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\begin{document}

\title{Attitudes and concerns of nursing students against the COVID-19 vaccine,
willingness to be vaccinated: A cross-sectional study}



\author[1]{Zeynep Dasikan}%
\author[1]{Mashood Katuntu  WAISWA}%
\affil[1]{Ege Universitesi}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
Background: COVID-19 vaccine acceptance by the nurses of the future is
important to increase the population immunity. Aim: This study aimed to
determine the attitudes and concerns of nursing students towards the
coronavirus disease-2019 (COVID-19) vaccine, their willingness to be
vaccinated, and the factors affecting their willingness in the second
wave of the COVID-19 pandemic. Method: This cross-sectional study was
conducted between February 1, 2021, to March 30, 2021, using an online
questionnaire in 498 nursing students in Turkey. Results: While 64.5\%
of nursing students had the intention to be vaccinated against COVID-19,
35.5\% had no intention to be vaccinated (29.3\% hesitant and 6.2\%
unwilling). Students expressed their attitudes and concerns on the lack
of COVID-19 vaccine information (65.7\%), its effectiveness (41.6\%),
safety (45.8\%), and side effects (50.8\%). Students did not intend to
be vaccinated due to insufficient trust in the vaccine effectiveness
(84\%), the continuous COVID-19 mutation, vaccines side effects
(68.9\%), and not trusting the supplied vaccine (55.4\%). Students' high
education level, high family income perception, previous vaccine
rejection, family members with COVID-19 infection, COVID-19 information
from official institutions, trusting health professionals' COVID-19
explanations, and attitudes and concerns toward vaccines for their
intention to be vaccinated are the affecting factors (p \textless{}
0.05). Conclusions: Nursing students are known to be future healthcare
professionals and play a decisive role in counseling individuals in the
community on the risks of COVID-19 and the benefits of the vaccine.
Therefore, focusing on training that is aimed at increasing vaccine
knowledge, eliminating their negative attitudes and concerns, and
building confidence in vaccines is necessary.%
\end{abstract}%



\sloppy


\textbf{Attitudes and concerns of nursing students against the COVID-19
vaccine, willingness to be vaccinated: A cross-sectional study}

\textbf{Abstract}

\textbf{Background:} COVID-19 vaccine acceptance by the nurses of the
future is important to increase the population immunity.

\textbf{Aim:} This study aimed to determine the attitudes and concerns
of nursing students towards the coronavirus disease-2019 (COVID-19)
vaccine, their willingness to be vaccinated, and the factors affecting
their willingness in the second wave of the COVID-19 pandemic.

\textbf{Method} : This cross-sectional study was conducted between
February 1, 2021, to March 30, 2021, using an online questionnaire in
498 nursing students in Turkey.

\textbf{Results:} While 64.5\% of nursing students had the intention to
be vaccinated against COVID-19, 35.5\% had no intention to be vaccinated
(29.3\% hesitant and 6.2\% unwilling). Students expressed their
attitudes and concerns on the lack of COVID-19 vaccine information
(65.7\%), its effectiveness (41.6\%), safety (45.8\%), and side effects
(50.8\%). Students did not intend to be vaccinated due to insufficient
trust in the vaccine effectiveness (84\%), the continuous COVID-19
mutation, vaccines side effects (68.9\%), and not trusting the supplied
vaccine (55.4\%). Students' high education level, high family income
perception, previous vaccine rejection, family members with COVID-19
infection, COVID-19 information from official institutions, trusting
health professionals' COVID-19 explanations, and attitudes and concerns
toward vaccines for their intention to be vaccinated are the affecting
factors (p \textless{} 0.05).

\textbf{Conclusions:} Nursing students are known to be future healthcare
professionals and play a decisive role in counseling individuals in the
community on the risks of COVID-19 and the benefits of the vaccine.
Therefore, focusing on training that is aimed at increasing vaccine
knowledge, eliminating their negative attitudes and concerns, and
building confidence in vaccines is necessary.

\textbf{Keywords:} COVID-19; vaccine; hesitancy; intention; concerns;
nursing student.

