General attitudes toward and awareness of vaccines among students at a university in Northern Cyprus

ABSTRACT

Misinformation and movements against vaccines put public health at risk. This study investigated vaccine awareness and opinions on the anti-vaccination movement among students at three faculties of Eastern Mediterranean University. Data were collected by questionnaire. Exposure to anti-vaccination propaganda increased proportionally with the size of the cities where participants were born. In total, 88.6% of the participants declared that they planned to vaccinate their children, while those who did not cited various reasons including the belief that vaccines do not work, that vaccines are harmful, and that it is better to be infected naturally. 60.6% of participants reported that they would get vaccinated against SARS-CoV-2 if there was an effective vaccine. Meanwhile, 24.5% of participants were not sure whether would get vaccinated even if it were possible, 11.4% of participants stated that they would not vaccinate their children for a variety of reasons. These results are important, especially in the context of a pandemic, because students will become leaders in education, business, and media, and thus shape the thoughts and opinions of future generations. The anti-vaccination movement is building momentum, and is especially influential in big cities; therefore, it is vital to change our approach to informing students about vaccination.

KEYWORDS:

• Vaccine
• anti-vaccination movement
• college students
• pandemic

Introduction

Immunization refers to the effect of vaccination on the immune system and is considered by the World Health Organization (WHO) to be one of the world’s great health success stories. Many infectious disease outbreaks have been controlled by vaccines.¹ However, recently there has been a considerable increase in emotion-driven anti-vaccine information on various websites. These websites often claim that vaccines cause idiopathic diseases, impair natural immunity, have underreported side effects, and are driven by profit.² The anti-vaccine movement leads people to hesitate regarding vaccination, because of the alleged links between vaccines and idiopathic chronic diseases, such as autism and diabetes, as well as claims that additives in vaccines, such as mercury, lead to serious adverse side effects.³ Unfortunately, because of the anti-vaccine lobby and websites opposing vaccines, diseases that were previously controlled effectively, such as measles, have returned to Europe and America.⁴

An Australian study examining parental attitudes and concerns about vaccines reported incomplete vaccine coverage in approximately 8% of children, and found that 2% of parents were against vaccinating of their offspring.⁵ A study from Turkey showed that belief in the important protective effects of vaccines was significantly lower among people with lower levels of education than among those with higher levels of education.⁶ However, knowledge gaps pertaining to vaccines and immunization are not limited to less-educated people; Zarobkiewicz et al. reported that university students in Poland also have significant knowledge gaps.⁷

In this study, we investigated the awareness of and general attitudes toward vaccines of university students in Northern Cyprus, as well as their opinions on the anti-vaccination movement. Students at the Faculty of Education were included, since they will become teachers who shape the opinions of vaccines of future generations, and thus will have a great impact on public health. Students at the Faculty of Business and Economics were also eligible because they will likely be in charge of insurance plans and workplaces where vaccines are required. Finally, students at the Faculty of Communication and Media Studies were enrolled because the anti-vaccination movement started on the internet and in certain media, and these students will influence these platforms, and thus public opinion, in the future. Students of medical and health-science-related faculties were not considered because of overwhelming evidence that they are much more likely to be in favor, and trusting, of vaccines.

Materials and methods

A cross-sectional survey was conducted between March 2019 and June 2020. As discussed above, the study population comprised students attending different faculties of Eastern Mediterranean University (EMU), including the Faculty of Education, Faculty of Business and Economics, and Faculty of Communication and Media Studies.

The study was approved by the Health Subcommittee of EMU Research and Publication Ethics Board with decision number ETK00-2020-0055. Data were collected using a modified version of a questionnaire employed in a similar study conducted at universities in Poland. The original questionnaire comprised 27 items. Our version also covered sociodemographic characteristics and included three parent-related items, as well as an item related to vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The questionnaire was translated into Turkish, and participants could respond in either English or Turkish.

