Background
On 11 March 2020, the World Health Organization (WHO) declared coronavirus disease-2019 (COVID-19) a global pandemic [1]. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of COVID-19 is a respiratory virus transmitted from person-to-person via droplets. With the lack of antiviral treatment and despite the implementation of non-pharmaceutical interventions (NPIs), the number of COVID-19 cases is still increasing worldwide [Reference Chen2–Reference Saied4]. Consequently, vaccines remain the most effective way to prevent the spread of COVID-19 [Reference Chen2, Reference Al-Metwali5]. Currently, there are nine COVID-19 vaccines in early or limited use with eight vaccines approved for full use [Reference Chen2, Reference Gavi6–8]. The record time of development of these vaccines generated a global hesitancy among many and has affected the roll-out of vaccines to control the spread of SARS-CoV-2 [Reference Saied4].
Vaccine hesitancy, defined as the ‘delay in acceptance or refusal of vaccines despite availability of vaccine services’, has been an ongoing challenge [Reference Saied4, 9]. Vaccine hesitancy is caused by multiple factors and varies with time, place and vaccines [9, Reference Green10]. These factors include complacency (individual perceptions of the risks vs. the need for vaccination), convenience (availability, affordability and accessibility to vaccines) and confidence (trust in the safety and effectiveness of the vaccine and the delivering healthcare system and in the decisions of policymakers) [9]. The ‘3Cs’ are helpful in understanding factors that contribute to vaccine hesitancy [9, Reference Sallam11]. These include contextual influences (e.g. historic, socio-cultural, environmental, health system/institutional, economic or political factors), individual and group influences (personal perception of the vaccine including knowledge, awareness, conspiracy beliefs, attitudes or a personal experience with a vaccinated family member/friend), as well as vaccination influences (costs, mode of delivery, mode of administration, strength and knowledge of healthcare workers, risks or benefits) [Reference Larson12, Reference MacDonald13].
The willingness to take the vaccine varies based on vaccine safety and effectiveness [Reference Kateeb14]. Several countries have conducted studies and reported on COVID-19 vaccine hesitancy. The highest COVID-19 vaccine acceptance rates were reported among adults in Ecuador (97%), Malaysia (94%), Indonesia (93%) and China (91%) [Reference Wang15–Reference Harapan19]. High trust in government is posited as to why these acceptance rates are so high [Reference Sallam20]. In the USA, vaccine acceptance rates were reported among adults (between 57.5% and 68.5%) [Reference Sallam20], medical students (75.5%) [Reference Lucia, Kelekar and Afonso21], dental students (56%) [Reference Mascarenhas22] and the general population (78%) [Reference Khubchandani23]. Unfortunately, COVID-19 vaccine acceptance rates in the Middle Eastern populations have been among the lowest worldwide: Lebanon (21%) [Reference Al Halabi24], Jordan (28.4–37.4%) [Reference Sallam11, Reference Al-Qerem and Jarab25, Reference El-Elimat T26], Qatar (43%) [Reference Khaled27], Iraq (62%) [Reference Al-Metwali5], Saudi Arabia (65%) [Reference Al-Mohaithef and Padhi28], Turkey (66%) [Reference Salali and Uysal29] and Israel (75%) [Reference Dror30].
University and college students form an important part of every society. Students are considered insightful, influential, open-minded, educated and responsive to public health issues [Reference Barello31]. Moreover, university students are considered as young highly knowledgeable adults who are at high risk of transmitting SARS-CoV-2 and at low risk of developing COVID-19-associated complications [Reference Tavolacci, Dechelotte and Ladner32]. The general trend in research was to focus on vaccination perception among parents and physicians while neglecting university students. In the past few years, recent studies reported on vaccine hesitancy or acceptance among university students due to the shift in healthcare decision making from parents to university students [Reference Baldovin33, Reference Šálek, Čelko and Dáňová34]. Moreover, the presence of gaps in knowledge about vaccine safety and effectiveness was reported among university students (e.g. nursing, medical and pharmacy students) [Reference Baldolli35]. To investigate COVID-19 vaccine hesitancy among this important population, various studies have been conducted in the region among medical students [Reference Saied4], dental students [Reference Kateeb14, Reference Riad36] and university students in general [Reference Al-Mulla37, Reference Sallam38]. The purpose of this study was to identify the readiness, behavioural intentions and predictors of obtaining the COVID-19 vaccine among university students at the American University of Beirut (AUB). Our study is the first to use a theoretical approach to assess vaccine hesitancy among a large group of graduate and undergraduate students in Lebanon.