\textbf{INTRODUCTION}

The World Health Organization (WHO) declared a pandemic on March 11,
2020, due to the emergence of the coronavirus disease-2019 (COVID-19) in
December 2019 in Wuhan, China. On the same day, the first official case
in Turkey was confirmed\textsuperscript{.} The COVID-19 pandemic has
caused a public health crisis and socially, economically, and
psychosocially affected the public social distancing, movement
restrictions, public health measures (hygiene, face mask, and social
distance), and social and economic measures have been taken against the
pandemic. These measures were intended to play an important role in
halting the spread of the pandemic while allowing a large part of the
population to acquire natural immunity against the
virus\textsuperscript{{[}2, 3{]}.} These measures were also aimed to
control the transmission until vaccines were readily available to the
population. Vaccines have been proven to be the most successful and
highly effective public health interventions to control and eradicate
vaccine-preventable diseases, as well as reduce and prevent serious
disability or death due to infectious diseases \textsuperscript{{[}2, 4,
5{]}.} However, for a safe and effective vaccination program to reach
optimum effectiveness, high intake rates by the population are
required\textsuperscript{{[}6-8{]}.}

The concept of ``vaccine hesitancy'' is defined as the delay or refusal
to accept the vaccination despite the availability of vaccination
services and has been recognized as ``one of the top 10 threats to
global health'' by the WHO. Vaccine reluctance remains a limiting factor
in the global efforts to control the current pandemic with its adverse
health and socioeconomic consequences \textsuperscript{{[}9, 10{]}}.
Healthcare providers (HCPs) are considered the most reliable source of
information on vaccines and are expected to be aware of vaccination
risks and benefits. Surprisingly, vaccine hesitancy has been confirmed
among healthcare professionals (medical doctors, nurses, dentists, etc.)
Studies showed that the rate of vaccine acceptance among nurses is low.
A study conducted with HCPs (physicians, nurses, dentists, pharmacists,
and health personnel) in Turkey revealed that approximately 84.6\% of
HCPs and 66.5\% of nurses were willing to accept the COVID-19 vaccine
when available \textsuperscript{{[}11{]}}. Similarly, Hong Kong and
Israel studies revealed that 63\% and 61\% of working nurses showed
their willingness to be vaccinated against COVID-19, respectively.
Another study that was conducted among nursing students from seven
European countries (Greece, Albania, Spain, Cyprus, Italy, Czech
Republic, and Kosovo) reported that 44 \% of participants would accept a
safe and effective COVID-19 vaccine\textsuperscript{.}

Main concerns that were described in previous studies included vaccine
efficacy and safety, possible side effects, misinformation, religious
beliefs, and personal freedom violations. These concerns have been also
reinforced by different conspiracy theories that predominantly circulate
on social media \textsuperscript{{[}13, 14{]}.} The pandemic poses a
great risk to HCPs who are often in direct contact with infected
patients. Immunization would be vital to protect HCPs and control
hospital-acquired transmission. HCPs have a key role in helping the
public to overcome their vaccination doubts and
concerns\textsuperscript{{[}2, 10, 13, 15{]}.} Thus, as future HCPs,
understanding and increased acceptance among nursing students toward the
COVID-19 vaccine to manage the pandemic, both now and in the future, is
very important\textsuperscript{{[}9{]}}. Vaccination acceptance by
nursing students does not only protect them against the virus but is
also a source of information on public immunization
\textsuperscript{{[}9, 10{]}.}Existing vaccine hesitancy studies among
healthcare nursing students are very rare.

Therefore, this study aimed to determine the attitudes and concerns of
nursing students toward the COVID-19 vaccine, their willingness to be
vaccinated, and the factors that affect their willingness in the second
wave of the COVID-19 pandemic.

