Argument Analysis

RESEARCH ARTICLE

National attitudes of medical students

towards mandating the COVID-19 vaccine and

its association with knowledge of the vaccine

Danel MayanID 1*, 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]

Abstract

Background

With the introduction of the novel COVID-19 vaccine, public hesitancy is being experienced

with 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.

Objectives

To determine the attitude of U.S. medical students toward mandating the COVID-19 vaccine

to healthcare workers and patients, as well as whether their knowledge of the vaccine plays

a role in their view.

Methods

The authors emailed a survey link to all U.S. medical schools with request to distribute it to

their medical students. The survey remained open from 02/09/2021 to 03/15/2021 and

included questions to determine the attitude of the medical students toward recommending

the COVID-19 vaccine, and general knowledge questions about the vaccine. Chi square,

Fisher’s exact test, and linear regression were conducted to determine associations

between willingness to recommend the COVID-19 vaccine and general knowledge of the

vaccine.

Results

Among 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, and

16.27% approved of making it mandatory to patients. Additionally, those who tested most

knowledgeable of the vaccine were less likely to approve of making the vaccine mandatory

for patients (66.67% vs. 72.70). Those that tested most knowledgeable were also more

likely to personally receive the vaccine (72.35% vs 62.99%) as opposed to those that tested

the least knowledgeable who were less willing to personally receive the vaccine (4.12% vs

14.17%).

PLOS ONE

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OPEN ACCESS

Citation: Mayan D, Nguyen K, Keisler B (2021)

National attitudes of medical students towards

mandating the COVID-19 vaccine and its

association with knowledge of the vaccine. PLoS

ONE 16(12): e0260898. https://doi.org/10.1371/

journal.pone.0260898

Editor: James Andrew Rowley, Harper University

Hospital, UNITED STATES

Received: August 29, 2021

Accepted: November 18, 2021

Published: December 22, 2021

Copyright: © 2021 Mayan et al. This is an open access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the paper and its files.

Funding: The authors received no specific funding

for this work.

Competing interests: The authors have declared

that no competing interests exist.

Conclusions

The data revealed that a slight majority of medical students support a vaccine mandate

toward healthcare workers while a minority of medical students support a vaccine mandate

toward healthcare workers. Additionally, medical students that had relatively high knowl-

edge of the vaccine correlated with not approving of making the vaccine mandatory for

patients. However increased knowledge of the vaccine correlated with increased willingness

to personally receive the vaccine.

Introduction

Vaccines against highly transmittable infectious diseases are one of the most effective medical

interventions available and save millions of lives each year [1]. Previously, vaccines for infec-

tious diseases required years of development and clinical evaluation before being authorized

for 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 to

COVID-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 Drug

Administration’s Emergency Use Authorization, with Pfizer BioNTech most recently receiving

full 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 of

vaccine services–remains a limiting factor for achieving optimal herd immunity against highly

transmittable diseases. Refusal of vaccines is associated with an increased risk of contracting

the target disease [5]. Several factors that drive vaccine hesitancy for the COVID-19 vaccine

have 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 to

the 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 acquiring

herd immunity. With these thoughts, the idea of a vaccine mandate has been brought up in the

media especially after full FDA approval of the vaccine has been granted. Many businesses

have already began requiring their employees to receive the vaccine, and more recently federal

plans have been unveiled to mandate that employees of large business receive the vaccine or be

subjected to weekly testing. Although controversial, some feel that a mandate is the only way

to 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 students

play a notable role in counseling patients about the novel coronavirus and providing accurate

information about vaccination. Medical students will likely encounter vaccine-hesitant

patients during their clinical rotations. Therefore, it is essential that medical students possess

accurate 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 students

view immunization favorably and are more likely to gain comfort counseling vaccine-hesitant

patients following a targeted curriculum on infectious disease and immunology [8].

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This study was conducted to determine the attitudes of U.S. medical students toward

receiving the COVID-19 vaccine in addition to their approval toward mandating the vaccine

to patients and/or healthcare workers. Additionally, it also sought to determine whether their

degree of knowledge about the vaccine plays a role in their view.

