Factors Influencing COVID-19 Vaccination Intentions Among College Students: A Cross-Sectional Study in India

Background: Students act as messengers in delivering effective messages for better uptake of health-promoting behavior. Understanding their knowledge about coronavirus disease 2019 (COVID-19), intentions to use the COVID-19 vaccine, and its associated factors will help develop promising strategies in vaccine promotion concerning the current COVID-19 pandemic. Methods: A cross-sectional online survey was carried out among students in the healthcare and non-healthcare sectors to assess their intentions to get vaccinated against the COVID-19. A non-probability snowball sampling technique was used to recruit study participants (N = 655) through social media platforms and emails. Study participants were recruited across the country, including six major geographical regions (Eastern, Western, Northern, Southern, North-east, and Central) in India between November 2020 and January 2021 before the introduction of the COVID-19 vaccine. Descriptive statistics were used to present the sociodemographic, and vaccine-related behaviors of the study participants. Key determinants that likely predict vaccine acceptance among students were modeled using logistic regression analysis. For each analysis, p < 0.05 was considered significant. Results: A total of 655 students were recruited, 323 from healthcare and 332 from non-healthcare sectors, to assess their intentions to receive the COVID-19 vaccine. Of the 655 students, 63.8% expressed intentions to receive the COVID-19 vaccine. The acceptance was higher among non-healthcare students (54.07 vs. 45.93%). At the time of the study, 27.8% of the students indicated that they had been exposed to a confirmed COVID-19 patient. A vast majority (93.4%) of the students knew about the COVID-19 virus, and most (89.3%) of them were aware of the development of a COVID-19 vaccine. The history of vaccine hesitancy was found to be low (17.1%). Only one-third (33.4%) of the students showed concern about contracting COVID-19. Trust in the healthcare system [adjusted odds ratio (aOR): 4.13; (95% CI: 2.83–6.04), p < 0.00] and trust in domestic vaccines [aOR: 1.46; (95% CI: 1.02–2.08), p < 0.05] emerged as the significant predictors of student's intention to get vaccinated. Higher acceptance for vaccine was observed among students in the non-healthcare [aOR: 1.982; 95% CI: 1.334–2.946, p < 0.00]. Conclusion: This study shows that the Indian college students had relatively high levels of positive intentions to receive COVID-19 vaccines, although about one-third were not sure or unwilling to receive the vaccine, highlighting possible vaccine hesitancy. Informational campaigns and other strategies to address vaccine hesitancy are needed to promote uptake of COVID-19 vaccines.


