COMPARISON OF THE EFFECTIVENESS OF WRITTEN LITERATURE ONLY VERSUS AN INTERVENTION PROGRAM TO REDUCE COVID-19 VACCINE HESITANCY AMONG HIGH SCHOOL STUDENTS IN PAKISTAN

Abstract

Coronavirus disease-2019 (COVID-19) vaccine hesitancy can interfere with efforts to control the disease.  In this study we aimed to compare the efficacy of a school-based program versus an already used educational brochure to reduce COVID-19 vaccine hesitancy among 9th and 10th grade students in Balochistan, Pakistan, in order to inform efforts to improve vaccine uptake in the study population.  Study subjects were recruited from 30 schools in Balochistan, Pakistan during September 2023 
- February 2024.  Inclusion criteria for study subjects were, being a 9th or 10th grade student at a study school and being willing to participate in the study.  Exclusion criteria for study subjects were being unwilling to participate in the study or attending a non-study school.  Study subjects were divided into 2 groups: an intervention group and a control group. Intervention subjects underwent an educational program about COVID-19 and the COVID-19 vaccine that consisted of lectures and presentation of various media.  Control subjects were given a routinely used educational brochure about COVID-19 and the COVID-19 vaccine.  Both control and intervention subjects were asked to complete a questionnaire both prior to and after the intervention.  The questionnaire assessed subject knowledge about COVID-19 and the COVID-19 vaccine, subject confidence (subject trust in the efficacy and safety of the COVID-19 vaccine and subject trust in healthcare professionals and policymakers endorsing the vaccine), vaccine convenience (subject perceived ease of being vaccinated with the COVID-19 vaccine) and subject complacency (subject perceived risk and necessity of receiving the COVID-19 vaccine).  Each question was given a score, and the scores were totaled and classified.  Subject knowledge, subject confidence, vaccine convenience and subject complacency were classified by percentile: having a low score (<34th percentile), medium score (34th-66th percentile) and high score (>67th percentile).   For complacency, a higher score indicated a lower complacency.  A total of 780 subjects were included in the study: 386 (49.5%) (with 59.3% males) in the intervention group and 394 (50.5%) (with 56.6% males) in the control group.  The mean (±standard deviation (SD)) ages of intervention and control subjects were: 16 (±1.3) (range: 10-19) and 15.6 (±1.3) (range: 10-19) years, respectively.  The mean (±SD) knowledge scores in the intervention and control groups increased significantly (p=0.001 and p=0.001, respectively) from before intervention (8.7 (±2.9) and 9.0 (±2.7), respectively) to after the intervention (11.7 (±2.5) and 9.6 (±2.3), respectively).  The mean (±SD) subject knowledge scores in the intervention and control groups prior to the intervention were not significantly different from each other (p=0.120).  The mean subject knowledge score in the intervention group after the intervention was significantly higher (p<0.001) than the control group after the intervention.  The mean (±SD) subject confidence score in the intervention group decreased significantly (p<0.001) from before the intervention (41.4 (±6.4)) to after the intervention (40.5 (±6.5)) and the mean (±SD) subject confidence score in the control group increased significantly (p<0.001) from before the intervention (41.0 (±6.3)) to after the intervention (42.8 (±6.2)).  The mean subject confidence scores in the intervention and control groups before the intervention were not significantly different from each other (p=0.330).  The mean subject confidence score in the intervention group was significantly lower than the control group (p<0.001) after the intervention.  The mean (±SD) vaccine convenience score in the intervention group increased significantly (p<0.001) from before the intervention (38.5 (±7.6)) (to after the intervention (40.1 (±6.2)) but the mean (±SD) vaccine convenience score in the control group decreased significantly (p<0.001) (from before the intervention (37.9 (±7.1)) to after the intervention (35.8 (±5.3).  The mean vaccine convenience scores were not significantly different between the intervention and control groups before the intervention.  The mean vaccine convenience score was significantly higher (p<0.001) in the intervention group after the intervention than in the control group after the intervention.  The mean (±SD) subject complacency score in the intervention group increased significantly (p=0.006) in the intervention group from before the intervention (30.6 (±6.4)) to after the intervention (34.2 (±0.7)) and the mean (±SD) subject complacency score in the control group increased significantly (p=0.006) from before the intervention (31.5 (±5.8)) to after the intervention (35.5 (±5.8)).  The mean subject complacency scores in the intervention and control groups before the intervention were not significantly different from each other (p=0.034). The mean subject complacency score after the intervention was significantly higher in the intervention than the control group (p=0.006), indicating lower complacency and greater recognition of COVID-19 risks and need for vaccination in the intervention group.  Significantly more (adjusted odds ratio (aOR) = 3.716; 95% confidence interval (CI): 1.323-10.443; p=0.013) subjects in the intervention (51.0%) than the control group (35.0%) stated they would be willing to receive the COVID-19 vaccine after the intervention.  In the intervention group, there was a significant positive association between being willing to have the COVID-19 vaccine and having a high knowledge score (aOR = 6.085; 95% CI: 2.523-14.676; p<0.001), having a high vaccine convenience score (aOR = 4.899: 95% CI: 1.984-12.094; p=0.001) and having a high subject complacency score (aOR = 4.521: 1.887-10.828; p=0.001).  Female subjects in the intervention group, but not in the control group, were significantly more likely to receive the COVID-19 vaccine than male subjects (aOR = 4.761; 95% CI: 1.711-13.251; p=0.001).  Prior to the intervention, 43.0% of subjects in the intervention group and 35.0% of subjects in the control group were willing to receive the COVID-19 vaccine (p=0.022) and after the intervention, 51.0% of subjects in the intervention group and 35.5% of subjects in the control group (p<0.001) were willing to receive the vaccine.  The percentage of subjects in the intervention group who were willing to receive the vaccine after the intervention increased significantly (p<0.001) and the percentage of subjects in the control group who were willing to receive the vaccine after the intervention also increased significantly (p<0.001) but to a lower extent.  Our results show the school-based intervention significantly improved subject knowledge and subject convenience and decreased subject complacency and subject confidence about receiving the COVID-19 vaccine and was more effective than the control brochure.  After the intervention, subjects in the intervention group were significantly more likely than subjects in the control group to receive the COVID-19 vaccine.  However, the proportion of subjects who were willing to receive the vaccine was still low (only 51.0%).  Further studies are needed to determine what interventions might improve the willingness to receive the COVID-19 vaccine.