Knowledge, attitude, and practice of Egyptian medical students towards healthcare workers’ recommended vaccines: a nationwide cross-sectional survey

Background Vaccination of healthcare workers (HCWs) is pivotal in decreasing the incidence of contagious infections in hospital settings. In this study, we assessed the knowledge, attitude, and practice regarding HCWs’ recommended vaccines among medical students and interns in Egypt. Methods A multicenter, cross-sectional study was conducted using a structured, pilot-tested, and self-administered questionnaire among Egyptian medical students and interns. We invited 1332 participants to our survey using a systematic random sampling that included participants across nine medical schools in Egypt during the 2021–2022 academic year. Results Out of 1332 participants, 1141 completed our questionnaire with a response rate of 85.7%. Overall, 43% of the participants had intermediate knowledge (knew 2–3 HCWs’ recommended vaccines). Furthermore, 36.7% had received a booster dose of at least one of the HCWs’ recommended vaccines over the last 10 years, with only 6.1% having received all recommended vaccines. Hepatitis B vaccine was the most widely known (71%) and received (66.7%). Interns were more likely to know, receive, and recommend HCWs’ recommended vaccines. The majority (> 90%) agreed that vaccination is beneficial and safe, with a median score of eight (interquartile range [IQR: Q25-Q75]: 7–9) out of ten for vaccine efficacy and eight (IQR: 7–8) for safety. However, the median score for hesitancy was five (IQR: 2–7). The most common influential and limiting factors for vaccination were scientific facts (60.1%) and fear of vaccine side effects (44.9%). Conclusion Although medical students in Egypt have good knowledge of and attitudes towards vaccination, there is a gap in their practices. Interventions are needed to improve vaccination uptake among medical students in Egypt. Supplementary Information The online version contains supplementary material available at 10.1186/s12909-024-05712-8.


Introduction
Vaccination plays a crucial role in preventing infections in communities and healthcare settings, particularly among high-risk individuals.World Health Organization (WHO) and Center for Disease Control (CDC) prioritize vaccination coverage for children and high-risk groups including healthcare workers (HCWs) [1].The CDC strongly recommends that HCWs receive vaccines such as Hepatitis B, MMR (Measles, Mumps, Rubella), Varicella (Chickenpox), Influenza, and DTaP (Diphtheria, Tetanus, Pertussis) [1,2].Moreover, it recommends that microbiologists and HCWs who come into contact with Neisseria meningitidis-infected individuals should receive meningococcal vaccine [1].Additionally, due to the gap between childhood vaccinations and working as an HCW, booster doses or revaccination may be necessary to maintain high levels of immunity.
Ensuring high vaccination rates among HCWs is critical to prevent the transmission of infections to patients and maintain the integrity of the healthcare system.This is particularly relevant in the context of the COVID-19 pandemic, which highlights the importance of vaccination in preventing the spread of COVID-19 [3,4].However, there is an increasing rate of vaccine hesitancy, not only in general population but also among HCWs which has impacted vaccine-related behavior and uptake [5][6][7].This is concerning as HCWs are considered to be the most influential for patients regarding vaccinations [8].Patient decision about vaccination is usually associated with their trust in their HCWs [9].
Medical students are the future of the healthcare system and their attitude and practice towards vaccines will shape the future of vaccine uptake among HCWs and patients.Internationally, multiple studies have evaluated the knowledge and attitude of medical students towards vaccines.However, most of these studies included only one or a limited number of vaccines, such as influenza, HBV, and COVID-19 [10][11][12].Generally, medical students are aware of the importance of vaccination, however there is a gap between knowledge and practice.Rostkwoska et al. reported that 99.2% of European medical students were aware of booster vaccinations; however, only 68% had taken any [13], which could be attributed to vaccine hesitancy.
In low-and middle-income countries, it is estimated that vaccination coverage for HCWs is lower than highincome countries.For example, WHO has estimated that only 18-39% of HCWs in low-and middle-income countries have HBV vaccination coverage compared to 67-79% in high-income countries [14].In Egypt, most of the available studies have evaluated the attitudes of medical students towards only COVID-19 vaccination.Saied et al. explored the beliefs and barriers of medical students towards COVID-19 vaccines and found that 46% of Egyptian medical students were hesitant to receive COVID-19 vaccines [15].Another study evaluated vaccination rates and found that 83.2% of Egyptian medical students were vaccinated [16].However, to our knowledge, there is no or limited data regarding the other HCWs' recommended vaccines.
This study is underpinned by the Health Belief Model (HBM) and the Theory of Planned Behavior (TPB), which provide a theoretical basis for understanding health behaviors, including vaccination uptake [17].The HBM posits that individuals are more likely to engage in health-promoting behaviors if they perceive a higher susceptibility to a health issue, believe the health issue has serious consequences, think taking a specific action would reduce their susceptibility or severity, and perceive fewer barriers to taking that action [18].The TPB, on the other hand, suggests that an individual's behavior is influenced by their intentions, which are shaped by their attitudes towards the behavior, subjective norms, and perceived behavioral control [19].Understanding the current knowledge and attitude of medical students and interns towards HCWs' recommended vaccines will help to develop strategies to improve vaccination rates and protect the health of both HCWs and the population.
This study aims to assess the prevalence, knowledge, and attitudes towards HCWs' recommended vaccinations among medical students and interns in Egypt.Furthermore, being shortly after the pandemic, it has special focus on COVID-19 and flu vaccines as they were highly recommended.Additionally, it examines the factors influencing the use of booster doses.
The specific research questions are: 1. What is the prevalence of uptake of HCWs' recommended vaccinations among medical students and interns in Egypt? 2. What is the level of knowledge and what are the attitudes of medical students and interns towards these vaccinations?3. What factors influence the uptake of booster doses among medical students and interns?