\textbf{2. METHOD}

\textbf{2.1. Design and setting}

This cross-sectional study was conducted online during the second wave
of the COVID-19 pandemic between February 1, 2021, to March 30, 2021.
The sample of the study consisted of 1100 students who are enrolled in
the Faculty of Nursing of a public university in the metropolitan city
of Izmir. Out of 524 students who voluntarily participated in the study,
a total of 498 students were included, whereas 26 students who had been
vaccinated against COVID-19 were excluded because their willingness to
be vaccinated can no longer be questioned. The COVID-19 vaccination
program in Turkey started on January 14, 2021, with the Chinese-made
inactivated vaccine Sinovac, which was to be administered in two doses
to HCPs and the elderly over 65 years of age. Phizer/BioNTech mRNA
vaccines were introduced onto the vaccination program on April 02,
2021\textsuperscript{{[}1{]}.} By the time this study was conducted,
nursing students had not been included in the national immunization
program.

\textbf{2.2. Instruments}

A questionnaire that was prepared by other researchers in line with the
literature was used to collect data \textsuperscript{{[}9, 16-18{]}.} It
consisted of three parts. The first part included demographic
characteristics (5 questions), history of chronic diseases and
allergies, seasonal flu vaccination status in the last 2 years,
vaccination rejection status for himself or his relatives until now (4
questions). The second part included COVID-19 risk perception, perceived
COVID-19 impact on self-experiences and COVID-19 information sources and
reliance on COVID-19 HCP statements, etc. (8 questions). The third part
included attitudes and concerns about the COVID-19 vaccine (8 items) in
three options (1 = Agree; 2 = Undecided, 3 = Disagree), intention to get
COVID-19 vaccine in one question (1 = yes, 2 = no, 3 = undecided), and
the reasons for not wanting to be vaccinated were asked with one
question for those who answered ``unwilling'' and ``undecided.''
Opinions of three experts in the field of Public Health Nursing and
Women's Health and Diseases nursing were taken for the questionnaire
form, and arrangements were made in line with their suggestions. Data
was collected by sharing the online questionnaire form in the WhatsApp
groups and during online course lectures in each class. Informed consent
was obtained from the participants before moving on to the survey items
on the survey platform. An average of 6--8 min is needed to fill out the
survey.

\textbf{2.3. Data analysis}

The Statistical Package for the Social Sciences version 25.0 package
program (IBM Corp.; Armonk, NY, USA) was used to evaluate the data. Mean
(standard deviation), frequency, and percentage were used in the
descriptive data, and the Chi-square test and student t-test were used
in data analysis. The significance level of p \textless{} 0.05 was
accepted for all hypotheses.

\textbf{2.4. Ethical considerations}

Ethical permission to carry out the research was obtained from Ege
University Health Sciences Scientific Research and Publication Ethics
Committee (Approval number: 2021/982). Written informed consent was
obtained from all students who participated in the study.

\textbf{RESULTS}

The mean age of 498 nursing students between the ages of 18--29 years
who participated in the study was 21.06 \selectlanguage{ngerman}± 1.74 and the majority (85.1\%)
were female. The introductory characteristics of the students are
presented in Table 1. The majority of nursing students (81.3\%) think
that the COVID-19 pandemic will continue for a long time, they view
having COVID-19 infection as a moderate and very serious problem
(90.6\%), and 63.3\% of them have the risk of contracting COVID-19
infection. COVID-19 infection was experienced by 8.2\% of nursing
students and the pandemic process affected the lives of many of them
badly or very badly (87\%). Most students (87.8\%) follow the news about
COVID-19 at a moderate and advanced level, and the primary sources of
information (75.9\%) are the WHO/ Ministry of Health (MoH) Scientific
Committee and social media (72.7\%). However, 57.6\% stated their trust
in the explanations of HCPs (Table 2).

\textbf{COVID-19 vaccine attitudes and concerns, willingness to get
vaccinated and barriers}

Nursing students reported that the information about the current
COVID-19 vaccine was insufficient (65.7\%), the vaccine side effects
(50.8\%), the vaccine was effective (41.2\%), and the vaccine was safe
(45.8\%) (Figure 1). While 64.5\% of students were willing to be
vaccinated against COVID-19, 35.5\% are unwilling (6.2\%) and hesitant
(29.3\%). The reasons for their included insufficient trust in the
vaccine efficacy (84\%) due to COVID-19 virus mutation (Figure 2).

