The Best WritersRESEARCH ARTICLENational attitudes of medical studentstowards mandating the COVID-19 vaccine andits association with knowledge of the vaccineDanel MayanID1*, Kenny Nguyen1‡, Brian Keisler2‡1 University of South Carolina School of Medicine, Columbia, South Carolina, United States of America,2 Department of Family and Preventive Medicine, University of South Carolina School of Medicine, Columbia,South Carolina, United States of America‡ These authors also contributed equally to this work* [email protected]AbstractBackgroundWith the introduction of the novel COVID-19 vaccine, public hesitancy is being experiencedwith many turning to healthcare professionals for advice. As future physicians, medical stu-dents play a critical role in the public’s view of the vaccine.ObjectivesTo determine the attitude of U.S. medical students toward mandating the COVID-19 vaccineto healthcare workers and patients, as well as whether their knowledge of the vaccine playsa role in their view.MethodsThe authors emailed a survey link to all U.S. medical schools with request to distribute it totheir medical students. The survey remained open from 02/09/2021 to 03/15/2021 andincluded questions to determine the attitude of the medical students toward recommendingthe COVID-19 vaccine, and general knowledge questions about the vaccine. Chi square,Fisher’s exact test, and linear regression were conducted to determine associationsbetween willingness to recommend the COVID-19 vaccine and general knowledge of thevaccine.ResultsAmong the 1,899 responses from medical students representing 151 U.S. medical schools,57.82% approved of making the COVID-19 vaccine mandatory to healthcare workers, and16.27% approved of making it mandatory to patients. Additionally, those who tested mostknowledgeable of the vaccine were less likely to approve of making the vaccine mandatoryfor patients (66.67% vs. 72.70). Those that tested most knowledgeable were also morelikely to personally receive the vaccine (72.35% vs 62.99%) as opposed to those that testedthe least knowledgeable who were less willing to personally receive the vaccine (4.12% vs14.17%).PLOS ONEPLOS ONE | December 22, 2021 1 / 10a1111111111a1111111111a1111111111a1111111111a1111111111OPEN ACCESSCitation: Mayan D, Nguyen K, Keisler B (2021)National attitudes of medical students towardsmandating the COVID-19 vaccine and itsassociation with knowledge of the vaccine. PLoSONE 16(12): e0260898. James Andrew Rowley, Harper UniversityHospital, UNITED STATESReceived: August 29, 2021Accepted: November 18, 2021Published: December 22, 2021Copyright: © 2021 Mayan et al. This is an openaccess article distributed under the terms of theCreative Commons Attribution License, whichpermits unrestricted use, distribution, andreproduction in any medium, provided the originalauthor and source are credited.Data Availability Statement: All relevant data arewithin the paper and its files.Funding: The authors received no specific fundingfor this work.Competing interests: The authors have declaredthat no competing interests exist.ConclusionsThe data revealed that a slight majority of medical students support a vaccine mandatetoward healthcare workers while a minority of medical students support a vaccine mandatetoward healthcare workers. Additionally, medical students that had relatively high knowl-edge of the vaccine correlated with not approving of making the vaccine mandatory forpatients. However increased knowledge of the vaccine correlated with increased willingnessto personally receive the vaccine.IntroductionVaccines against highly transmittable infectious diseases are one of the most effective medicalinterventions available and save millions of lives each year [1]. Previously, vaccines for infec-tious diseases required years of development and clinical evaluation before being authorizedfor use for the general population. Through recent advancements in rapid vaccine develop-ment and the unprecedented pressure placed on our healthcare systems and economies due toCOVID-19, several vaccines for SARS-CoV-2, such as those manufactured by Pfizer BioN-Tech, Moderna, and Johnson & Johnson, have been approved for use by the Food and DrugAdministration’s Emergency Use Authorization, with Pfizer BioNTech most recently receivingfull FDA approval [2,3].COVID-19 vaccine availability, however, does not guarantee uptake by healthcare workers[4]. Vaccine hesitancy the delay of acceptance or refusal of vaccines despite the availability ofvaccine services remains a limiting factor for achieving optimal herd immunity against highlytransmittable diseases. Refusal of vaccines is associated with an increased risk of contractingthe target disease [5]. Several factors that drive vaccine hesitancy for the COVID-19 vaccinehave been identified. Safety, quality control, side effects, and efficacy are among the most nota-ble drivers of vaccine hesitancy for the COVID-19 vaccine, partly due to concerns related tothe speed of the vaccine development and testing [6,7].Although the vaccine has been proven to be effective at mitigating the effects of COVID-19,the hesitance of much of the public to receive the vaccine greatly limits the success of acquiringherd immunity. With these thoughts, the idea of a vaccine mandate has been brought up in themedia especially after full FDA approval of the vaccine has been granted. Many businesseshave already began requiring their employees to receive the vaccine, and more recently federalplans have been unveiled to mandate that employees of large business receive the vaccine or besubjected to weekly testing. Although controversial, some feel that a mandate is the only wayto eradicate the disease.Despite the potential reluctance and hesitancy of the public to accept any vaccine (e.g.,influenza), health care providers remain trusted advisors and influencers of vaccination deci-sions. As an integral part of the healthcare team and as future physicians, medical studentsplay a notable role in counseling patients about the novel coronavirus and providing accurateinformation about vaccination. Medical students will likely encounter vaccine-hesitantpatients during their clinical rotations. Therefore, it is essential that medical students possessaccurate knowledge