Article Medical Students and SARS-CoV-2 Vaccination: Attitude and Behaviors Bartosz Szmyd 1 , Adrian Bartoszek 1,2,*, Filip Franciszek Karuga 1,3 , Katarzyna Staniecka 1, Maciej Błaszczyk 1 and Maciej Radek 1 1 Department of Neurosurgery, Spine and Peripheral Nerves Surgery of Medical University of Lodz, 90-549 Łód´z,Poland; [email protected] (B.S.); fi[email protected] (F.F.K.); [email protected] (K.S.); [email protected] (M.B.); [email protected] (M.R.) 2 Department of Pathophysiology, Medical University of Lublin, 20-090 Lublin, Poland 3 Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 92-215 Łódz, Poland * Correspondence: [email protected] Abstract: Since physicians play a key role in vaccination, the initial training of medical students (MS) should aim to help shape their attitude in this regard. The beginning of vaccination programs against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an excellent time to assess the attitudes held by both medical and non-medical students regarding vaccination. A 51- to 53- item questionnaire including the Depression, Anxiety and Stress Scale was administered to 1971 students (49.21% male; 34.86% MS); two career-related questions were also addressed to the MS. The majority of surveyed students indicated a desire to get vaccinated against SARS-CoV-2, with more medical than non-medical students planning to get vaccinated (91.99% vs. 59.42%). The most common concern about SARS-CoV-2 infection was the risk of passing on the disease to elderly relatives. While conspiracy theories regarding the COVID-19 vaccine are less popular among MS, Citation: Szmyd, B.; Bartoszek, A.; both groups indicated concerns that vaccines may cause autism is equally common (~5%). Further Karuga, F.F.; Staniecka, K.; Błaszczyk, studies exploring social attitudes towards the SARS-CoV-2 vaccine are a necessary first step to M.; Radek, M. Medical Students and optimizing vaccination programs and achieving herd immunity. SARS-CoV-2 Vaccination: Attitude and Behaviors. Vaccines 2021, 9, 128. Keywords: COVID-19; SARS-CoV-2; vaccination; healthcare workers; depression; anxiety; stress https://doi.org/10.3390/ vaccines9020128 Academic Editor: 1. Introduction Vasso Apostolopoulos As physicians play a key role in vaccination, the initial training of medical students Received: 5 January 2021 (MS) should not only provide accurate medical knowledge but should also help shape Accepted: 3 February 2021 Published: 5 February 2021 attitudes regarding the topic [1]. Unfortunately, nearly a third of final-year MS feel inade- quately prepared to deal with the clinical aspects of vaccination, especially communication Publisher’s Note: MDPI stays neutral issues with vaccine-hesitant patients [1]. This may well be a product of the excessive with regard to jurisdictional claims in focus on theoretical knowledge typified in educational programs and the resulting lack of published maps and institutional affil- practical skills [2]. This limitation of current medical training is highlighted by the fact that iations. the Internet is considered to be a better source of information about vaccines than medical studies (59% vs. 52% of MS, respectively) [3]. Other significant determinants of vaccine uptake include the clinical years of medical study and any previous history of recommended vaccination (e.g., against influenza) [1,4,5]. The current public debate about vaccination against severe acute respiratory syndrome Copyright: © 2021 by the authors. Licensee MDPI, Basel, Switzerland. coronavirus 2 (SARS-CoV-2) is not only a good opportunity to assess student attitudes This article is an open access article and behaviors toward vaccination, but also to examine the psychological environment distributed under the terms and of the students resulting from this situation, such as any depression, anxiety, and stress conditions of the Creative Commons symptoms. Therefore, the present study attempts to identify any relationship between the Attribution (CC BY) license (https:// aforementioned factors, as well as the current state of knowledge regarding vaccination creativecommons.org/licenses/by/ among students, and their readiness to become vaccinated against SARS-CoV-2. We 4.0/). hypothesize that: Vaccines 2021, 9, 128. https://doi.org/10.3390/vaccines9020128 https://www.mdpi.com/journal/vaccines Vaccines 2021, 9, 128 2 of 12 • medical studies form pro-vaccination behaviors; • depression, anxiety, and stress related to the public debate on vaccination increase the willingness to get vaccinated. 