A mixed-methods study to identify factors associated with MenACWY vaccine uptake,barriers and motivations towards vaccination among undergraduate students

Abstract

Background:

In response to an outbreak of severe meningococcal disease caused by serogroup W, the UK introduced the meningococcal ACWY (MenACWY) for adolescents and new university students as a control measure.

Objective:

To estimate MenACWY vaccine uptake and identify factors associated with uptake, barriers and motivations towards vaccination among university students.

Design:

Mixed methods including a cross-sectional survey, 7 interviews and 1 focus group.

Setting:

A Scottish university between April and May 2016.

Methods:

Inclusion criteria were <25 years and attending university for the first time (MenACWY eligible). All first-year undergraduates (n = 5,808) were invited to take part in the survey via email, and qualitative participants were recruited through the survey. The final sample consisted of 768 students, representing 13% (768/5,808) of the target population.

Results:

MenACWY uptake among the sample was 71.5% (549/768). Older students (22–24 years) were less likely than younger students (18 years) to have been vaccinated [adjusted odds ratio (aOR) = 0.21; 95% confidence interval (CI) = 0.06–0.77], and male students were less likely to be vaccinated than female students (aOR = 0.667; 95% CI = 0.45–0.96). In comparison to international students, domestic students had a significantly higher odds of vaccination (aOR = 3.89; 95% CI = 2.64–5.72). Communication barriers were most frequently identified as reasons for non-vaccination. Most vaccination occurred before starting university (76.7%, 421/549), highlighting access barriers. Meningococcal disease knowledge was low; a significant association (p < 0.001) was found between knowledge and vaccination uptake. Some participants were unaware of their vaccination history. They perceived meningococcal disease as severe, but disease risk as low. Key motivations were knowledge of the benefits of vaccines, influence of others and social responsibility.

Conclusion:

Students outside main UK-based, core age cohorts were under-immunised and focused efforts are needed to improve vaccination rates. Future student vaccination programmes could focus on raising awareness of the serious implications of meningococcal disease. Additional benefit may be gained from emphasising the benefits of vaccinations for society as a whole.

Keywords

Barriers immunisation meningococcal disease Scotland undergraduate students vaccination vaccine uptake

Introduction

Invasive meningococcal disease (IMD), caused by the bacterium Neisseria meningitidis, is associated with high morbidity and mortality. In developed nations, the population case fatality ratio (CFR) is around 10% but can reach as high as 40% in individuals diagnosed with septicaemia (Pace and Pollard, 2012; Rosenstein et al., 2001). Furthermore, approximately 10%–20% of survivors suffer from permanent disabilities such as limb loss, hearing impairment, brain damage and learning difficulties (Pace and Pollard, 2012). University students have a higher risk of developing IMD and are approximately 11 times more likely to develop IMD than non-students (Mandal et al., 2017), as a result of higher levels of bacterial carriage due to close living situations (e.g. halls of residence; Christensen et al., 2010; Neal et al., 1999, 2000) and a higher prevalence of social risk factors (kissing, clubbing and smoking; MacLennan et al., 2006).

A critical feature of meningococcal conjugate vaccines is their ability to offer protection against bacterial carriage and therefore subsequent transmission (Trotter and Maiden, 2009). This provides indirect protection for non-vaccinated individuals. In the UK, meningococcal C (MenC) conjugate vaccine was introduced for all those aged <25 years with ongoing programmes for toddlers and adolescents. Its success in providing indirect protection is well documented (Campbell et al., 2010; Maiden et al., 2008; Ramsay et al., 2003; Trotter and Maiden, 2009). Vaccine coverage in the targeted age groups was approximately 85%, which resulted in an over 80% drop in incidence (Miller et al., 2001) and a 66% reduction in serogroup C carriage (Maiden et al., 2002).

