medical and nursing students is different from that of other professional peers. A recent survey in Jordan showed that healthcare students (43.5%) were more receptive to COVID-19 vaccines than their peers in scientific or humanities schools (23.6%) . Another survey of French college students showed that medical students (75.9%) were more likely to get vaccinated than other professional students (58.0%). Notably, the vaccine acceptance of nursing students (50.0%) was much lower than that of medical and pharmacy students (81.0%) (Tavolacci et al., 2021) . Therefore, more attention should be paid to nursing students in future research.

Plenty of recent literature highlights the factors associated with the COVID-19 vaccination intention. For example, a cross-sectional study on the Chinese public showed that the increased likelihood of COVID-19 vaccine acceptance was associated with being male, married, perceived higher risk of infection, previous influenza vaccination, beliefs in vaccine efficacy, and valuing medical advice (Wang et al., 2020a) . Additionally, a systematic review on healthcare workers showed that age, health status, and attitudes towards COVID-19 vaccines were other factors for the vaccination intention (Galanis et al., 2020) . Out of these studies, only a few reported on the general vaccination beliefs. For instance, a nationally representative cross-sectional study in the UK found that vaccination intention was related to general vaccination beliefs (Sherman et al., 2020) . This study could also be used as a theoretical reference for future research to explore the associations between vaccination J o u r n a l P r e -p r o o f intention and other factors because it has considered comprehensive aspects, including sociodemographic factors, vaccination status, general vaccination beliefs, and attitudes towards COVID-19 and COVID-19 vaccination. Additionally, few studies have explored the reasons behind reservations about vaccination. Notably, a previous survey on nurses explored the reasons behind the unwillingness to vaccinate. The reasons included doubts on efficacy and safety, believing vaccination unnecessary, and lack of time to vaccinate (Wang et al., 2020b) . Moreover, perceived contraindication and vaccine-related information were shown to be critical factors for vaccine hesitancy (Dror et al., 2020) . Therefore, future studies need to include these factors while exploring the reasons behind the unwillingness to vaccinate.

Improving the acceptance of COVID-19 vaccines among nursing students is considered an important strategy to prevent infection and build public confidence in vaccination.

Therefore, there is an urgent need to investigate the status and identify factors associated with COVID-19 vaccination intention among nursing students. One cross-sectional study in Europe indicated that less than half (43.8%) of nursing students were willing to accept COVID-19 vaccination (Patelarou et al., 2021) . Gender, working experience, previous influenza vaccination, trust in the government and medical staff, and knowledge of COVID-19 vaccines were some of the factors contributing to vaccination intention.

Nevertheless, these findings should be interpreted with caution since vaccination beliefs were not considered. This study also did not explore the reasons for the uncertainty of vaccination.

Moreover, some researchers have refined the classification of vaccination intentions (Kregar Velikonja et al., 2021; Sherman et al., 2020) . Kregar Velikonja et al. (2021) surveyed nursing students in three European countries and the results showing that the proportions of vaccine J o u r n a l P r e -p r o o f acceptance, vaccine hesitancy, and vaccine refusal were 35.0%, 43.0%, and 22.0%, respectively. These findings indicated that European nursing students had a high incidence of vaccine hesitancy and refusal, which were serious health issues to threaten the effectiveness of COVID-19 vaccination programs. Although a cross-sectional survey in China has investigated the willingness of nursing students toward COVID-19 vaccines (Jiang et al., 2021) , the situation of vaccine hesitancy and refusal remains unknown. Given the huge cultural difference between Europe and China, the present study aimed to investigate the status of COVID-19 vaccination intention and explore its associated factors among Chinese nursing students, which may lay a scientific foundation for government, healthcare organizations, and universities to develop targeted vaccination programs for nursing students according to different vaccination intentions.

This cross-sectional study was conducted from 4 January to 20 January 2021, when China had announced the approval of the first COVID-19 vaccine on 31 December 2020.

Nursing students, including junior college, undergraduate, and graduate students, were invited to the study through a secure online survey platform (Wenjuanxing). The research team used WeChat and QQ (popular social media platforms in China) to recruit the students and send the survey link to university faculty or staff. They cooperated with the research team and utilized their contact networks to distribute the questionnaires. Incomplete questionnaires could not be submitted. For the COVID-19 vaccination intention, participants were asked the following question (Sherman et al., 2020) : "When a coronavirus vaccination becomes available to you, how likely are you to receive one?" Responses were rated on an 11-point scale ranging from 0 (extremely unlikely) to 10 (extremely likely). Derived from prior research (Sherman et al., 2020) , the response options were divided into three categories: (1) very unlikely to get vaccinated (response of 0-2), (2) uncertain about getting vaccinated (response of 3-7), and (3) very likely to get vaccinated (response of 8-10). Notably, those whose response was "unlikely" or "uncertain" were further asked to give specific reasons in a multiple-choice question. The options involved suspicions on vaccine efficacy, concerns about safety, believing vaccination unnecessary, general vaccine refusal, and perceived contraindication.