2. Materials and Methods 2.1. Study Design and Participants An online survey was performed among Polish medical (MS) and nonmedical students (NMS; control group). NMS comprised all students except those of dentistry, dietetics, emer- gency medical services, laboratory diagnostics, medicine, nursing, obstetrics, pharmacy, and physiotherapy students. The self-administered online questionnaire was available on Google Forms between 22 and 25 December 2020, during the public debate on SARC-CoV-2 vaccination, before the first vaccination rollout in Poland on 27 December 2020 (including healthcare workers and students of medical faculties). All MS were invited to take the survey through institutional emails, university-affiliated websites, and social media profiles (Facebook). However, as the authors only had access to the institutional emails of students from the Medical University of Lodz (MS), NMS were invited only through social media. 2.2. Measurement Tools A three-part questionnaire was prepared. The first part concerned general information such as age, gender, income, professional status, the population size of the place of residence and work, previous SARS-CoV-2 infection in participants themselves or their relatives, fear of getting infected, willingness to get vaccinated against SARS-CoV-2, and past medical history of mandatory and recommended vaccinations. The second part focused on their grades in microbiology, clinical immunology, introduction to pediatrics, and infectious diseases courses. The final part included the standardized Depression, Anxiety and Stress Scale-21 Items questionnaire (DASS-21) to measure the intensity of depression, anxiety, and stress. As the DASS-21 scale encompasses the previous week, and the MS were due to receive vaccination from 27 December 2020, the study was performed one week before this date. Each item was rated on a 0–3 scale, so that the total scores ranged from 0 to 63. A higher score suggests more severe depression, anxiety, and/or stress symptoms. The scale is widely used in the Polish population [6]. The internal consistency of the DASS-21, assessed with Cronbach’s α, was sufficient for the study (0.921). 2.3. Data Collection All participants were aware of the study conditions and gave informed consent to participate. Confidentiality and anonymity were maintained and no data that could help identify a responder were collected. The local Bioethics Committee confirmed that, according to Polish law and Good Clinical Practice regulations, the study does not require the approval of a Bioethics Committee (KB nr 542/20) [7]. 2.4. Sample Size Calculation and Statistical Analysis The sample size calculation was performed using a calculator provided by The Uni- versity of British Columbia [8]. The frequency of students who wish to be vaccinated was calculated separately for MS and NMS (94% and 70%, respectively) based on the first fifty questionnaires. To provide a standard α = 0.05 and β = 0.80, the minimum size of each group was 40. The collected data were verified for completeness, quality, and consistency as de- scribed previously [7]. Statistical analysis was performed using STATISTICA 13.1 (TIBCO, Palo Alto, Santa Clara, CA, USA). A level of 5% was used as a significance threshold for all results unless stated otherwise. The distribution of the obtained data was assessed by the Shapiro-Wilk test (p > 0.05 for normal distribution). Data with a normal distri- bution are reported as mean with standard deviation (SD), while non-normal data are presented as median with IQR (1. quartile–3. quartile) [9,10]. The relationship between two independent subgroups was assessed using Student’s t-test for normally distributed Vaccines 2021, 9, 128 3 of 12 data, or the Mann-Whitney U-test for non-normally distributed data. The qualitative data were analyzed using the chi-square test, Yates-corrected chi-square or Fisher’s exact test based on the size of the smallest subgroup (n ≥ 15, 15 > n ≥ 5, 5 > n, respectively) [11]. All qualitative findings are presented as n (%). Finally, binary logistic regression was performed to properly evaluate the eventual facilitators/barriers affecting the willingness to be vaccinated as soon as possible. 3. Results 3.1. Study Group Our study group consisted of 1971 students: 687 (35.23%) MS and 1284 (56.70%) NMS. Their median age was 21 (20–24) and 20 (19–22), respectively. Most of them grew up in the countryside and/or small cities (<50,000 residents) and studied in cities of over 500,000 residents. Details are presented in Table1. Table 1. Study and control group characterization (n = 1971). Medical Students Non-Medical Students Total; n 687 1284 Male; n (%) 242 (35.23%) 728 (56.70%) Median age 21 (20–24) 20 (19–22) Population of the place of employment/study; n (% of complete data): City > 500,000 residents 502 (75.83%) 588 (50.56%) City > 250,000 residents 69 (10.42%) 175 (15.05%) City > 100,000 residents 29 (4.38%) 143 (12.3%) City > 50,000 residents 14 (2.12%) 63 (5.42%) City < 50,000 residents 23 (3.48%) 126 (10.83%) Countryside 25 (3.77%) 68 (5.84%) Place of residence as a child; n (% of complete data) City > 500,000 residents 145 (21.90%) 215 (18.49%) City > 250,000 residents 50 (7.55%) 87 (7.48%) City > 100,000 residents 74 (11.18%) 155 (13.33%) City > 50,000 residents 72 (10.87%) 121 (10.4%) City < 50,000 residents 151 (22.80%) 296 (25.45%) Countryside 170 (25.70%) 289 (24.85%) 3.2.