Methods
Study design, participants and sample size
The study was a randomised, cross-sectional study. It was approved by the Institutional Review Board (IRB) at the AUB. Participants were both undergraduate and graduate students enrolled at the AUB. At the time of the study, there were approximately 9495 students enrolled at the university: 7794 undergraduates and 1701 graduates. A sample size estimate using the sample size calculator from Raosoft (http://www.raosoft.com) indicated that 367 completed surveys from undergraduate students and 314 completed surveys from graduate students were needed to achieve external validity (95% confidence interval (CI); 5% margin of error and a 50% response distribution). Based on nearly an identical study in the USA that was completed just weeks before this one, we estimated a maximum of a 20% response rate. Therefore, we invited 3805 undergraduate and graduate students who were 18 years old and above to participate.
Survey instrument
The survey instrument was built using LimeSurvey (LimeSurvey, version 3.14.8; Hamburg, Germany). Survey questions were developed based on previously published literature on attitudes and behaviours about vaccination [Reference Saied4, Reference Lucia, Kelekar and Afonso21, Reference Sallam38]. The survey included questions based on the integrated behavioural model (IBM) (to assess attitude, perception and behavioural intentions) [Reference Glanz, Rimer and Viswanath39], precaution adoption process model (PAPM) (to assess readiness to get vaccinated) [Reference Weinstein, Sandman and Blalock40] and the extended parallel processing model (EPPM) (to assess cognition and emotional reactions) [Reference Witte41]. The survey was divided into sections with a total of 35 questions.
The first section asked questions related to the PAPM stage of readiness, history of COVID-19 infection and behavioural intentions towards getting the vaccine once available to students. The second section consisted of questions entailing participant's salience, instrumental and experiential attitudes and knowledge about SARS-CoV-2 vaccine. Salience was assessed using three questions to determine the importance of getting vaccinated among students (4-point scale ranging from ‘not important at all’ to ‘very important’). Instrumental and experiential attitudes were assessed using seven questions to determine the level of favourability among students towards the COVID-19 vaccine (5-point scale with 5 being the most favourable). Knowledge about SARS-CoV-2 infection and the vaccine was assessed using eight true/false questions. The third section of the online survey included eight questions that assessed students' level of confidence to perform actions related to getting a COVID-19 vaccine (4-point scale questions from ‘not confident at all’ to ‘very confident’). The fourth section included questions related to environmental constraints and perceived behavioural control towards vaccination. Environmental constraints were assessed using 12 questions related to the effect of specific environmental conditions on getting or not getting the vaccine (a 5-point scale from ‘very easy’ to ‘very difficult’ and a 4-point scale from ‘significant impact’ to ‘no impact’). Perceived control of getting the COVID-19 vaccine was assessed in a 5-point scaled question (from ‘not under my control’ to ‘completely under my control’).
The fifth section of the survey assessed perceived social norms (descriptive and subjective norms). Descriptive norms were assessed using eight questions related to the likelihood of individuals in the student's social network to get the COVID-19 vaccine (5-point scale ranging from ‘very unlikely’ to ‘very likely’ in addition to ‘not applicable’). Subjective norms were measured using eight questions related to the perceived influence of others regarding obtaining the vaccine (4-point scale ranging from ‘not influential at all’ to ‘very influential,’ in addition to ‘not applicable’).
