Background: Widespread vaccination coverage is essential for reducing the COVID-19 havoc and regarded as a crucial tool in restoring normal life on university campuses. Therefore, our research aimed to understand the intention to be vaccinated for COVID-19 among Pakistani university students. Methods: This cross-sectional study was conducted in five administrative units of Pakistan, i.e., Punjab, Sindh, Balochistan, Azad Jammu and Kashmir, and Khyber Pakhtunkhwa. We obtained data from 2,865 university students between 17th January and 2nd February, 2021, using a semi-structured and self-administered questionnaire. We used Stata (version 16.1, StataCorp LLC) for data management and analysis. Results: The majority (72.5%) of our respondents were willing to take COVID-19 vaccine. The current level of education had a statistically significant relationship with the intention to be vaccinated (p < 0.05). Respondents answered 11 questions encompassing five different domains of the Health Belief Model (HBM). All the items of HBM were significantly associated with the positive intention towards receiving the vaccine (p < 0.05). We conducted a multivariable logistic regression analysis to assess the relative contribution of different factors towards the intention to receive COVID-19 vaccine. Multiple factors such as belief that vaccination should be mandatory for everyone (AOR: 3.99, 95% CI: 3.20–4.98) and willingness to take vaccine even if it is not free (AOR: 3.91, 95% CI: 3.18–4.81) were observed to be associated with high odds of showing willingness to be vaccinated against COVID-19. Conclusion: Most of our study participants intended to take vaccines based on their belief regarding the high effectiveness of COVID-19 vaccine. But as rumor-mongers are generating and spreading conspiracy theories daily, the health department and policymakers need to undertake evidence-based campaigns through electronic and social media to ensure expected countrywide vaccination coverage. In this case, our study findings can serve as a foundation for them to ensure mass vaccination coverage among university students, which is crucial now to reopen the dormitories and restore everyday life on campuses.
The coronavirus disease-2019 (COVID-19) outbreak caused by the new severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) virus is wreaking havoc throughout the world [[
Researchers have been working feverishly on treatments to limit the COVID-19 pandemic. While particular highly effective antiviral medications have yet to be identified, significant progress has been made in developing vaccines to combat the disease [[
The Health Belief Model (HBM) is a prominent framework for analyzing human health behaviours. The HBM construct is made up of several subdomains, including perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action [[
University students play a critical role in all societies. They are regarded as wise, influential, receptive, informed, and responsive to public health challenges. To ensure herd immunity and develop effective COVID-19 vaccination programs, it is crucial to identify the factors that influence the intention and behaviour of the specialized group with possible reluctance or hesitancy about COVID-19 vaccines. Furthermore, the majority of university students live in residential halls and shared housing. If the authority decides to reopen physical classes without enough vaccination coverage, the COVID situation will surely deteriorate. Considering the situation, Pakistan Government has taken a policy to vaccinate university students on a priority basis. [[
This cross-sectional study was conducted among Pakistani university level students. The data collection period was between 17
Graph: Fig 1 Administrative unit wise distribution of the study participants (A) and population (B). [Islamabad and Federally Administered Tribal Areas (FATA) were excluded] (Created with ArcGIS version 10.5).
We reached undergraduate and graduate level university students from five administrative units of Pakistan, i.e., Punjab, Sindh, Balochistan, AJK, and KP. A team of experienced researchers planned, executed and monitored the entire procedure. As we have used convenience sampling method, the data collectors approached as many potential respondents as possible irrespective of their socio-economic condition, and ethnicity to represent participants from different backgrounds. We informed the participants regarding the goals and objectives of the study, and explicit informed written consent was obtained from all study subjects. After that, we shared a pre-tested semi-structured and self-administered questionnaire with the respondents to write their responses. Our volunteers helped the participants through proper explanation when they faced difficulties to grasp specific item(s) while answering the questionnaire.
