http://orcid.org/0000-0003-1648-7362
ABSTRACT
Influenza infection poses the same risk to healthcare students as to practising clinicians. While there is substantial dialog about the benefits, risks, and ethics of mandatory influenza immunization policies in Canada, there has been little engagement of healthcare students. To explore the knowledge, attitudes, beliefs, and behaviours of healthcare students, we administered a web-based survey to students at Dalhousie University. Influenza vaccination status varied by program type, with 86.3% of medical students (n = 124) and 52.4% of nursing students (n = 96) self-reporting receipt of the influenza vaccine both in the previous and current seasons; pharmacy students’ coverage fell between the two. Pharmacy students had higher mean knowledge scores (10.0 out of 13 questions) than medical (9.26) and nursing (8.88) students. Between 56.1% and 64.5% of students across disciplines were in support of a mandatory masking or vaccination policy, and between 72.6% and 82.3% of students would comply if such a policy were in place. A sense of duty to be immunized, desire to be taught more about influenza and influenza vaccine, belief that the hospital has a right to know vaccination status, support for declination policy, and willingness to accept consequences of noncompliance were all predictors of student support of mandatory policies. Medical and pharmacy students tended to hold more pro-influenza vaccination attitudes, had higher knowledge scores, and better vaccine coverage than nursing students. Based on the overall vaccination behaviour, knowledge, beliefs, and attitudes of students surveyed, this study demonstrates that mandatory influenza immunization policies are generally supported by the next generation of practitioners.
Influenza is a serious vaccine-preventable disease, ranked among the top 10 infectious diseases affecting the Canadian population.Citation1 Influenza is a frequent cause of outbreaks in acute and long-term care facilities; approximately 3,500 Canadians, mostly seniors, are estimated to die from influenza or its complications annually.Citation2,Citation3 Immunization is one of the most effective tools to prevent influenza; despite national recommendations, only 32.5% of Canadians and 48.8% of Nova Scotians aged 12 or older received their annual influenza vaccine.Citation4
Because of the risk of influenza to themselves and their patients,Citation5–Citation8 it is recommended that all healthcare providers be immunized with annual influenza vaccine.Citation9 Despite these recommendations, vaccine uptake among healthcare providers is well below national target goals (> 80%).Citation10 Many interventions, such as education, mobile immunization carts, vaccination champions, incentives, and required declination signature forms, have been demonstrated to improve vaccine coverage; however, none alone or in combination have succeeded in achieving target coverage rates.Citation11,Citation12 Mandatory immunization policies, such as mandatory vaccination (all individuals must be vaccinated) and mandatory masking or vaccination (individuals must be vaccinated or wear a mask in patient-care areas), have achieved target vaccine ratesCitation13 and are supported by the Centers for Disease Control and Prevention (CDC) and multiple professional organizations such as the American Academy of Pediatrics and the Society for Healthcare Epidemiology of America.Citation14,Citation15 However, mandatory policies have been met with individual and organized resistance by healthcare providers and their unions.Citation16–Citation18
Once they begin their clinical rotations, students in the health professions share the same risks to themselves and to their patients as practising clinicians. There is also a recognition that students’ attitudes and biases are formed early in their education.Citation19–Citation21 While there is substantial dialog about the benefits, risks, and ethics of mandatory influenza vaccination policies in Canada, there has been little engagement of healthcare students who would be the future healthcare workers affected if mandatory vaccination policies were to be implemented. This study aimed to explore the knowledge, attitudes, beliefs, and behaviours of Canadian medical, nursing, and pharmacy students towards mandatory policies related to influenza immunization.
Results
Demographics
A total of 302 students responded to the survey; 82 (27.2%) from nursing, 96 (31.8%) from pharmacy, and 124 (41.1%) from medicine (). Responses were received from 11.3% of total nursing students, 27.5% of total pharmacy students, and 21.5% of total medical students. Study participants in each program were generally evenly distributed across year of study. Medical students tended to be somewhat older than pharmacy and nursing students. The female proportion of respondents (91.5% of nursing, 77.1% of pharmacy, and 60.5% of medicine) was similar to the proportion in the programs (92.3%, 70.1%, and 51.7%, respectively).
