Attitudes of school teachers toward influenza and COVID-19 vaccine in Greece during the COVID-19 pandemic

ABSTRACT

Our study aims to assess the attitudes, knowledge, and influenza vaccine uptake of school teachers, the intention to uptake influenza vaccine as well as the COVID-19 vaccine and to identify factors associated with vaccine acceptance during the COVID-19 pandemic in Greece. A cross-sectional online survey was conducted among elementary and kindergarten school teachers in the area of Western Greece from June 2020 to August 2020. A self-administered questionnaire was distributed via an internet-based link along with an invitation e-mail. Responses from 399 participants were retrieved. 139 (34.8%) had received the annual influenza vaccine in the season 2019–2020, whereas 215 (53.9%) stated that they would get it in the forthcoming season 2020–2021 (p < .001). 152 (38.1%) intent to get the COVID-19 vaccine when available. For COVID-19 vaccine factors that were independently associated with the intention to uptake included more than 15 years at work (p = .001), prior influenza vaccine uptake (p = .003), believing that COVID-19 vaccine should be mandatory (p = .04) and that school teachers are a high-risk group for COVID-19 (p = .001). In conclusion, COVID-19 pandemic appeared to have an impact on the intention of school teachers to get vaccinated for influenza. The low level of COVID-19 vaccine acceptance intention among the teachers in our cohort warrants further attention. Public health interventions should aim to increase knowledge on both influenza and COVID-19 and prevention of them via immunization in this particular at-risk population.

KEYWORDS:

• Health policy
• public health
• school teachers
• influenza
• covid-19

Introduction

Worldwide, few studies have focused on attitudes, knowledge, and vaccination coverage of school teachers, and the majority of them refer to measles and influenza.^1−,2 School teachers generally have a low vaccine acceptance rate, which may be improved with targeted education.^1-,2 Thus, teacher’s adherence to the National Immunization Schedule is crucial in order to protect themselves and their students. During the H1N1 influenza pandemic in 2009, the National Scientific Committee for the Treatment of the New Influenza Pandemic in Greece included teachers in the priority vaccination groups for influenza. Since then, annual influenza vaccination has been strongly recommended by healthcare providers but is not mandatory for school teachers in Greece.

Coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared as a pandemic in March 2020 and currently various vaccines have been studied and licensed for disease prevention. At present, there is a strict prioritization in place for those who will receive one of the licensed vaccines and school teachers have not been given high priority as yet. One of the reasons behind this is that evidence so far suggests that children and schools play only a limited role in overall SARS-CoV-2 transmission.³ Contrarily, to the role of young children as one of the main influenza reservoirs in the community, for COVID-19 older children are much more likely to contribute to the community spread of the virus.⁴ Consequently, COVID-19 might spread more easily within high school settings than in the elementary schools.⁴

Nonetheless, a deepest and thorough understanding of the carriage and transmission potential of SARS-CoV-2 in children is of paramount importance for predicting the spread of the virus in school and community settings. School reopening for face-to-face teaching with various mitigation strategies in place (including physical distancing, face masks wearing, enhanced hand hygiene, decreased class sizes, and different class start and end times) may reduce the risk of SARS-CoV-2 spreading but not put it down to zero.⁵ The main reason behind this is that the transmission of COVID-19 in schools is largely dependent on community transmission.^6,7 As a result, when community rates are high, there is an increased likelihood that SARS-CoV-2 will be introduced to, and potentially transmitted within the school environment.^6,7

At the beginning of March 2021, the U.S. Department of Health and Human Services stated that all states should immediately make eligible all teachers, school staff, and child care workers for COVID-19 vaccination.⁸ This is the first worldwide recommendation about giving priority to this group. However, teachers’ views upon acceptance of this particular vaccine have not been thoroughly studied as yet.

Our study aims to assess the attitudes, knowledge, and influenza vaccine uptake of kindergarten and school teachers and the intention to uptake influenza vaccine as well as COVID-19 vaccine and to identify factors associated with vaccine acceptance during the COVID-19 pandemic in Western Greece.

