Search Results (351)

COVID-19 vaccine hesitancy (VH), like attitudes towards other vaccines, is a critical global public health concern. Despite numerous studies covering psychological, sociodemographic, and other determinants of vaccine acceptance, resistance, and hesitance, few studies have reported these factors among students, particularly in politically unstable settings like Ukraine. This cross-sectional, descriptive, and quantitative study assesses hesitancy towards COVID-19 vaccines, utilizing the 5Cs Model. Among 936 respondents surveyed in 2023, 64% received at least one shot of the COVID-19 vaccine (acceptant), 11% were still considering getting vaccinated (hesitant), and 25% refused vaccination (resistant). Vaccination behavior is significantly associated with the 5Cs. Higher collective responsibility significantly increased acceptance and reduced resistance, while higher constraints lowered the chances of being either acceptant or resistant. Confidence protected against resistance. Complacency, counterintuitively, reduced odds of resistance, pointing to differences between passive hesitancy and active refusal. Male gender and sources of information and misinformation influenced confidence. Collective responsibility was positively associated with official sources and negatively with conspiracy beliefs. Complacency increased with official sources, while constraints and calculation were least explained by predictors. Practical barriers should be tackled through improved accessibility and fostering collective responsibility via targeted communication strategies. These findings provide actionable insights for policymakers, healthcare providers, and academic institutions to enhance vaccine uptake among university students, particularly in crisis settings. Full article

African, Caribbean, and Black (ACB) communities face increased COVID-19 morbidity and mortality, coupled with significant barriers to vaccine acceptance and uptake. Addressing these challenges requires innovative, multifaceted strategies. Peer-led interventions, grounded in critical health literacy (CHL) and critical racial literacy (CRL), and integrating collaborative equity learning processes, can enhance community capacity, empowerment, and health outcomes, contributing to long-term health equity. This paper describes and presents the evaluative outcomes of a peer-led intervention aimed at enhancing COVID-19 vaccine confidence and acceptance. The Peer-Equity Navigator (PEN) intervention consisted of a specialized training curriculum grounded in CHL and CRL. Following training, PENs undertook a 5-month practicum in community or health settings, engaging in diverse outreach and educational activities to promote vaccine literacy in ACB communities. The evaluation utilized a modified Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) Framework, using quantitative and qualitative methods to collect data. Sources of data included tracking records with community feedback, and a PEN focus group, to assess program feasibility, outreach, and effectiveness. From 16 September 2022, to 28 January 2023, eight trained PENs conducted 56+ community events, reaching over 1500 community members. Both PENs and community members reported high engagement, endorsing peer-led, community-based approaches and increased vaccine literacy. The PEN approach proves feasible, acceptable, and effective in promoting positive health behaviors among ACB communities. This intervention has clear implications for health promotion practice, policy, and research in equity-deserving communities, including immigrants and refugees, who also face multiple and intersecting barriers to health information and care. Full article

Background: Pharmacy technicians are increasingly involved in immunization services, enhancing vaccine accessibility and reducing pharmacies’ workload. This scoping review aims to (1) provide a comprehensive overview of pharmacy technicians’ involvement in immunization services across various healthcare settings and countries, and (2) conduct a comparative analysis of training curricula for pharmacy technicians on immunization. Methods: A scoping review was conducted following the Arksey and O’Malley framework. A comprehensive search of the PubMed and Scopus databases was performed using keywords and MeSH terms such as “pharmacy technician(s)”, “immunization”, “vaccination”, “role”, and “involvement”. Studies included assessed pharmacy technicians’ roles in vaccine administration, training, and public health outcomes. Descriptive and thematic analyses were used to synthesize the findings. In addition, a supplementary analysis of immunization training curricula was conducted, reviewing programs from different countries to identify similarities, differences, and gaps in course structure, content, and delivery formats. Lastly, a comprehensive toolkit was developed, offering guidelines intended to facilitate the implementation of immunization training programs. Results: A total of 35 articles met the inclusion criteria, primarily from the United States of America (n = 30), Canada (n = 2), Ethiopia (n = 1), Denmark (n = 1) and United Kingdom (n = 1). The findings indicate that pharmacy technicians contribute significantly to vaccine administration, patient education, and workflow optimization, particularly in community pharmacies. The COVID-19 pandemic accelerated their involvement in immunization programs. Key challenges include regulatory barriers, a lack of standardized training, and resistance from other healthcare professionals. Facilitators include legislative support (e.g., the PREP Act), structured training programs, and collaborative pharmacist–technician models. Conclusions: Pharmacy technicians can play a vital role in expanding immunization services, improving vaccine uptake, and reducing pharmacist workload. Addressing regulatory inconsistencies, enhancing training, and fostering interprofessional collaboration are crucial for their effective integration of immunization programs. Since immunization by pharmacy technicians is not yet allowed in many EU countries, this review will provide a foundational basis to address their potential to support the healthcare workforce and improve access to immunization services. Full article

