Knowledge, Attitudes, Perceptions, and Acceptance of COVID-19 Vaccination among Pharmacy and Non-Pharmacy Students

University students are a sub-group of the population at high risk of COVID-19 infection, and their judgments on vaccination affect the public attitudes towards vaccination. Thus, the present study aimed to assess the knowledge, attitudes, perceptions, and acceptance of the COVID-19 vaccine among pharmacy and non-pharmacy students. A cross-sectional study was conducted by enrolling pharmacy (375) and non-pharmacy (225) students from the universities in Lahore. Chi-square analysis was used for significant frequency distributions and a 5-point Likert scale was used to score attitude, perception, and acceptance. The majority of the students were aged between 19–24 years, hailing from urban and middle-class families with good self-reported health. The preferred vaccine was Pfizer, followed by Sinopharm and Sinovac. The major source of information was social media, followed by government campaigns and family members. The pharmacy students demonstrated better knowledge and positive attitudes toward COVID-19 vaccination. The non-pharmacy students scored higher for the questions based on scientific leads, myths, and baffling conspiracies. The non-pharmacy students showed higher hesitancy/barrier total scores related to their trust in the health system, COVID-19 vaccine storage, and efficacy. Data suggested that pharmacy students exhibited better knowledge, positive attitudes, and perceptions about COVID-19 vaccination. Overall, vaccine efficacy and safety were mutual concerns. Nonetheless, non-pharmacy students were hesitant due to mistrust in the health system of Pakistan.


Introduction
A coronavirus-related pneumonia outbreak was discovered in Wuhan, China, in December 2019. Since then, the outbreak expanded rapidly over the world, with tens of thousands of cases in more than 160 nations [1]. At the Munich Security Conference in 2020, Tedros Adhanom Ghebreyesus, WHO's director-general said, "We're not only currently fighting a pandemic; we're fighting an infodemic". Since the beginning of COVID-19, the prevalence of misleading information, fake news, and conspiracy theories have greatly increased [2]. Conflicting viewpoints and detrimental beliefs are frequently sparked by discussions among people. In particular, the development of vaccines to prevent COVID-19 is the most frequently discussed subject. The flash flood of materials from many sources

Study Population
A total of 600 students, pharmacy (n = 375) and non-pharmacy (n = 225), from the University of Punjab and other universities constituted our test sample. A sampling frame consisted of undergraduate and master's students enrolled at the universities. Rao-soft software estimated a sample size of 584 with a 5% margin of error and a 95% confidence interval, with a 50% expected response with expected population size of students~2 million attending universities of Lahore. However, almost 800 students were approached for data collection. The research participants were enrolled using following inclusion and exclusion criteria: Inclusion criteria: All the students, enrolled in undergraduate or master's degree programs at the university either in pharmacy or non-pharmacy subjects (fine arts, language, social and Islamic studies, social and administrative sciences, pure sciences and engineering), irrespective of age, gender, ethnicity, religion, social class and willing to participate were enrolled in the study.
Exclusion criteria: All post-graduate students and those not willing to participate were excluded.
The questionnaire was sent to subject experts/academicians for content validation, and thereafter their expert opinion was incorporated to make the questionnaire simpler and more objective-driven. The reliability of the questionnaire was evaluated with Cronbach's alpha (0.78), with SPSS version 22. Face validation of the questionnaire was done by conducting a pilot study on 20 students after feedback from the students during the pilot study. The data obtained during the pilot study was not included in the final analysis.
The self-administered questionnaire was distributed to selected students, who were asked to submit the filled forms at the department admission office for final collection. A total of 800 questionnaires were distributed, out of which only 600 questionnaires were finalized for inclusion-incomplete forms (n = 133) and those not returned (n = 67) to the admission office were considered dropouts. The questionnaire was divided into the following 5 sections.
Section 1: basic demographic, such as age, gender, marital status, area of residence, socioeconomic status, the field of study, and overall health condition.
Self -reported health was estimated by asking a single question: 'How would you rate your health?', and by providing them response options; good-no health issues (mental or physical), fair-mild health issues (mental or physical), poor-major health issue (mental or physical) that must be treated.
Section 2: Fifteen statements were included regarding knowledge about the COVID-19 vaccine and vaccines in general to assess the relevant information and the response to the question was taken on a correct/incorrect basis. Section 3: Attitudes and perceptions regarding the COVID-19 vaccine were assessed utilizing twenty-one statements based upon a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree.
Section 4: Hesitancy and barriers regarding the COVID-19 vaccine were assessed utilizing nineteen statements based upon a 5-point Likert scale from 1 = strongly disagree to 5 = strongly agree.