Materials and methods

A cross-sectional online survey was conducted among school teachers in the area of Western Greece from June 2020 to August 2020. All 4215 registered teachers in the area were eligible to participate among which 897 teach in the kindergarten school (4–5 years old) and 3318 in the elementary school (6–12 years old). A recent study from Italy estimated that the COVID-19 pandemic increased the intention to get vaccinated against the seasonal flu in the general population by a factor of 1.82.⁹ Assuming that the pandemic would have had a similar effect among the Greek school teachers, a minimum of 395 participants would be required to reveal 1.8 times increase in the intention to be vaccinated against the flu, with 80% power and at 1% alpha.

A self-administered questionnaire was distributed to all registered school teachers via an internet-based link along with an invitation e-mail. An information sheet about the study was included at the beginning of the questionnaire, followed by an electronic consent form. The participants who agreed to join the study filled in the questionnaire on their own electronic devices. A second invitation e-mail was sent 2 weeks after the first one as a reminder to participate in the survey. Τhe development of the questionnaire was performed by the authors based on previous similar studies in the field [2–5]. Prior to initiating the study in order to ensure clarity, content validity and internal consistency, the original version of the questionnaire was distributed to 20 teachers (pilot phase). Following the review of the issues raised by the pilot study participants, the questionnaire was adjusted accordingly by the research team to its final form.

The questionnaire was written in Greek and consisted of two parts. The first part concerned information on teachers’ demographics including sex, age, educational level, marital status, years at work, and the number of children if any. The second part of the questionnaire assessed influenza vaccine uptake, general knowledge and attitudes toward influenza vaccination, awareness of vaccine risk and potential benefits as well as intention to accept COVID-19 vaccination and general attitudes and knowledge toward this particular vaccination. The study protocol was approved by the Regional Steering Committee of Patras Medical School (decision number: 5846 (19.05.2020).

All statistical analyses were performed with IBM SPSS 25.0 software. Categorical variables are expressed as absolute and relative frequencies, while continuous variables are presented as means ± standard deviations. Bivariate analysis uses the chi-square test. We then used multiple logistic regression analysis to identify factors independently associated with the intention to receive the influenza vaccine and potential COVID-19 in the forthcoming season. For this analysis, we have compared only the characteristics and views of teachers that have already decided whether they would accept or not the vaccine. Hence, those that have not yet decided where not included. Univariable logistic regression was applied to explore factors that influence intention of vaccine uptake (influenza or COVID-19). Statistically significant variables in the exploratory analysis were subsequently included in a multivariable stepwise logistic regression model. The crude (unadjusted) and the adjusted effects of each variable were expressed by its odds ratio (OR) ± 95% confidence intervals (CIs).

All tests were 2-tailed, and the level of significance was set to 0.05 for all analyses.

Results

Characteristic of survey respondents and vaccine uptake

A total of 399 out of 4215 registered teachers filled in the online questionnaire (response rate 9.5%). Among them, 278 were teachers of the elementary school (69.7% of cohort) whereas 121 were kindergarten teachers (30.3%). The demographic characteristics of the surveyed population and the rates of vaccine coverage are presented in Table 1. With regard to receipt of prior vaccination, 139 (34.8%) had received the annual influenza vaccine in the season 2019–2020 and 215 (53.9%) stated that they would get the influenza vaccine in the forthcoming season 2020–2021 (chi-square test, p < .001), which is 1.6 times higher than the previous percentage. This may not be accurate and potentially underestimates the true increase in the vaccine uptake as 52 teachers have not yet decided. Table 2 shows the perceptions and beliefs toward influenza vaccine and COVID-19 vaccine.

Table 1. Characteristics of the surveyed population (n = 399) and vaccine uptake (influenza, COVID-19)