COVID-19 vaccine hesitancy in Pakistan is a barrier to optimal vaccine uptake and has been situated within a context of hesitancy towards other vaccines. A mixed-methods study was conducted during the initial COVID-19 vaccine roll-out in 2021 in four union councils in Peshawar, consisting of a cross-sectional survey, eight focus group discussions (FGDs) with community members and eight in-depth interviews with healthcare workers (HCWs) to assess perceptions toward vaccines. Multivariable logistic regression was used to assess factors associated with COVID-19 vaccine hesitancy. Of 400 survey participants, 57.3% were vaccine acceptant and 42.8% vaccine hesitant. Just over half (56.8%) perceived COVID-19 vaccines to be safe. Most (88%) reported trust in HCWs to provide accurate vaccine information. FGDs revealed that women received less information about the vaccine compared to men and cultural restrictions were barriers even for those willing to be vaccinated. Correlates of vaccine acceptance included male sex (aOR 2.25; 95% CI 1.29–3.91), age 50 years or greater (aOR 1.74; 95% CI 1.19–6.31), social network support (e.g., vaccine acceptance among an individual’s social network) in receiving COVID-19 vaccines (aOR 2.38; 95% CI 1.45–3.89), community concern about COVID-19 spread (aOR 2.84; 95% CI 1.73–4.66), and trust in HCWs to provide vaccine information (aOR 3.47; 95% CI 1.62–7.42). Future vaccine promotion should prioritize engaging community leaders, sharing transparent information, combatting misinformation and rumors, and implementing household-based interventions especially targeting the importance of vaccination among women and young people to increase uptake. Full article

The 100-Day Mission, coordinated by the Coalition for Epidemic Preparedness Innovations (CEPI) and endorsed by significant international stakeholders, aims to shorten the timeframe for developing and implementing vaccines to 100 days after the report of a new pathogen. This ambitious goal is outlined as an essential first step in improving pandemic preparedness worldwide. This review highlights the mission’s implementation potential and challenges by examining it through the lens of low- and middle-income countries (LMICs), which often face barriers to equitable vaccine access. This article explores the scientific, economic, political, and social aspects that could influence the mission’s success, relying on lessons learned from previous pandemics, such as the Spanish flu, H1N1, and COVID-19. We also examined important cornerstones like prototype vaccine libraries, accelerated clinical trial preparedness, early biomarkers identification, scalable manufacturing capabilities, and rapid pathogen characterization. The review also explores the World Health Organization (WHO) Pandemic Agreement and the significance of Phase 4 surveillance in ensuring vaccine safety. We additionally evaluate societal issues that disproportionately impact LMICs, like vaccine reluctance, health literacy gaps, and digital access limitations. Without intentional attempts to incorporate under-resourced regions into global preparedness frameworks, we argue that the 100-Day Mission carries the risk of exacerbating already-existing disparities. Ultimately, our analysis emphasizes that success will not only rely on a scientific innovation but also on sustained international collaboration, transparent governance, and equitable funding that prioritizes inclusion from the beginning. Full article