The total student population of the three faculties who are expected to shape the thoughts of future generations with their occupation was 4,521 (the Faculty of Education, n = 1,928; the Faculty of Business and Economics, n = 1,873; the Faculty of Communication and Media Studies, n = 720). A sample size of 355 was determined using the OpenEpi sample size calculator,⁸ with a confidence level of 95%. A stratified random sampling method was applied according to the population sizes of the three faculties. Within each faculty, a simple randomization procedure was applied according to the classes. Permission to distribute the questionnaire was obtained from faculty professors.

The target sample size was not achieved because the period of questionnaire distribution was cut short due to the coronavirus disease 2019 (COVID-19) pandemic and subsequent quarantine measures. Therefore, the questionnaire was offered in an online format. E-mails were sent to lecturers requesting permission for the distribution of the questionnaire during their online lectures.

Statistical analyses were performed using the SPSS 20.0 statistical package. Descriptive statistics were used for sociodemographic features and to summarize the characteristic of variable. The sample was analyzed based on gender, age, nationality, department, religion, origins of birth and year of studies. The relationship between variables was analyzed using the chi-square test.

Results

As stated above, the target sample size was 355 individuals; however, only 313 questionnaires were filled out because of the COVID-19 pandemic. Fourteen additional responses were received after the questionnaire was made available online for students in the Faculty of Business and Economics attending online classes. Thus, 327 questionnaires were ultimately filled out (overall response rate = 92.1%).

Tables 1 and 2 show the student demographic characteristics and general knowledge and attitudes toward vaccination, immunization, and anti-vaccine movement, respectively.

Table 1. Demographic characteristics of the students

	Number	Percentage %
Gender  Female  Male	173 154	52.9 47.1
Age  18–20  21–23  24–26  >26	158 110 37 22	48.3 33.6 11.3 6.7
Nationalty  Turkish Cypriot  Turkish  Arab  African  Iranian  European  Azeri  Other  Missing	111 90 44 53 13 6 6 2 2	33.9 27.5 13.4 16.2 3.9 1.8 1.8 0.6 0.6
Origins of birth  Village  Town with less than 200,000 population  City with less than 1,000,000 population  City with more than 1,000,000 population	45 62 108 112	13.8 19 33 34.3
Religion  Muslim  Christions  Jewish  Deist  Atheist  Other	233 34 4 21 15 20	71.3 10.4 1.2 6.4 4.6 6.1
Year of the study  First year  Second year  Third year  Fourth year	80 94 53 70	24.5 28.7 16.2 21.4
Post-graduate	30	9.2
Faculty  Business and Economics  Education  Communication and Media Studies	119 151 57	36.4 46.1 17.4

Table 2. General knowledge and attitudes toward vaccination, immunization, and anti-vaccine movement of the students

	Number	Percentage %
Do you know what an anti-vaccination movement is?  Yes What is your opinion about the anti-vaccination movement?  Rather bad  Definitely bad  Ambiguous  Rather good  Definitely good	143 36 32 43 17 15	44 25.1 22.3 30.1 11.8 10.4
Has anyone ever tried to convince you that vaccination is harmful?  Yes Students who are exposed to anti-vaccination propaganda  Originated from a village  Originated from town  Originated from a small city  Originated from a big city	80 4 15 26 40	24.7 8.9 16.4 24.3 36
Do you know any consequences of a decrease in the percentage of vaccinated people?  Yes	55	16.8
Will you vaccinate your children?  No Reason for not-vaccinating  Risk of advers effect  Vaccines do not work  Getting ill is better	37 17 16 4	11.4
		45.9 43.2 10.8
How common are adverse effects of vaccination?  1 person in 10,000  1 person in 100,000  1 person in 1,000,000	86 73 75	30.6 26 26.7
Percentage of the population should get vaccinated to sustain herd immunity  80%  85%  90%  100%	65 73 61 49	20.8 19.5 23.3 19.5
Do you agree that the post-disease immunity persists longer than the post-vaccination immunity?  Yes  I have no opinion	102 78	31.6 55.1

In total, 60.6% of participants stated that they would get vaccinated against SARS-CoV-2 if there were an effective vaccine, while 24.5% were not sure if they would get vaccinated even if it were possible; this proportion was significantly higher among the Faculty of Communication and Media Studies students. Meanwhile, 63.5% of participants who plan to vaccinate their child declared that they would get vaccinated against SARS-CoV-2 if there were an effective vaccine. However, only 35.1% of participants who do not plan to vaccinate their child declared that they would get vaccinated against SARS-CoV-2 if there were an effective vaccine.