	n	%
Gender
Male	88	22,1
Female	311	77,9
Age group (years)
22–31	46	11,5
32–41	102	25,6
42–51 52-67	138 113	34,6 28,3
Subspecialty
Kindergarten teacher	121	30.3
Elementary/Primary school teacher	278	69.7
Marital status
Married/cohabiting	287	71.9
Divorced	28	7
Non married/single	84	21.1
Mean number of years working as a teacher
0–15	159	39.8
15–30	182	45.6
>30	58	14.5
Number of children
no children	110	27.6
1 child	89	22.3
2 children	161	39.8
>3 children	39	9.8
Higher degree
Yes (Master, Ph.D)	143	35.8
No	256	64.2
Main vaccine information source
Family doctor	190	47.6
Internet	128	32.1
Mass media	41	10.3
Other	38	9.5
Influenza vaccine uptake (2019–2020season)
Yes	139	34.8
No	260	65.2
Intention to uptake influenza vaccine 2020–2021 season
Yes	215	53,9
Not decided yet	52	13
No	132	33.1
Intention to uptake COVID-19 vaccine 2020–2021 season
Yes	152	38.1
Not decided yet	88	20.6
No	159	39.8

Table 2. Attitudes and perceptions toward influenza vaccine and COVID-19 vaccine

Influenza related questions	N	%
Do you believe you belong to a high-risk population to contract influenza due to your profession?
Disagree	40	10.0
Neither agree nor disagree	64	16.0
Agree	295	73.9
Do you believe that influenza vaccination should be mandatory to school teachers?
Disagree	163	40.9
Neither agree nor disagree	95	23.8
Agree	141	35.3
Do you believe that influenza vaccine has serious side effects?
Disagree	163	40.9
Neither agree nor disagree	125	31.3
Agree	111	27.8
How effective is influenza vaccination in preventing disease?
Not at all effective	18	4.5
A little effective	143	35.8
Very effective	238	59.6
Main reason for influenza vaccine refusal (2019–2020 season) (more than one answer can be given)
Not effective vaccine	18	7.0
Fear about side effects	72	27.6
Lack of time	27	10.3
Not necessary vaccine	94	36.1
Lack of healthcare provider recommendation	79	30.3
Cost of the vaccine	7	2.6
COVID-19 related questions	n	%
Do you believe you belong to a high-risk population to contract COVID-19 due to your profession?
Disagree	35	8.7
Neither agree nor disagree	52	13.0
Agree	312	78.1
Do you believe that COVID-19 vaccination should be mandatory to school teachers?
Disagree	147	36.8
Neither agree nor disagree	109	27.3
Agree	143	35.8
Main reason for refusing the COVID-19 vaccine (more than one answer can be given)
Fear about side effects	257	64.4
New vaccine not adequately tested	236	59.1
Lack of vaccine effectiveness	67	16.8
Healthcare provider recommendation	25	6.3
Cost	17	4.3
Unnecessary vaccine	30	7.5
Other	7	1.8

Sociodemographic characteristics that are associated with vaccine uptake and intention to get vaccinated

With regard to influenza vaccine receipt the 2019–2020 season in bivariate analysis we found no statistically significant associations with sex or possession of higher educational degree. However, respondents belonging to the age group 32–41 years old were more likely to have received the vaccine compared to the other age groups (chi-square test, p = .003). In addition, married or cohabiting teachers and those have children were also more likely to have received the vaccine the previous year (chi-square test p = .006 and p = .05, respectively,). Finally, kindergarten teachers were more likely to have received an annual flu vaccine compared to elementary school teachers (chi-square test p = .005).

With regard to the intention to receive influenza vaccine for the forthcoming season 2020–2021, the age group 52–67 years old were more likely to receive the vaccine compared to the other age groups (chi-square test, p = .003) and teachers with no children were less likely to do so (chi-square test, p = .002). Sex, possession of a higher degree, subspecialty, and marital status were not associated with the intention to get vaccinated.

With regard to the intention to get the COVID-19 vaccine, we found that men compared to women (chi-square test, p = .003) and belonging to the age group 52–67 years old were more likely to get vaccinated (chi-square test, p = .026). In addition, teachers with a mean number of >15 years at work were more likely to accept a COVID-19 vaccine (chi-square test, p = .001). Finally, teachers with no children were less likely to get vaccinated versus those with children (chi-square test, p = .021).