Methods

Data 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 a

population of U.S. medical students. Inclusion criteria included being enrolled in a MD or DO

program at a U.S. medical school. Participation was acquired via an email sent to the student

affairs offices of all 212 U.S. medical schools with request to distribute the website link for the

online survey (Fig 1) to their students. Follow up emails were sent to the research departments

of 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. A

total 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 attitudes

toward 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 clicks

versus 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 as

most knowledgeable (scale of 3) or not (scale of 1, 2). 5 knowledge questions about the

COVID-19 vaccine were further included in the survey. The number of correctly answered

questions 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 recommendation

for the COVID-19 vaccine toward patients, recommendation for the COVID-19 vaccine

toward healthcare workers, and attitude toward personally receiving the vaccine. Although the

vaccine recommendations were originally designed as 3-level questions (“I would make it

mandatory,” “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 the

groups were dichotomized to those that would make the vaccine mandatory (“I would make it

mandatory”) 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 a

participant selected that they would not recommend the vaccine, it was also assumed that they

would 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 would

not make it mandatory” category. The 5-level attitude toward personally receiving the vaccine

was also dichotomized, due to the same issue, as “will receive vaccine” (“willing” combined

with “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 survey

responses. These comments were grouped by similarity of content and quantified to determine

the most commonly reported statements supporting or not supporting their survey selections.

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Fig 1. COVID-19 vaccination survey.

https://doi.org/10.1371/journal.pone.0260898.g001

PLOS ONE Medical students’ recommendation toward the COVID-19 vaccine

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Descriptive analysis was conducted to summarize the characteristics of the entire sample.

Comparisons of demographics and knowledge were conducted by each of the four attitude

outcomes, 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 statistical

analysis 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 board

designated 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 to

complete and submit the survey they agreed to participate.

Results

The 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% of

medical students ranked themselves as being the most knowledgeable of the vaccine, the

majority of surveyed medical students (71%) answered all 5 questions correctly, with less than

5% correctly answering only 0–3 questions. A minority of medical students (16%) designated

their 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 Percentage

Demographics

Age (mean: years) 1899 25.79

<25 Years 649 34.18

25–29 years 1091 57.45

30 and over 159 8.37

Female 1221 64.30

Race and ethnicity

Non-Hispanic White 1338 70.46

Minority (African American and Asian) 377 19.85

Other or Unknown 184 9.69

School Year

1st year 578 30.44

2nd year 422 22.22

3rd year 450 23.70

4th year 449 23.64

Knowledge on COVID-19 vaccine

Self-ranked as the most knowledgeable 341 17.96

Correctly answered 0–3 questions 91 4.79

Correctly answered 4 questions 446 23.49

Correctly answered 5 questions 1362 71.72

Attitude

Make wearing face masks mandatory 1458 76.78

Make patient receiving COVID-19 vaccine mandatory 309 16.27

Make healthcare worker receiving COVID-19 vaccine mandatory 1096 57.71

Would willingly receive or did willingly receive the COVID-19 vaccine 1772 93.31

https://doi.org/10.1371/journal.pone.0260898.t001

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designated their approval in making it mandatory for healthcare workers. Nearly all of the sur-

veyed medical students (93%) designated that they would receive/ have received the vaccine

willingly.

Medical students in the “would not recommend the vaccine” and “would not make the vac-

cine mandatory” group were combined into the “would not make the vaccine mandatory”

group and compared to the “would make the vaccine mandatory.” These results are shown in

Table 2. 77% of medical students selected that they would make wearing face masks manda-

tory, 16% approve of making the vaccine mandatory for patients, and 58% approve of making

the vaccine mandatory for healthcare workers.

Table 2 also displays the statistics of both demographics and knowledge on the COVID-19

vaccine when compared with attitude outcomes. The 25–29 year age group was less likely to

make receiving the COVID-19 vaccine mandatory for healthcare workers (55.38% vs. 50.27%,

p = 0.03), with the remaining ages not significantly associated with other attitude outcomes.