Materials and methods
We conducted a multicenter, cross-sectional study using a structured, pilot-tested, and self-administered questionnaire to evaluate the knowledge, attitude, and practice of medical students regarding HCWs' recommended Using Raosoft online calculator (https://www.raosoft.com/samplesize.html),we calculated the sample size to achieve a 99% confidence interval, a 4% margin of error, and a 50% response rate to increase the power and accuracy to capture the diversity across medical universities throughout Egypt.This yielded a sample size of 1024.To account for a 30% non-response rate, the total required sample was 1332 which was divided proportionately among universities based on the overall number of students.Within each university, we used a simple random sampling technique, and the sample was divided equally between academic, clinical, and internship years.The first three years were considered academic, the next three years were clinical, and the last year was the internship year.We randomly selected participants from the students' lists for each class using random.org.

Data collection
University teams were formed with local coordinators, who obtained student lists from official sources.Invitations to participate were sent to the selected individuals between September and November 2022 via email and social media platforms, with a unique code provided to each participant.A voluntary consent form was required for participation.

Questionnaire development
The questionnaire was developed by the principal investigators through a literature review and reviewed by two experts for clarity and relevance.A pilot study was conducted among seven universities to gather feedback on the questionnaire's format, clarity, and completion time.Changes were made based on this feedback to improve question clarity.Pilot study responses were not included in the final analysis.The questionnaire, consisting of 29 questions divided into four sections, was administered in English using Google Forms.It included a cover letter, sociodemographic questions, practice and knowledge questions, attitudes towards vaccination questions, and attitudes towards specific vaccines (COVID-19 and flu).The questionnaire can be found in the supplementary files.

Statistical analysis
Descriptive statistics are presented as numbers and percentages for qualitative data and median and interquartile range (IQR) [Q25-Q75] for quantitative data.We used the chi-square test to assess the associations between categorical variables.Wilcoxon rank sum test (Mann Whitney) and Kruskal Wallis test were used to assess the association between gender, educational level, and attitudes regarding efficacy, safety, and hesitancy.Knowledge about recommended vaccines was divided into three categories: low knowledge (0-1 vaccines), intermediate knowledge (2-3 vaccines), and high knowledge (4-6 vaccines).A p-value of 0.05 was used as the limit for statistical significance.Statistical analyses were performed using the SAS statistical software (version 9.4; SAS Institute Inc., Cary, NC, USA).