A significant difference was found between nursing students' intentions
to get COVID-19 vaccine, class, family income perception, previous
vaccination rejection, family members having COVID-19 infection, the
WHO/ MoH Scientific Committee as primary sources of COVID-19 information
and relying on HCP COVID-19 statements (\emph{p} \textless{} 0.05),
(Table 1, 2). Attitudes and concerns towards the COVID-19 vaccine
positively or negatively affected nursing students' intention to be
vaccinated (\emph{p} \textless{} 0.05), (Table 3).

\textbf{DISCUSSION}

HCPs are considered the most reliable source of information on vaccines,
and their recommendations play a major role in patients' vaccination
decisions. Hence, vaccine acceptance by HCPs would increase vaccine
uptake by the public. Frontline HCPs, including nurses, are susceptible
to acquiring the virus due to a variety of factors, including exposure,
inadequate supply of personal protective equipment, and inadequate
infection control. Therefore, being vaccinated will not only protect
them and their families but will also allow them to advise their
communities to get vaccinated against COVID-19. A universal vaccination
program is an important measure to control the pandemic and achieve herd
immunity. Vaccine hesitancy is a limiting step in global attempts to
control the current pandemic with adverse health and socioeconomic
consequences \textsuperscript{{[}9,10, 19{]}.}

The current study revealed that two-thirds (64.5\%) of the nursing
students were willing to get the vaccine. Our findings are consistent
with the intention of the nurses working in our country to be
vaccinated\textsuperscript{.} While the willingness of the students to
be vaccinated against COVID-19 was low in the United States and across
seven European countries (45\%; 44 \%, respectively)\textsuperscript{{[}
3,13{]}} , it was higher among Chinese students
(83.3\%)\textsuperscript{.} In other studies conducted on medical
students revealed that 73\% intended to be vaccinated in the
USA\textsuperscript{{[}21{]},} whereas 35\% in
Egypt\textsuperscript{{[}9{]}.} A rapid systematic review of 13 studies
that assess the attitudes toward COVID-19 vaccination among the HCPs
concluded that vaccine acceptance varied widely and ranged from 27.7\%
to 77.3\% \textsuperscript{{[}19{]}.} However, these studies also
revealed that the intention to be vaccinated differed between nursing
students and HCPs. Our study also showed that younger students and those
with milder viral exposure are more likely not to accept the vaccine
compared to older students. Differences between various studies are
attributed to the sample difference, data collection time, morbidity and
mortality rate in countries, vaccine information sources, types of
approved vaccines between countries, and rapid and changing flow of
country-specific information about the disease or
vaccines\textsuperscript{{[}9,11,13,15{]}.}

Our findings also indicated that their willingness to receive the
vaccine was not without concerns and/or hesitation. The current study
revealed that the students' attitudes and concerns on COVID-19 vaccine
mostly included the inadequacy of vaccine information, its side effects,
effectiveness, and safety, the thought that they were used as
experiments for COVID-19 vaccine application, and the thought of
preferring natural immunity rather than being vaccinated. Several
studies that assess the attitudes and concerns toward the COVID-19
vaccine revealed that participants commonly expressed their concerns
toward the vaccine effectiveness and side effects, insufficient vaccine
information, distrust of the supplied vaccine and the supplier company,
negative effects of the media, thoughts that there should be no vaccine
according to their sources, thoughts that the COVID-19 vaccine will
infect the virus or change their genetic structure, and thought that
they are used as experiments in the COVID-19 vaccine
application\textsuperscript{{[}7, 9, 13,15, 22{]}.} These expressed
concerns about vaccine efficacy are not surprising, as vaccine
development can take 10--15 years \textsuperscript{{[}11{]}.} However,
other concerns, such as the vaccine will change their genetic structure,
the vaccine will infect COVID-19, and that they are used as experiments
in vaccine application, arise. Vaccine misinformation and insufficient
advanced vaccine information can increase anxiety and lead to an
overestimation of potential side effects. Many hesitant individuals are
anticipated to accept the vaccine if they were reassured on vaccine
safety and effectiveness and if reliable information is
provided\textsuperscript{{[}21{]}.}