Females were more likely to make wearing face mask mandatory (67.70% vs. 53.06%,

p<0.0001) and would personally be willing to receive the vaccine (65.18% vs. 51.97%,

p = 0.003), but were less likely to approve of making the vaccine mandatory for patients

(58.90% vs. 65.35%, p = 0.03). Non-Hispanic Whites were less likely to make wearing face

masks mandatory (67.35% vs. 80.73%, p<0.0001), less likely to approve of making the vaccine

mandatory for patients (60.19% vs. 72.45%, p<0.0001) and for healthcare workers (67.70% vs.

Table 2. Proportion of demographics and knowledge of the COVID-19 vaccine by attitude outcomes.

Variables (percentage) Mask mandatory Vaccine mandatory for

patients

Vaccine mandatory for

healthcare workers

Will receive vaccine

Yes No Yes No Yes No Yes No

N 1458 441 309 1590 1096 803 1772 127

Demographics

Age (mean: Years) 25.77 25.88 25.98 25.76 25.77 25.82 25.78 25.99

<25 Years 34.77 32.20 31.72 34.65 35.86 31.88 34.31 32.28

25–29 years 56.58 60.32 58.58 57.23 55.38� 60.27 57.45 57.48

30 and over 8.64 7.48 9.71 8.11 8.76 7.85 8.24 10.24

Female 67.70��� 53.06 58.90� 65.35 63.50 65.38 65.18�� 51.97

Race and ethnicity

Non-Hispanic White 67.35��� 80.73 60.19��� 72.45 67.70�� 74.22 70.26 73.23

Minority (African American and Asian) 22.57��� 10.88 28.16��� 18.24 22.81��� 15.82 20.37� 12.60

Other or Unknown 10.08 8.39 11.65 9.31 9.49 9.96 9.37 14.17

School Year

1st year 29.56 33.33 29.13 30.69 30.47 30.39 30.08 35.43

2nd year 23.87�� 16.78 23.62 21.95 24.36�� 19.30 22.18 22.83

3rd year 22.84 26.53 22.01 24.03 21.35�� 26.90 23.53 25.98

4th year 23.73 23.36 25.24 23.33 23.81 23.41 24.21� 15.75

Knowledge on COVID-19 vaccine

Self-ranked as the most knowledgeable 18.31 16.78 19.42 17.67 18.80 16.81 18.28 13.39

Correctly answered 0–3 questions 4.46 5.90 5.83 4.59 4.29 5.48 4.12��� 14.17

Correctly answered 4 questions 23.46 23.58 27.51 22.70 24.18 22.54 23.53 22.83

Correctly answered 5 questions 72.09 70.52 66.67� 72.70 71.53 71.98 72.35� 62.99

�: p<0.05

��: p< 0.001

���: p< 0.0001.

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74.22%, p<0.0001). African Americans and Asians were more likely to approve mandating

wearing face masks (22.57% vs. 10.88%, p<0.0001), more likely approve of making the vaccine

mandatory for patients (28.16% vs. 18.24%, p<0.0001) and healthcare workers (22.81% vs.

15.82%, p = 0.0002), and more likely to willingly receive the vaccine (20.37% vs. 12.60%,

p = 0.03). Those who correctly answered 5 questions were less likely to approve of making the

vaccine mandatory for patients (66.67% vs. 72.70%, p = 0.03) but were more likely to receive

vaccine for themselves (72.35% vs 62.99%, p = 0.02). Those who correctly answered 0–3 ques-

tions were less willing to personally receive the vaccine (4.12% vs 14.17%, p<0.0001).