UK vaccination policy was changed in 2015 following an outbreak of severe disease caused by serogroup W. Before the start of the outbreak, serogroup W accounted for 1%–2% of cases annually, before rising to 15% in 2013–2014. Furthermore, clinical follow-up of patients revealed that cases tended to be older, previously healthy and presented with septicaemia, the more serious form of IMD (Ladhani et al., 2015). The Joint Committee on Vaccination and Immunisation (JCVI) recommended the introduction of the meningococcal ACWY (MenACWY) conjugate vaccine, which provides protection against serotypes A, C, W and Y, as a control measure for young people aged 13–14 years [replacing the meningococcal C (MenC) conjugate vaccine in the routine immunisation schedule]; alongside a catch-up campaign targeting 14–18 year olds, which commenced in August 2015. Recognising the increased risk for students, a freshers’ programme was implemented nationally, offering the MenACWY to all first-time university entrants <25 years; however, receipt of the vaccine was not mandatory for admission to university. The catch-up campaign was delivered through primary care, and all eligible in Scotland (estimated by date-of-birth) to be in school-leaving cohorts were sent a centrally issued letter by NHS Scotland informing them of their eligibility and encouraging them to arrange an appointment with their general practitioner (GP) in order to receive the vaccine before starting university (Scottish Government, 2015). This communication was not centrally issued in England and Wales; however, GPs practices were encouraged by the Department of Health (DoH) to send a letter to inform their patients of their eligibility (Public Health England, 2017a). International students or those older than 17–18 years were informed indirectly via University and College Admissions Services (UCAS) or through wider advertisements.

Barriers to vaccine uptake are complex and context-specific, but commonly related to a lack of knowledge and accessibility (Larson et al., 2014). Research has highlighted that understanding perceptions of vaccinations, diseases and risk is key to understanding uptake and ensuring acceptability (Hilton et al., 2013; Yarwood et al., 2005). Most young adults and adolescents have had little experience of vaccine-preventable diseases; it has been suggested that this may present challenges in maintaining high uptake, diverting attention to negative aspects of vaccines (Hilton et al., 2013; Yarwood et al., 2005). Research into motivations influencing meningococcal vaccine uptake in students has highlighted the importance of time (Bednarczyk et al., 2015), perception of risk (Bednarczyk et al., 2015; Blagden et al., 2017; Patel et al., 2012), knowledge (Blagden et al., 2017; Blödt et al., 2011; Hunter and Weinstein, 2016), influence of health professionals and parents (Bednarczyk et al., 2011; Boehner et al., 2003; Patel et al., 2012) and belief in vaccinations (Boehner et al., 2003; Patel et al., 2012).

In the UK, it has been shown that vaccines delivered through primary care in contrast to those through schools have a lower uptake (Booth et al., 2000; Sinka et al., 2014). The estimate of MenACWY uptake (published August 2017) in England for the current eligible cohort of all 17–18 year olds supports this, as it is particularly low, at 29.4% (Public Health England, 2017b). However, this estimate does not distinguish between students and non-students. An estimate of MenACWY uptake generated from a review of medical records at the University of Nottingham was only 31% before arrival at the university; however, unvaccinated respondents were targeted upon registration with the university health service (Turner et al., 2017). Other cross-sectional surveys at UK universities, Belfast and Liverpool, have estimated MenACWY uptake as 71.5% and 68.1%, respectively. Furthermore, they reported that MenACWY uptake is associated with age (Blagden et al., 2017; Moore et al., 2017) and perceived effectiveness of the vaccine and knowledge of meningitis risk (Blagden et al., 2017). A limited awareness of IMD signs and symptoms and a belief that the MenACWY offers full protection against IMD among students was also reported (Moore et al., 2017).

It is important to understand the factors which influence vaccine uptake among students to contribute to the limited body of literature. Students are at increased risk of IMD, and ensuring a high vaccine uptake among this cohort has previously been shown to be fundamental for generating indirect protection for unvaccinated individuals (Campbell et al., 2010; Ramsay et al., 2003; Read et al., 2014; Trotter and Maiden, 2009). The primary aim of this research was to estimate MenACWY uptake among university students and identify barriers and motivations towards vaccination in students using a mixed-methods approach.