Intention to uptake influenza and COVID-19 vaccine during the forthcoming 2020-2021 season

In a multiple logistic regression model incorporating variables with p < .05 associated with intention to receive the above vaccines, we identified factors that are independently associated with future receipt of the two vaccines in the 2020–2021 season (Table 3). For intention to uptake the influenza vaccine in the forthcoming year factors that are independently associated with its receipt included prior influenza vaccine uptake (p = .005), believing that the influenza vaccine should be mandatory (p = .006) and believing that school teachers are a high-risk group for influenza disease (p = .001). Similarly, for intention to uptake COVID-19 vaccine factors that are independently associated with its receipt included mean years at work more than 15 years (p = .001), prior influenza vaccine uptake (p = .003), believing that COVID-19 vaccine should be mandatory (p = .04) and that school teachers are a high-risk group for COVID-19 (p = .001).

Table 3. Determinants of intention to uptake influenza and COVID-19 vaccine in the 2020–2021 season

	Univariable Analysis		Multivariable Analysis*
Variables	crude OR (95% CI)	P-value	adjusted OR (95% CI)	P-value
Intention to uptake influenza vaccine
Gender (female)	0.845 (0.652–1.348)	0.753
Years at work (>15 yrs)	1.513 (0.995–2.091)	0.12
Marital status (married/cohabiting)	1.734 (1.319–2.866)	0.05	1.859 (0.852–2.761)	0.2
Having children (Yes)	0.948 (0.752–1.196)	0.655
Education (Higher degree)	1.269 (0.816–1.443)	0.08
Belief that influenza vaccine should be mandatory	1.466 (1.157–1.858)	0.002	1.324 (1.081–1.662)	0.006
Belief that school teachers are high risk of contracting influenza	1.350 (1.356–1.907)	0.001	1.245 (1.286–2.007)	0.001
Prior influenza vaccine uptake	1.859 (1.252–2.761)	0.002	1.725 (1.354–2.824)	0.005
Intention to uptake COVID – 19 vaccine
Gender (female)	0.651 (0.861–3.918)	0.324
Years at work (>15 yrs)	1.324 (1.231–1.622)	0.001	1.232 (1.321–1.855)	0.001
Marital status (married/cohabiting)	2.056 (0.760–5.562)	0.324
Having children	1.171 (0.980–4.673)	0.251
Education (Higher degree)	1.249 (0.860–1.743)	0.07
Belief that COVID-19 vaccine should be mandatory	1.513 (1.095 − 2.091)	0.012	1.564 (1.195 − 2.591)	0.04
Belief that school teachers are high risk of contracting COVID-19	1.225 (1.752–4.196)	0.001	1.201 (1.732–4.216)	0.001
Prior influenza vaccine uptake	1.334 (1.234–2.564)	0.002	1.365 (1.334–2.864)	0.003

OR, odds ratio; CI, confidence interval.

*Only variables significantly associated with vaccine uptake in univariable analysis (p < .05) were included in the multivariable models.

Discussion

This cross-sectional prospective survey aimed to explore influenza vaccination coverage, intention to uptake influenza and COVID-19 vaccine in the 2020–2021 season as well as factors associated with the above attitudes among school teachers in Western Greece.

Influenza vaccine uptake (2019–2020 season)

Influenza vaccination coverage was low in our survey as only one-third of the study participants had been vaccinated the previous year. This suboptimal coverage is worrying given the fact that teachers have daily contact with young children who are the main reservoirs of influenza in the community. Other studies conducted in Europe have shown even lower percentages. In Poland for instance, in a cross-sectional study the vaccine coverage of teachers against influenza was much lower (4.8%) on the sample studied.¹⁰ Moreover, in a study on a nationally representative sample of the Italian population including teachers only 14.4% of them were vaccinated for influenza the 2019–2020 season.¹¹ With regard to the reasons reported behind this low vaccine uptake in our population, these were mainly beliefs that this vaccine is not necessary and effective, lack of healthcare provider recommendation and fear of vaccine related side effects. Similarly, in the Polish study, the main reasons for non-vaccination were lack of confidence in its efficacy and concern about its adverse effects.¹⁰These reasons are not unique to teachers but are barriers to vaccination among the public worldwide, as stated by a recent WHO systematic review on influenza vaccine hesitancy.¹² Understanding and addressing psychological, contextual, sociodemographic, and physical barriers that are specific to teachers could help future immunization efforts in this group.^1–1113,14 Interestingly, in a US survey in 2018, teachers’ positive attitudes and knowledge were associated with increased vaccination rates.¹³