Results
We collected data from nine of the ten selected universities.A total of 1,321 individuals were randomly selected from nine universities located across six regions of Egypt.Of these, 1,141 students completed the survey, resulting in a response rate of 86.4%.The demographic characteristics of the participants are summarized in Table 1.Most of the respondents were Egyptian (89.4%), male (51.9%), first-generation medical students (65.6%), and living in urban areas (63.6%).Furthermore, 95% of the participants had received vaccinations as part of a national campaign during infancy, and 78% reported having access to a vaccination center at their institution or governorate.

Knowledge of booster vaccinations
Approximately 85% of participants reported knowing at least one HCW-recommended vaccine, while only 3.8% were knowledgeable about all six recommended vaccines.Moreover, 43% and 25% of the participants had intermediate and high knowledge, respectively (Table 2).The most commonly recognized vaccine was HBV vaccine (Fig. 1A).Interns and clinical-year students were more likely to have intermediate knowledge than academicyear students (49.7% and 49.1% vs. 32.4%,P < 0.001).Moreover, males were more likely to have higher knowledge than females (27.7% vs. 22.6%, P = 0.003) and were more likely to have intermediate knowledge (Table 2).
Additionally, Egyptian nationality (44.6% vs. 33.1% for non-Egyptians, P = 0.0457) and geographical region (P = 0.0329) significantly influenced intermediate knowledge.Other sociodemographic factors, including type of residence and generation, were not significantly associated with knowledge (P > 0.05).

Attitudes towards booster vaccination
More than 90% of the participants agreed that vaccination is useful and safe and that everyone should be vaccinated.Additionally, 92.2% of participants recognized the necessity of booster doses to ensure adequate protection (Table 3).Interns demonstrated higher awareness of revaccination importance and compliance (37%) compared to clinical and academic students (28.1% and 31.7%,respectively; P < 0.001).Conversely, clinical students exhibited awareness but uncertainty regarding full vaccination, while academic students were more likely to encounter this information for the first time compared to interns and clinical students.Type of residence (urban: 34.4% vs. rural: 28%; P = 0.0116), presence of a vaccination center (yes: 34.7%, no: 22%, not sure: 22.9%; P = 0.0038), and nationality (Egyptian: 31% vs. non-Egyptians: 41.3%; P = 0.0009) were also significantly associated with awareness of the need for revaccination.Interestingly, over 50% of the participants reported an intention to take booster doses or at least perform a blood analysis to ensure immunity.
Regarding the mandatory nature of booster vaccination, approximately 88% and 67% of the participants believed that these vaccines should be mandatory for medical staff and medical students, respectively.Interns were more likely to support mandatory vaccination than academic students (72% vs. 62.6%, P = 0.01).Additionally, females were more likely than males to endorse mandatory vaccination for medical students (71% vs. 63.5%,P = 0.002).Furthermore, 74% of participants indicated  that they would advise their colleagues, friends, and family to receive booster vaccinations.Educational grade (Table 3) and type of residence (urban: 75.6% vs. rural: 70.8%; P = 0.044) were significantly associated with the intention to recommend booster vaccination.Moreover, the presence of a vaccination center at the participants' institutions or governorates was significantly associated with the intention to recommend booster vaccination (yes: 38%, no: 15.6%, not sure: 15.4%; P = 0.0008).However, other sociodemographic characteristics, including gender, region, generation, and nationality, were not associated with this recommendation (P > 0.05).
Out of ten, our participants reported a median score of eight (IQR:  4).The presence of a vaccination center was also associated with higher median scores (median [IQR] score = 8 [7-9] vs. 7 [6][7][8]; P = 0.005] for safety.Neither the type of residence nor region was associated with safety or efficacy (P > 0.05).Additionally, no significant association was found with hesitancy in any of the demographic data.