Methods

Study design

A mixed-methods approach was adopted. MenACWY uptake, barriers to vaccination and knowledge were assessed by an online cross-sectional survey. Focus groups and semi-structured interviews generated qualitative data around personal experiences of MenACWY vaccination programme, perceptions of vaccines and IMD and motivations towards vaccinations.

Study population and recruitment

The study took place at the University of Edinburgh and data were collected between 21 April and 27 May 2016. All first-year undergraduates from the University of Edinburgh were identified through university distribution lists and invited by email to take part (n = 5,808), with two subsequent reminder emails approximately 7 days apart. A small incentive was offered to encourage participation in the survey through a prize draw to win a GBP 25 voucher. Analysis was restricted to those <25 years old, attending university for the first time (those eligible to receive the MenACWY). All survey respondents were provided with two explanations of what the MenACWY was through the recruitment email and an introduction page at the start of the survey.

Participants in the qualitative elements of the study were recruited through a question at the end of the survey. This was an active recruitment process on the part of the participant, as they had to contact the project organiser by email to note their interest. They received information about the qualitative study and subsequently an invitation to take part in the focus group. Those unable to attend the focus group were invited to attend an interview. To encourage participation, a GBP 10 voucher was offered to each student who participated in the qualitative study. Interviews lasted approximately 1 hour, and the focus group was approximately 1 hour and 30 minutes. They were recorded, transcribed verbatim and analysed manually.

Survey design

The survey was designed in collaboration with Health Protection Scotland and researchers who had conducted similar research (Moore et al., 2017). To enhance the validity of the survey, the survey was piloted with a group of five students at Glasgow Caledonian University. The pilot resulted in minor changes to the wording of some questions to improve clarity. A summary of the survey structure can be viewed in online Appendix 1.

Topic guide design

The topic guide was designed around activities, which intended to encourage interactions and tease out understanding (Krueger and Casey, 2014). A summary is contained in online Appendix 1.

Quantitative data analysis

In addition to basic descriptive analysis, sample demographics were compared using chi-square tests or Fisher’s exact test where appropriate. Knowledge of IMD and vaccinations was evaluated by asking participants to state ‘yes’, ‘no’ and ‘not sure’ to statements. A knowledge score was computed for 11 questions, with respondents awarded a point for each correctly evaluated statement (with the highest possible score being 11). Knowledge scores were compared for vaccinated and unvaccinated individuals using a non-parametric Mann–Whitney U test. Adjusted logistic regression was used to identify factors associated with vaccination. All statistical analyses were conducted using SPSS Version 22 for Mac OS X (IBM Corp.).

Qualitative data analysis

A thematic analysis was carried out. Data collection and analysis took place concurrently, with early findings and codes informing further work (Glaser and Strauss, 1967). Recordings were listened to and transcripts repeatedly read and cross-compared to identify cross-cutting themes (Strauss and Corbin, 1990). Through this process, a framework for coding and further data analysis was developed.

Ethical considerations

Approval was granted by the Centre for Population and Health Sciences Ethics Committee at the University of Edinburgh in April 2016. Qualitative participants were provided with an information sheet before providing written informed consent. Survey respondents were also provided with an electronic information sheet attached to the recruitment email before providing informed consent through a survey question.

Results: cross-sectional survey

Participant characteristics

Of the 5,808 first-year undergraduates invited to take part, 816 responded (response rate = 14%) and 48 were excluded as they did not meet the inclusion criteria. The final sample consisted of 768 students (13% of target population). The majority of the sample were women (74%), aged 19 years old (55.2%) and UK domestic students (79%; Table 1).

Table 1.

Survey respondents and first-year undergraduates at the University of Edinburgh.