The association of demographics and knowledge of the COVID-19 vaccine with attitude

outcomes were further examined with multiple logistic regression. Odds ratios and 95% confi-

dence intervals were reported in Table 3. Females remained statistically significant: they were

more likely to make wearing face masks mandatory (OR: 1.92, 95% CI: 1.53–2.39) and were

more likely to willingly receive the vaccine (OR: 1.74, 95% CI: 1.20–2.52) than males. Com-

pared with non-Hispanic Whites, African Americans and Asians were more likely to make

wearing face masks mandatory (OR: 2.60, 95% CI: 1.87–3.62), more likely to make receiving

the vaccine mandatory for patients (OR: 1.88, 95% CI: 1.40–2.51) as well as for healthcare

workers (OR: 1.61, 95% CI: 1.27–2.05), and more willing to personally receive the vaccine

(OR: 1.83, 95% CI: 1.06–3.18). Other or unknown race/ethnicity were more likely to make

wearing face mask mandatory (OR: 1.47, 95% CI: 1.00–2.17), compared with non-Hispanic

Whites. Compared with medical students in their first year of study, those in their second year

were more likely to make wearing face masks mandatory (OR: 1.68, 95% CI: 1.21–2.32). Com-

pared with those that correctly answered 0–3 questions correctly, medical students who cor-

rectly answered 4 questions correctly (OR: 3.30, 95% CI: 1.71–6.36) or 5 (OR: 3.57, 95% CI:

1.98–6.44) were more likely to personally receive the vaccine.

Table 3. Odds ratios and 95% confident intervals from the multiple regression of attitude on demographics and knowledge on COVID-19 vaccine.

Variables Mask mandatory Vaccine mandatory 1

Vaccine mandatory 2

Will receive vaccine

Demographics

Age (Years) 1.00 (0.96, 1.04) 1.02 (0.98, 1.07) 1.00 (0.97, 1.04) 0.97 (0.92, 1.03)

Female 1.92 (1.53, 2.39) 0.78 (0.60, 1.01) 0.93 (0.77, 1.13) 1.74 (1.20, 2.52)

Race and ethnicity

Non-Hispanic White Ref Ref Ref Ref

Minority (African American and Asian) 2.60 (1.87, 3.62) 1.88 (1.40, 2.51) 1.61 (1.27, 2.05) 1.83 (1.06, 3.18)

Other or Unknown 1.47 (1.00, 2.17) 1.49 (0.999, 2.22) 1.06 (0.78, 1.45) 0.71 (0.41, 1.22)

School Year

1st year Ref Ref Ref Ref

2nd year 1.68 (1.21, 2.32) 1.16 (0.82, 1.63) 1.25 (0.96, 1.62) 1.05 (0.63, 1.73)

3rd year 0.97 (0.72, 1.30) 0.97 (0.68, 1.38) 0.78 (0.60, 1.01) 0.97 (0.59, 1.58)

4th year 1.23 (0.89, 1.69) 1.12 (0.78, 1.60) 1.00 (0.76, 1.31) 1.74 (0.98, 3.11)

Knowledge on COVID-19 vaccine

Self-ranked as the most knowledgeable 1.28 (0.95, 1.71) 1.18 (0.86, 1.63) 1.20 (0.94, 1.53) 1.54 (0.90, 2.63)

Correctly answered 0–3 questions Ref Ref Ref Ref

Correctly answered 4 questions 1.22 (0.72, 2.06) 0.98 (0.55, 1.75) 1.43 (0.91, 2.27) 3.30 (1.71, 6.36)

Correctly answered 5 questions 1.28 (0.78, 2.10) 0.77 (0.44, 1.33) 1.34 (0.87, 2.07) 3.57 (1.98, 6.44)

Note:

1, Vaccine mandatory for patients

2, vaccine mandatory for healthcare workers.