All the data were analyzed using SPSS version 24.0. Descriptive statistics were used to summarize the sociodemographic characteristics of the study participants. Differences in groups were analyzed using the chi-square test. Correlations among vaccination intention, J o u r n a l P r e -p r o o f beliefs and attitudes towards COVID-19 and COVID-19 vaccination were analyzed using Pearson or Spearman correlation coefficient as appropriate. The hierarchical regression analysis was used to examine the relationship between COVID-19 vaccination intention and the variables. Variables entered into the model were selected based on theoretical relevance (Sherman et al., 2020) ; no variable selection procedures were employed. Five groups of variables were included in the model: sociodemographic characteristics, vaccination status, general vaccination beliefs, beliefs and attitudes towards COVID-19 and COVID-19 vaccination. Regression coefficients were used to evaluate the association effect while R 2 was used to determine the variance explained by the model. The statistical significance level for all tests was p<0.05.

This study was approved by the University"s Institutional Review Board. Before the survey, all participants were asked to give informed consent.

A total of 1,070 nursing students from 12 schools in eight provinces completed the survey. The detailed information of nursing students is shown in Table 1. The mean age was 19.87±1.89, with the majority being women (82.1%). More than 90.0% of participants were Han Chinese and had no religious affiliations. Notably, junior college students and undergraduates (82.1%) accounted for the majority of participants. 36.2% had clinical practice experience in healthcare facilities over the past six months. 64.1% had an average monthly household income of less than 5000 RMB and 44.2% had a personal monthly J o u r n a l P r e -p r o o f expenditure of 1000-1500 yuan. Additionally, most (80.6%) participants rated their health as good to excellent while 52.1% reported confirmed or suspected cases in their cities.

Concerning the COVID-19 impact on daily life, 44.1% rated it as large or very large.

Participants perceived that the public was at a greater risk of COVID-19 than themselves (90.6% vs. 51.1% reporting high or very high risk). Regarding the vaccination status, only 10.9% of participants had received seasonal influenza vaccination in the past two years, 9.9% had received the HPV vaccine, and 22.8% were planning to receive the first dose of the HPV vaccine. Figure 1 displays the COVID-19 vaccination intention of nursing students. The scores showed a significant negative skew (mean=7.24, standard deviation=2.29, median=8).

Overall, 51.9% of nursing students were very likely to get vaccinated, while 43.4% were uncertain, and 4.7% were unwilling to vaccinate against COVID-19.

There were significant differences among the unwilling, uncertain, and willing groups in gender, education level, clinical practice experience in healthcare facilities, perceived the risk of COVID-19 infecting the public and themselves, COVID-19 impact on daily life, and current plan to receive HPV vaccines ( Table 3 shows the hierarchical regression analysis results where sociodemographic characteristics, such as gender and education level, were included in Step 1. The results showed that these factors had little (3.3%) contribution to vaccination intention. Subsequently, vaccination status was added in Step 2, and it showed little contribution (1.0%). In

Step 3 13.7%, p<0.001). Additionally, they were less likely to have general vaccine refusal (3.9% vs.

11.8%, p=0.011) compared to those who were unwilling to accept vaccination.

This study advances our knowledge of factors associated with COVID-19 vaccination intention among Chinese nursing students. The results indicated that beliefs on general vaccination and COVID-19 vaccination were the most critical factors for vaccination intention. Additionally, this study explored the different reasons behind uncertainty and unwillingness to vaccination. These findings may help governments, healthcare organizations, and universities develop targeted programs and interventions to improve vaccine coverage.

In this study, more than half (51.9%) of nursing students were likely to get vaccinated.

These findings were consistent with the results from a systematic review which showed that 56.0% of healthcare workers were willing to vaccinate against COVID-19, although there was a wide range (from 28.0% to 82.0%) among studies (Galanis et al., 2020) . Additionally, the acceptance rate of the COVID-19 vaccines among nursing students in this study is J o u r n a l P r e -p r o o f slightly higher than that reported by two European studies (43.8% and 35.0%) (Kregar Velikonja et al., 2021; Patelarou et al., 2021) . This may be because students had more confidence in COVID-19 vaccines given that China has rich experience in epidemic management and vaccine development. Moreover, 43.4% of nursing students were uncertain about vaccination while 4.7% were unwilling to vaccinate. Similarly, a cross-sectional study in France showed that the proportions of healthcare students who were undecided and unlikely on vaccination were 26.7% and 15.6%, respectively (Tavolacci et al., 2021) . In contrast, a previous survey in Italy showed that only 13.9% of university students intended to vaccinate during the pandemic (Barello et al., 2020) . These contradictory results could be attributed to differences in the study populations, variations in morbidity and mortality among countries, and research during different periods of the COVID-19 pandemic. Notably, a higher rate of vaccine skepticism was reported in nursing students, suggesting that vaccine hesitancy remains a challenge to fight COVID-19 (Dror et al., 2020) . Recently, some experts have recommended calling for multilevel efforts at the policy, healthcare organizations, and university levels, and applying evidence-based strategies to influence behavior change and address vaccine hesitancy (Chevallier et al., 2021; Finney Rutten et al., 2021) . There is an urgent need to draw on the evidence base in social, behavioral, communication, and implementation science, and encourage the use of individual and organizational interventions to increase the vaccination acceptance among nursing students. The results demonstrated that nursing students with clinical practice experience in healthcare facilities were less likely to vaccinate. This was inconsistent with common knowledge that healthcare professionals are more likely to vaccinate due to their higher risk of infection. Additionally, recent studies have presented similar findings concerning the association between these two variables. A cross-sectional study on nursing students in Europe showed a negative relationship between clinical practice and vaccination acceptance infection, little knowledge on vaccines, and more suspicions on vaccine efficacy (Galanis et al., 2020) . This finding highlights a major issue in healthcare institutions since nurses and nursing students have more direct contact with patients than other healthcare workers.