Variable	Survey Respondents(n = 768)	Target Population (1^st year undergraduates)(n = 5,808)
Variable	N (%)	N (%)
Gender
Male	197 (25.7)	2,349 (40.4)
Female	568 (74.0)	3,457 (59.3)
Prefer not to say	3 (0.3)	2 (0.03)
Age
18 years	34 (4.4)	238 (4.0)
19 years	424 (55.2)	2,678 (46.3)
20 years	233 (30.3)	1,649 (28.4)
21 years	58 (7.6)	581 (10.0)
22–24 years	19 (2.5)	662 (11.3)
Student status^a
Domestic	607 (79.0)	4,339 (74.6)
International	161 (21.0)	1,469 (25.4)
University college
College of Humanities and Social Science	408 (53.1)	3,719 (64.0)
College of Medicine and Veterinary Medicine	114 (14.8)	645 (11.2)
College of Science and Engineering	246 (32.0)	1,446 (24.8)

‘Prefer not to say’ category within gender was excluded from the analysis.

International/domestic student status was assumed based on student’s secondary education location (outside of the UK or inside of the UK).

MenACWY uptake

MenACWY uptake among survey respondents was 71.5% (n = 549; Table 2). Significant associations were found between vaccination status and year of birth (age) (χ² = 53.363; p < 0.001), student status (χ² = 74.943; p < 0.001) and gender (χ² = 5.791; p = 0.028). Specifically, uptake was highest among 18-year-old (79.4%; n = 27) and 19-year-old respondents (79.2%; n = 336) and lowest in those aged 22–24 years (36.8%; n = 7). In addition, MenACWY uptake was highest in domestic students (78.7%; n = 478) and lowest in international students (44.1%; n = 71). A higher proportion of female students (73.9%) were vaccinated in comparison to male students (65%; Table 3).

Table 2.

Summary of MenACWY uptake, communication and access to the vaccination programme (N = 768).

	N (%)
MenACWY uptake
Vaccinated	549 (71.5)
Unvaccinated	219 (28.5)
Received a letter
Yes	370 (48.2)
No	166 (21.6)
Cannot remember	232 (30.2)
Period when respondents received the MenACWY
Before starting university	421 (76.7)
After starting university	128 (23.3)

MenACWY: meningococcal disease caused by groups A, C, W and Y.

Table 3.

Factors associated with MenACWY uptake (N = 768).

	Vaccination status
Variable	Vaccinated (%)(n = 549)	Unvaccinated (%)(n = 219)	χ² (p value)	aOR (95% CI)	p value
Gender
Female	420 (73.9)	148 (26.1)	5.79 (0.02)	1	0.028
Male	128 (65.0)	69 (35.0)	5.79 (0.02)	0.66 (0.45–0.96)	0.028
Age
18 years	27 (79.4)	7 (20.6)		1
19 years	336 (79.2)	88 (20.8)		1.02 (0.42–2.48)
20 years	155 (66.5)	78 (33.5)	53.36 (<0.001)	0.64 (0.26–1.59)	<0.001
21 years	24 (41.4)	34 (58.6)		0.29 (0.10–0.80)
22–24 years	7 (36.8)	12 (63.2)		0.21 (0.06–0.77)
Student status^a
International	71 (44.1)	90 (55.9)	74.94 (<0.001)	1	<0.001
Domestic	478 (78.7)	129 (21.3)	74.94 (<0.001)	3.89 (2.64–5.72)	<0.001

MenACWY: meningococcal disease caused by groups A, C, W and Y; aOR: adjusted odds ratio; CI: confidence interval.

International/domestic student status was assumed based on student’s secondary education location (outside of the UK or inside of the UK).

Among survey respondents, 48.2% (n = 370) of respondents recalled receiving a letter. In relation to access, most vaccinated respondents (76.7%; n = 421) received a letter before starting university (Table 2). A significant association was found between receiving a letter and vaccination status (χ² = 67.06; p < 0.001). Of those who received a letter, 90.2% (n = 334) were vaccinated, in contrast to 60.2% (n = 100) non-recipients. A significant association was also found between when respondents received the vaccine (prior to starting university or after) and student status (χ² = 49.738; p < 0.001). Among presumed domestic students (educated in the UK), 81.6% (n = 390) received the vaccine before university, in contrast to 43.7% (n = 31) of international students (educated outside the UK).