INTRODUCTION
The coronavirus disease 2019 (COVID-19) pandemic has continued to affect multiple domains of human lives since its emergence at theend of 2019 (1). The increasing cases of COVID-19 had an adverse effect on all spheres of life, the economy, and the environment during the lockdown period (2). On 30 January 2020, the World Health Organization (WHO) declared an outbreak, a Public Health Emergency of International Concern (3). The COVID-19 pandemic has significantly affected the lives of college students physically, academically, financially, and psychologically (4). To prevent widespread transmission of the COVID-19 virus among college staff and the young adult population, higher-education institutions across the country have rapidly switched from in-person to online learning (5). Growing attention has been paid to vaccinate high-risk populations to control the COVID-19 pandemic. Young adults and students are critical populations for the vaccination campaign and could act as messengers in delivering effective messages for better uptake of vaccines among their families and communities (6). Students in the healthcare sector are considered to have highrisk exposures to COVID-19 and have been given priority in vaccine allocations (6). In India, the COVID-19 vaccine was introduced in a phased manner with the first phase focused on healthcare workers, frontline workers, and populations at high risk as part of concerned control measures (7). Covishield (Serum Institute of India) and Covaxin (Bharat Biotech) were the two vaccines approved for restricted emergency use (8,9). However, at the time of the study, acceptance of these vaccines remained skeptical, with safety (10) and efficacy (11) as major concerns. Students and younger populations seemed to play an important role in determining vaccine acceptance in the community, with contrasting effects in different countries (12), but information on the same was lacking in India.
Vaccine hesitancy was a significant issue even before the COVID-19 pandemic (13). The WHO considered this phenomenon as one of the top ten threats in global health in 2019. The available evidence seems to show that the intention to get vaccinated against COVID-19 is lower among younger adults and young people (14). Younger individuals may believe that COVID-19 poses a less serious threat to themselves than to other age groups (15). To attain complete protection from the COVID-19 viruses, the vaccines need to be widely accepted by all subgroups of the populations, including youth (16). In the United States of America (USA), though it reported the highest number of confirmed cases of COVID-19 in 2020, only half of the medical students expressed willingness to participate in a vaccine trial and about 23% were hesitant to get vaccination (17). Similarly, only 35% of the medical students in Egypt (18), 45% of nursing students in Europe (19), and 52.8% of college students in New Jersey, USA, indicated their intention to receive COVID-19 vaccine (4). Although, a majority (86.1%) of the university students in Italy were willing to receive COVID-19 vaccine (20). Numerous studies reported that lack of trust in healthcare and/or health officials are common barriers to vaccination (21)(22)(23). However, there is a lack of such information from India on the prevalence of vaccination intentions and the reasons for such intentions among students in India.
Given that students could play an essential role in the global vaccination campaign by influencing the vaccination intentions of their families and communities, their perception and acceptance of COVID-19 vaccines, including factors associated with those intentions, need to be investigated. Accordingly, we conducted a study to assess the intention to receive the COVID-19 vaccine and predictors of uptake among students in India. The findings from this study could help policymakers to prioritize strategies for effective interventions to promote vaccination among college students.

Study Design and Sample
A cross-sectional study was conducted among college students including healthcare and non-healthcare sectors across India. The survey was conducted between November 2020 and January 2021 during the "first wave" and before the introduction of COVID-19 vaccines in India. Students (N = 655) were recruited from an online survey via a self-reported questionnaire through social media, like WhatsApp, Facebook, and Twitter. Thus, primarily a convenient sampling technique was used. Further, the snowball sampling technique was used for enlisting additional participants, where the invited participants were requested to pass on the invitations to their peers. The minimum required sample size was estimated to be 576 with a 50% acceptance rate, 5% absolute precision, and 95% confidence level. The design effect was kept at 1.5. We recruited a total of 655 students of which 323 students were from healthcare and 332 students were from non-healthcare sectors. Participants aged 18 years or above who are currently living in India were included in the study. An online informed consent was obtained from all the participants before the survey. Only those provided the informed consent were taken to the questionnaire web page to initiate the survey.

Study Questionnaire
The questionnaire was informed by a literature review of similar studies (24,25). The survey assessed various domains, such as (1) previous immunization behaviors; (2) perception of vaccines; (3) current knowledge about COVID-19 and personal experiences about COVID-19; and (4) sociodemographic characteristics, including age, sex, marital status, educational status, family size and income, social status, religion, caste, and residence. Some of the key questions that were asked include whether "they ever refused a vaccine for themselves or a child considering it as useless or dangerous"; "if they ever postponed a vaccine recommended by the physician" for assessing the general perception toward vaccine; "before the interview if they were aware of the COVID-19 virus that is currently circulating in the community"; "Is there currently any vaccine being prepared for the pandemic Coronavirus strain"; "do you have any history of staying or traveling with confirmed COVID-19 patient"; and "how concern are you that your family member will be infected with COVID-19 virus, " for estimating the current knowledge and personal experience about COVID-19.