It is worth commenting on one contradictory finding regarding the school teachers’ attitudes that although the majority agree that they belong to a high-risk group for contracting influenza, due to their profession, only one-third of them is in favor of introducing a mandatory influenza immunization policy. Of note, in Greece vaccination of school teachers, although recommended, is not mandatory. The same views were expressed by teachers in Poland with 43.8% of them believing that they belong to a group at high risk for influenza, whereas 25.6% believe that vaccination of teachers should be mandatory.¹⁰ We have already mentioned the reasons behind vaccine hesitancy which could well account for this contradiction, and multidimensional public health efforts should be in place to clarify misconceptions.

For the teachers in our cohort, the main sources of information about influenza were in order of descending frequency: family doctor (47.6%), internet (32.1%) and mass media (10.3%). A similar situation has been reported in two Italian studies involving school teachers where primary care doctor was the main information source.^9,11 However, in Poland teachers stated that their main source of information about influenza was television.¹⁰ In this study, the percentage of vaccinated teachers was very low indicating the importance of reliable information sources.

Intention to uptake influenza vaccine the season 2020–2021

It is of interest to note that the percentage of teachers that intend to get influenza vaccination in the forthcoming influenza season was higher than the year before and this difference was statistically significant. Half of the teachers state that they intend to get the vaccine. Of note, older teachers are more likely to do so and this association was also confirmed in the multivariate analysis. This may reflect the overall COVID-19-related morbidity and mortality increasing with age and act as a reminder of infectious disease susceptibility. Influenza and COVID-19 are both respiratory diseases and share similar modes of transmission. Thus, teachers might have perceived the risk of contracting influenza higher than the season 2020–2021. In addition, teachers who have children were more likely to get vaccinated for flu next year compared to those who have not. This could reflect the positive attitudes of parenthood toward vaccination in general due to possible compliance to routine childhood vaccines. However, research in this particular issue is very limited. A study from Australia focusing on how having children affects the vaccine attitudes among vaccine-hesitant and vaccine-refusing parents revealed contradictory findings.¹⁵ Hence, although in our cohort parenthood seems to increase vaccine uptake, this finding cannot be generalized.¹⁵ We also have to point out at this point out here though that the COVID-19 pandemic has increased the overall insecurity for the future, and this effect might have been more pronounced for parents who would more likely accept a vaccine to protect both themselves and their family.

Intention to uptake COVID-19 vaccine

Regarding the intention of teachers to accept COVID-19 vaccination, 38.1% of the teachers in our sample agreed that they would get the vaccine when available, whereas 39.8% stated they would not do so and 20.6% have not yet decided. Intention to uptake the new COVID-19 vaccine appears lower compared to the one reported in the adult general population in Greece in a study conducted in the same period.¹⁶ In particular, on a random sample of 1004 respondents, 57.7% stated that they are going to get vaccinated for COVID-19. Nonetheless, the lower acceptance rate of our population of kindergarten and primary school teachers highlights the design of specific and targeted interventions to increase vaccine uptake in this group. Interestingly, in an Italian study, also conducted during the first wave of the pandemic, 51% of respondents (teachers included among them) stated their intention to be vaccinated.¹¹ In a study among nurses in Hong Kong between February and March 2020, 40% had intention to receive the COVID-19 vaccination.¹⁷ In a new global survey of the World Economic Forum/Ipsos including 20,000 adults, 74% of the respondents say they are willing to receive the COVID-19 vaccine, but the 26% deficit is significant.¹⁷

The main reasons that teachers in our cohort would not get vaccinated are the fear of side effects of the vaccine as well as the fact that it has not been in use for many years. These reasons have been reported in other studies relevant to COVID-19 vaccine acceptance.^9,16–18 Of note, previous influenza vaccine acceptance has been a strong predictor of acceptance of COVID-19 vaccine. Similar results were reported from a study conducted in nurses in Hong Kong, as well as in studies conducted during the H1N1 pandemic. In particular, the uptake of seasonal influenza vaccine was a strong predictor of H1N1 vaccine uptake.^19,20 Thus, there is some evidence that reinforcing acceptance of the annual flu vaccine would be beneficial in the management of future pandemics and public health interventions should also take this into account as an indirect benefit of annual influenza vaccine. Finally, teachers that have mean years at work more than 15 years are more likely to accept a COVID-19 vaccine, which is somewhat expected given the widespread information about the association of COVID-19 disease severity and age.