Table 1. Study population demographics and general characteristics.
Vaccination behaviour
A total of 76.8% of student respondents had received the influenza vaccine the previous year (2014–2105), and 85.4% were immunized in the current year (2015–2016); 8.9% of the students had not received influenza vaccine for both the current and previous season. A total of 71.2% had been vaccinated both years (). Vaccination rates varied by program type: All medical students had received the vaccine for at least one of the two years and 86.3% had received it both years. For nursing students, 24.4% had received the vaccine neither year and 52.4% had received it both years. Pharmacy student vaccination rates fell between the two. For those who received the influenza vaccine, the most frequently cited primary reason was the desire to protect oneself (34.1%) and to protect one’s patients (31.8%) (). The most commonly cited secondary reasons were protecting one’s family (64.8%) (among those who did not cite it as their primary reason), protecting one’s patients (59.0%), and protecting oneself (55.5%). For those who did not get vaccinated in either year, the primary reason cited was either being too busy or forgetting (55.8%); the most commonly cited secondary reasons were being too busy (18.6%), having limited contact with high-risk patients (14.0%), not being at significant risk to get influenza (14.0%), and previously receiving the influenza vaccine and still getting influenza (14.0%) ().
Figure 1. Primary (dark gray bars) and secondary (light gray bars) reasons A. for getting vaccinated reported by students who had received influenza vaccine, and B. for not getting vaccinated in students who had not received the vaccine.
Knowledge and beliefs
Students were generally knowledgeable about influenza and influenza vaccine; the mean number of correct responses was 9.4 out of the 13 questions. Pharmacy students had a higher mean knowledge score (10.0) than medical (9.26; p = 0.012) or nursing (8.88; p = 0.0003) students. There was a diversity of opinion about the use of declination forms and mandatory vaccination policies; however, most students felt that they would comply with those policies. There were differences between the programs, with medical and pharmacy students holding more pro-influenza vaccination attitudes than nursing students.
A total of 90% of students believed it was their duty to receive the annual influenza vaccine; a higher proportion of pharmacy and medical students than nursing students held this belief (). While a majority (82.5%) of all students felt that it was the hospital’s right to know their vaccination status, pharmacy (92.7%) and medical students (85.5%) were more in agreement with this statement than nursing students (65.9%). Most students thought that it was the hospital’s and university’s responsibility to ensure that staff and students are taught about influenza and are offered vaccine (84.8%) and that hospitals are responsible for making policy to decrease the risk of transmission of influenza from students and staff to patients (86.8%). More pharmacy students than medical or nursing students thought that hospitals should increase their efforts to get staff immunized. Pharmacy and nursing students thought that more should be taught in their curriculum. There was little support for declination forms among the surveyed students (52.3%), although a majority of students from all programs indicated their willingness to accept the consequences of not complying with a mandatory masking or vaccination program or a mandatory vaccination program (61.9%).
Table 2. Healthcare students’ beliefs, overall and by program discipline, about influenza immunization and immunization policies.
While a majority of students from all programs supported a mandatory masking or vaccination policy, between 18% and 25% of students neither agreed nor disagreed with this type of policy () and 14% to 25% of students opposed a mandatory masking or vaccination policy. Between 73% and 82% of students responded that they would get vaccinated if there were a mandatory masking or vaccination policy, while 3% to 4% thought that they would wear a mask. Three percent of medical students, 5% of pharmacy students, and 12% of nursing students indicated that they would neither wear a mask nor get vaccinated if there were a mandatory policy. Less than 10% of students indicated that they would protest, be part of an appeal, or file a grievance against such a policy. Student support of a mandatory vaccination policy without a masking alternative was variable, with no differences among the three programs; approximately one-third of students supported such a policy, one-third opposed it, and one-third neither agreed nor disagreed with the policy.
Table 3. Healthcare students’ attitudes, overall and by program discipline, towards mandatory masking/vaccination or mandatory vaccination policies.
