Attitudes and Perceptions Towards COVID-19 Vaccine Uptake Among Pharmacy Students

By: Dr. Edward T. Chiyaka, Dr. Carrie L. Griffiths, and Dr. Andrew J. Woods

Abstract

Introduction: Pharmacists are essential to patients’ systems for managing their medications and can also provide vaccine recommendations and counsel vaccine-hesitant patients. During the COVID-19 public health emergency, all frontline healthcare workers were mandated to get vaccinated; however, not all were fully vaccinated. This study evaluated COVID-19 vaccine hesitancy, uptake, and perceptions among pharmacy students.

Methods: Pharmacy students from three private pharmacy schools in the United States were invited to participate in an anonymous online cross-sectional survey distributed using QualtricsXM to answer questions about their attitudes and perceptions toward the COVID-19 vaccine.

Results: There were 182 respondents. Among them, 87% had received at least one dose of either Moderna, Pfizer-BioNTech, or Johnson & Johnson’s Janssen vaccine, and 13% had not been vaccinated or were vaccine-hesitant. The vaccine-hesitant group was likely to cite vaccine side effects (61%) and religious beliefs (30%) as some of the reasons for not getting vaccinated. Furthermore, 65% of the hesitant group were extremely unlikely to consider taking the vaccine even if it received full approval from the Food and Drug Administration.

Conclusion: Most pharmacy students have already received the COVID-19 vaccine, but there is a significant proportion who have not been vaccinated, citing concerns about effectiveness, side effects, and religious beliefs. Given the expanded role of pharmacists in patient care and their potential influence in improving vaccine uptake in their communities, there is a need to improve vaccine uptake among them.

Keywords: COVID-19, pharmacy students, vaccine hesitancy, vaccine uptake, COVID-19 vaccine

Introduction

Pharmacists play a significant role in the drug therapy management framework of patients.1 In addition to processing prescriptions and providing patient care activities, pharmacists in the community, hospital, ambulatory, and managed care settings may also offer outreach or additional services to prescribers and patients. While pharmacists had previously provided vaccines in select states, their roles were expanded during the COVID-19 public health emergency, including giving the COVID-19 vaccination.2 This means that pharmacists, like other healthcare providers, can also provide vaccine recommendations, vaccinate patients, and counsel vaccine-hesitant patients. According to research on vaccine acceptance among healthcare workers, the propensity of healthcare workers to recommend COVID-19 vaccination to their patients was found to be positively correlated with their vaccination rates3. Additionally, studies have demonstrated that the involvement of pharmacists in administering immunizations has improved vaccination rates.4-6

Vaccine hesitancy is one of the significant barriers to COVID-19 vaccine uptake, as identified by the World Health Organization (WHO) and the U.S. Centers for Disease Control and Prevention (CDC).7,8 While all frontline healthcare providers have been prioritized, and many are being mandated to get vaccinated, not all have been fully vaccinated. The literature has evaluated vaccine uptake in college students and medical and dental students but not pharmacy students.9-13 The purpose of this study was to assess COVID-19 vaccine hesitancy, uptake, and perceptions among pharmacy students.

Methods

A cross-sectional study was conducted among pharmacy students from private pharmacy schools in North Carolina from September 27 to November 2, 2021. The anonymous online survey was distributed to potential participants via email using QualtricsXM. Informed consent was obtained before the respondent entered the survey. The University’s Institutional Review Board approved the study protocol.