The questionnaire we used in this study consisted of several sections: (a) Socio-demographic variables; (b) Impact and vulnerabilities of COVID-19; (c) Health belief model (HBM) variables; (d) Intention to receive COVID-19 vaccine. Overall, there were 26 items in the questionnaire and took around 7–8 minutes to complete. Our questionnaire was prepared based on the tool developed by Sherman et al. 2020 [[
The questionnaire was adapted by forward and backward translation, iterative revision, and consensus by experts. Each translation was reviewed by three independent health-care providers, psychologists and sociologists who were proficient in both English and Urdu. The accuracy of the translations was certified. There was cent percent strong agreement about the items in questionnaire among these subject experts.
The predictor variables were categorized into three blocks:
- The socio-demographic variables were: gender, marital status, education level, being involved in health care, area of primary residence (rural, semi-urban, urban), monthly family income, number of family members.
- Impact and vulnerabilities of COVID-19 related predictors were: previously being diagnosed as having COVID-19, any family member impacted by COVID-19, presence of senior citizen(s) in the family, chronic disease history (any or more than one of the following: hypertension, chronic kidney disease, Chronic obstructive pulmonary disease, chronic liver disease, etc.), previous vaccination history.
- The section—attitude and beliefs about COVID-19 and its vaccine, were developed based on the five domains of HBM model: perceived susceptibility, perceived severity, perceived benefits, perceived barriers and cues to action.
Items in the impact and vulnerabilities of COVID-19 and HBM model were measured on dichotomous scale (yes, no).
The outcome variable was the intention to take COVID-19 vaccine. It was measured by only one question—"When a coronavirus vaccination becomes available to you, are you going to take one?". The response was binary (yes–positive intention towards vaccine acceptance, no–hesitant/not intended to take vaccine).
Before widely disseminating the questionnaire to our participants, we conducted pre-testing of the questionnaire on randomly selected university level students who were kept excluded from original study. For the pre-testing, we enrolled university students from different socioeconomic classes. The authors took into account the suggestions made by participants and adjusted them, keeping things consistent with current literature. Then, the questionnaire was finalized after a thorough discussion among the authors and was then distributed to the study participants. We have shared the final questionnaire as S1 Questionnaire.
We conducted descriptive analysis to present positive attitude of the participants towards COVID-19 vaccine acceptance in terms of socio-demographic characteristics, impact and vulnerabilities of COVID-19, past experience of vaccination and components of HBM. Chi-square tests of association was used to assess the relationship between categorical variables. Overall, intention towards vaccine acceptance was portrayed using pie chart. We performed multivariable logistic regression analysis whereby figuring out the influencing factors for COVID-19 vaccine taking intention. A receiver operating characteristics (ROC) curve was illustrated as an indicator of good fit of multivariable logistic regression model. Data processing and analysis was carried out using Stata (version 16.1, StataCorp LLC). All statistical tests were two-tailed and p-values less than 5% was considered as statistically significant.
The study was approved by the Institutional Review Board (IRB)/Ethical Review Committee (ERC) of North South University (2021/OR-NSU/IRB-No.0304) as part of a multi-country study. Ethical approval for this study was also obtained from the Institutional Review Board (IRB) of Government College University Faisalabad (GCUF), Pakistan (GCUF/IRB/688). All the study procedures were carried out following the guidelines shared by the IRBs. We have followed the ethical standards outlined in the Declaration of Helsinki (1964) and its subsequent amendments or equivalent ethical principles.
A total of 2,865 respondents participated in the study. We received participation from respondents of various socio-demographic backgrounds by monthly family income types and area of primary residence. Overall, 72.5% of students (n = 2076) had positive intention and the remaining 27.5% (n = 789) had negative intention to take vaccine when it becomes available (Fig 2).
Graph: Fig 2 Distribution of respondents according to their intention to take vaccine.
Majority of female (72.8%) and male (71.6%) participants intended to take the vaccine. The willingness to get vaccinated against COVID-19 was higher among married (74.4%) and unmarried (72.6%) respondents compared to divorced/widowed/separated respondents (52.0%). A substantial portion (70.8%) of the undergraduate-level students showed interest to take COVID-19 vaccine, while the intention was even higher among graduate-level students (75.6%). Majority (74.4%) of the students involved with health care had the intention to take the vaccine. Similar proportion of participants from small (72.7%) and large (72.3%) families expressed their intention to get vaccinated. However, after conducting chi-square test of association, only education level was found statistically significantly associated with intention to take COVID-19 vaccine (p<0.05) (Table 1).
