COVID-19 vaccine hesitancy among undergraduate students in Thailand during the peak of the third wave of the coronavirus pandemic in 2021

Introduction

The novel coronavirus disease 2019 (COVID-19) has affected the whole world, including Thailand, where the total number of cases reached over 1.3 million on 13 September 2021 (World Health Organization 2021). A high number of deaths were reported due to COVID-19, either from respiratory failure or complications resulting from the vaccine (Bangkok Post 2021a; Wipatayotin 2021). Even though the novel COVID-19 vaccine has shown both its effectiveness and failures after the first six introductory months, it is still important to achieve herd immunity by getting more people fully vaccinated (D’Souza and Dowdy 2021). The Thai government has successfully procured approximately 63 million COVID-19 vaccine doses (as of 22 February 2021), accounting for 45% of the Thai population, and the country allocated the first dose of COVID vaccine on 16 March 2021. Similar to other countries’ vaccine strategies, during the first phase it was individuals working in healthcare who were prioritized, followed by people with chronic diseases and older persons.

As warned by the World Health Organization in 2019, vaccine hesitancy is regarded as a global health threat. Amid the pandemic, hesitancy toward COVID-19 vaccines has been found paradoxically even in the population of the United States, where their Food and Drug Administration-approved vaccines are effective and safe (D’Souza and Dowdy 2021). This behaviour of delay in acceptance or refusal of vaccines can arise from several determinants, ranging from social to political to health service experiences (Dubé et al. 2013). Likewise, the COVID-19 vaccine acceptance rate among the Thai population could be increased by several factors, including vaccine safeness (Kitro et al. 2021).

The 3C (Confidence, Complacency, Convenience) model of vaccine hesitancy was introduced to map three main factors influencing vaccine uptake (Local Government Association 2021). Based on the limited amount of COVID-19 vaccine in Thailand, effective vaccine allocation is hard to achieve by considering social benefits and equity. In April 2021, Thailand started to vaccinate the adult populations after the prioritized group. However, the current COVID-19 vaccine supply is exceptionally limited (at the time of the study), with uncertainty to access, especially in younger adult populations. A research study in Thailand indicated that adults aged 40 years and above tended to obtain vaccinations sooner compared to younger adults (Kitro et al. 2021). The lower vaccine acceptance rate poses a problem because it is insufficient to prevent disease transmission.

The Bangkok Metropolitan Area (BMA) is the place where COVID cases are increasing daily, with the coronavirus outbreak starting from boxing events and entertainment complexes and affecting young Thai adults, who are considered the vulnerable group (Rajatanavin et al. 2021). Moreover, outbreak in the second wave was far greater and more complex than in the first wave. Information regarding barriers to vaccine uptake among young adults living in this area is still unknown. This study aims to determine the COVID-19 vaccine hesitancy rate among a group of Thai undergraduate students and ascertain the predictors of the hesitancy.

Materials and methods

Study design and data collection

A cross-sectional study was conducted using Google Form with undergraduates in the BMA. The online self-administered survey was distributed in June–July 2021, amid the peak of Thailand’s third wave of COVID-19. At the time of data collection, a limited number of young people were taking the vaccine due to the vaccine allocation policy. This area (BMA) with high COVID cases was chosen to understand the COVID-19 vaccine perspectives of those who currently reside in the high-risk pandemic location. Despite the fact that the BMA is made up of six provinces, three (Nakhon Pathom, Pathum Thani and Nonthaburi) were targeted in order to maintain generalizability.

University administrative staff aided in distributing invitation emails to their university students via the survey link. The students had the right to decide whether or not to participate in the survey after reading the consent webpage introduction. No personal data were collected in order to maintain confidentiality and anonymity. The average time of survey completion was about 30 min (Figure 1).

Figure 1:

Map of the Bangkok metropolitan area (BMA), with the starred provinces chosen as study areas.

Results

Discussion

To the best of our knowledge, this study was one of the first to examine attitudes toward COVID-19 vaccines among undergraduate students enrolled in universities located in the BMA. Thailand distributed the first dose of the COVID-19 vaccine on 16 March 2021 during the first phase, with the priority for individuals working in healthcare, followed by people with chronic diseases and older persons. According to the vaccine allocation plan, during the period of data collection in this study (June–July 2021), university students were not categorized as a priority group.