Survey Instrument

Survey items were developed based on research on attitudes and perceptions toward the COVID-19 vaccine for different health professions.9,10,14 Most of the questions came from the Vaccine Confidence Survey Question Bank, which contains CDC’s recommended COVID-19 vaccine confidence and uptake survey items.15 Authors made some adjustments and added more questions to the validated templates to adequately examine the identified themes. The survey assessed different factors, including participants’ personal vaccine behavior; general attitudes and perception towards COVID-19 vaccines; current knowledge about COVID-19 vaccines; the perceived likelihood of COVID-19 infection; personal experience with COVID-19 as well as demographic factors such as age, sex, race, and year of study. We assessed vaccine uptake and hesitancy for the COVID-19 vaccine with the question, “The U.S. Food and Drug Administration (FDA) issued an emergency use authorization (EUA) for three vaccines, Pfizer-BioNTech, Moderna, and Johnson & Johnson’s Janssen in the United States to prevent COVID-19. Have you been vaccinated using any of the three vaccines? (Select yes if you have received at least one dose)”. Participants who responded “no” were asked the following question: “The Pfizer COVID-19 vaccine has received full approval from the FDA. If you were offered the Pfizer vaccine, how likely are you to take it?”

Data Analysis

Data were analyzed using IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, N.Y., USA). Descriptive statistics were used to describe the study participants’ demographic features and other survey questions, such as frequencies and percentages. The items on the Likert scale were reclassified as strongly disagree or disagree and strongly agree or agree. Proportions of vaccine hesitancy and vaccine acceptance were computed and compared. Chi-square tests were used to identify statistically significant differences between the vaccine-hesitant and vaccine-acceptance groups on various survey items. Statistical significance was established at an alpha of p < 0.05.

Results

A total of 182 pharmacy students completed the survey, a 19% response rate. Most of the participants were: females (79.7%), white (72.5%), and aged between 18 – 24 years (60.4%) (Table 1). There was a similar distribution of participants across years in pharmacy school (22% to 28.6%). About 87% of the participants received at least one dose of Moderna, Pfizer-BioNTech, or Johnson & Johnson’s Janssen vaccine. Among the vaccinated, approximately 16% indicated that they got vaccinated because their school mandated vaccination, while the other 84% had been voluntarily vaccinated. Statistically significant differences in vaccine hesitancy were found based on sex and year in pharmacy school (p-values .022 and .046, respectively). We observed the highest prevalence of COVID-19 vaccine hesitancy among female students (60.9%) and students in their first year of pharmacy school (43.5%) compared to their corresponding groups.

About 13% of the participants had not been vaccinated at the time of survey completion. Among these, approximately 65% indicated they were extremely unlikely to consider taking the vaccine even if it received full approval from the FDA. Only 17.4% were somewhat likely or extremely likely to receive the vaccine after full approval. Also, about 61% of the vaccine-hesitant group indicated that they were concerned about the vaccine’s side effects as the reason for not getting vaccinated; 30% cited religious beliefs as the reason for not getting vaccinated. Not enough long-term studies assessing side effects and fertility issues were cited by the vaccine-hesitant group as some of the most concerning issues about the COVID-19 vaccines.

Fewer participants agreed to have experience with COVID-19. About 10% of the participants indicated they had a COVID-19 infection, while nearly a quarter had cared for someone who had a COVID-19 infection at some point. Only two-thirds (59.9%) had personally known someone with a COVID-19 infection. Most participants agreed that they were likely to be exposed to COVID-19 as future pharmacists, and they considered the COVID-19 vaccination important as healthcare providers (Table 2). The majority of the pharmacy students (87.9%) agreed that vaccines are essential for them to stay healthy as future pharmacists; the development of a COVID-19 vaccine is important to decrease the spread of the disease (80.8%); and COVID-19 vaccination is important for the overall public health of our communities (81.9%). However, fewer pharmacy students agreed that COVID-19 vaccination should be mandatory for all healthcare providers (58.5%) and the general public (38.5%). Among those unwilling to take the vaccine, only 4.3% agreed that the COVID-19 vaccination should be mandatory for healthcare providers and the public. Interestingly, of those hesitant to vaccinate, more than 78% indicated that they planned on getting the influenza vaccine this season. Furthermore, less than 30% of the vaccine-hesitant group indicated that they would be motivated to receive a COVID-19 vaccination to protect the health of family/friends, the health of coworkers, or the health of the community. Only 30.4% of this group indicated they would be motivated to receive a COVID-19 vaccine to protect their health.