Factors associated with MenACWY uptake

In multivariate analysis, older students (22–24 years) were less likely than younger students (18 years) to have been vaccinated [adjusted odds ratio (aOR) = 0.21; 95% confidence interval (CI) = 0.06–0.77] and male students were less likely to be vaccinated than female students (aOR = 0.66; 95% CI = 0.45–0.96). In comparison to international students, domestic students had a significantly higher odds of vaccination (aOR = 3.89; 95% CI = 2.64–5.72; Table 3).

Reasons for receiving/not receiving the MenACWY

Most frequently selected reasons for receiving the MenACWY were related to the vaccine being free (65.2%; n = 358), accessible (61.4%; n = 337) and parent/guardian recommendation (61.4%; n = 315) (Table 4).

Other notable factors (selected by 46%; n = 253) were the letter, health professional recommendation and school/college/university recommendation (Table 4). Furthermore, of 370 letter recipients, 68.6% selected it as an important decision factor.

Table 4.

Reasons for receiving/not receiving the MenACWY.

Reasons for receiving the MenACWY	N (% vaccinated)
1. Vaccine free of charge	358 (65.2)
2. Easy access to vaccine (convenience, location)	337 (61.4)
3. Parent/guardian recommendation	315 (57.4)
4. Letter received in the post informing you of vaccination programme	253 (46.0)
4. School/college/university recommendation	253 (46.0)
4. Health professional (doctor, nurse) recommendation	253 (46.0)
5. Received sufficient information on disease and vaccine	216 (39.3)
6. Information provided on leaflets and posters	86 (15.6)
7. Prior exposure to disease (friends, family and self)	42 (7.6)
8. Friends ^a	8 (1.4)
Reasons for not receiving the MenACWY	N (% unvaccinated)
1. Did not have enough information about the disease and/or vaccine to make an informed decision	76 (35.0)
2. Did not know about a meningitis vaccine	75 (32.4)
3. Had a meningitis vaccine in the past	57 (26.0)
4. Too busy (time/forgot) ^a	31 (14.2)
5. Afraid of injections	31 (14.1)
6. Concerned about vaccine side effects	27 (12.3)
7. Issues accessing the vaccine ^a	8 (3.7)
8. Did not feel it was necessary ^a	6 (2.7)
9. Do not trust the quality of health services	7 (3.2)
10. Had meningitis (meningococcal disease) in the past	3 (1.4)

Reasons have been placed in order, with the most frequently selected presented first.

Categories which were not predetermined and created from free-text responses.

The most frequently selected reasons for not receiving the MenACWY (unvaccinated respondents) were not receiving enough information about disease/vaccine (34.7%; n = 76) and not knowing about meningitis vaccine (34.25%; n = 75) and past meningitis vaccine (26%; n = 57; Table 4).

Knowledge

The average knowledge score for vaccinated respondents was 5.4 (standard deviation (SD) = 2.2, range = 0–11) compared to 4.1 (SD = 2.2, range = 0–10) for unvaccinated recipients (p < 0.001). A table showing the knowledge statements and a histogram of knowledge scores can be viewed in online Appendix 2.

Over half of respondents (57.2%; n = 439) either did not think it was possible to develop IMD after being vaccinated or were unsure. Only 49.3% of respondents knew the signs and symptoms of IMD. Moreover, 23% (n = 126) of vaccinated individuals believed that they are fully protected against meningococcal disease and 33.9% (n = 181) are unsure.

Results: qualitative study

Sample

Seven semi-structured interviews (six vaccinated and one unvaccinated) and one focus group (four vaccinated participants) took place. Participants are referred to by a number, followed by focus group (FG) or interview (Int). A summary of the participants can be viewed in online Appendix 3.