Factors associated with being vaccinated
In the univariate analyses, the demographic characteristics of older age, male gender, field of study, and year of study were associated with vaccination status; all except gender remained significant in the multivariate analysis (). Specifically, being a medical student, over the age of 24 years, and a first-year compared to a third-year student was associated with being vaccinated against influenza. In the univariate analysis, factors associated with being immunized were a sense of duty to be immunized, belief that the hospital has a right to know immunization status and to increase efforts to have staff vaccinated, acceptance of a declination form policy, and willingness to accept consequences of not complying with vaccination policy. In the multivariate analyses, only a sense of duty to be immunized and believing it would be useful to learn more about influenza vaccine and risks of influenza were associated with being immunized.
Table 4. Demographic and belief factors that predicted a student having received influenza vaccine in the year that the survey was administered (2015–2016).
Factors associated with supporting vaccination policies
Neither demographics nor knowledge scores were associated with the students’ support of a mandatory masking or vaccination policy or a mandatory vaccination policy in the univariate analysis; in the multivariate analysis, male gender was associated with support for the mandatory masking or vaccination policy (). In the univariate analysis, factors associated with support of the mandatory masking or vaccination policy were sense of duty to be immunized; desire to be taught more about influenza and influenza vaccine; belief that the hospital has a right and obligation to know vaccination status, for developing policies to decrease influenza transmission to patients, for making staff aware about influenza and influenza vaccine and offering vaccine, and increasing efforts that staff be immunized; support for declination policy; and willingness to accept the consequences of not being vaccinated. In the multivariate model, belief that the hospital should increase its efforts to ensure workers are vaccinated and willingness to accept the consequences of not adhering to the policy were associated with support of the mandatory masking or vaccination policy. In the univariate analysis, support for the declination policy and willingness to accept the consequences of not adhering to the policy were associated with support for a mandatory vaccination policy; in the multivariate analysis, the hospital’s right to know about vaccination status, declination forms, and willingness to accept the consequences of nonadherence were associated with support of the policy.
Table 5. Demographic and beliefs factors that predicted students’ support of mandatory masking/vaccination or mandatory vaccination policies.
Discussion
In this study, we explored the knowledge, attitudes, beliefs, and behaviours of nursing, medical, and pharmacy students towards mandatory influenza vaccination policies and self-reported receipt of influenza vaccine. Behaviour, attitudes, and beliefs of students are formed early in their educationCitation19 and, therefore, may be predictive of their attitudes, beliefs, and behaviours as healthcare providers. In this study, we found that, although there were some differences among nursing, pharmacy, and medical students, overall knowledge was high about influenza and the influenza vaccine. A majority of students in all three programs received their annual influenza vaccine each year and were supportive of a mandatory masking or vaccination policy aimed at increasing compliance with influenza vaccine recommendations. The most common reason for complying with influenza vaccination policies was the desire to protect one’s patients and oneself. The most common reason given by students who were not getting immunized was either being too busy or forgetting, although not feeling to be at risk was a frequently cited secondary reason. Medical and pharmacy students tended to be more supportive of influenza vaccination policies than nursing students. The majority of students in all three programs supported mandatory masking or vaccination policies; < 10% indicated that they would protest, be part of an appeal, or file a grievance against one of the mandatory policies. Among all students, only 3%–4% responded that they would wear a mask if there were a mandatory mask or vaccination policy. There was less support for a mandatory vaccination policy without a masking option; approximately one-third of students supported, one-third opposed, and one-third neither supported nor opposed such a policy.