Graph
Table 1 Socio-demographic characteristics of the study participants (n = 2865).
Intention to take COVID-19 vaccine Total Yes No Variables n n (%) n (%) Sex Male 644 461 (71.6) 183 (28.4) 0.376 Female 2201 1603 (72.8) 598 (27.2) 3rd Gender 20 12 (60.0) 8 (40.0) Marital Status Married 86 64 (74.4) 22 (25.6) 0.066 Unmarried 2754 1999 (72.6) 755 (27.4) Divorced/Widowed/ Separated 25 13 (52.0) 12 (48.0) Current Level of Education Undergraduate Student 1866 1321 (70.8) 545 (29.2) 0.006 Graduate Student 999 755 (75.6) 244 (24.4) Health Care Worker No 2259 1625 (71.9) 634 (28.1) 0.223 Yes 606 451 (74.4) 155 (25.6) Monthly Family Income (PKR) ≤ 20000 1953 1424 (72.9) 529 (27.1) 0.711 21000 to 40000 275 198 (72.0) 77 (28.0) ≥ 41000 637 454 (71.3) 183 (28.7) Primary Residence Rural 414 298 (72.0) 116 (28.0) 0.888 Semi-urban 2178 1577 (72.4) 601 (27.6) Urban 273 201 (73.6) 72 (26.4) Family Type Small (⩽ 5) 1153 838 (72.7) 315 (27.3) 0.829 Large (≥ 6) 1712 1238 (72.3) 474 (27.7)
1 Note:p-values were determined by Chi-square tests
- 2 † Data expressed as n within rows
- 3 ‡ Data expressed as n (%) within rows.
The perceived impact of COVID-19 influenced the intention to take vaccine against it (Table 2). Majority (68.8%) of participants affected from COVID-19 were willing to take the vaccine. In case of family members affected by COVID-19, almost 8 out of every 10 participants (78.0%) were ready to be vaccinated. We observed similar intentions among families having any elderly member(s) (> 60 years); more than three-quarters of them agreeing to take the vaccine. A similar trend was also observed in the participants having chronic disease(s) (78.8%) and vaccinated for any other disease(s) in the last few years (79.9%). After conducting chi-square test, we found—family members affected by COVID-19, having any elderly member (> 60 years) in the family and previous vaccination history were significantly associated with willingness to take COVID-19 vaccine (p < 0.05).
Graph
Table 2 Impact and vulnerabilities of COVID-19, past experience of vaccination and their association with the intention to take COVID-19 vaccine.
Intention to Take COVID-19 Vaccine Total Yes No Questions on impact and vulnerabilities n n (%) n (%) Were you diagnosed as having COVID-19? No 2618 1906 (72.8) 712 (27.2) 0.181 Yes 247 170 (68.8) 77 (31.2) Was any of your family members affected by COVID-19? No 2292 1629 (71.1) 663 (28.9) 0.001 Yes 573 447 (78.0) 126 (22.0) Do you have any elderly (>60 years) member in the family? No 1518 1058 (69.7) 460 (30.3) <0.001 Yes 1347 1018 (75.6) 329 (24.4) Do you have any chronic disease? No 2747 1983 (72.2) 764 (27.8) 0.115 Yes 118 93 (78.8) 25 (21.2) Did you take any vaccine within the last few years? No 2427 1726 (71.1) 701 (28.9) <0.001 Yes 438 350 (79.9) 88 (20.1)
- 4 Note:p-values were determined by Chi-square tests
- 5 † Data expressed as n within rows
- 6 ‡ Data expressed as n (%) within rows.