In the bivariate analyses, students in the vaccine acceptance group were statistically significantly different (p < .05) compared to those in the vaccine-hesitant group on most of the survey items except for the following items: I had COVID-19 infection; I cared for someone with COVID-19 infection; and I personally know someone who has died from COVID-19 infection. Also, no statistical differences between the vaccine acceptance and vaccine-hesitant groups were observed by age and race.

Discussion

As trusted healthcare providers, pharmacists’ understanding and acceptance of vaccination against SARS-CoV-2 is paramount in combating the COVID-19 pandemic. Healthcare providers are the principal source of vaccine information and directly influence the vaccination decisions of their patients and social networks.16-19 The current study evaluated the attitudes and perceptions towards COVID-19 vaccine uptake among pharmacy students from three private pharmacy schools in North Carolina. Despite most respondents acknowledging an inherent increased risk of contracting SARS-CoV-2 because of providing direct patient care, 13% of participating pharmacy students reported COVID-19 vaccine hesitancy/refusal. Our study found a lower rate of COVID-19 vaccination hesitancy/refusal among pharmacy students than previously reported rates of COVID-19 vaccine hesitancy/refusal among nursing, medical, and dental students in the United States, which varied from 21.6 percent to 44.5 percent.9,10,20,21 A global study of COVID-19 vaccination hesitancy among students or trainees in healthcare professions revealed an average of 19 percent vaccine hesitancy rate.22 While the vaccine hesitancy rate from our study is lower than previously reported vaccine hesitancy rates for other healthcare professionals, the findings are particularly concerning because pharmacists are widely regarded as the most influential healthcare workers and key sources of vaccine information for patients and caregivers.

Similar to published data regarding vaccine hesitancy among healthcare professionals and students, our results suggest pharmacy students who are younger in age or female are more hesitant to accept a COVID-19 vaccination.3,9,23-25 Contrary to similar published studies, our results indicate that non-Hispanic white pharmacy students are less accepting of a COVID-19 vaccination than their minority counterparts.23 Each pharmacy school involved in this study offered free COVID-19 vaccination on campus, thereby minimizing or eliminating barriers to COVID-19 vaccination access within their respective student populations, unlike the general population. Thus, lack of access did not factor in receiving the COVID-19 vaccine.

COVID-19 vaccination hesitancy data published before or in the early stages of the widespread availability of the vaccines indicate that safety and potential adverse effects were at the crux of healthcare worker and student disinclination. Almost 90% of pharmacy students expressing vaccination hesitancy in our study noted general concern about COVID-19 vaccination safety and adverse effects approximately a year after vaccinations were made available to healthcare providers. Similar to previously reported data, participating pharmacy students identifying as female indicated concerns about the COVID-19 vaccination’s potential impact on fertility. These findings add to the need to continue assessing the long-term effects of COVID-19 vaccinations, specifically in women of childbearing age. A surprising proportion of vaccine-hesitant respondents cited insufficient evidence for vaccine efficacy, a somewhat concerning finding given that the survey population expected to have a basic understanding of scientific evidence generation. This result suggests that perhaps greater emphasis related to the analysis of medical literature is warranted within pharmacy curricula.

First-year pharmacy students were significantly less likely to accept a COVID-19 vaccination when compared to second, third-, and fourth-year pharmacy students. This finding correlates to other published studies indicating that less healthcare education and experience increases the likelihood of vaccine hesitancy or refusal.3,24-26 Healthcare professionals entering practice in the past decade are more likely to lack sufficient vaccine-related knowledge and thus certainty in initiating and leading vaccine-related conversations with patients.14,27,28 A lack of vaccine-related understanding and confidence in navigating discussions with other providers and patients related to vaccination could translate to decreased vaccine uptake within the communities pharmacists serve. Pharmacy students receive immunization education and training through pharmacy curricula. As a result, pharmacy students demonstrate better than average vaccine-related knowledge than other healthcare professional students.14 Over 78% of pharmacy students in the vaccine-hesitant group and about 90% of all respondents stated they plan on receiving the flu vaccine this season. However, enhanced educational opportunities exist throughout pharmacy curricula – certainly regarding the use of mRNA-based vaccinations considering the advent of their efficacy. Research on vaccine acceptance among healthcare workers has revealed that the propensity of healthcare workers to recommend COVID-19 vaccination to their patients was positively correlated with their vaccination rates.3 Therefore, promoting vaccination uptake among healthcare providers has been suggested to increase vaccine uptake in patients. While the COVID-19 pandemic continues to slow, our study findings may indicate future behavior if additional vaccines are required.