of SARS-CoV-2 and the available vaccine options to dispel misinforma-tion surrounding the COVID-19 vaccine. Previous studies have shown that medical studentsview immunization favorably and are more likely to gain comfort counseling vaccine-hesitantpatients following a targeted curriculum on infectious disease and immunology [8].PLOS ONE Medical students’ recommendation toward the COVID-19 vaccinePLOS ONE | December 22, 2021 2 / 10This study was conducted to determine the attitudes of U.S. medical students towardreceiving the COVID-19 vaccine in addition to their approval toward mandating the vaccineto patients and/or healthcare workers. Additionally, it also sought to determine whether theirdegree of knowledge about the vaccine plays a role in their view.MethodsData was collected with a survey created in REDCap, a secure, cloud-based survey and data-base software provided by the University of South Carolina. We conducted this study with apopulation of U.S. medical students. Inclusion criteria included being enrolled in a MD or DOprogram at a U.S. medical school. Participation was acquired via an email sent to the studentaffairs offices of all 212 U.S. medical schools with request to distribute the website link for theonline survey (Fig 1) to their students. Follow up emails were sent to the research departmentsof schools that did not respond. Additional participation was recruited via medical student-targeted social media. Financial incentive was not provided for completion of the survey. Atotal of 2,025 responses were received. Among them, 126 students did not provide their demo-graphic information, leaving 1,899 with full records.The survey determined demographics (age, gender, race/ethnicity, and school year),assessed general knowledge about the Pfizer and Moderna COVID-19 vaccines, and attitudestoward vaccine recommendation/mandate practices. It remained open from 02/09/2021 to 03/15/2021. Contact information was not collected from participants and amount of survey clicksversus amount of survey completions was not recorded.The surveyed medical students were asked to rank their knowledge of the COVID-19 vac-cine on a scale of 1 3, with 3 being the most knowledgeable. This ranking was dichotomized asmost knowledgeable (scale of 3) or not (scale of 1, 2). 5 knowledge questions about theCOVID-19 vaccine were further included in the survey. The number of correctly answeredquestions was categorized into three levels: correctly answered 0 3 questions (the reference),correctly answered 4 questions, and correctly answered all 5 questions.Three primary attitude questions were provided in the survey, including recommendationfor the COVID-19 vaccine toward patients, recommendation for the COVID-19 vaccinetoward healthcare workers, and attitude toward personally receiving the vaccine. Although thevaccine recommendations were originally designed as 3-level questions (“I would make itmandatory,” “I would recommend it,” and “I would not recommend it”), the “I would not rec-ommend” option had too few respondents to allow for proper evaluation of statistics so thegroups were dichotomized to those that would make the vaccine mandatory (“I would make itmandatory”) and those that would not make the vaccine mandatory (“I would recommend it”combined with “I would not recommend it”). The logic behind this grouping being that if aparticipant selected that they would not recommend the vaccine, it was also assumed that theywould not recommend mandating it as well. Likewise, if a participant selected “I would recom-mend it” over “I would make it mandatory,” it was assumed that they did not support a man-date even though they still support recommending the vaccine, thus fitting into the “I wouldnot make it mandatory” category. The 5-level attitude toward personally receiving the vaccinewas also dichotomized, due to the same issue, as “will receive vaccine” (“willing” combinedwith “very willing”) or “will not receive the vaccine” (“indifferent” combined with “reluctant”and “very reluctant”).Participants were given the option of leaving comments to explain or support their surveyresponses. These comments were grouped by similarity of content and quantified to determinethe most commonly reported statements supporting or not supporting their survey selections.PLOS ONE Medical students’ recommendation toward the COVID-19 vaccinePLOS ONE | December 22, 2021 3 / 10Fig 1. COVID-19 vaccination survey. ONE Medical students’ recommendation toward the COVID-19 vaccinePLOS ONE | December 22, 2021 4 / 10Descriptive analysis was conducted to summarize the characteristics of the entire sample.Comparisons of demographics and knowledge were conducted by each of the four attitudeoutcomes, chi-square test for frequency and t-test for continuous variables. Additionally, mul-tiple logistic regressions were used to estimate the odds ratio (OR) and 95% confidence inter-val (CI) of demographics and knowledge for each of the four attitude outcomes. All statisticalanalysis was conducted at the significance level of 0.95, using the software SAS version 9.4(SAS Institute, Cary, North Carolina).For this cross-sectional study, the University of South Carolina institutional review boarddesignated this study as human subjects exempt, February 8, 2021. Informed consent was pro-vided on the first page of the survey and respondents were made aware that by volunteering tocomplete and submit the survey they agreed to participate.ResultsThe sample size totaled 1899 medical students enrolled at an MD or DO program at a U.S.medical school. The average age of the study sample was 26 years old, with 64% being female.The detailed characteristics of the respondents are shown in Table 1. Although only 18% ofmedical students ranked themselves as being the most knowledgeable of the vaccine, themajority of surveyed medical students (71%) answered all 5 questions correctly, with less than5% correctly answering only 0 3 questions. A minority of medical students (16%) designatedtheir approval in making the vaccine mandatory for patients, while a slight majority (58%)Table 1. Surveyed medical students’ demographics, knowledge, and attitude toward the COVID-19 vaccine.Variables Number PercentageDemographicsAge (mean: years) 1899 25.79