Participants were asked 11 questions encompassing five domains of the HBM. All the items of different domains of the HBM were significantly associated with COVID-19 vaccine-taking intention (p < 0.05). Most of the participants (74.2%) were worried about catching the coronavirus, and 54.8% of the study subjects (n = 1571) believed that they were not immune to COVID-19. In the perceived severity domain, we observed that most respondents thought coronavirus would be a mild illness for them, and too much fuss was being made about the risk of the coronavirus, although, 81.2% of respondents (n = 2325) reported that the pandemic significantly impacted their lives. Under the perceived benefit domain, more than eight-tenths (n = 2362) of the participants had a strong belief regarding the effectiveness of COVID-19 vaccine, and nearly three-fourth (n = 2195; 76.6%) of the participants said vaccination should be mandatory for everyone. In contrast, 74.1% (n = 2124) of the total participants reported they were worried about the vaccine's side effects. Although nearly 90% (n = 2507, 87.5%) of the respondents believed all of them were responsible for reducing the spread of COVID-19, only 1753 participants (61.2%) were willing to pay for the vaccine (Table 3).
Graph
Table 3 Beliefs and attitude towards COVID-19 and its vaccine in relation to intention to take COVID-19 vaccine.
Intention to Take COVID-19 Vaccine Total Yes No Questions on belief and attitude n n (%) n (%) Perceived Susceptibility Are you worried about catching coronavirus? No 740 408 (55.1) 332 (44.9) <0.001 Yes 2125 1668 (78.5) 457 (21.5) Do you believe you are immune to the Coronavirus? No 1571 1171 (74.5) 400 (25.5) 0.006 Yes 1294 905 (69.9) 389 (30.1) Perceived Severity Do you believe that the Coronavirus disease would be a mild illness for you? No 1347 924 (68.6) 423 (31.4) <0.001 Yes 1518 1152 (75.9) 366 (24.1) Do you think too much fuss is being made about the risk of the Coronavirus? No 1178 814 (69.1) 364 (30.9) 0.001 Yes 1687 1262 (74.8) 425 (25.2) Did the Coronavirus pandemic have a big impact on your life? No 540 299 (55.4) 241 (44.6) <0.001 Yes 2325 1777 (76.4) 548 (23.6) Perceived Benefits Do you think vaccination should be made mandatory for everyone? No 670 253 (37.8) 417 (62.2) <0.001 Yes 2195 1823 (83.0) 372 (17.0) Do you think people who are at risk of serious illness from the Coronavirus, need to be vaccinated on priority basis? No 1043 790 (75.7) 253 (24.6) 0.003 Yes 1822 1286 (70.6) 536 (29.4) Do you think vaccines will work against COVID-19? No 503 180 (35.8) 323 (64.2) <0.001 Yes 2362 1896 (80.3) 466 (19.7) Perceived Barriers Are you afraid/concerned about the safety/side effects of the COVID-19 vaccine? No 741 457 (61.7) 284 (38.3) <0.001 Yes 2124 1619 (76.2) 505 (23.8) Cues to Action Do you think we are all responsible for reducing the spread of the Coronavirus? No 358 180 (50.3) 178 (49.7) <0.001 Yes 2507 1896 (75.6) 611 (24.4) Do you agree to take the COVID-19 vaccine if it is not free? No 1112 549 (49.4) 563 (50.6) <0.001 Yes 1753 1527 (87.1) 226 (12.9)
- 7 Note:p-values were determined by Chi-square tests
- 8 † Data expressed as n within rows
- 9 ‡ Data expressed as n (%) within rows.
Table 4 represents the simple and multivariable logistic regression analyses of factors associated with the positive intention to take COVID-19 vaccine. The thought that vaccination should be mandatory for everyone (Adjusted Odds Ratio [AOR]: 3.99, 95% Confidence Interval [CI]: 3.20–4.98) and willingness to take vaccine even if it is not free (AOR: 3.91, 95% CI: 3.18–4.81) were found to have the highest odds of having positive intention to be vaccinated against COVID-19. Participants who were anxious about catching coronavirus had greater odds (AOR: 1.59, 95% CI: 1.26–2.01) of willingness to take the vaccine. Those who held belief regarding the high effectiveness of COVID-19 vaccine were more willing to get vaccination (AOR: 2.97, 95% CI: 2.31–3.83). Participants who said "only people who were at risk of serious illness from coronavirus, need to be vaccinated on a priority basis" were 44% less likely to take COVID-19 vaccine (AOR: 0.56, 95% CI: 0.45–0.71). Participants who believed everyone has a responsibility to reduce the spread of COVID-19 were found to be 1.54 times (AOR: 1.54, 95% CI: 1.14–2.08) more likely to be vaccinated against COVID-19. Lastly, graduate-level students had higher odds of COVID-19 vaccine-taking intention (AOR: 1.30, 95% CI: 1.05–1.61) than undergraduate-level students.