Although studies of the knowledge, attitudes, beliefs, and behaviours of healthcare students regarding mandatory influenza vaccination policies are few, these data are consistent with the existing literature. Without standardization of knowledge questions, it is difficult to compare knowledge across studies. In contrast to some studies,Citation22,Citation23 our participants were relatively well informed about influenza and influenza vaccine. Protection of one’s patients and familyCitation22 and oneselfCitation22–Citation24 was also cited by healthcare students in Saudi Arabia, Italy, and Australia. While first-year students in our study were more likely to be immunized than third-year students, there was no clear pattern of increased or decreased influenza vaccine as students progressed through their program, similar to that found in a Spanish study.Citation25 This is in contrast to other studies where later-year students were more likely to be immunized than new students.Citation22,Citation23 Lack of perception of riskCitation22,Citation23,Citation26,Citation27and concern about vaccine adverse eventsCitation22,Citation23,Citation27 were important factors for not being immunized in several studies. As in our study, inconvenience, forgetting, being too busy, and fear of needles were also cited by respondents in other healthcare student studies.Citation22–Citation24,Citation27 Our data are also similar to the literature in suggesting that a substantial majority of healthcare students are supportive of mandatory influenza immunization policies.Citation23,Citation25,Citation27–Citation29
Mandatory influenza immunization policies have become more widespread in healthcare institutions in the United States and Canada since the pioneering policy implemented at Seattle’s Virginia Mason Medical Center.Citation13 In a 2014 survey of 2,077 health professional programs in the US, 32% required influenza vaccination.Citation30 In Canada, 20.9% of 134 health professional programs across the country indicated that they had a mandatory influenza immunization program. Most of the remainder strongly encouraged students to receive the vaccination. Multiple studies have indicated that influenza vaccine uptake rates among healthcare students closely parallel the rates of vaccine coverage among healthcare workers at their institutions.Citation23,Citation27,Citation31
Despite vocal opposition of mandatory vaccination or mandatory masking or vaccination policies by some healthcare providersCitation17 and court challenges initiated by some healthcare unions,Citation15 surveys of healthcare providers demonstrate overall support for mandatory policies similar to those found in our study of healthcare students. In a study at the University of Pennsylvania, 85% of respondents agreed with mandatory influenza vaccination.Citation32 Another survey of a pediatric network in Philadelphia found 74.4% support of a mandatory policy.Citation33 In another study at a tertiary care children’s hospital in Kansas City, 70% of healthcare respondents supported the hospital's mandatory influenza vaccination policy.Citation34 Interestingly, support for mandatory policies was found to be higher among healthcare providers covered by the policies than those not included in the mandate.Citation35 In contrast, an Australian study found general support for mandatory policies covering some infectious diseases but less than one-half supported inclusion of influenza vaccination in the mandates.Citation36
While one of a small number of studies evaluating the knowledge, attitudes, beliefs, and behaviours of healthcare students, our study has a number of limitations. As with all surveys and particularly surveys of students done by research staff at their institution, our survey was susceptible to a social desirability bias, despite assurances that responses would be anonymous. Vaccination rates were determined by self-report and could be affected by recall bias; however, self-report of influenza vaccination in the current season has been demonstrated to provide a valid measure of vaccine exposure when medical records or registry data are not available.Citation36 Our response rate was low, ranging from 11.3% to 27.5%, with no mechanism to determine whether respondents were representative of the entire student population. Other response biases could also have occurred; for example, students with strong opinions (either for or against mandatory policies) might have been more likely to respond to the survey, and students who chose not to be vaccinated may have been less likely to respond. As well, our survey was administered to students from three programs at a single institution in Nova Scotia where mandatory policies were not in existence; we can only speculate as to whether the results can be generalized to all students in Nova Scotia, students across Canada, or students in institutions or jurisdictions where mandatory policies are in place.