University students and HCPs use various resources through social media
and personal networks to acquire COVID-19 infection and vaccine
information \textsuperscript{{[}9{]}}. A study conducted among medical
and health students revealed that social media was used as an important
source of information about the virus \textsuperscript{{[}23{]}}.
Another study involving students from a large public university in New
Jersey stated that the most reliable sources of COVID-19 vaccine
information were official health institutions (78.1\%) and medical
professionals (63.2\%), respectively \textsuperscript{{[}24{]}}. In the
current study, official health institutions (WHO and MoH) were reported
to be the primary sources of information among the students, whereas
social media (72.7\%) came second. Vaccine concerns and hesitancy are
heightened by social media, conspiracy theories, and
misinformation\textsuperscript{{[}9,11{]}}. Infodemia, as characterized
as the spread of misleading and false information by the WHO, must be
tackled\textsuperscript{{[}23{]}} to eliminate the lack of information
and misinformation about the COVID-19 vaccine, thus providing training
on this subject in the curriculum is necessary.

The current study revealed that the most common reasons for not wanting
to be vaccinated were distrust in vaccine effectiveness due to the
mutation of the virus, vaccines side effects, distrust of the current
vaccine and the company, and the negative effects of news in the media.
Similar results were obtained in previously conducted studies, wherein
most of the reasons for the unwillingness to be vaccinated against
COVID-19 include constantly mutating severe acute respiratory syndrome
coronavirus 2 virus, vaccine ineffectiveness, serious long-term side
effects, insufficient vaccine information, rapid vaccine production,
preference for natural immunity, the thought that COVID-19 vaccines
would change the DNA structure, fear that the vaccines would cause
infertility, fear of high financial costs if the vaccine is not free,
and media misrepresentation of the vaccine \textsuperscript{{[}9, 10,
13, 21{]}.}

\textbf{4.1. Factors associated with the intention to be vaccinated
against COVID-19}

The willingness to be vaccinated does not depend on just one factor. It
can be affected by the individuals' social, cultural, and economic
structures, age, gender, information from HCPs, individual or familial
COVID-19 infection experiences, chronic diseases, general attitudes and
beliefs toward vaccines, previous experiences of vaccine rejection, and
traditional social messages \textsuperscript{{[}11, 15{]}.} The current
study revealed a low COVID-19 vaccine acceptance among students who were
in lower classes, with low family income perception, and with previous
vaccine rejection experience. Similar studies that were conducted among
HCPs revealed high acceptance rates among the male gender, increasing
age, education, and income level \textsuperscript{{[}15, 19, 25, 26{]}}.

Some studies revealed a relationship between prior seasonal influenza
vaccination and intention to be vaccinated against
COVID-19\textsuperscript{{[}13, 17, 18, 24, 26{]}} . The current study
revealed no correlation between the influenza vaccination of nursing
students in the last 2 years (8.8\%) and the intention to be vaccinated
against COVID-19. However, previous vaccine rejection experience, either
by the individual or a relative (17.1\%), negatively affected one's
intention to be vaccinated against COVID-19. Individual or familial
experiences of vaccine rejection is an obstacle to acquiring herd
immunity through vaccination, and many countries have reported an
increased incidence of vaccine-preventable diseases in recent years
\textsuperscript{{[}18{]}}. This may cause very serious consequences
worldwide as it threatens all historical achievements in reducing the
burden of infectious diseases that have been affecting humanity for
centuries\textsuperscript{{[}7{]}.}