Graph
Table 4 Sociodemographic factors, and health-beliefs regarding COVID-19 association with vaccine acceptance.
Variables Univariate Analysis Multivariable Analysis OR (95% CI) AOR (95% CI) Current Level of Education Undergraduate Student 1 1 Graduate Student 1.28 (1.07–1.52) 1.30 (1.05–1.61) Was any of your family members affected by COVID-19? No 1 1 Yes 1.44 (1.16–1.79) 1.15 (0.87–1.50) Do you have any members in your family who are over 60 years old? No 1 1 Yes 1.35 (1.14–1.59) 1.15 (0.94–1.42) Did you take any vaccine within the last few years (willingly/out of need)? No 1 1 Yes 1.62 (1.26–2.07) 1.22 (0.90–1.65) Perceived Susceptibility Are you worried about catching coronavirus? No 1 1 Yes 2.97 (2.49–3.55) 1.59 (1.26–2.01) Do you believe you are immune to the Coronavirus? No 1 1 Yes 0.79 (0.67–0.94) 1.00 (0.81–1.22) Perceived Severity Do you believe that the Coronavirus disease would be a mild illness for you? No 1 1 Yes 1.44 (1.22–1.70) 1.10 (0.90–1.36) Do you think too much fuss is being made about the risk of the Coronavirus? No 1 1 Yes 1.33 (1.13–1.57) 1.02 (0.82–1.25) Did the Coronavirus pandemic have a big impact on your life? No 1 1 Yes 2.61 (2.15–3.18) 1.24 (0.95–1.60) Perceived Benefits Do you think vaccination should be made mandatory for everyone? No 1 1 Yes 8.08 (6.67–9.79) 3.99 (3.20–4.98) Do you think people who are at risk of serious illness from the Coronavirus, need to be vaccinated priority basis? No 1 1 Yes 0.77 (0.65–0.91) 0.56 (0.45–0.71) Do you think vaccines will work against the COVID-19? No 1 1 Yes 7.30 (5.93–8.99) 2.97 (2.31–3.83) Perceived Barriers Are you afraid/concerned about the safety/side effects of the COVID-19 vaccine? No 1 1 Yes 1.99 (1.67–2.38) 1.04 (0.82–1.33) Cues to Action Do you think we are all responsible for reducing the spread of the Coronavirus? No 1 1 Yes 3.07 (2.45–3.85) 1.54 (1.14–2.08) Do you agree to take the COVID-19 vaccine if it is not free? No 1 1 Yes 6.93 (5.77–8.32) 3.91 (3.18–4.81)
- 10 Note
- 11 *OR = Odds ratio; AOR = Adjusted odds ratio; CI = Confidence Interval; p-value significant at *<0.05 and
- 12 **<0.001.
Area under the ROC curve shows that the multivariable logistic regression model was 83.6% good fit (Fig 3). The area under ROC curve was determined by plotting sensitivity versus 1- specificity. Our model could correctly classify 83.6% of the positive and negative intentions to get the COVID-19 vaccine.
Graph: Fig 3 Receiver Operating Characteristic (ROC) analysis of the multivariable logistic regression model.
