COVID-19 vaccination experiences of students at Hanoi Medical University in 2021-2022
Tran Tho Nhi1, Hoang Phuc Loc1,*, Vuong Ngoc Ha1, Vuong My Duyen1, Hoang Thi Huyen Trang1, Pham Kieu Trang1, Phan Thanh Hai1 ABSTRACT
Objectives: The study described the experiences of the COVID-19 vaccination and the need for vaccination with the 4th dose of vaccine COVID-19 among students of Hanoi Medical University in 2021-2022.
Method: We conducted a cross-sectional study combining qualitative and quantitative approaches.
We collected quantitative data online using REDCap and performed in-depth interviews to get qualitative information.
Results: 449 people participated in the study and the majority of those felt satisfied with the vaccination process (98,4%). If the fourth injection is deployed, 81.1% of the participants would agree, while prioritizing the choice of the Pfizer vaccine (62.6%). The in-depth interview results with 40 people showed five primary feelings during the injection, including anxiety, suspense, fear, non-anxiety, and satisfaction.
Recommendations: It is important that the government and each citizen should work together in order to solve the negative experiences and enhance the rate of satisfaction of the students.
Keywords: COVID-19, Immunization, Vaccination needs, Cross-sectional descriptive study, Immunization experience, Students of Hanoi Medical University
Author:
1 Hanoi Medical University, Hanoi, Vietnam Email: [email protected]
I. INTRODUCTION
Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus 1. Vietnam has 10,727,918 cases of COVID-19 with more than 43,000 deaths as of July 29, 2022 2. The urgency for vaccination against COVID-19 is increasing as the new variants of the SARS-CoV-2 virus made the
global pandemic more complicated, including Vietnam. Since July 29, 2022, Vietnam has deployed an expanded immunization with more than 151,7 million doses of the COVID-19 vaccine, creating a coverage rate of at least one dose of the COVID-19 vaccine of more than 76,6% Vietnamese population. The rate of fully vaccinated students with two doses
of vaccine is 80,7% of the population aged 18 years and older 3. A study at Jimma University Institute of Health in Ethiopia involving more than 300 students aimed to assess awareness, attitudes, and acceptance regarding COVID-19 vaccines and to assess the reasons for vaccine rejection of students. This study showed that only 41% of students had a good understanding of COVID-19 vaccines, and 224 (57.9%) of them had a positive attitude toward COVID-19 vaccines. Statistics showed common reasons why students refused to receive the vaccine include: lack of information about the vaccine (37.2%); safety of the vaccine (39.9%) 4. A study of 3119 residents in China willing to receive an additional dose of the COVID-19 vaccine, accounting for a total of 93,7%. An additional dose of vaccination is recommended to be a considerable supplementary intervention 5. In Vietnam, information about people's experience of getting vaccinated against COVID-19 is still incomplete. Additionally, medical students were considered the priority groups for COVID-19 vaccination due to the large proportion among medical staffs and the main voluntary resources for community support, which had explained the necessary to study about their experiences.
Therefore, we conducted this study aiming to describe the experience after being vaccinated against the COVID-19 vaccine and the need for vaccination with the 4th dose of vaccine COVID-19 among students of Hanoi Medical University in 2021-2022.
II. RESEARCH SUBJECTS AND METHODS 1. Research subjects
We selected the research subjects who were studying at Hanoi Medical University from the first year to the sixth year in all faculties, with inclusion criteria including (1) students who received at least one dose of the COVID-19 vaccine; (2) students who agreed to participate in the study. Students who did not complete the survey were eliminated.
2. Research methods
2.1. Study design: Cross-sectional study, qualitative and quantitative combined.
2.2. Time and place of the study: The data collection was carried out at Hanoi Medical University from May 20, 2022, to June 15, 2022.
2.3. Sampling method
Quantitative research: Convenience sampling.
The research had 449 students participating in and completing online forms.
Qualitative research: Targeted sampling. In- depth interviews with 40 students (20 men, 20 women) from different majors were conducted.
The students were given different types of vaccines. We collected until no new information is obtained, and information was saturated at the 35th record. We continued to interview but there was no new value so we decided to stop at the 40th participant.