Tables 3 and 4 show the students’ opinions on vaccination according to faculty and nationality, respectively.

Table 3. The students’ opinions on vaccines according to the faculty variable

	Business and Economics Faculty (n = 119)	Communication and Media Studies Faculty (n = 57)	Education Faculty (n = 151)	p
Will you vaccinate your children?  Yes, n(%)	107 (91.5)	49(86)	132(87.4)	0.46
Do you think that parents who do not vaccinate their children should be penalized?  No, n(%)	30 (26.3)	17 (29.8)	76 (50.1)	0.008*
Has anyone ever tried to convince you that vaccination is harmful?  Yes, n(%)	36(30.8)	14(25)	30(20)	0.121
Do you think thiomersal containing vaccine is dangerous?  Yes, n(%)	57(49.6)	27(48.2)	88(59.5)	0.17
Do you know what an anti-vaccination movement is?  Yes, n(%)	47(40.2)	23(40.4)	73(48.3)	0.33
Would you get vaccinated, if there is an effective vaccine against new coronavirus?  Yes, n(%)	77(64.7)	32(56.1)	89(60)	0.002^#

*The majority of the participants studying in the Faculty of Education thought that parents who could not vaccinate their children should not be punished, but this rate was significantly lower among students of the Faculty of Business and students of the Media Faculty (p = 0.008). # The proportion of wanted to get vaccinated against SARS-CoV-2 was significantly lower among the Faculty of Communication and Media Studies students (p = 0.002).

Table 4. The students’ opinions on vaccination according to the nationality variable

	Turkish Cypriot	Turkish	Arabic	Iranian	African	p
Will you vaccinate your children?  Yes, n(%)	96(86.5)	80(88.9)	39(88.6)	12(92.3)	46(90.2)	0,26
Has anyone ever tried to convince you that vaccination is harmful?  Yes, n(%)	13(11.7)	24(26.7)	13(29.5)	4(30.8)	19(38.0)	0.01*
Do you think thiomersal containing vaccine is dangerous?  Yes, n(%)	63(58.3)	57(64.8)	15(34.1)	6(46.2)	22(44.0)	0.01^#
Do you know what an anti-vaccination movement is?  Yes, n(%)	46(41.4)	42(46.7)	19(43.2)	8(61.5)	24(47.1)	0.66
Would you get vaccinated, if there is an effective vaccine against new coronavirus?  Yes, n(%)	63(56.8)	54(60)	27(61.4)	8(61.5)	37(69.8)	0.59

* Turkish Cypriot students were less exposed to anti-vaccination propaganda than Turkish, Arabs, Iranians and Africans (p = 0.01). ^#The majority of students considered vaccines containing thimerosal to be dangerous; this rate was significantly higher among the participants from Northern Cyprus and Turkey than among those from African countries, Arab countries, and Iran (p = 0.01).