Factors affecting students' opinions towards booster vaccination
The most influential factors in students' opinions regarding the booster vaccination were scientific facts (60.1%) and senior physicians or professors (15%) (Fig. 2A).There was a significant association between the factors affecting students' opinions and gender (P = 0.01), educational grade (P = 0.01), and nationality (P = 0.002).Academic students were more likely to be influenced by social media than interns (14.6% vs. 7.8%, P = 0.01).However, there was no significant association with other demographic factors (P > 0.05).

Flu vaccine
Approximately 35% of participants were aware that influenza vaccination is one of the HCW-recommended vaccinations.Regarding vaccination rates, 17.6% reported receiving a seasonal flu vaccine in the past year and approximately 49.4% reported having been vaccinated at least once before.However, only 5.1% of students reported receiving a booster vaccine every season.Gender (males: 31.3% vs. females: 21.9%, P = 0.002), generation (non-first-generation: 31.6% vs. first-generation: 24.2%, P = 0.002), and educational grade (academic: 35.9% vs. clinical: 21.5%; P = 0.001) were significantly associated with receiving the flu vaccine multiple times, but not seasonally.In contrast, the type of residence and region did not affect the rate of influenza vaccination (P > 0.05).

Discussion
To the best of our knowledge, this is the first study from Egypt to examine the knowledge, attitude, and practice of medical students towards HCWs' recommended vaccines across various educational levels, including interns.Overall, there was a positive attitude towards HCWs' recommended vaccination.However, most participants had moderate knowledge with a gap in the actual practice of receiving vaccines.

Knowledge of HCWs' recommended vaccines
Approximately 43% and 25% of the students showed moderate and high knowledge levels, respectively.Notably, knowledge increased with educational grade, particularly among interns and clinical-level students, compared to academic-year students.This difference in knowledge likely stems from the greater exposure of these students to clinical settings, which enables them to witness the impact of vaccination in real-world scenarios.Moreover, a more rigorous curriculum for clinical-level students encompasses comprehensive information about vaccinations, facilitating the accumulation of knowledge over time [20,21].These findings align with those of previous studies conducted in the United States and Europe [13,[22][23][24].Similarly, gender showed a significant association with knowledge about HCWs' recommended vaccines, with females being more likely to have higher knowledge than males which is inconsistent with previous studies from Europe that showed no difference [13].

Practice of participants towards HCWs' recommended vaccines
Our study found a notable disparity between medical students' knowledge and practice, as only 8.1% of participants reported receiving two or three recommended vaccines in the past decade.Consistent with literature, HBV vaccine had the highest rates of both knowledge (70.9%) and practice (66.7%), likely due to the high prevalence of HBV infection in Egypt [25].Previous studies have reported similar findings in Vienna, and Pakistan, where the rate of HBV vaccination reached 80% [26,27].
Conversely, varicella and meningococcal vaccines are the least known and received vaccines.In our study, the MMR vaccination rate was 29.2%, which is lower than the average vaccination rates reported in several European countries which was about 80% [13].Similar to knowledge, interns were more likely to receive booster vaccination which is consistent with findings from previous studies [13].However, there was no significant difference in booster vaccination rates between academic-and clinical-year students or between male and female students.Having a vaccination center at the participants' institutions or in their respective regions was positively correlated with increased knowledge and vaccine uptake.This underscores the potential of these centers to raise awareness and promote adherence to the recommended vaccines among healthcare students.

Attitude of participants towards HCWs' recommended vaccines
The participants expressed positive views on vaccine safety and effectiveness, with little variation.Consistent with the literature, the majority (91%) of participants believed that vaccines were safe and effective [26,28].Attitudes towards booster vaccines were also positive due to awareness of the need for revaccination.Medical training and clinical exposure influenced attitudes, with interns and clinical year students reporting higher scores.Although 90% of the participants agreed that vaccination was safe and that everyone should be vaccinated, only 74% would recommend booster vaccinations to their colleagues, friends, and family.This discrepancy may reflect vaccine hesitancy among the participants.Our study found a median hesitancy score of 5/10, with 7.2% of the participants expressing uncertainty or unwillingness to receive booster vaccines.Similar hesitancy patterns are observed among medical students regarding influenza, COVID-19, and HBV vaccines [13,[24][25][26].