2.4. Data collection
REDCap was used to build an online survey questionnaire. The questionnaire was built based on information about the vaccination history, including 4 main contents: general information, vaccination factor, satisfaction factor, and need for 4th dose. At the end of the
survey, we asked for the subject's approval to have them in our in-depth interview. Once participants agreed, the lead researcher contacted eligible participants to schedule an in-person interview. The interviews took place in lecture halls of Hanoi Medical University and lasted from 20 to 30 minutes. Participants were asked a series of open-ended questions about their experiences before, during, after the COVID-19 vaccination, demand for 4th dose and related factors until there were considerable similarities between interviewers’ replies and no more new information, we ended our interview process. All interviews were digitally recorded and transcribed in Vietnamese with identifying information removed and participants’ names pseudonymized.
2.5. Data analysis
We used the SPSS 25 software to clean and analyze the data. Descriptive statistics were used to describe the frequency and proportions of quantitative variables. Regarding the qualitative component of the research, we used the content analysis strategy of in-depth interviews: all field notes and transcriptions were read and coded for types of emotions during the injection processes and demand for 4th dose. The codes were grouped into summary concepts with a concise name.
2.6. Ethical considerations
The research protocol was approved by the scientific council according to Decision No. 780/QĐ-ĐHYHN dated April 8, 2022.
Participants were provided with complete information about the study and voluntarily participated in the study. The subjects could refuse to participate at any time during the study. Information provided by participants was confidential and used for research purposes only.
III. RESULTS
1. The general characteristics of the participants
Characteristics of the 449 students participating in this study are presented in Table 1. Most students received three doses of the vaccine (77.3%), while a few received four doses (0.7%). Most respondents felt satisfied with their vaccinations (98.4%). It also reveals that if the 4th dose injection is implemented, up to 81.1% of the participants will agree to receive it. Among already infected students, the rate of 3rd injection was the highest (69.1%), with the majority agreeing that they will continue to inject the 4th dose (79.1%). Pfizer was the most preferred vaccine (62.6%) because some subjects presumed that there were few unwanted effects after injection (51.2%). Most information about vaccination was accessed passively (76.2%) with the principal sources from the websites of the Government and the Ministry of Health (77.1%). In addition, 1.1%
of the subjects said that their primary source of information came from their schools and teachers.
Table 1. General characteristics of study subjects (n=449)
Characteristics Got COVID-19
n (%)
Not yet infected n (%)
Total n (%) Gender
Male Female
97 (39.0) 152 (61.0)
79 (39.5) 121 (60.5)
176 (39.2) 273 (60.8) Number of doses of vaccine administered
1 dose 2 doses 3 doses 4 doses
0 (0,0) 76 (30.5) 172 (69,1)
1 (0.4)
1 (0.5) 22 (11.0) 175 (87.5)
2 (1.0)
1 (0.2) 98 (21.8) 347 (77.3)
3 (0.7) Satisfied with vaccination
Yes No
243 (97.6) 6 (2.4)
199 (99.5) 1 (0.5)
442 (98.4) 7 (1.6) Agree to receive 4th dose (if implemented)
Yes No
197 (79.1) 52 (20.9)
167 (83.5) 33 (16,5)
364 (81.1) 85 (18.9) Vaccine priority choice
AstraZeneca Pfizer Moderna Sputnik V Vero Cell
82 (32.9) 156 (62.7)
6 (2.4) 1 (0.4) 4 (1.6)
62 (31.0) 125 (62.5)
8 (4,0) 4 (2.0) 1 (0.5)
144 (32.1) 281 (62.6) 14 (3.1)
5 (1.1) 5 (1.1) Reasons for prioritizing vaccines
Highly effective
Few unwanted effects after injection Everyone around is injecting
Has the most information
Finding the source of production reliable Other
116 (46.6) 120 (48.2) 48 (19,3) 47 (18.9) 100 (40,2)
13 (5,2)
102 (51.0) 110 (55,0) 40 (20,0) 55 (27.5) 72 (36.0) 2 (1,0)
218 (48.6) 230 (51.2) 88 (19,6) 102 (22.7) 172 (38.3) 15 (3.3)
Characteristics Got COVID-19 n (%)
Not yet infected n (%)
Total n (%) How to access information about vaccines
Actively searching for
Passive reading (from social networks, news, ...)