Data Analysis
The data were analyzed using SPSS (IBM, version 22) unless otherwise reported. Descriptive analysis was performed to estimate the percentages and frequencies of the two arms. Associations of dependent variables including knowledge, attitude, beliefs and self-perceived effectiveness and independent variables, such as demographics, were estimated using Pearson's Chi-square. An alpha value of 0.05 or less was considered statistically significant.

Assessment of Student's Knowledge, P and NP, about COVID-19 Vaccine Information
Knowledge of students about COVID-19 vaccines, pharmacy (P), and non-pharmacy (NP) are summarized in Table 3. The pharmacy (P) students demonstrated better knowledge about the COVID-19 vaccination than non-pharmacy (NP) students. Data revealed that the majority of the students knew about the viral nature of COVID-19 (P: 99.5%, NP: 96.9%, p = 0.012). More than 90% of the pharmacy students knew that the COVID-19 vaccine can reduce the spread of disease (P: 90.1%, NP: 82.7%, p = 0.008) and the severity of disease symptoms (P: 90.1%, NP: 88.4%, p = 0.514), being well acquainted with the process of getting vaccinated (P: 90.7%, NP: 87.6%, p = 0.229). Additionally, the majority of the pharmacy students understood the need for more than one dose(s) of vaccine (P: 94.1%, NP: 86.7%, p = 0.002) and that the vaccine stimulates the immune system to produce antibodies (P: 90.7%, NP: 80%). The majority of the pharmacy students believed that, after vaccination, there was a need to follow preventive measures (P: 88%, NP: 80.9%, p = 0.017) and that antibiotics were not an alternative to the COVID-19 vaccine (P: 76.8%, NP: 64.4%, p = 0.001) ( Table 3).

Assessment of Attitudes and Perception of Students, Pharmacy vs. Non-Pharmacy
Respondent's attitudes and perceptions were scored using a 5-point Likert scale, as summarized in Table 4. Data revealed that NP students scored higher for the questions related to misconceptions and myths about the COVID-19 vaccine, such as the use of fetal tissues in vaccine development (P: 2.74 ± 1.04, NP: 3.04 ± 0.098, p = 0.00046), with a highest effect size of 0.297, that it contains controversial substances (P: 2.74 ± 1.09, NP: 2.98 ± 1.08, p = 0.011), causes infertility (P: 2.33 ± 1.10, NP: 2.63 ± 1.18, p = 0.002), with an effect size of 0.263, and contains 5G nano-chips to control people (P: 2.25 ± 1.13, NP: 2.48 ± 1.29, p = 0.023) with an effect size of 0.190. Conversely, pharmacy students scored higher for the question about the normalization of life after COVID-19 vaccination (P: 3.17 ± 1.07, NP: 2.94 ± 1.19, p = 0.018). No significant differences were found in the observed scores for the rest of the items regarding attitudes and perceptions (Table 4).  p values: * 0.05-0.002, ** < 0.002. Responses were based on a 5-point Likert-type scale with 1 = Strongly Disagree 2 = Disagree 3 = Neutral 4 = Agree 5 = Strongly Agree. Mean Attitude scores greater than 3 (midpoint/neutral score) were treated as high, and those below 3 as having a low mean score.

