This cross-sectional study aimed at identifying the social cognitive variables that predict influenza vaccination intentions of German medical students and their reasons for refusal and acceptance of vaccination. We identified only few studies that focused exclusively on medical students [21-25]. Two of these studies report insufficient knowledge [21,22], while the other three studies focus on medical student’s reasons for acceptance and refusal of influenza vaccination [23-25]. In these cross-sectional studies, reported vaccination coverage rates range from 4.7 to 58.1%. In accordance, this study showed that only a small proportion of the medical students were motivated to get vaccinated against influenza in both samples (22% and 23% respectively) and that an even smaller proportion (12.9%) had been vaccinated in 2012. This is also consistent with the vaccination coverage rates of other HCP groups reported in European healthcare settings, including some of the studies about medical students [21,22,25-28]. However, some studies that included students had reported considerably higher vaccination rates [8,16,23]. Some studies had additionally found that clinical medical students are more likely to be vaccinated than pre-clinical students [23,24], while another study had found no difference between these two groups of students [22].
Reasons for accepting the vaccine found in previous studies were self-protection, patient protection, and that the vaccine was offered for free [23-25]. One study additionally found professional ethics, setting an example for patients, vaccine safety and the recommendation for HCP to get vaccinated as facilitating factors [24]. In the current study, the most common reasons reported for getting vaccinated against influenza were self-protection, patient protection and the protection of family and friends. Reasons for refusal of the vaccine reported in previous studies were inconvenience, forgetfulness, concerns about side-effects, perceiving vaccination as being unnecessary, and the cost of the vaccine. Students further indicated a low risk-perception, laziness and lack of knowledge [21-25]. Reported reasons for not getting vaccinated in the current study were mostly associated with a low risk-perception, fear of side-effects, and the disbelief in the effectiveness of influenza vaccination. To a lesser extent, organizational barriers were revealed to be a possible inhibiting factor, mirroring factors associated with refusal of influenza vaccination in other studies [8,23,28]. As was mentioned before, easy access to the vaccine is not always offered to medical students [7], even when they have regular patient contact.
Results further suggested that participants who did not expect important others to want them to get vaccinated were more likely to have no intention to get vaccinated as opposed to being unsure about their future vaccination intentions. Injunctive norm additionally mediated the relationship between instrumental attitude and intention. This is surprising since in the RAA, perceived norms and attitude predict intention independently [17]. Our findings suggest that medical students that have a negative instrumental attitude towards influenza vaccination might be even more susceptible to negative injunctive norms that they might encounter when entering a clinic, and that these two determinants predict their intention to get vaccinated. One possible explanation for this is that medical students are much more susceptible to injunctive norms in general because of their lower status in the healthcare hierarchy, as opposed to other HCP groups. This stresses the importance of intervening early in medical students’ education so that they form the right instrumental attitudes towards influenza vaccination before entering clinics. Moreover, higher feelings of autonomy in the decision whether to get vaccinated increased the probability of having no intention to get vaccinated as opposed to being unsure. A high intention to get vaccinated was most likely for participants who had a positive instrumental attitude and who also had high feelings of autonomy. Scores on autonomy were generally very high, suggesting that medical students feel completely free to choose whether to get vaccinated against influenza. High feelings of autonomy do not seem to be a barrier, as long as they are paired with positive instrumental attitudes.
The mentioned factors are significant but relatively weak predictors of the intention to get vaccinated against influenza. This indicates that there might be additional factors involved in the motivation of students to get vaccinated. The factors included in the multinominal logistic regression did not capture the organizational issues suggested in other studies, such as the inconvenience of getting vaccinated, not being offered vaccination, or getting vaccination for free [8,23]. However, previous studies have shown that these factors are perceived barriers to vaccination, and hospitals should therefore increase the accessibility of free vaccines to medical students and include them more actively in vaccination programs. This could also be an explanation for why the percentage of students who are vaccinated is smaller than the percentage of students who intend to get vaccinated against influenza. This intention-behavior gap has been identified across a broad range of health behaviors, including influenza vaccination [18,29].
This is one of the few studies to investigate the factors preceding the intention to get vaccinated among medical students. However, this study has some limitations worth mentioning. Firstly, the survey included only 18 items to reduce the length and to increase the response rate. Including more items that capture factors identified in other studies could have improved the predictive power of our model. Secondly, due to an unforeseen change in the set-up of the study, the second sample was missing questions on demographics, facilitating and inhibiting reasons, as well as the vaccination status of the participants. Therefore, we were only able to compare the intention to get vaccinated and its possible predictors across the two samples. We cannot say anything about differences in the number of people who were vaccinated. However, intention did not differ between the two years, making it likely that we would not have found considerable differences in vaccination rates between the two samples.