Communication, information and access to the MenACWY

Participants reported effective communication of the programme, particularly those who received a letter. They described how this made the programme more ‘official’ (2Int and 4Int). Participants described being ‘sufficiently’ (5Int) informed about IMD and vaccinations as they ‘knew the basics’ (6Int). However, some participants reported they would have liked more information about clinical implications of IMD. They suggested that being better informed might encourage people to get vaccinated:

For people who are unsure about vaccines, tell them: unfortunately if you get meningitis, this could happen. (8FG)

There was a lack of information about the severity of it [meningitis], there should have been more of a public health drive. (7Int)

Participants described uncertainty around vaccination history and therefore being unsure whether MenACWY was necessary.

It was difficult to know whether we had the vaccine and whether we needed it. My mum told me I had a meningitis vaccine so I didn’t need it … we need to be more aware about types of meningitis vaccines, I had no idea there was more than one type. (5Int)

Participants also described it as being ‘important that the vaccine was free’ (8FG, 5Int, 3Int). In regard to accessing the vaccine, participants expressed mixed views. Some reported access through their GP was ‘easy’ (2Int). However, others highlighted a lack of information and direction, particularly as the programme was different to their previous experiences:

We had to go out our way and call up our doctor and get it ourselves, it was different … It was good that we were trying to be independent, but it would have been better if they did it in school. (5Int)

Similar to the survey data, participants had mostly received the vaccine pre-university. They spoke about how little time they had during the first semester and suggested students would be less likely to seek vaccination once term began:

We had to go out of our way to make an appointment during Freshers’ week. That’s something that could really put people off, it adds to the list of administrative things that you’ve got to do’. (3Int)

Perceptions of meningococcal disease and risk

Participants perceived IMD (referred to as ‘meningitis’) as severe. Participants described being less aware of IMD in contrast to other diseases and that this affected their perception of severity:

I had never heard of meningitis but I’d heard a lot about HIV and malaria. It’s much more common so it makes you assume they’re more dangerous. (8FG)

Conversely, participants with more awareness of IMD perceived IMD as more serious:

Meningitis stands out, I know if a friend got it I’d be much more concerned about that than if they’d got anything else … I think it’s because of when I was in primary school a teacher told me that his relative had died of meningitis. (2Int)

Participants understood and acknowledged their age group was at risk. They understood IMD risk factors and some described IMD being transmitted through ‘close contact’ (3Int, 9FG). University campuses were described as a bacterial ‘breeding ground’ (3Int). However, a cross-cutting theme to emerge was that participants did not see themselves as ‘personally’ at risk:

There’s a blasé attitude, people get the vaccine and then they just don’t think any more of it. It’s one of those diseases that nobody gets. (4Int)

I’m not worried about it … it’s not something I think I’m really at risk of. (2Int)

Motivation for receiving vaccines

Benefits of vaccination

Vaccinations were described positively, as the most effective method of preventing disease as they ‘stopped you getting the disease in the first place’ (8FG):

When you learn about the impact vaccines have on our country and the rest of the world, you realise how important they are. (5Int)

I do feel like I’m much safer from meningitis since I’ve got the vaccine. (8FG)

One aim of this research was to explore participants’ decision-making process in relation to their experience with vaccinations. Many reported not feeling like they made an ‘active’ decision, suggesting vaccines are viewed as a routine part of society:

It wasn’t a question of: ‘are we gonna get it?’ It was like: ‘when are we gonna get it?’ … so, it wasn’t really a decision as such. You just do it. You just get vaccines. (6Int)

Social responsibility

Participants also described how their decision was informed by knowledge that in doing so they would also protect others. The term ‘social responsibility’ (11FG, 2Int and 5Int) was used regularly:

You’re responsible for making sure you’re safe from diseases, which are high risk to you and other people. You’re doing good for yourself but you’re doing good for society as a whole. It’s something people should realise. (5Int)

Most people would argue that it’s right to do something if it’s going to protect everyone … Its selfish to think ‘I don’t need this’. (8FG)

Influence of others (friends, family and healthcare professionals)

The influence of healthcare professionals, parents and peers was identified as a key motivator. Participants spoke about their trust in ‘figures of authority’ (2Int, 1Int and 6Int) and how this had an effect on their decision. They also described how the collective action of everyone seeking vaccination was a reminder.