Amid the local third wave of COVID-19, approximately 40% COVID-19 vaccine hesitancy was found, similar to results found in US university students (Kecojevic et al. 2021; Sharma, Davis, and Wilkerson 2021). Among the participants, anti-vaccination was declared by 4.6%, with some considering it not important to receive the COVID-19 vaccines (2.6%). However, it should be noted that the hesitancy rate is dependent on time, population and COVID-19 severity in the study area, as portrayed in several research studies with the same sample group at different timeframes (Caserotti et al. 2021; Williams et al. 2021). A recent poll also noticed a slight increase in the COVID-19 vaccine hesitancy rate among the general Thai population (Bangkok Post 2021c), with reasons for hesitancy ranging from safety to effectiveness of the vaccine, rather than the basic demographic characteristics such as gender (Bangkok Post 2021c; Wipatayotin 2021). Despite the fact that this study included only those who had not received vaccination against COVID-19, a previous local study also revealed that compared to foreigners in Thailand, the locals had lower vaccine acceptance unless otherwise recommended by employers or health providers (Kitro et al. 2021).

A significant association was found between COVID-19 vaccine hesitancy and education level. As a comparison, Year 2 students or higher were more hesitant towards COVID-19 compared to Year 1 students. One of the probable reasons could be that students in Year 1 started their education though the online system with less interaction with friends, so if they got the vaccine they could have some social interaction. On the other hand, the students in Year 2 and higher attained more knowledge during their school year, which might cause them to weigh up the benefits and side-effects before receiving the vaccine. Thus, at the period of data collection they might be unsure of the effectiveness of the COVID-19 vaccine. This similarity was found among New Jersey college students, who were attending their junior school were willing to take the COVID vaccines (Kecojevic et al. 2021).

Our study found a significant association between enrolled course type and vaccine hesitancy, with those on non-health-related courses (47.5%) being more vaccine hesitant than those taking health courses. Similar results were found among university students in Jordan and China (Bai et al. 2021; Sallam et al. 2021). Those who are already exposed to health information may have a better understanding of the onset of coronavirus and its prevention strategies, specifically vaccinations. However, this prediction was not found to be significant in the multivariate model due to the fact that there could be a vaccine-hesitant group among those students on health-related courses (32.9%). Several studies reported that medical and nursing students had COVID-19 vaccine hesitancy (Alshehry et al. 2022; Kanyike et al. 2021; Saied et al. 2021).

Importantly, beliefs about COVID-19 vaccines played a role in vaccine hesitancy among Thai undergraduates: 64.6% of undergraduates were reluctant to vaccinate due to their negative views on the COVID-19 vaccine, which is identical to the result found in another study (Troiano and Nardi 2021). These young undergraduates might have doubts about the side-effects of a novel COVID-19 vaccine that has been studied for less than a year (Hershan 2021; Saied et al. 2021), hence there was a remarkably high percentage (88.9%) of participants who agreed with the following statement: “taking a new COVID-19 vaccine will make me feel like a guinea pig”. The reports of mild side-effects after receiving the COVID-19 vaccine in younger female Thai populations could potentially influence vaccine hesitancy (Watcharananan et al. 2022), therefore trust needs to be promoted to install a positive attitude towards COVID-19 in order to increase vaccine uptake (Kalam et al. 2021).

Perceptions towards healthcare providers, vaccine developers and medicine were identified to be associated with hesitancy among the undergraduates. Those who viewed these healthcare services as negative (57.6%) were more COVID-19 vaccine hesitant than those who viewed them as positive (22.4%). As healthcare providers’ recommendations were proven to increase people’s willingness to get vaccinated against the COVID-19 virus, it is important that vaccine recipients have trust and respect for the healthcare system and vaccine producers (Al-Mistarehi et al. 2021; Kitro et al. 2021; Wong et al. 2021). Community vaccine collaboratives also emphasized that instead of solving the “vaccine mistrust” problem, it is necessary to “promote trustworthiness” of the health system, which includes the health providers and researchers behind the COVID-19 vaccines (Kitro et al. 2021; Scott et al. 2021). Therefore, Thai healthcare service providers need to refocus on their credibility and reliability in order to persuade more undergraduates to get vaccinated.

The more individuals believe in conspiracy, the more likely they are to be COVID-19 vaccine hesitant (Murphy et al. 2021; Watcharananan et al. 2022). In this study, undergraduates who believed false information about the spread of the virus (50%) were more likely to be vaccine hesitant, similar to UK adults (Freeman et al. 2020). As rumours and false information about the spread of the virus continue to exist, it is necessary to inform undergraduates with verifiable facts in order to enhance their understanding of vaccines (Islam et al. 2021).

Further research is highly recommended with larger sample sizes and diverse characteristics to explore further associations. Hesitancy rates of other age groups should be investigated for representativeness of the population. However, Thai public health units could utilize the findings of this research for vaccine awareness campaigns to prevent the spread of infection and control the COVID-19 pandemic.

Conclusions

Hesitancy towards the COVID-19 vaccine among undergraduate students posed a significant challenge to achieving herd immunity and preventing the spread of infection in Thailand. A COVID-19 immunization campaign focusing on its safety, benefits and effectiveness should be implemented through various effective media sources. In addition, conspiracy beliefs about vaccines should be eradicated with true information, and both positivity and transparency should be used in promoting COVID-19 vaccines.