Statistical Analysis
Descriptive analysis was conducted for socio-demographic characteristics of the responses to the survey. The age variable was categorized into three groups: 18-25, 26-35, and above 35 years. Gender was coded as a binary variable (male and female). Marital status was grouped into two categories (married and single). The educational status was categorized into three groups (postgraduate, graduate, and high school/diploma). Five response options were provided to family monthly income <INR 5,000 (about USD 71), 5,000-10,000, 11,000-20,000, 21,000-50,000, and >50,000. The geographical region of India was grouped into six categories (East, West, North, South, Central, and North-east), and the place of residence was categorized into urban vs. rural. "Yes" and "no" options were used for categorizing responses to certain questions, such as previous immunization behavior, perception of vaccines, awareness about COVID-19, and personal experience concerning COVID-19. In addition, they were asked "How concerned you are that you or someone in your family will be infected with COVID-19 virus?" and the responses were recorded in a three-point Likert scale (very concerned, somewhat concerned, and not at all concerned). "Do you have trust in the healthcare system to manage the current situation related to COVID-19?" was categorized into very likely, somewhat likely, and not at all. Bivariate analysis was conducted between all variables with the dependent variable of interest. Multiple logistic regression analysis was conducted to examine the association between the students receiving the COVID-19 vaccine with their sociodemographic and vaccination behaviors. A p < 0.05 was considered significant. Data analysis was conducted using Stata 15 software (STATA Corporation, College Station, TX, USA).

Ethical Consideration
The study was approved by the Institutional Research Ethics Committee of the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. All participants provided informed consent. Steps were taken to ensure confidentiality and privacy of the information provided by the participants, and only de-identified data were used.

RESULT
A total of 655 students participated in the study, with 49.3% from healthcare sectors and 50.6% from non-healthcare sectors.   Table 1). Most (93.4%) of the participants were aware that the COVID-19 virus was circulating in the community; 89.3% of the students were aware that a "COVID-19 vaccine" was being prepared. About a little less than two-thirds (64.5%) of the students reported having trust in the healthcare system of India, and a little more than half (56.0%) reported having confidence in domestic vaccines. About 27.7% of students reported having had a history of travel or contact with a confirmed COVID-19 patient. Only one-third (33.4%) of the students were concerned about contracting the COVID-19 virus. A large proportion of students (82.9%) did not have any history of vaccine hesitancy ( Table 2). A majority (89.3%) of the students knew that COVID-19 vaccines  Table 2).
In bivariate analysis, intention to receive COVID-19 vaccine seems to be slightly higher among non-healthcare sector students than among healthcare sector students (68.1 vs. 59.4%, p = 0.02), higher among unmarried students when compared to those who were single (33.9 vs. 66.0%), and higher among postgraduate (42.8%) and undergraduate students (40.1%) when compared to diploma/higher secondary students ( Table 3). Knowledge about the development of the COVID-19 vaccine, risk perception, trust in the healthcare system, and trust in the domestic vaccine was found to be independently associated with vaccine intention among students ( Table 4). Table 5 shows a multivariable logistic regression analysis of the factors influencing the COVID-19 vaccine uptake among students. We found that those who trusted the healthcare system (vs. those who did not trust) (aOR = 4.13, 95% CI: 2.83-6.04, p < 0.001), and those who had confidence in domestic vaccines (vs. those who did not have confidence) (aOR = 1.46, 95 % CI: 1.02-2.08, p = 0.03) had higher odds of reporting willingness to receive COVID-19 vaccines.