123 (49.4) 191 (76,7)
107 (53.5) 151 (75.5)
230 (51.2) 342 (76.2) Main source of information
The websites of the Government and the MOH
Science magazine Online newspaper
Social networks (Facebook, Tiktok, ...) Friends, neighbors
Other
187 (75,1) 70 (28.1) 81 (32.5) 174 (69.9) 130 (52.2)
4 (1.6)
159 (79.5) 62 (31.0) 74 (37.0) 129 (64.5)
93 (46.5) 1 (0.5)
346 (77.1) 132 (29.4) 155 (34.5) 303 (67.5) 223 (49.7)
5 (1.1)
The results of Table 2 show that in the 1st and 2nd doses, most students received the AstraZeneca vaccine with the respective rates of 84.6% and 81.3%. However, among the students who received the 3rd dose, Pfizer was the vaccine
with the highest percentage (85.7%). Three students had received the 4th dose of these vaccines: Pfizer, Moderna, and Vero Cell.
Table 2. The number of vaccines given through each dose Type
Doses
AstraZeneca n (%)
Pfizer n (%)
Moderna n (%)
Sputnik V n (%)
Vero Cell n (%)
Total n (%) 1st dose 380 (84.6) 38 (8.5) 7 (1.6) 5 (1.1) 19 (4.2) 449 (100) 2nd dose 364 (81.3) 58 (12.9) 7 (1.6) 5 (1.1) 14 (3.1) 448 (100) 3rd dose 37 (10.6) 299 (85.7) 11 (3.2) 1 (0.3) 1 (0.3) 349 (100) 4th dose 0 (0.0) 1 (33.3) 1 (33.3) 0 (0.0) 1 (33.3) 3 (100)
2. Experiences of COVID-19 vaccination Medical students had some experiences throughout injections such as anxiety (39), suspense (5), fear (12), non-anxiety (33), and satisfaction (10). These experiences varied with the number of injections. Feelings of fear, anxiety and suspense tended to subside after
each dose. In contrast, satisfaction increased in later injections. In particular, the feeling of non-anxiety tended to increase in the 2nd dose and decreased gradually in the 3rd dose. In addition, there were no records of suspense in the 2nd dose.
Figure 1. Students' experiences through injections 2.1. Feeling of anxiety before, during, and
after injections
Before the first dose, our subjects were extremely nervous because of their first experience with the COVID-19 vaccination.
Most were worried about side effects such as post-injection anaphylaxis, allergy, and death.
"Before the injection, I was kind of nervous because there were quite a few cases of anaphylaxis which led to eventual death.
There are cases where the vaccine-induced
anaphylaxis did not manifest until the next day, not just 30 minutes after that" (A, female, Traditional Medicine)
Meanwhile, a few showed no anxiety during the injections because they had consulted experienced people or obtained testimonials on social networks.
"My parents already had the 1st injection. They also had some side effects, so I knew how to handle them. Therefore, I feel there is nothing to worry about." (B, male, General Medicine)
Anxiety Suspense Fear Non-anxiety Satisfaction
Experiences
Dose
28 8 7 1
4 1
8 4 2
9 15 12
2
0 1 2 3 4
4 7
In the 2nd dose, the anxiety of side effects decreased, because they had experienced the 1st dose or asked for the experiences of people who had already been injected.
"Those who have experienced the 2nd dose told me that 2nd dose has no severe symptoms as the 1st dose, so I was as normal" (B, male, General Medicine)
However, the anxiety depends on how one felt after the 1st injection. Some participants who got side effects after injection felt more worried.
"Instead of waiting for 30 minutes, I had to sit there for an hour, to make sure I'm good to go."
(C, male, General Medicine)
Especially, in the 2nd dose and 3rd dose, the anxiety was mostly related to the combination of vaccines instead of post-injection side effects, compared to the 1st dose. Many students disagreed with the combination of two different vaccines:
"I feel that I have partly understood about AstraZeneca injections. Now that I use another vaccine such as Pfizer, I don't know or feel about it yet, so I feel unsafe." (D, female, Traditional Medicine)
On the contrary, after three doses of injection, some students were not anxious anymore because of their previous experience as well as consulted information from people around them:
"The second time I went for the injection, I didn't worry too much. Because the first time I went for the injection, it was normal, and I didn't get too tired as everyone said. So the second time I went for the injection, I was just
fine." (A, female, Traditional Medicine)
On the other hand, at the time of 3rd injection, some students had been infected with COVID-19, so they no longer felt anxious and felt more optimistic about the pandemic situation.
"With the pandemic situation in Hanoi, it got better after I had contracted COVID-19 [...] I honestly have a more optimistic mindset when I'm done with COVID-19." (C, male, General Medicine)
2.2. Feeling of suspense before, during, and after injections
Often accompanied by anxiety, the suspense of getting vaccinated for the first time was also an experience mentioned by most students.