Assessment of COVID-19 Vaccine Hesitancy and Barriers among Pharmacy and Non-Pharmacy Students
The COVID-19 vaccine acceptance was assessed using a 5-point Likert scale between pharmacy and non-pharmacy students summarized in Table 5. Data suggested that compared to pharmacy students, non-pharmacy students scored higher for the items questioning Pakistan's healthcare system, such as lack of trust in Pakistan's healthcare system (P: 3.18 ± 1.28, NP: 3.46 ± 1.21, p = 0.011) with size effect of 0.225 and improper storage of vaccines (P: 2.94 ± 1.21, NP: 3.19 ± 1.07, p = 0.013). Additionally, positive scores were obtained for NP students for the items that signified their fear of injections/needles (P: 2.46 ± 1.27, NP: 2.78 ± 1.35, p = 0.004) with effect size of 0.244 and about contracting COVID-19 at the vaccination centers (P: 2.68 ± 1.13, NP: 2.92 ± 1.10, p = 0.012) having effect size of 0.215. Though surprisingly, NP students demonstrated higher scores when asked that COVID-19 vaccines will not stop the spread of COVID-19 (P: 2.55 ± 1.08, NP: 2.77 ± 1.14, p = 0.020) with effect size of 0.2 (Table 5).

Discussion
Numerous studies have shown that students representing health education sectors demonstrated vaccine hesitancy, e.g., 46% in Egypt [18], 23% in the USA [19], 10.6% in India [7], 17.8% in Israel [20], 62.7% in Uganda [21] and 75.5% in Zambia [22]. Thus, the present study evaluated knowledge, attitudes, perceptions, and acceptance of the COVID-19 vaccine among pharmacy and non-pharmacy students of Lahore, Pakistan. Data revealed that the majority of the students were between 19-24 years of age, hailing from urban areas with good self-reported health. The students majorly rely on social media information, yet pharmacy students preferred Pfizer, and NP students preferred Chinese vaccines, Sinovac and Sinopharm, for vaccination. Overall, pharmacy students exhibited better knowledge, positive attitudes, and perceptions toward COVID-19 vaccination, yet efficacy and safety were major concerns for all the students. The NP students still believed in certain myths due to misconceptions. In this context, non-pharmacy students scored higher on a 5-point Likert scale for a few hesitancy and barrier questions, demonstrating vaccine acceptance challenges.
A fundamental challenge for the health authorities is the acceptance of the COVID-19 vaccine among healthcare workers and the public across countries worldwide. Poor health literacy, lack of knowledge, delusional beliefs, and conspiracy theories about the COVID-19 vaccine pose a serious challenge to vaccination in Pakistan [23,24]. With overall good self-reported health, social media was the most relied upon source of information to both pharmacy (44.5%) and non-pharmacy (37.3%) students, followed by the information provided by the government authorities (24.4-26.4%). These findings, that social media, and the internet were the major sources of information for students, were in complete agreement with previous studies from Bangladesh (33.4%), Vietnam (87.61%), Jordan (83.4%), and Egypt (75.5%) [25]. However, as acknowledged in previous studies [26,27], some credit goes to the government of Pakistan, as government authorities were rated as the second major source of information by the students. However, it is pertinent to mention that extreme care should be exercised while relying on social media and social network information, since our previous findings indicated that almost 58% of sources of myths and misconceptions about the COVID-19 vaccine came from social media/networks [28]. Furthermore, compared to NP students, P students demonstrated better knowledge in terms of the causative agent of the disease, the role of the vaccine in reducing the spread of the disease, dosing requirements, and its impact on the immune system. The knowledge-based misconceptions were higher among NP students, e.g., the dose requirements, impact of vaccines on the spread and even cure of the disease, and the chances of auto-immune disease with vaccination. Similar to these findings, a study from Pakistan demonstrated better knowledge among those acquiring medical education [26], a study from Bangladesh showed positive knowledge among 58.13% of university students [29], and 42.4% of university students in the UAE demonstrated good knowledge about COVID-19 vaccine [4]. Nevertheless, for the items with incorrect answers, NP students, >84%, answered otherwise, e.g., antibiotics can be alternatives to vaccines, no need to follow personal protective measures, and the post-vaccination chances of auto-immune disease. Yet, a certain number of pharmacy students also responded incorrectly to knowledge items, possibly due to the inability of the students to cross-verify information when social media information is the major source, corroborating several previous reports [4,29,30].
