Knowledge of and Self-Expressed Stigma for COVID-19 Vaccination among Pre-University Students in a College in South India: A Cross-Sectional Study

ABSTRACT

Background:

Coronavirus disease 2019 (COVID-19) is a contagious infection characterized by severe acute respiratory syndrome (SARS-CoV-2). Safe and effective vaccines are game-changers in the global vision of marking an end to the challenges posed by the COVID-19 pandemic. However, vaccine hesitancy due to perceived stigma and misinformation is a grave cause of concern.

Objectives:

To assess pre-university students’ self-expressed stigma regarding COVID-19 vaccination and its association with their knowledge.

Materials and Methods:

A cross-sectional study was adopted for this research. A structured questionnaire approach was used to gather data from 384 students purposively at the selected pre-university college. The structured questionnaire consisted of three sections that explored the socio-demographic characteristics of the study participants, knowledge of vaccination, and self-expressed stigma, respectively. A total of 384 respondents took part in the study.

Results:

The study observes a low positive relationship (r = 0.25, P < 0.01) between knowledge and self-expressed stigma toward vaccination. Further, it was observed that participants from rural backgrounds had lower knowledge and self-expressed stigma scores than participants from urban settings. It is pertinent to note that participants with other sources of information had higher knowledge than those who used the internet, friends/peers, or newspapers. Both of the aforementioned findings are statistically significant.

Conclusion:

The interventions should revive trust in national health authorities, structured awareness campaigns by government agencies, and media coverage about the safety and efficacy of vaccines. In addition, it is also important to support citizens in ensuring that they have access to the right information from authentic sources in times of crisis.

INTRODUCTION

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative virus for the ongoing coronavirus disease 2019 (COVID-19) pandemic.[1,2] SARS-CoV-2 emerged in late 2019 in Wuhan (Hubei, China) and quickly became a global threat affecting 220 countries.[1,2] As of December 2021, the COVID-19 pandemic has resulted in more than 76.2 million cases and more than 1.6 million deaths worldwide.[1] The pandemic has had a devastating impact worldwide, which prompted the need for mitigation policies.[3] The ground strategy followed by most countries worldwide was to reduce the transmissibility of the disease, often by non-pharmaceutical interventions (NPIs), including enforcing masks, hand sanitization, social distancing, travel restrictions, school closures, and partial or complete lockdowns.[4] So far, NPIs have been able to slow down the progression of the disease, but the most promising strategy to confine the pandemic and provide hope to reduce mortality and morbidity rates is medical technology. Medical technology includes effective, safe, and affordable antiviral agents and vaccines. As of December 2020, no antiviral drugs have been approved that were developed explicitly against SARS-CoV-2.[5,6,7,8] The US Food and Drug Administration (FDA) has granted remdesivir emergency use authorization for severely ill hospitalized patients with COVID-19.[9,10] However, the WHO recommended against its use in November 2020.[11] With the news on the approval of the SARS-CoV-2 vaccine, there’s a rising optimism to see an end to the pandemic through herd immunity.[12,13,14] The threshold for SARS-CoV-2 herd immunity is estimated to range between 50 and 67%.[15] One major obstacle facing the achievement of such a goal is believed to be vaccine hesitancy and skepticism among the population worldwide.[16] Vaccine hesitancy was defined by the WHO Strategic Advisory Group of Experts as “delay in acceptance or refusal of vaccination despite the availability of vaccination services.”[17] Vaccine acceptability is determined by confidence, convenience, and complacency. Confidence is defined as “the trust in the safety and effectiveness of the vaccine, trust in the delivery system as the healthcare system, and trust in the policy-makers.” Many people have doubts about vaccine safety. This is a significant challenge for healthcare providers, policy-makers, community leaders, and governments.[17] Moreover, vaccination convenience refers to the relative ease of access to the vaccine, including physical availability, affordability, and accessibility.[17] The results of the current study could assist policy-makers in undertaking proactive campaigns and well-designed strategies by highlighting the importance of vaccination to the community and encouraging vaccine uptake and acceptance to stop further deaths and to confine the spread of the pandemic.

MATERIALS AND METHODS

This cross-sectional survey-based study was approved by the Institutional Ethical Committee (KAHER/INS/2022/D-1025). A total of 384 male and female students were selected from the pre-university college in a purposive manner. Informed consent was obtained from the study participants (and appropriate competent authorities) before the start of the survey. The sampling method used to conduct the study among pre-university college students was based on the inclusion and exclusion criteria. Male and female adolescents (16–18 years) who have not taken COVID-19 vaccination were included. Eligible participants unwilling to participate in the study were excluded. The structured questionnaire is divided into three sections: the first section contains the socio-demographic details of each student. The remaining two sections assess knowledge and self-expressed stigma regarding COVID-19 vaccination, respectively. The knowledge section contains 20 five-point Likert scale questions with 0 being strongly disagree and 4 being strongly agree. The negative statements are reverse-coded and higher scores indicate better knowledge. The scores obtained per individual have been summed up to obtain the knowledge score for the individual. The self-expressed stigma section contains 10 five-point Likert scale questions with 0 being definitely no and 4 being definitely yes. The negative statements are reverse-coded and higher scores indicate higher stigma. The scores obtained per individual have been summed up to obtain a self-expressed stigma score for the individual.