Even though our study’s vaccine hesitation rate of 13% is lower than previously reported hesitancy rates among other students and healthcare workers, the vaccination rate is alarming. Using trusted voices and leaders to advocate for vaccination(s), giving convenient access to vaccines, and a greater focus on raising awareness and education have all been suggested as possible measures to increase vaccination rates among students in healthcare professions.22

Strengths and Limitations

Participants were selected from three private pharmacy schools in one state. As a result, the findings may not apply to other schools or communities. As with any survey-based study, our findings are influenced by recall bias, reliance on self-reported habits, and the inability to demonstrate cause-andeffect correlations. The survey response rate was low across all three participating institutions, which could have skewed the study’s findings. Furthermore, non-responding students may have been vaccination hesitant, resulting in an underestimating vaccine hesitancy among pharmacy students. Despite these limitations, to our knowledge, this is the first study to evaluate the attitudes and perceptions toward COVID-19 vaccine uptake among pharmacy students in the United States. Additionally, the number of respondents is on par with similar published studies.9,13 Vaccinations available for approximately one year at the time of survey distribution, and information related to efficacy and safety are more robust than previously published studies.

Conclusion

The present study evaluated pharmacy students’ attitudes and perceptions toward COVID-19 vaccine uptake. Most students expressed positive attitudes toward COVID-19 vaccines and the value of the vaccines for themselves, their families, and the communities they serve. They also had strong positive perceptions of the role of vaccines in decreasing the spread of diseases and improving the overall public health of communities. Despite most of the students having been vaccinated, some expressed concern about potential side effects or were concerned that the vaccines may not be effective. Pharmacists are frontline healthcare practitioners who can play a pivotal role in advocating for and providing vaccinations. With the recent authorization for pharmacists to administer vaccines, including the COVID-19 vaccines, they must demonstrate their confidence that the benefits of COVID-19 vaccination exceed the risks.

Authors: Edward T. Chiyaka, Ph.D., is an Assistant Professor of Pharmacy at Wingate University School of Pharmacy in Wingate, NC. e.chiyaka@wingate. edu. Carrie L. Griffiths, PharmD, is an Associate Professor of Pharmacy at Wingate University School of Pharmacy. Andrew J. Woods, PharmD, is an Associate Professor of Pharmacy at Wingate University School of Pharmacy.

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Table 1

Socio-demographic characteristics of participants

org/10.1093/cid/ciab054

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26. Baniak LM, Luyster FS, Raible CA, et al. COVID-19 vaccine hesitancy and uptake among nursing staff during an active vaccine rollout. Vaccines. 2021;9(8):858. http://dx.doi.org/10.3390/vaccines9080858

27. Betsch C, Wicker S. E-health use, vaccination knowledge and perception of own risk: drivers of vaccination uptake in medical students. Vaccine. 2012;30(6):1143-1148. http://dx.doi. org/10.1016/j.vaccine.2011.12.021

28. Mergler MJ, Omer SB, Pan WK, et al. Association of vaccine-related attitudes and beliefs between parents and health care providers. Vaccine. 2013;31(41):4591-4595. http://dx.doi. org/10.1016/j.vaccine.2013.07.039

*Chi-square was used to determine significance, defined as p<.05, between vaccine -hesitant and vaccine acceptance groups. P1=first professional year; P2=second professional year; P3=third professional year; P4=fourth professional year

Survey responses among COVID -19 vaccine acceptance and hesitant pharmacy students

Participants that responded affirmatively (agree/strongly agree)