DISCUSSION
Studies on COVID-19 in India have described the effect of COVID-19 on medical education (26), the relationship between COVID-19 and the suicidal tendency among healthcare professionals and students (27,28) and COVID-19-related anxiety among students (29,30). However, none have reported uptake of COVID-19 vaccine among students, especially those in the healthcare sector. This study is one of the first studies that examined the willingness of hypothetical vaccine for COVID-19 among students in India.
Our findings indicate a relatively good level of willingness (63.8%) among the healthcare and non-healthcare sectors to receive COVID-19 vaccines. However, the low or lack of intention to vaccinate among one-third of the sample in this study indicate vaccine hesitancy that needs to be tackled. Our findings are in line with the percentages of students (35-52.8%) who reported willingness to receive the COVID-19 vaccine in European countries and the USA (4,18). In this study, we also found that the students in the non-healthcare sector were more willing to receive COVID-19 vaccines (54.0%) than those in the healthcare sector (45.9%). We also found that trust in the healthcare system and domestic vaccines was related to intention to receive COVID-19 vaccines. This finding of ours is similar to a survey conducted among college students in South Carolina, where 73.9% of students trust healthcare authorities, and that trust was significantly associated with COVID-19 vaccine acceptance (31). While this study found high levels of trust in domestic vaccines and their association with COVID-19 vaccine acceptance, a study conducted in China reported that imported vaccine was preferred over domestic vaccine (32). Concerning the risk perception for COVID-19 infection, in this study, the participants reported a lower risk perception of getting infected, possibly reflecting an optimism bias, our expectations (low risk of infection) are better than reality (actual risk of infection) (15,33).
In multivariable analysis, age, gender, and education were not significantly associated with vaccine acceptance. This finding contrasts with the results of other studies conducted in Portugal (23) and Indonesia (34), where vaccine acceptance was significantly associated with education and marital status, respectively; a lower intention to be vaccinated against COVID-19 among women was also reported (35). Perceived adverse events of the COVID-19 vaccine could be a possible reason for hesitancy, as highlighted by various studies among university students and the general population (18,31). Studies have shown that adverse events and poor vaccine efficacy could be possible reasons for vaccination hesitancy among medical students (36). Studies among other populations too have reported several reasons for hesitancy toward COVID-19 vaccines, including sideeffects of the vaccine (37), speed of development of the vaccine (38), uncertainty about the effectiveness (39), and effective duration of the vaccine, and medical mistrust (40).
Students are considered as trusted influencers and ambassadors for vaccine promotion (41). Vaccine hesitancy among students, especially those in the healthcare sector, and other priority groups has potentially negative consequences to themselves and may influence vaccine acceptance among the general population (42). For example, one study reported that vaccinated healthcare providers were more likely to recommend vaccination to their patients (41).
This study has several limitations. First, being a cross-sectional study, the predictors of vaccine acceptance may not be causal and may only reflect potential associations through unknown mechanisms. However, the identified significant predictors are in line with the potential mechanisms of vaccine acceptance documented in the literature. Nevertheless, the intention to receive COVID-19 vaccines may vary over time and structural contexts. Second, the study used convenient and snowball sampling to recruit participants, and thus the results may not be generalizable to all students of healthcare and non-healthcare sectors. Third, an online self-administered questionnaire form was used instead of a face-to-face interview, with potential bias in reporting; however, studies in the health field have shown that there may not be a difference between a self-administered and interviewer-administered questionnaire (43,44). The reasons for the refusal or low willingness to receive COVID-19 vaccines need further investigation, possibly using qualitative or mixed methods approaches. Despite these limitations, this study provides critical information on the factors that impact the acceptance of COVID-19 vaccination among college students in India. Furthermore, the data presented in this study could act as a piece of baseline information for future comparisons, i.e., how the intention to vaccinate varied over time.

CONCLUSION
In this study, we found suboptimal levels of willingness to receive COVID-19 vaccines, with nearly one-third not sure or willing to receive a vaccine, indicating high levels of potential vaccine hesitancy. Trust in the healthcare system, including vaccine safety and effectiveness, was a significant factor for COVID-19 vaccine acceptance among students. It is pertinent to design an evidence-based strategy to promote the uptake of vaccination among students, which could include informational campaigns that address vaccine hesitancy. In addition, strategies demonstrating the effectiveness and safety of the vaccine will be essential when rolling out the COVID-19 vaccination programs and those strategies will certainly have implications beyond the COVID-19 pandemic.

DATA AVAILABILITY STATEMENT
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

ETHICS STATEMENT
The studies involving human participants were reviewed and approved by Institutional Research Ethics Committee of Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India. The patients/participants provided their written informed consent to participate in this study.

AUTHOR CONTRIBUTIONS
BP, LJ, MG, and AA conceptualized the study and designed the tools. BP, LJ, JV, PS, VC, BP, SK, RS, SP, SB, NR, VR, TK, KG, BM, LS, MG, and AA conducted the study at the national level and collected the data. BP and LJ analyzed the data. LJ drafted the introduction. BP drafted the methods and results. LJ and VC drafted the discussion. MG and AA provided guidance, particularly related to the strategy and recommendations. All authors reviewed drafts, provided edits, and approved the final submission.