Students had this feeling due to being injected with a new vaccine or because the waiting time before injection was long.
"The feeling was relatively nervous and a bit worried because this was the first time I was injected with this vaccine and it wasn't too common at that time, most people at that time just got the first injection, so I'm a bit worried about the side effects after the injection." (F, male, General Medicine)
"My mood before the injection was that I was nervous, very shy about the fact that I had to wait for a long time to get the injection." (G, male, General Medicine)
However, this feeling of suspense was not noted during the second injection because of the previous injection experience. In the 3rd dose, this feeling was again recognized because it was related to the combination of
vaccines, specifically because the vaccine was administered differently compared to the previous injections
“Being suspenseful because of trying a new kind of vaccine.” (H, male, General Medicine) 2.3. Feeling of fear before, during, and after injections
The third experience that students reported when receiving the first injection was a feeling of fear - mostly due to side effects after the injection
"It's also a bit scary that I wonder whether the fever will go away. Is it serious enough to require emergency care?" (I, female, Nursing) The fear of side effects after the injection continued to be reported in the 2nd injection.
“Actually, before the injection, I was still afraid that it would have a reaction like the 1st shot, that my hand would hurt.” (J, male, General Medicine)
Moreover, at this time of injection, there was an additional feeling of fear because the interval between the 2 doses was shortened compared to the recommended one.
“Pushing the 2nd injection to about one and a half months, while the recommendation is 3 months, at that time it was a bit afraid of anaphylaxis or after that the effect was not high.” (K, female, General Medicine)
With the 3rd injection, fear about the gap between 2 doses was still noted. However, unlike the second dose, the feeling of fear this time was due to the prolonged interval between the two injections, leading to some students being apprehensive about the effectiveness of
the vaccine.
"It's almost 3 months but there is still no notice to let students go back to school for more injections… I was afraid that the effectiveness of the vaccine would not be high, so I decided to give it a shot." (L, male, General Medicine) 2.4. Feeling of satisfaction before, during, and after injections
Besides anxiety and suspense, some students said they felt satisfied with the quality and effectiveness of vaccines as well as vaccination services. In the first injection, due to the current pandemic situation, the number of vaccines was limited, so the satisfaction with the first injection mainly comes from being injected at the right time.
“Before the injection, I was quite happy because I was vaccinated during the pandemic.” (M, male, General Medicine)
The feeling of satisfaction continued to be recorded in the second injection, mainly because they received the same vaccine and did not experience any side effects after the injection.
“After I heard about the Astra injection, I felt quite satisfied. and comfortable because the first shot is Astra, it is suitable for the second shot to be also Astra." (D, female, Traditional Medicine)
Most of the satisfaction in the third injection came from the effectiveness of the vaccine.
"I feel a little satisfied, the booster injection will also increase the effectiveness of the vaccine."
(N, male, Traditional Medicine)
3. Need for 4th dose
After interviewing the students, the need for the 4th dose was recorded with two opposing opinions. That were agreeing and disagreeing with the injection. The reasons for agreeing to the injection include the desire to improve their own resistance, fear of the symptoms of COVID-19, and the request for injections from the authorities.
"I think I will because in this time of COVID, being vaccinated will improve my resistance, it will limit the risks of catching COVID next time." (O, female, General Medicine)
On the contrary, the reason for not agreeing to the injection mainly depends on the pandemic situation.
“I will not choose the 4th dose because in my opinion, I think the 3rd injection is enough and now the pandemic has eased. And there's no obligation here, so I won't choose the 4th injection.” (P, female, General Medicine)
In addition, the study used Fisher's exact statistical test between 2 variables: satisfaction with vaccination and consent to the 4th dose.
The results showed that the satisfaction rate about vaccination between the group agreeing and disagreeing was statistically significant with 95% confidence (p=0.027).
IV. DISCUSSION
The research result indicated that students had diverse experiences in the vaccination process, including anxiety, suspense, fear, non-anxiety, and satisfaction. The negative experiences such as anxiety, fear, and nervousness were mainly related to side effects after injection, which
were mostly reported in the first injection.
A previous study about side effects and perceptions following COVID-19 vaccination in Jordan had shown that more than half of the participants had fear of post-injection side effects 6. Moreover, post-vaccination side effects also seemed to be one of the main hindrances to vaccine acceptance among medical students 7 and healthcare workers
8. However, those negative reactions tended to subside with the injections. It could be explained that while the first dose was being implemented, the information about vaccines and post-injection side effects was still limited to access. Besides, the fact that the COVID-19 vaccines were developed in a short amount of time that seemed to bring negative impacts.