Factors that limit vaccine uptake
When participants were asked about reasons that might prevent them from receiving booster vaccinations, 44.9% reported their fear of side effects as a major concern.This fear could be influenced by misinformation regarding the side effects of COVID-19 vaccines that circulated just before this study was conducted [29,30].Interestingly, most of those who reported fear as a limitation were students in their academic years.Meanwhile, interns and students in their clinical years cited a lack of time as the main limitation.Additionally, participants from urban areas were more likely to cite lack of time as a limitation.

Factors that influence vaccine uptake
The most influential factors shaping medical students' opinions on vaccination were scientific facts (60.1%), and senior physicians or professors (15%).Interns (63%) and clinical students (62.7%) were more likely to form opinions based on scientific facts.Interestingly, participants who reported social media as an influencing factor had less positive attitudes towards vaccine safety and efficacy than those influenced by scientific facts or senior physicians.These observations highlight the need for evidence-based and accurate information regarding the dissemination of vaccines among healthcare students.

Flu vaccine
Our study found that only 35% of the participants were aware that the flu vaccine is recommended for HCWs, ranking fourth on the list.Additionally, while 49.4% reported receiving at least one influenza vaccine shot, only 17.6% had received a shot within the previous year, which is similar to the results of a previous study [12].Surprisingly, academic students were more likely to have received the seasonal flu vaccine in the past year than clinical students and interns, in contrast to the findings of Walker et al. [12] but consistent with Rostkowska et al. and Gray et al. [13,31].This may be due to academic students' greater exposure to vaccination opportunities on university campuses and their compliance with vaccination requirements for attending classes or clinical placements [32].

COVID-19 vaccine
Approximately 80% of the participants in our study received at least two doses of the COVID-19 vaccine, consistent with findings in Egypt, and nearly double the rate of the general population (44.3%) [16,33].This high vaccination rate may be attributed to the government's requirement for all university students to be vaccinated before returning to campus, after the lockdown measures were lifted.Notably, this trend aligns with the higher coverage rates among healthcare workers in Germany (91.7%), Italy (82%), Portugal (87%), and Greece (81.9%).Similar to the pattern observed for influenza vaccination, academic students were more likely to receive the COVID-19 vaccine than clinical students and interns.

Limitations of our study
Although our study has several strengths, including having participants from all study years in nine institutions, with a high response rate of 86.4%, some limitations should be considered.First, we were unable to collect data from the Fayoum geographic region, which represents less than 5% of all Egyptian medical students.Second, the timing of our questionnaire, conducted shortly after the onset of the COVID-19 pandemic, may have influenced some results, particularly the attitudes toward vaccination.Additionally, due to questionnaire length constraints, we could not include sections on other vaccines beyond flu and COVID-19, which were prioritized given the ongoing pandemic.

Conclusions
Overall, medical students showed intermediate knowledge of HCWs' recommended vaccines with a positive attitude towards vaccination.The participants expressed strong agreement on the safety and efficacy of the vaccines with neutral hesitancy.Additionally, the students supported the implementation of mandatory booster vaccines for both the staff and students.However, there is still a gap in vaccination practices.Therefore, we recommend initiating vaccination campaigns to raise awareness and enhance vaccination practices, particularly for medical education and training.

*Fig. 2
Fig. 2 Factors influencing (A) and limitations (B) of vaccination with HCWs? recommended vaccines Keywords Healthcare worker, Booster, Vaccine, Egypt, Medical student, COVID-19, Flu vaccine vaccines.This study was approved by the institutional review board of Benha University.

Table 1
Sociodemographic characteristics of the participants

Table 2
Knowledge of HCWs' recommended vaccines among medical students and interns

Table 3
Attitudes of medical students and interns towards HCWs' recommended vaccines

Table 4
Median, interquartile range and mean rank values of scores assessing safety, efficacy, and hesitancy of HCWs' recommended booster vaccination