Several areas of future research can be identified as a result of this study. A broader sampling of healthcare students from other locations and from institutions with a range of policies would demonstrate whether or not the findings can be generalized. Longitudinal studies would be informative to explore how attitudes and beliefs change over time from program entry to graduation and then through years of employment. Additional research into the appropriate learning environment in the early years of professional education may be important; interprofessional education may enhance more uniform pro-vaccination attitudes and beliefs and may be seen as a part of a more general trend to greater collaboration in the delivery of education programs in the healthcare professions.Citation19–Citation21 Despite relatively high scores on the knowledge questions, student respondents wished to have more information provided to them in their curriculum, with early introduction of vaccination principles likely being important in the development of pro-vaccination policies.Citation22,Citation38–Citation40 Messages related to the benefits of vaccination to family, patients, and selfCitation22,Citation28 and as an ethical responsibilityCitation38 will likely be most persuasive. As with other healthcare providers, it is essential to eliminate barriers and address logistical issues, such as convenient locations and times, for programs targeted to students.Citation23,Citation27,Citation38,Citation41
Methods
Study setting, population, and design
The study took place in Halifax, Nova Scotia, between April and May 2016. Medical, pharmacy, and nursing students at Dalhousie University were asked to complete the survey. Dalhousie University is the largest university in the Maritime provinces, with a medical school enrollment of 576 students in a four-year program, a pharmacy school enrollment of 349 students in a 4-year program, and a nursing school enrollment of 727 students in a 2- or 4-year program. Survey invitations were distributed by email by the student affairs offices at the university; all students enrolled in the three programs for the 2015–2016 academic year were eligible to participate. The emails contained a link to a web-based electronic survey and provided information about the study and an invitation to participate. The first electronic screen explained the study and contained a consent statement that they were able to complete. The rest of the survey was available to those who provided informed consent for participation. Participants were offered an opportunity to enter their names into a draw for $10 coffee gift certificates. The study received Research Ethics Board approval at the IWK Health Centre, an affiliated institution of Dalhousie University.
Survey instrument development
The survey instrument was constructed following Dillman’s principles of survey design, and the theory of planned behaviour served as the theoretical framework for the design of the survey but was not used exclusively for the analysis. This theory has been used widely to predict health-related behaviours, and its efficiency and validity are recognized in general and for immunization-related behaviours. The principal components of this model helped identify critical internal and external factors that impact the decision to be vaccinated or comply with the institutional policies.Citation42,Citation43 The survey contained 40 questions including demographics, information, and vaccination status (8 items), knowledge (13 items), beliefs (9 items), and attitudes toward policy options (10 items). Knowledge questions covered information about influenza disease, transmission, and risks, and the safety and effectiveness of influenza vaccine. Beliefs statements testing opinions about influenza vaccination of healthcare providers and attitudinal statements related to vaccination policy were structured with a 5-point Likert response scale ranging from “strongly disagree” to “strongly agree.” In the development of the survey instrument, content validity was assessed by presenting the questions to a panel of 3 infectious disease specialists with a focus in vaccine research. Each question as well as the survey overall was evaluated by the experts using a rating worksheet with a 4-point ordinal rating scale. Items that received a high content rating were retained (3 or 4); those with low ratings were eliminated or modified and re-evaluated. In addition to this quantitative assessment of content validity, a qualitative assessment was obtained through use of a focus group of 12 postgraduate students to provide feedback on clarity, wording, and relevance of the survey items. Test re-test reliability was also assessed by having 4 individuals complete the survey twice at an interval of 1 month. A correlation coefficient of > 0.7 was used to denote reasonable consistency over time.
Data management and statistical analysis
All analyses were performed in SAS 9.4 (SAS Institute, Cary NC). Because of the defined population available, a sample size calculation was not performed.
Continuous variables were described by summary statistics (mean and standard error) and categorical variables as proportions and associated two-sided 95% confidence intervals. Logistic regression was used to model binary responses, and proportional odds cumulative logistic regression models were used to model ordinal responses. Statistical tests were considered significant when p-values were < 0.05, and no adjustment was made for multiple comparisons. Estimated odds ratios were reported, together with their associated 95% confidence intervals.
Logistic regression/cumulative logit models were used to explore predictive factors for behaviours and attitudes, including immunization and support of policies. A limited number of predictors (age, gender, program, year of study, and nine attitude variables) were chosen as covariates of interest in multivariate models to predict each of the three outcomes of interest (immunization status, support of masking policy, and support of vaccination policy), using a stepwise algorithm for model selection.
Disclosure of potential conflicts of interest
No potential conflict of interest was reported by the authors.
Acknowledgments
The authors thank the staff of the Canadian Center for Vaccinology for data management and the staff of the School of Nursing, Faculty of Medicine, and College of Pharmacy for distribution of the electronic surveys.
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