On the other hand, the majority of positive reactions occurred from the second and third injections. The reasons for the satisfaction were reported after having at least one injection, not suffering from side effects after injection, or having COVID-19 before. The main cause of this trend may stem from the fact that at the time when the second and the third injection was implemented, the vaccine coverage was higher and the information related to the vaccine was more easily accessed.
Most of the students reported the desire to have the 4th dose, which was mainly owing to the need of improving their own resistance, suppressing severe symptoms of COVID-19 as well as prevent complications. Moreover, a randomized controlled trial in China also found that the booster dose considerably improved antibody concentrations and generated good
immune memory 9. On the contrary, the participants who disagreed were mostly positive to COVID-19 once or witnessed asymptomatic cases and a decline in the number of new cases.
It can be seen from the findings that the vaccination experience changed through the injections, combined with the change in the epidemic, which would likely have a great impact on the student's need for the next vaccination. Therefore, it is necessary to develop a new strategy to increase the coverage of the 4th dose vaccine in the student population.
Limitations: The fact that the data collection was conducted on undergraduate medical students could lead to the limited perspective related to the vaccination experience, and the information about vaccine distribution, arrangement & development of vaccination strategies, etc., was not exploited on students.
V. CONCLUSIONS AND RECOMMENDA- TIONS
Research showed that students' experience with COVID-19 vaccination at Hanoi Medical University includes 5 main emotions: anxiety, suspense, fear, non-anxiety, and satisfaction. In particular, such feelings as anxiety, fear, and suspense were mainly related to post-injection side effects and these negative reactions were most common at the 1st dose, while non-anxiety and satisfaction were more common from the 2nd and 3rd injections. In addition, the research results also showed that the majority of students would agree to get the 4th dose.
Findings of the current study point to the necessity of a deeper understanding of
any related factors influencing students’
experiences. Based on those factors, it is important that the government and each citizen should work together in order to solve the negative experiences and enhance the rate of satisfaction of the students.
REFERENCES
1. Coronavirus. Accessed July 28, 2022. https://
www.who.int/health-topics/coronavirus
2. WHO Coronavirus (COVID-19) Dashboard.
Accessed July 29, 2022. https://covid19.who.
int
3. VnExpress. Số liệu vaccine Covid-19 Việt Nam và Thế giới mới nhất hôm nay trên VnExpress. Tin nhanh VnExpress. Accessed July 29, 2022. https://vnexpress.net/covid-19/
vaccine
4. Asres F, Umeta B. COVID-19 vaccines:
awareness, attitude and acceptance among undergraduate University students. J Pharm Policy Pract. 2022;15(1):32. doi:10.1186/
s40545-021-00397-6
5. Qin C, Wang R, Tao L, Liu M, Liu J.
Acceptance of a Third Dose of COVID-19 Vaccine and Associated Factors in China Based on Health Belief Model: A National Cross- Sectional Study. Vaccines. 2022;10(1):89.
doi:10.3390/vaccines10010089
6. Hatmal MM, Al-Hatamleh MAI, Olaimat AN, et al. Side Effects and Perceptions Following COVID-19 Vaccination in Jordan: A Randomized, Cross-Sectional Study Implementing Machine Learning for Predicting Severity of Side Effects. Vaccines.
2021;9(6):556. doi:10.3390/vaccines9060556 7. Zhang J, Dean J, Yin Y, et al. Determinants of COVID-19 Vaccine Acceptance and Hesitancy: A Health Care Student-Based Online Survey in Northwest China. Front Public Health. 2022;9:777565. doi:10.3389/
fpubh.2021.777565
8. Wang J, Feng Y, Hou Z, et al. Willingness to receive SARS-CoV-2 vaccine among healthcare workers in public institutions of Zhejiang Province, China. Hum Vaccines Immunother. 17(9):2926-2933. doi:10.1080/21 645515.2021.1909328
9. Zeng G, Wu Q, Pan H, et al. Immunogenicity and safety of a third dose of CoronaVac, and immune persistence of a two-dose schedule, in healthy adults: interim results from two single- centre, double-blind, randomised, placebo- controlled phase 2 clinical trials. Lancet Infect Dis. 2022;22(4):483-495. doi:10.1016/S1473- 3099(21)00681-2