Some research suggests that vaccination acceptance is also affected by
other motivational and psychological factors, such as anxiety,
experiences, and disease risk perception \textsuperscript{{[}3, 27{]}}.
Many of the nursing students in the study perceived COVID-19 infection
as a serious problem that would continue for a long time and two-thirds
of them believed their risk of contracting infection, although the rate
of individual infection is low (8.2\%), whereas the rate of infection
and death in the family and close environment is detected as higher.
Additionally, the pandemic process has negatively affected the lives of
students. An increased intention to be vaccinated was observed in
students whose family members had COVID-19 infection, but no difference
was observed in other factors. Nursing students in Europe also perceived
contracting COVID-19 infection as a serious problem at similar
rates\textsuperscript{{[}13{]}}, whereas a study among medical students
in Egypt confirmed that 4.4\% had had an infection and 51.5\% in their
immediate social environment had contacted the
virus\textsuperscript{{[}9{]}}. Among the COVID-19 vaccination
motivations, the fear of being infected or the fear of infecting the
family and the history of chronic disease increased the tendency to be
vaccinated\textsuperscript{{[}9, 13, 19, 25, 26, 28{]}}. The study
of\textsuperscript{{[}13{]}} revealed that the pandemic process
adversely affected the mental health of nursing students and increased
their depression and anxiety levels.

The current study observed that students whose primary sources of
COVID-19 information were official institutions (WHO and MoH) and those
who relied on the statements of HCPs had an increased intention to be
vaccinated. People who rely on government sources, doctors, and public
health experts' explanations about COVID-19 information were more likely
to accept the vaccine \textsuperscript{{[}13,19, 21, 25, 29{]}}.
Obtaining information from unreliable sources and social media increased
students' suspicions about vaccines. The presence of the anti-vaccine
movement, especially on social media, may have contributed to the
unwillingness to be vaccinated \textsuperscript{{[}15, 30{]}}.

In the current study, nursing students' intention to be vaccinated was
positively affected by vaccine effectiveness and safety, among the
attitude that concerns the vaccine and its side effects, lack of
information about the vaccine, whereas seeing oneself as an experiment
in the vaccine administration and the thought that natural immunity
preference, acquisition of COVID-19 from the vaccine, the vaccine will
change the genetic structure were negative factors. The study conducted
with Palestinian nurses revealed that the factors that prevent the
intention to be vaccinated included preference of natural immunity, fear
of long-term vaccine complications, insufficient vaccine information,
fear of the vaccine, and the misrepresentation of the media about the
vaccine \textsuperscript{{[}22{]}}. Vaccine efficacy and safety,
insufficient knowledge about the vaccine, and fear of long-term side
effects are consistent with studies of \textsuperscript{{[}9, 10,
31{]}\textbf{.}} Students may have negative cognition in vaccination.
That's why, schools should strengthen education on adverse reactions of
COVID-19 vaccine, not only from knowledge, but also from psychological,
physiological, so that students can have eliminate fear and enhance the
willingness to vaccinate.

\textbf{4.2. Limitations}

The study was conducted for exploratory purposes, which tried to ensure
the participation of as many students as possible. Therefore, a power
analysis was not performed. The study was done a month or two after the
vaccine was released, which may reflect the students' desire to get
their first vaccine. The intention to be vaccinated is not a real
vaccination behavior. Therefore, it may not directly predict the actual
future vaccination behavior. Prospective studies can be done to analyze
the differences between the actual vaccination behavior and
pre-vaccination intention. These research results do not represent all
nursing students in the country, but they can give an idea for
vaccination applications.

\textbf{5. CONCLUSION}

One-third of nursing students do not intend to be vaccinated. Concerns
and barriers related to the vaccine included lack of information,
safety, efficacy, and side effects, as well as false beliefs that the
vaccine will transmit viruses and they are used as experiments. HCPs can
encourage individuals to receive vaccines. Nursing students are known to
be the future HCPs and will play a decisive role in counseling
individuals in the community about the risks of COVID-19 and the
benefits of the vaccine; therefore, focusing on training that is aimed
at increasing the knowledge of vaccines, eliminating their negative
attitudes and concerns, and building confidence in vaccines is
necessary. Nursing students should be encouraged to read scientific
research to eliminate misinformation through social media. Using and
following reliable news sources can build trust in vaccines.

\textbf{Conflicts of Interest:}

The authors declare no conflict of interest.

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\end{enumerate}

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