I was very aware that everyone else was doing it. It was a reminder that I had to get on and do it. (4Int)

Several others spoke about how their friendship group composition influenced their decision. Some participants described how they were aware of others whose friendship groups differed and therefore had not had similar influences:

It depends on your friend group. As soon as we got the letter, we all made sure we got the vaccine. But my flatmate didn’t get the jag at all, she didn’t get round to it. That was what her friends did as well. I guess you can just end up in a group of friends that have that attitude. (6Int)

I don’t think that any of my friends have received it … If I had someone who was driving me get it then I would do it … or if a lot of my friends were proactive. (7Int)

Discussion

This study used a mixed-methods approach to assess MenACWY uptake and contributing barriers/motivations to receiving the MenACWY vaccine among first-year university students at the University of Edinburgh. It adds to the current body of literature in the context of government recommendations in response to an outbreak. Among survey respondents, MenACWY uptake was 71.5%, suggesting a high level of protection and reduced probability of carriage and transmission (Ramsay et al., 2003; Read et al., 2014; Trotter and Maiden, 2009). This result is similar to that reported for students in Belfast (71.5%; Moore et al., 2017) and Liverpool (68.1%; Blagden et al., 2017), strengthening the validity of our findings. However, uptake was much higher than the figure reported for the overall 17- to 18-year-old cohort in England (29.4%; Public Health England, 2017b). It has been suggested that a higher uptake in students compared to non-students could be increasing health inequalities (Blagden et al., 2017). Uptake was lowest among international students (44.4%) and older students (36.8%), a finding reiterated in research conducted at other universities in the UK (Blagden et al., 2017; Moore et al., 2017). We also found that MenACWY uptake was higher among female students (73.9%). In addition to demographic factors, knowledge and perception of risk for IMD and vaccinations, social factors (influence of others and social responsibility) were identified as barriers/motivations towards vaccination through the qualitative arm of the study.

In this study, we found that communication of the vaccination programme using an invitation letter was highly effective, as 90.2% of respondents who received a letter were vaccinated and 46% of vaccinated respondents identified the letter as an important decision making factor. This supported qualitative findings in which participants described how receiving a formal letter lent gravitas to the need to arrange vaccination. The most frequently selected explanations for non-vaccination were related to lack of information, rather than an objection to vaccines, suggesting communication efforts may not be reaching all. Older students and international students would not have received a letter, which may explain the lower uptake in these cohorts. Changing immunisation schedules and limited knowledge of personal vaccination history have previously been defined as barriers to uptake (Gowda et al., 2012; Johnson et al., 2008). In support of this, some participants were uncertain whether MenACWY vaccination was necessary as they were unaware of their vaccination history.

Our results align with those from previous research in which ease of access and free vaccinations have been shown to influence uptake among students (Bednarczyk et al., 2015). Participants reported being busy during their first weeks and thus less likely to seek vaccination once term commenced. This was supported by our survey findings: the majority of vaccinated respondents (76.3%) had been vaccinated pre-university. Busy schedules at the start of term may explain the lower uptake among international students, as many may only have access to free vaccine upon arrival (Turner et al., 2017). Our results suggest that further efforts are required to increase the accessibility of vaccinations recommended for international students.

In line with previous research (Blagden et al., 2017; Hunter and Weinstein, 2016), this study found knowledge to be a significant predictor of vaccination. This is concerning when there is generally a low awareness of IMD signs and symptoms (Hilton et al., 2013; Moore et al., 2017; Wang et al., 2014) and a low perception of risk of IMD among young people (Hilton et al., 2013; Wang et al., 2014). We found that more than half of study participants believed they were fully protected from IMD or were unsure. Furthermore, 50.7% of respondents did not know or were unsure of the signs and symptoms of IMD, and qualitative study participants reported a low perception of risk.