Finally, section six of the survey targeted conspiracy beliefs regarding the importance, safety and efficacy of the vaccine in addition to the financial aspects of the vaccine. These included beliefs related to the media as a driver of unnecessary fear about COVID-19, the potential harm from the vaccine vs. COVID-19 disease, the more severe impact of flu compared to COVID-19, the hidden information by pharmaceutical companies regarding vaccination health outcomes and the vaccine as an attempt to control people and take away personal freedom. The last section addressed socio-demographic characteristics of students (age, gender, programme of study, rank and nationality), health status (flu vaccination habit and history of chronic diseases) and sources of knowledge about COVID-19 (social media, friends, family, healthcare workers, YouTube, TV, medical journals, government websites and medical websites).
Data collection
Data were anonymously collected between 11 May 2021 and 18 June 2021 – the date marking the start of the vaccination campaign at the AUB. The registrar's office at the AUB provided the IRB with a random list of undergraduate and graduate students who previously agreed to share their contact information. Consequently, the IT team, in collaboration with the IRB, uploaded the emails of those students to LimeSurvey. Invitations and reminders (n = 4) were sent anonymously to potential participants via standardised mass emails containing the eligibility criteria and the survey link. The investigators did not request or have any location on the survey where students could mark their identity or any identifying information. The survey link was also shared on official university platforms on social media (Facebook Inc., Twitter, Instagram and Whatsapp messenger). The survey was accessible to undergraduate and graduate students who are ≥18 years of age and enrolled at the AUB.
Statistical analysis
Data analysis was performed using STATA SE 13.0. Descriptive statistics (frequencies, percentages and means) were reported. We generated three groups to categorise vaccine willingness: (1) vaccine accepting (those who are willing to take or already took the vaccine), (2) vaccine hesitant (those who are hesitant to take the vaccine) and (3) vaccine resistant (those who decided not to take the vaccine). Chi-square test of proportions was used to compare categorical variables across the vaccine willingness groups (accepting, hesitant and resistant). Backward stepwise regression and multiple logistic regression models were used to assess the association between the vaccine hesitancy or resistant groups and their knowledge about COVID-19 and its vaccine, environmental constraints, self-efficacy, perceived control, instrumental and experiential attitudes, salience, response cost and efficacy and descriptive and subjective norms. We simultaneously estimated the odds ratios (ORs) with its corresponding 95% CIs to determine the associations between the variables retained from the stepwise regression (P <0.05) and the hesitancy group (comparison group) vs. vaccine acceptance group (reference group). Similarly, we estimated the OR and its 95% CI to determine the associations between the retained variables and the vaccine resistant group (comparison group) vs. its reference group (hesitancy and acceptance groups). We adjusted for control variables (views regarding the impact of COVID-19 on Lebanon, views regarding getting vaccinated against COVID-19, conspiracy thinking, flu vaccination habit and health behaviours) in both multivariable logistic regression models. A p-value <0.05 was considered statistically significant.
Results
Demographic characteristics of study participants
Of the 3805 students who were invited to participate, 800 participants (21%) from seven academic units at the AUB completed the survey. The mean age was 21 ± 0.14 years with the majority being Lebanese (85%), undergraduate students (75%) and females (57%) (Table 1). The acceptance, hesitant and resistant groups represented 87%, 10% and 3% of students enrolled in the study, respectively. Our data show that residency area, nationality and university rank differed significantly among the three groups (Table 1).
Table 1. Demographic characteristics of study participants and COVID-19 vaccine intentions
χ 2 tests were used to compare the frequencies in the cells for each variable. A p-value of <0.05 was considered significant.
Health behaviours, perceptions and COVID-19 vaccines
We assessed the variation of health status and health behaviours among the vaccine groups: accepting, hesitant and resistant groups. Our data show that the three groups differed significantly on several variables including adherence to NPIs (wearing a facemask, social distancing, hand hygiene, avoiding in-door spaces and going out) as well as a history of flu vaccination (Table 2). It was clear that almost all respondents who received the flu vaccine during the past 3 years were accepting of the COVID-19 vaccine. Our data show that previous history of COVID-19 infection and testing positive for COVID-19 did not differ among the three vaccine willingness categories (Table 2). Similarly, these groups significantly differed when we enquired about an agreement with conspiracy beliefs and perceptions about COVID-19 infection and vaccine (Table 3). Pharmaceutical companies, manipulation by a higher power, the vaccine taking away personal freedom and governmental control were mainly where the three groups differed.