Discussion

As one of the most effective public-health measures, vaccines have ensured that many children are protected from a variety of infectious diseases that can cause disability and death.⁹ In addition to saving lives, vaccination of children results in considerable public health cost savings.¹⁰ However, the anti-vaccination movement continues to grow. The WHO declared vaccine hesitancy to be one of the top 10 threats to global health in 2019.¹¹

The most common reasons cited by some of the students in our study regarding their intention to not vaccinate their child included the belief that vaccines have side effects that can harm children, that vaccines do not work, and that being infected with the disease is a better way to improve immunity. More than half of the participants believed that thiomersal-containing vaccines are harmful; this proportion was significantly higher among women than men. The majority of respondents considered vaccines containing thiomersal to be dangerous; this rate was significantly higher among the participants from Northern Cyprus and Turkey than among those from African countries, Arab countries, and Iran. The belief that thiomersal-containing vaccines are harmful may have been due to knowledge that mercury is generally harmful to the body. However, there is no evidence that the low levels of thiomersal use in vaccines cause harm other than a local reaction.^12–14

In our study, exposure to anti-vaccine propaganda varied by ethnicity, with the Turkish Cypriot and Turkish participants being exposed to less of this propaganda than Arabs, Iranians, and Africans. This may be due to cultural factors and/or the governments of these countries. Participants from large cities were exposed to more anti-vaccine propaganda than those from towns and villages; propaganda tends to be focused in large cities. However, there was no significant relationship between the degree of exposure to anti-vaccine propaganda and gender, age, faculty, religion, or year of studies. A recent study by Figueiredo et al.¹⁵ found that reduced vaccine uptake was related to male gender and having less education. However, Wagner et al.¹⁶ found no association between education and vaccine hesitancy. Other studies have found that people in high-income regions are the least confident about vaccine safety, and have less in trust vaccines compared with people in low-income regions.^17,18 We also found that the Faculty of Education students were more against punishing parents refusing to vaccinate their children compared with the Faculty of Business and Economics and Faculty of Communication and Media Studies students; thus, opinions on important matters varied among faculties. A Polish reported that medical university students were more supportive of punishing parents who did not vaccinate their children than non-medical university students.⁷ Thus, anti-vaccine attitudes and exposure to propaganda are multifaceted phenomena.

In total, 24.5% of our participants were not sure if they would take a SARS-CoV-2 vaccine, while 15.5% indicated that they would not get vaccinated even if there were an effective vaccine. Moreover, the proportion was significantly higher among the Faculty of Communication and Media Studies students. Information pollution during the early period of the COVID-19 pandemic, discussions about whether the vaccine would be beneficial, and uncertainty regarding the vaccine production process all influenced the media students. Negative propaganda against vaccination, negative discourse, and baseless media reports confuse the issue of vaccination. In a survey of 1,663 British people, around one in six reported they would refuse to get vaccinated against SARS-CoV-2, and a similar proportion were undecided. That study also noted that respondents who were more hesitant about potential vaccines trusted social media as a source of information about the pandemic.¹⁹

Another similar study performed in Italy, one of the most affected countries, during the COVID-19 pandemic found that out of 735 university students, 86.1% intended to take a vaccine, while 13.9% were either not sure or did not intend to get vaccinated.²⁰ Similar to our study, these findings show that although the majority of students plan to take the vaccine, the proportion who are unsure or unwilling to get vaccinated is still significant, which could have consequences for public health.

The main limitation of this study was the negative impact of the pandemic and subsequent quarantine on the response rate, which may also have influenced the opinions of some of the respondents.

To our knowledge, no previous studies on attitudes toward and awareness of vaccines have focused on Northern Cyprus or EMU. Moreover, our findings should serve as a useful reference for future research. The results provide important insight into the beliefs of university students regarding vaccines, in general and in the context of a pandemic.

Most of our participants intended to vaccinate their children. However, even in the context of the current pandemic, 11.4% stated that they would not vaccinate their child, citing a variety of reasons. Therefore, it is important to reevaluate strategies for addressing vaccine hesitancy, which has a great impact on public health and the likelihood of disease outbreaks.

Authors’ contributions

All authors participated in all the parts of the preparation of the manuscript. Also, all authors share editorial rights. The final revision is made by NG.

Disclosure of potential conflicts of interest

The authors declare that they have no conflict of interests.

Acknowledgments

This research was conducted within the Eastern Mediterranean University Faculty of Medicine Introduction to Clinical Skills-2 Research program.