Social influences identified as important motivations towards vaccination included parents/guardians, healthcare professionals and peers. The role of peers emerged as an important motivation in both the survey (Table 4) and qualitative research. Our results suggest students seek out vaccination collectively because it seems the ‘normal’ thing to do (Streefland et al., 1999). Participants often described not making an ‘active decision’ to be vaccinated, suggesting that vaccinations are seen as routine (Larson et al., 2014). A similar finding was reflected in a social network analysis of influenza vaccine distribution in university students, which found that vaccinated students were more likely to think that other students were also vaccinated (Edge et al., 2015). Future vaccination campaigns could use information generated from student social networks to target programmes and increase vaccine uptake.

The final motivation towards vaccination was a feeling of ‘social responsibility’. Participants described being a morally obliged to get vaccinated if doing so would protect others. Providing information about how receiving meningococcal vaccines provides indirect protection through reducing bacterial carriage may therefore encourage more students to get vaccinated, a finding supported by research which found that 71% of unvaccinated students would be more likely to receive the influenza vaccine if they knew that receiving the vaccine would provide indirect protection for vulnerable family members (Bednarczyk et al., 2015).

Strengths and limitations

The mixed-methods approach adopted differs from other research in the field, which use either quantitative (Blagden et al., 2017; Moore et al., 2017; Tho et al., 2015; Wang et al., 2014; Yarwood et al., 2005) or qualitative (Hilton et al., 2013; Hilton and Smith, 2011) methods. Focus groups and interviews generate different types of data. However, combining them together is also advantageous (Lambert and Loiselle, 2008). The triangulation of different data types strengthens findings; participants’ perceptions are reinforced by descriptive data and vice versa. That said, the qualitative recruitment method employed here did not attract sufficient unvaccinated students, and recruitment might have been improved by recruiting from outside the pool of survey respondents. In addition, theoretical saturation was not achieved as a result of recruitment issues.

Cross-sectional surveys are sensitive to non-response bias; therefore, MenACWY uptake may be overestimated/underestimated (Levin, 2006). However, previous research has highlighted variability in response rates from surveys disseminated by email to university populations and that follow-up reminders can assist in increasing response rates (Shih and Fan, 2009). To try and minimise representative bias and get the best response rate possible, we sent two follow-up reminders. Furthermore, our response rate of 14% is higher than similar research which has adopted the same methodology (Van et al., 2010) and our sample size is similar or larger than other cross-sectional studies researching vaccine uptake among students (Bednarczyk et al., 2015; Patel et al., 2012). In addition, some of the measures in this study (e.g. vaccination status) are sensitive to recall bias. Representative bias was also evident within our survey sample, for example, male students and older students are under-represented when compared to the target population.

Conclusion

This study provides valuable insight into factors influencing vaccine uptake among university students, a cohort who are disproportionately affected by IMD (MacLennan et al., 2006; Mandal et al., 2017; Neal et al., 1999, 2000). Findings can be used to inform and improve vaccination programmes among students and young adults. A variety of interacting factors were found to influence vaccine uptake. High uptake was associated with successful communication and good access arrangements, and thus, future programmes should consider personalising communication. A lower level of uptake was observed among older and international students, suggesting the existence of communication and access barriers. Knowledge gaps were identified in relation to types of vaccines, signs and symptoms and personal vaccination history. Social factors, in particular a notion of social responsibility, were found to be key motivators towards getting vaccinated.

Supplemental Material

Appendix-final---0391_FINAL – Supplemental material for A mixed-methods study to identify factors associated with MenACWY vaccine uptake, barriers and motivations towards vaccination among undergraduate students

Supplemental material, Appendix-final---0391_FINAL for A mixed-methods study to identify factors associated with MenACWY vaccine uptake, barriers and motivations towards vaccination among undergraduate students by Kirsten MA Trayner, Niall Anderson and J Claire Cameron in Health Education Journal

Footnotes

Acknowledgements

The authors acknowledge the contribution of Vivian Lamb at Durham University and B. Cherie Millar and Peter JA Moore at Queen’s University Belfast for advice concerning survey structure.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding from the Usher Institute at the University of Edinburgh.

Supplemental Material

Supplemental material is available for this article online.

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