Table 2. Health behaviours and acceptability of COVID-19 vaccine among study participants
χ 2 tests were used to compare the frequencies in the cells for each variable. A p-value of <0.05 was considered significant.
Table 3. Conspiracies and perceptions about COVID-19 infections and vaccines among study participants
χ 2 tests were used to compare the frequencies in the cells for each variable. A p-value of <0.05 was considered significant.
Factors associated with vaccine hesitancy and resistance among AUB students
To determine the factors that predicted vaccine hesitancy and resistance, we performed a backward stepwise regression and a multivariate logistic regression using the IBM construct variables while adjusting for confounders. The IBM variables include knowledge (outside the model) descriptive norm, subjective norm, environmental constraints (outside the model), self-efficacy, perceived control, salience (outside the model), response cost and efficacy and instrumental and experiential attitudes. The confounders included variables related to conspiracy theories, getting the flu vaccine, views towards getting the vaccine, views towards the status of the pandemic in Lebanon and personal health behaviours related to COVID-19 prevention.
Disagreement with the statement that symptomatic cases are the only carriers of SARS-CoV-2 was a statistically significant predictor of hesitancy (OR = 5; 95% CI = 1.67–14.29; P = 0.004). However, participants who felt that the vaccine was safe (OR = 0.01; 95% CI = 0.002–0.08; P <0.001) and was in agreement with their personal views (OR = 0.1; 95% CI = 0.02–0.51; P = 0.004) despite the discouraging stories about the vaccine (OR = 0.1; 95% CI = 0.01–0.57; P = 0.01) were less likely to be hesitant (Table 4A).
Table 4. Factors associated with hesitancy towards COVID-19 vaccine among AUB students
aBackward stepwise regression and multiple logistic regression models were used to assess the association between the vaccine hesitant or resistant groups and multiple variables while adjusting for controls. A P <0.05 was considered statistically significant.
Following adjustment for confounders while retaining the variables from the backward stepwise regression with P <0.05, our data showed that none of these variables was significantly associated with vaccine resistance as compared to control groups (accepting and hesitant groups) (Table 4B).
Discussion
The WHO listed vaccine hesitancy as a top 10 threat to the control of vaccine-preventable diseases [42]. Vaccine hesitancy is usually linked to ideological beliefs as well as conspiracy ideations [Reference Dubé, Vivion and MacDonald43]. University students are a core part of society and a critical demographic to vaccination decision-making. During the college years is when most young adults become independent and responsible for their own health decision-making. University students are also leaders and play a critical role in spreading positive and informed facts about vaccines, thus influencing future generations [Reference Sallam38]. Consequently, identifying the willingness of university students to take the COVID-19 vaccine and the factors that predict vaccine hesitancy are important to the development of effective health communication campaigns and strategies to increase the rate of vaccination.
Few studies reported vaccine acceptability among university students in this region of the world. Our main findings show that the COVID-19 vaccine acceptance was high (87%) among students enrolled at the AUB and much higher than university students in Jordan (35%) [Reference Sallam38], dental students in Palestine (58%) [Reference Kateeb14], university students and staff in Qatar (62.5%) [Reference Al-Mulla37] and medical students in Egypt (35%) [Reference Saied4]. However, our results were similar to those reported among university students in Italy in terms of willingness to take the vaccine (86%) [Reference Barello31] and higher than those reported in France (58%) [Reference Tavolacci, Dechelotte and Ladner44].
It was interesting to note that our findings showed that males had higher intentions to obtain the vaccine than females. This result was corroborated by previous studies conducted among adults and dental students in Lebanon [Reference Al Halabi24, Reference Riad36] and among university students in Jordan [Reference Sallam38]. Moreover, Lebanese students had higher intentions to get the vaccine compared to other nationalities. Interestingly, a study of university students in Jordan reported that non-Jordanians had higher intentions to get vaccinated [Reference Sallam38]. Further research is needed to shed more light on this apparent difference by nationality.