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Discussion

This study was conducted to determine the attitudes of U.S. medical students toward receiving

the COVID-19 vaccine in addition to their approval toward mandating the vaccine to patients

and/or healthcare workers. Additionally, it also sought to determine whether their degree of

knowledge about the vaccine plays a role in their view. Based on the correctly answered knowl-

edge questions, participants were divided into 3 separate groups with each signifying a differ-

ent level of knowledge of the vaccine. Those who scored 0–3 questions correctly were inferred

to know little about the vaccine, those with 4 correctly answered questions were inferred to

know a lot about the vaccine, and those with 5 correctly answers questions were inferred to

having very good knowledge of the vaccine. However, only 0.95% of participants selected that

they would not recommend the vaccine to patients, and 1.18% selected that they would not

recommend the vaccine to healthcare workers, which limited our statistical analysis. To com-

bat this, the “I would not recommend” and the “I would recommend” group were combined

into a “I would not make it mandatory” group and compared to those that specifically selected

that they would make the vaccine mandatory. Although slight differences between group data

existed in terms of the amount of correctly answered question and their approval of making

the vaccine mandatory, the only truly statistically significant result was that those who cor-

rectly answered all 5 questions were less likely to approve of making the vaccine mandatory for

patients, however they were more likely to personally receive the vaccine. Additionally, those

who were least knowledgeable of the vaccine with only 0–3 correctly answered questions were

less willing to personally receive the vaccine. Therefore, these results suggest that a positive

correlation exists between knowledge of the vaccine and willingness to personally receive it.

An additional aim of this study was to determine the overall willingness of medical students

to recommend the vaccine. Among the surveyed students, 1.16% denoted themselves not

being willing to recommend the vaccine to patients, and 0.95% were not willing to recommend

it to healthcare workers. Additionally, only 0.58% of medical students showed any reluctance

toward personally receiving the vaccine. This is in contrast to a similar study conducted at a

single allopathic medical school that found that nearly a quarter of their medical students were

hesitant about receiving the vaccine [9].

Comments submitted by participants were grouped based on similarity of content and

were quantified to assess the most shared ideologies. Participants that indicated willingness to

recommend the vaccine as well as toward personally receiving it included the following as fac-

tors that influenced their decision: FDA and CDC endorsement, data from clinical trials, want-

ing personal safety during patient exposure, desire to protect others, as well as eagerness to

resolve the pandemic. Additionally, multiple medical students that indicated their approval

toward willingness to recommend the vaccine yet indicated hesitancy to personally receiving it

specified that their reasoning was that they did not want to take the opportunity away from

people that were more at risk of complications from COVID-19.

Among the participants that indicated that they would not recommend the vaccine, the

most reported factors that influenced their decision included lack of long-term effects of the

vaccine, perceived lack of effectiveness, as well as speed of vaccine development.

Although the participant groups were dichotomized, a limitation to this study was the rela-

tively small proportion of medical students selecting unwillingness to recommend the vaccine

in relation to those willing to recommend it. This prompted us to alter the scope of the study

to question attitudes toward vaccine mandates as opposed to primarily focusing on vaccine

recommendation. An additional limitation is that the medical students’ opinions regarding

making the COVID vaccine mandatory may change over time, especially as more data is made

available.

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Our results were able to show an association between high knowledge of the COVID vac-

cine and disapproval towards a vaccine mandate toward patients. Additionally, our study

showed a positive correlation between knowledge of the vaccine and willingness to personally

receive it. Lastly, we were able to show that the overwhelming majority of surveyed medical

students showed little reluctance to recommend or personally receive it. With much of the

public hesitant about receiving the COVID-19 vaccine, it is invaluable to know the attitudes of

future physicians that may play a role in largely altering the public’s perspective.

Supporting information

S1 File.

(XLSX)

Acknowledgments

The authors wish to thank the participating medical schools and medical students for allowing

us to survey them as well as Songyuan Deng and Dr. Kevin Bennett for their assistance with

the data analysis.

Author Contributions

Conceptualization: Danel Mayan, Brian Keisler.

Data curation: Danel Mayan.

Formal analysis: Danel Mayan.

Investigation: Danel Mayan, Kenny Nguyen, Brian Keisler.

Methodology: Danel Mayan.

Supervision: Brian Keisler.

Visualization: Kenny Nguyen.

Writing – original draft: Danel Mayan, Kenny Nguyen, Brian Keisler.

Writing – review & editing: Danel Mayan, Kenny Nguyen, Brian Keisler.

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