It has been well documented that meaningful knowledge about the disease and therapy would impact the patient's attitudes and perceptions toward future disease development and early prevention [24,31,32]. Overall, comparable mean scores were obtained between pharmacy and non-pharmacy students for the attitudes and perceptions questions, namely, that efficacy and safety cannot be trusted, that the COVID-19-infected person does not need a vaccine, that current vaccines do not protect against COVID-19 variants, that vaccines might change ones DNA, and that vaccination is a business strategy by big pharma companies, etc. Additionally, NP students' mean scores were higher in comparison to pharmacy students for the questions related to vaccine fallacy-vaccines were made from fetal tissues with effect size of 0.297, depicting moderate effect size of non-pharmacy education on this particular item, vaccines cause infertility (effect size 0.263), having moderate effect size on this item in NP students, and vaccines contain 5G nano-chip to contain and trace people. Such fallacies and fakeries have been reported previously among university students and the public regarding COVID-19 vaccines [33,34]. These data and above the knowledge responses suggested that both pharmacy and non-pharmacy students require specific education and training, not only to improve informed decisions towards COVID-19 vaccination but also to prepare them, particularly pharmacy students, to spread awareness and give recommendations or counsel to the vaccine-hesitant individuals. However, NP students' mean scores were higher for the responses related to barriers and hesitancy, namely, lack of trust in Pakistan's health system, with moderate effect size of 0.225, improper vaccine storage, fear of injection (effect size of 0.244), fear of contracting COVID-19 infection at the vaccination center, and belief that vaccines will not prevent COVID-19 infection. Overall, P and NP students showed low levels of mean hesitancy scores for several of the hesitancy questions. However, the high-grade hesitancy scores regarding efficacy and safety, the emphasis on the post-vaccine surveillance to assess the efficacy and safety concerns, and the lack of trust in government were found to be the major hesitancy/barriers among the students-posing vaccine acceptance challenges.
The data from our study and previous reports vividly state that challenges to vaccine hesitancy in university students are not new. However, they are diverse, with beliefs such as that there is insufficient information about efficacy and safety, lack of trust in vaccine sources and the government health system, and a concern over unforeseeable future vaccine-related health implications. Thus, overall, with more than above average knowledge, positive attitudes and perceptions, a few myths and misconceptions, and lowgrade hesitancy among students-the future educators, recommenders and counselors of anti-vaxxers-offering sufficiently effectual information, modification in the information based on socio-cultural needs, targeted interventions to dispel the myths, and hitting upon and regulating the sources of information conferring false perception about COVID-19 vaccines can help increase vaccine acceptance among university students.
The present study has several limitations, which could be addressed in the prospective research proposals. The cross-sectional design of the study does not allow us to document the responses over time-which are subject to change over time. The self-reported responses might be subject to bias due to an individual's recall ability, honesty, utmost surroundings, and psychological state. The study is limited to the pharmacy and non-pharmacy students of Lahore, and thus the results cannot be generalized to students of other health professions and universities of other provinces.
Thus, any attempt to address these limitations might accentuate the future research on this topic.

Conclusions
The study concluded that the majority of the students, pharmacy and non-pharmacy, resort to social media as a major source of information, followed by the information provided by the government authorities. The preferred vaccine choice was Pfizer by pharmacy students, while Chinese vaccines, Sinovac and Sinopharm by non-pharmacy students. Pharmacy students showed better knowledge of the items based on scientific leads, positive attitudes, and perceptions in terms of the normalization of life, which might be attributable to study area. Nevertheless, both, P and NP students were concerned about the efficacy and safety of vaccines. Majorly, only NP students believed in vaccine-related myths and delusional misconceptions about the COVID-19 vaccines, such as using fetal tissues and causing infertility. Hesitancy scores were higher in NP students for the items questioning the trust level in Pakistan's health system and the efficacy and safety of the COVID-19 vaccines.  Data Availability Statement: Data will be available on reasonable request to the corresponding author.
Acknowledgments: Authors acknowledged the cooperation of the students and the administrative heads of different universities and departments to allow the data collection.

Conflicts of Interest:
The authors declare no conflict of interest.