Intention is an elemental factor which influences the acceptance of health behaviours [[
We found that overall, 72.5% of the students in this study had positive intention towards vaccination which is similar to that found among general population. One European study published similar result where 73.9% of the participants were willing to receive the vaccine [[
In the perceived susceptibility domain, almost one fourth (74.2%, n = 2125) of our participants were worried about being infected by the coronavirus. This represents a high level of susceptibility perception which could spring preventive measures in this outbreak aiding in a greater epidemic control. Participants who were worried about catching coronavirus disease were more likely to show the intention to get vaccinated. This heightened sense of risk perception about COVID-19 influencing the vaccination intention has been reported by other researchers. It has been found that low or nonexistent risk perception of being affected by COVID-19 sways the intention to get vaccinated in the downward direction [[
In perceived severity domain, it was observed that four-fifths of the respondents agreed when asked if the pandemic had a big impact on their lives. But the perception regarding severity of COVID-19 was less tuned with around half of the participants thinking coronavirus disease to be a mild one and a little more than half of the participants thinking that too much fuss was being made about the disease. Paradoxically this thinking didn't negatively affect their intention to take vaccine contrary to what was suggested in previous studies [[
Quite expectedly we have seen that a positive intention to take vaccine was associated with a positive benefit perception among the participants. Eighty two percent of the respondents perceived that the vaccine will be effective, 76.6% thought that the vaccine should be mandatory for everyone, and more than three fifth opted for vaccination on a priority basis. These findings are in conformity with the HBM as it predicts that people with positive attitudes and strong subjective norms are more likely to accept a vaccine [[
The barriers to the willingness of receiving vaccine surfacing in our study were also apparent in previous studies [[
In the cues to action domain, we observed that those who believed that everyone is responsible for reducing the spread of coronavirus disease and those who were willing to pay for the vaccine if it is free were significantly more willing to take a vaccine upon availability than their counterparts. However, only 61.2% of our study participants were willing to pay for the vaccine. This percentage is much higher in studies conducted in Indonesia and Ecuador. They concluded that an estimated 78.3% and 85.0% of the population respectively, are willing to pay for the vaccine; majority of the Australian citizens are willing to pay to reduce the waiting time [[
According to the HBM and the theory of Planned Behavior, people with a belief that they have a high vulnerability to be ill are more willing to accept a vaccine [[
Another important determinant is the previous experience of vaccination. We found past history of vaccination to be significantly associated with COVID-19 vaccination intention. Around Eighty percent of the respondents that previously got vaccinated for any disease intended to take COVID-19 Vaccine, which was also reflected in the result of Several U.S. and Chinese studies with similar conclusion [[
This study, like most, is burdened by some limitations. As the data collection was according to convenience owing to our incapability of covering all the provinces, lack of generalizability may prevail. Apart from the selection bias due to convenient sampling, we used a single item measurement of vaccine intention and thus are not exempted from potential bias. As vaccine intention and hesitancy are complex and multidimensional constructs, diverse types of data usage and multiple measurement approaches are suggested to precisely pinpoint the factors of influence. The strength of this study is the large educated sample size and usage of the HBM in data collection. The main strength of the HBM is that it is easy to implement, apply, and test because of its use of simplified health-related constructs and thus it increases the reliability [[
Our study explored the factors affecting intention to take COVID-19 vaccine among Pakistani University Students where the current level of education had a statistically significant relationship with the intention to be vaccinated. The majority of our study participants intended to take vaccines based on their belief regarding the high effectiveness of the COVID-19 vaccine. We also found that most of the items of HBM were significantly associated with the positive intention towards receiving the COVID-19 vaccine. But as a group of people are generating and spreading conspiracy theories daily, the health department and the policymakers need to undertake evidence-based campaigns through all means to ensure expected countrywide vaccination coverage. In this case, our study findings can serve as a foundation for them to ensure mass vaccination coverage among university students, which is crucial now to restart offline classes and restore normal life on campuses.
S1 Dataset.
(DTA)
S1 Questionnaire.
(DOCX)
We would like to convey our heartfelt appreciation for the participants' assistance.
By Mosharop Hossian; Md Abdullah Saeed Khan; Anum Nazir; Mohammad Hayatun Nabi; Mehedi Hasan; Ramisha Maliha; Mohammad Ali Hossain; Md Utba Rashid; Nizwa Itrat and Mohammad Delwer Hossain Hawlader
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