The impact of receiving a past influenza vaccine was also influential. Our results showed that vaccine willingness/acceptability differed significantly by students’ flu vaccination habits of the recent past. Those who did not take the flu vaccine in the past 3 years were more vaccine hesitant than those who did. Our results were corroborated by the results of previous studies that showed that those who did not take the flu vaccine in 2019 were also less likely to take the COVID-19 vaccine [Reference Kateeb14, Reference AlAwadhi45, Reference Sherman46].
Numerous conspiracy theories regarding SARS-CoV-2 infection, the pandemic and COVID-19 vaccines have been and continue to be widely spread on social media. It is important to keep in mind that this is the first pandemic the world has experienced with social media. Thus, not only do we have a pandemic, but also we have an infodemic [Reference Khubchandani, Jordan and Yang47]. Misinformation and conspiracy theories are spread quickly among those who do not know how to evaluate the veracity of information. The current infodemic points to a need for a comprehensive, global approach to creating valid, reliable and trustworthy health information [Reference Khubchandani, Jordan and Yang47]. These conspiracy theories have included that the virus was man-made, was caused by 5G cell phone towers, that the vaccine injects microchips to manipulate humans, changes human DNA and causes infertility among females [Reference Saied4, Reference Sallam11, Reference Sajjadi48]. Our findings show the significant impact of conspiracy beliefs among the vaccine willingness groups. However, our results were contradictory to a previous study reporting an independent correlation between hesitancy and conspiracy beliefs among university students in Jordan [Reference Sallam38]. Previous studies reported that the lack of accurate information about vaccine safety, effectiveness and side effects in addition to misinformation from social media played a major role in hesitancy [Reference Saied4, Reference Kateeb14, Reference Sallam20, Reference Riad36].
In its recent report, the WHO advanced three strategies to increase COVID-19 vaccine acceptance: harnessing social influences, increasing motivation through transparent risk communication strategies and creating an enabling environment through making vaccination accessible and affordable [49]. Each of these strategies can be used by countries in our region of the world. Our results also show that higher salience and positive instrumental (cognitive beliefs about outcomes of vaccines) and experiential attitudes (emotional responses to the vaccination) in relation to vaccine safety, efficacy and personal views towards vaccination resulted in lower odds of vaccine hesitancy. Moreover, higher self-efficacy except for those being confident about paying the cost of vaccines was associated with lower odds of vaccine hesitancy. Furthermore, a high level of knowledge about COVID-19 disease and vaccine resulted in lower odds of vaccine resistance among AUB students. However, higher descriptive norms were associated with higher odds of vaccine resistance. Similar results were reported in previous studies among university and dental students in the region [Reference Kateeb14, Reference Riad36].
The results of this theory-based study can be utilised to design and test educational messaging campaigns to promote vaccination. However, our results should be cautiously interpreted. First, with a 20% response rate, a non-response bias may have been at work. Those students who did not respond may have affected the aggregated group results had they completed the survey. Second, although the study body at the AUB is diverse, we only surveyed students at the AUB. Therefore, the results are not generalizable to students at other universities in Lebanon or elsewhere. Moreover, this study was carried out before the vaccination campaign at the AUB and opinions may have changed since then.
Conclusion
The widespread prevalence of SARS-CoV-2 and its variants, and the fact that most of the world is not yet vaccinated, strongly suggest that evidence-based communication campaigns promoting vaccine acceptability should be designed and disseminated. Building vaccination trust among university students through the spread of clear messages is key to the success of vaccinating many.
Acknowledgements
The authors would like to thank Ms. Myriam Asmar for her contribution to discussions related to the study.
Author contributions
M.B.H. participated in recruitment, data acquisition, analysis and writing the first draft of the manuscript. S.S., M.P. and T.J. designed the study, prepared the analysis plan and critically reviewed the manuscript. N.M.M. oversaw the recruitment of participants, revised and critically analysed data and finalised the write-up of the manuscript. All authors read and approved the final manuscript.
Financial support
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Conflict of interest
None.
Ethical standards
The study has been approved by the Institutional Research Board (IRB) at the American University of Beirut (AUB)-Lebanon under the ethical approval number of BS-2021-0139.
Data availability statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Open access