With regard to teachers’ views on mandatory COVID-19 vaccination, approximately one-third of our participants believes that it should be mandatory. As for influenza, we have also observed the same paradox with COVID-19 that although the majority of teachers believes that they are at risk of contracting the disease due to their profession they do not wish to get vaccinated on a mandatory basis. We must mention at this point that our survey was conducted after the first wave of the pandemic and in particular during the summer period of relaxation of the restriction measures. One would assume that, during this particular time with low incidence of COVID-19, teachers might not have been over worried and subsequently request for the vaccine. On the other hand, in the beginning of 2021 with the strict lockdown following the second wave of the pandemic, there is a public demand for immunization of school teachers so that schools could reopen given that fact that school closure has detrimental effects on the overall pupils’ wellbeing. As a result, in March 2021 the U.S. Department of Health and Human Services issued a directive that all states immediately make eligible teachers, school staff, and childcare workers for COVID-19 vaccination across all vaccination providers.⁸ We anticipate therefore a change in teachers’ opinion in favor of vaccination acceptance. Teachers working on special schools which have remained open throughout the pandemic should obviously get priority at this point as non-pharmaceutical interventions such as physical distancing measures and wearing of face masks are difficult to implement.

Limitations

We acknowledge that our study has limitations. Most importantly, it was geographically restricted to Western Greece. Nevertheless, given the paucity of data in the field, it brings a great insight into the relevant area. Second, the low response rate indicates that e-mail invitations and online questionnaires might not be the best way for study recruitment. Even lower responses have been reported in similar studies conducted via online questionnaires in the field.^17,18,21 More reminder e-mails would have been useful to increase the response rate. Face-to-face interviews would perhaps be more appropriate, but due to school closures that was not possible during the study period. Nonetheless, the number of teachers that eventually responded to the online questionnaire was adequately powered to reveal changes. Third, recall bias issues cannot be excluded on vaccine uptake, as the collected information was based solely on teacher’s reports. Another reason for bias might be that the responders represent the population of teachers who are more interested in the subject of influenza and COVID-19 virus and therefore give more positive results. Unfortunately, it was impossible to perform a second survey on non-responders, ideally by telephone contact, to check for differences between the two cohorts. Moreover, we did not capture the views of teachers working in special schools where implementation of restrictive measures (such as physical distancing, facial masks, and adherence to strict hand hygiene) is difficult. In addition, secondary school teachers were not invited to participate and thus we might have underestimated intention to vaccinate for COVID-19 vaccine as data so far show that older children have the potential to transmit COVID-19 as adults. We should also point out that our study was conducted during the period of relaxation of restriction measures following the first wave of the pandemic and teachers might have been falsely reassured about the future of the pandemic. Finally, for both COVID-19 vaccination and influenza vaccination during the 2020–2021 season, we captured views on intention to get vaccinated which might not reflect what teachers would eventually do at the actual time of the vaccine offer given the dynamic nature of the pandemic.

Conclusion

In conclusion, we found suboptimal influenza vaccination rates among teachers of kindergarten and elementary schools in Western Greece. The COVID-19 pandemic appeared to have had an impact on the intention to get vaccinated for influenza perhaps due to the similarity of these two respiratory diseases and the overall anxiety for the future caused by the pandemic. However, the low level of COVID-19 vaccine acceptance intention among the teachers in our cohort warrants further attention. Public health interventions should aim to increase knowledge on both influenza and COVID-19 and prevention of them via immunization in this particular at-risk population due to the profession's nature. Finally, it is of paramount importance to emphasize health promotion development strategies in the school environment and build an overall positive attitude of teachers toward vaccination.

Disclosure of potential conflicts of interest

No potential conflicts of interest were disclosed.

Acknowledgments

The authors would like to thank all school teachers who filled in the questionnaires

Data availability statement

Data available on request from the authors