Therefore, more qualitative studies should focus on this population to understand their thoughts on COVID-19 vaccination.

Moreover, perceived greater impact on daily life was closely related to stronger intentions to receive COVID-19 vaccines. This corroborated with the previous research (Wang et al., 2020a) , possibly because nursing students were eager to return to normal life.

However, the perceived risk of COVID-19 to oneself was not related to vaccination intention, contrary to previous studies (Gagneux-Brunon et al., 2021; Sherman et al., 2020) . In this study, nursing students perceived that the public was at a higher risk of COVID-19 infection compared to themselves. This suggested that the nursing students were more concerned about other people"s wellbeing, possibly due to their sense of duty to protect others (Jackson et al., 2020) . Similarly, a recent survey on nurses revealed that collective responsibility was a critical factor for vaccination intention (Kwok et al., 2021) . Meanwhile, collectivism is the one of core elements of Chinese culture. Therefore, instilling a sense of collective responsibility in healthcare education may improve vaccination coverage among nursing students.

However, a stronger association between these two variables was reported by other studies (Galanis et al., 2020; Patelarou et al., 2021) . This difference may be attributed to the fact that J o u r n a l P r e -p r o o f developed countries have formulated national influenza vaccination policies and recommendations, while many developing countries like China have not (Galanis et al., 2020) . Additionally, the influenza vaccination rate in this study was low (10.9%) among nursing students. Therefore, it is necessary to learn successful experiences from countries with high influenza vaccination rates. Recently, some experts suggest combining seasonal influenza and COVID-19 vaccines due to the same susceptible population (Kwok et al., 2021) . Promoting influenza vaccination may increase the COVID-19 vaccination rates and this can be incorporated into future vaccination programs for nursing students.

Contrary to the previous reports (Galanis et al., 2020; Patelarou et al., 2021) , this study found no evidence of an association between gender and vaccination intention. The results also revealed that beliefs on general vaccination and COVID-19 vaccination were critical factors for the vaccination intention. The score of vaccination beliefs was independent of gender. This may be because women and men had similar beliefs on COVID-19 vaccination, resulting in a lack of differences in the vaccination intention. Unlike previous research (Olagoke et al., 2021) , religiosity was not related to vaccination intention. This may be due to the low rate (2.4%) of religious beliefs in this study"s population.

This study also explored the reasons behind the unwillingness to vaccination. The findings showed that hesitant nursing students had little trust in vaccines as they lacked vaccine-related information and worried about safety, corroborating with the previous studies (Patelarou et al., 2021; Wang et al., 2020b) . Therefore, there is an urgent need for the government, policymakers, and other stakeholders to build vaccine confidence through effective educational campaigns. According to WHO recommendations, these campaigns J o u r n a l P r e -p r o o f should particularly focus on explaining how vaccines work and how they are developed.

Information on the types, doses, onset, time of action of the vaccines should also be provided (WHO, 2020) . Moreover, nearly half of the participants were hesitant to receive a COVID-19 vaccine because they believed it was unnecessary. Future strategies should emphasize the risk of infection and the benefit of immunization to individuals and society.

Furthermore, nursing students unwilling to vaccinate were more prone to have general vaccination refusal. Consistent with previous research (Jiang et al., 2021) , there is no statistical difference between education level and vaccination intention. Additionally, a recent study showed that lower parental education was a predictor of vaccine refusal (Bertoncello et al., 2020) . This suggested that vaccine refusal may be instilled early in life and this may be difficult to change in the later stages. Nursing students holding negative beliefs on vaccines may be more likely to refuse vaccination. Moreover, misleading media reports on vaccines and conspiracy theories may be other setbacks to vaccination acceptance (Puri et al., 2020) . Therefore, authoritative healthcare organizations and schools should develop educational programs through effective information delivery methods like messaging, social media, and chatbots according to expert recommendations (Chevallier et al., 2021; Finney Rutten et al., 2021) . Special strategies, including campaigns targeted at anti-vaccination groups and using evidence-based measures to thwart false propaganda, may enhance vaccine confidence.

Identifying the factors influencing COVID-19 vaccination intention can provide useful information for governments, policymakers, and university authorities to increase the vaccine acceptance of nursing students. Vaccine hesitancy and refusal for nursing students were 46.461(< 0.001 * ) 100.85 2(<0.00 1 * ) Notes: B = unstandardized beta; β = standardized beta coefficient; R 2 = R square; adj R 2 = adjusted R square; Δ R 2 = R square change. * Statistically significant. 

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