RESULTS

The socio-demographic characteristics of the study subjects are depicted in Table 1. Almost two-thirds of students were female 246 (64%). Out of 384 responses, 285 (74.1%) belong to a nuclear family, and the rest 99 (25.4%) students were from joint family backgrounds. Among all the students, 258 (67.2%) were from the urban community, and the rest 126 (32.3%) were from the rural community. The internet continued to remain the most favorable source (272, 70.7%) of information, followed by newspapers, friends/peers, and other sources. Table 2 presents the descriptive statistics (mean and standard deviation) associated with knowledge scores and self-expressed stigma scores across gender, family type, residence, monthly family income (in INR), and source of information.

Table 1.

Frequency and percentage distribution of pre-university students to the demographic variables

Characteristics	Count (n)	Percentage
Gender
Male	138	35.9
Female	246	64.1
Type of family
Nuclear	285	74.2
Joint	99	25.8
Family income (per month)
Rs. 5,000 - Rs. 15,000	130	33.8
Rs. 15,000 - Rs. 25,000	75	19.5
Rs. 25,000 - Rs. 35,000	54	14.1
Rs. 35,000 above	125	32.6
Rs. 35,000 above	125	32.6
Type of residence
Urban	258	67.2
Rural	126	32.3
Source of information
Internet	272	70.8
Newspaper	61	15.9
Friends/Peers	28	7.3
Others	23	6.0

Table 2.

Comparison of knowledge and self-expressed stigma scores across socio-demographic characteristics

Characteristics	Categories	Knowledge scores (Mean±Standard deviation)	P	Self-expressed stigma scores (Mean±Standard deviation)	P
Gender	Male	53.30±6.26	0.092	22.62±4.25	0.103^
	Female	54.45±6.52		23.31±3.51
Family type	Nuclear	53.99±6.14	0.797	23.08±3.71	0.872
	Joint	56.00±7.26		23.01±4.05
Residence	Urban	54.04±6.74	0.979	23.60±3.69	<0.001*
	Rural	54.02±5.82		21.95±3.80
Monthly Family Income`	Rs. 5,000-Rs. 15,000	53.33±6.53	0.421	21.78±3.84	<0.001*
	Rs. 15,000-Rs. 25,000	54.03±7.98		23.49±3.29
	Rs. 25,000-Rs. 35,000	54.76±4.94		24.45±3.79
	More than Rs. 35,000	54.46±5.92		23.54±3.71
Source of Information`	Internet	53.78±6.81	0.002*	22.94±3.69	0.025*
	Newspapers	53.77±4.71		22.45±3.95
	Friends/Peers	52.96±5.85		24.79±4.43
	Others	59.04±4.74		24.09±3.33

*Significant at 5% level of significance, ^: Welch-t-test has been used; `: one-way ANOVA

Figure 1 presents the scatter plot to visually assess the relationship between knowledge and self-expressed stigma. Based on the scatter plot and subsequently Pearson’s correlation analysis, it is observed that there is a low positive linear relationship between knowledge and self-expressed stigma (r = 0.25, P < 0.01)

Figure 1.

Relationship between the knowledge and self-expressed stigma scores among the adolescent students from selected pre-university

DISCUSSION

This exploratory study seeks to identify patterns in various aspects of self-expressed stigma and knowledge associated with COVID-19 vaccination among pre-university students at a selected college in Karnataka. There were 138 (35.4%) male participants and 246 (64%) female participants. The study revealed that self-expressed stigma is quite prevalent among the study participants. Similar studies reported a lack of awareness and understanding in the context of vaccination among 62% of the subjects.[18,19,20,21] The study observed that there is a statistically significant association between the self-expressed stigma score and location of the respondents (P < 0.001) and monthly family income (P = 0.020). However, there is a lack of evidence suggesting an association between other socio-demographic characteristics (gender and family type) considered in the study and the knowledge and self-expressed stigma scores. In conclusion, this calls for the need for effective interventions that include restoring trust in national health authorities, structured awareness campaigns by government agencies, and provision of dissemination of information to the public by competent authorities directly. While newspapers are a successful medium in bringing down stigma, there is still a long way to go in the context of knowledge. This could be because several news items on COVID-19, which are often contradictory within different newspapers, are causing chaos in the minds of adolescents who look forward to inputs via non-print media. Multi-centric large-scale studies will enable the researchers to gather more evidence in the context of understanding adolescents’ perceptions on COVID-19 vaccination.[22,23,24]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.