Introduction: COVID-19 and influenza are viruses that have been major causes of morbidity and mortality worldwide. While a combination vaccine for these two viruses is currently in development, little is known about public perceptions and attitudes towards such a vaccine. Therefore, we have aimed to conduct a scoping review to evaluate the attitudes and reasons for the acceptance/rejection of a combination COVID-19 and influenza vaccination. Material and Methods: Our review has followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. Search terms included those on COVID-19, influenza, and combination vaccines. Searches were conducted in a total of 10 different databases, as follows: Embase, Global Health, Google Scholar, CINAHL, Medline, Scopus, ScienceDirect, PubMed, PsycINFO, and Web of Science. Results: Searches across all databases produced a total of 1763 results, of which five studies were deemed to be eligible for this review. Data from included studies encompassed a total of 20,581 participants across 14 countries. Generally, participants had favorable views towards a combination vaccine. However, attitudes varied by region, demographics, and prior vaccine exposure. Reasons provided for accepting a combination vaccine include low cost, reasonable effectiveness, fewer injections, and higher safety. However, reasons for rejection of a potential combination vaccine include a potential lack of evidence and studies regarding its effectiveness and a fear of possible side effects. Conclusions: There are generally positive attitudes and perceptions towards a combination vaccination for COVID-19 and influenza, and there are also specific segments of populations that may show hesitancy towards such a vaccine. Vaccination delivery programs should clearly demonstrate that these vaccines are safe and must concurrently address false rumors and misinformation. Ensuring that as many people as possible can receive the vaccination without barriers via equity in access should be a public health priority. It is also important to recognize the limitations of this work, especially that the review was limited to five studies, the majority of which were cross-sectional and relied on self-reporting. Full article

Background: The COVID-19 pandemic prompted extensive vaccination efforts globally, yet in the Philippines, many families remained unvaccinated. Caregivers are key decision-makers for family vaccination, but evidence on factors influencing their own vaccine uptake is limited. Methods: A cross-sectional survey of primary caregivers was conducted in low COVID-19 vaccine uptake regions in the Philippines from July to October 2023 using a validated questionnaire. Multivariable logistic regression identified enablers and barriers to vaccine uptake. Results: Among 775 respondents, 72.3% completed primary vaccination, 3.3% had incomplete vaccination, and 24.4% were unvaccinated. Key factors for vaccination included self, family, and community protection, and the influence of government regulations. Distrust in vaccine safety was the main barrier. Positive associations with vaccine uptake were found for age [30–45 years (aOR = 2.23) and 46–59 years (aOR = 2.84)], education [secondary (aOR = 2.25) and tertiary (aOR = 4.93)], and employment (aOR = 1.99). Confidence in vaccine safety (aOR = 1.92), vaccine effectiveness (aOR = 2.23), and satisfaction with vaccination efforts (aOR = 2.39) were additional enablers. Disagreement with restrictions on the unvaccinated was a barrier (aOR = 0.31). Conclusions: This study identified multiple factors influencing COVID-19 vaccination among primary caregivers in low uptake areas of the Philippines. Interventions addressing perceptions about vaccine safety and effectiveness, particularly among younger and less educated caregivers, may improve public trust and satisfaction with vaccination efforts. Full article

The COVID-19 pandemic has revealed the profound and lasting impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on the nervous system. Beyond acute infection, SARS-CoV-2 acts as a potent immunomodulatory agent, disrupting immune homeostasis and contributing to persistent inflammation, autoimmunity, and neurodegeneration. Long COVID, or post-acute sequelae of SARS-CoV-2 infection (PASC), is characterized by a spectrum of neurological symptoms, including cognitive dysfunction, fatigue, neuropathy, and mood disturbances. These are linked to immune dysregulation involving cytokine imbalance, blood–brain barrier (BBB) disruption, glial activation, and T-cell exhaustion. Key biomarkers such as interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), glial fibrillary acidic protein (GFAP), and neurofilament light chain (NFL) correlate with disease severity and chronicity. This narrative review examines the immunopathological mechanisms underpinning the neurological sequelae of long COVID, focusing on neuroinflammation, endothelial dysfunction, and molecular mimicry. We also assess the role of viral variants in shaping neuroimmune outcomes and explore emerging diagnostic and therapeutic strategies, including biomarker-guided and immune-targeted interventions. By delineating how SARS-CoV-2 reshapes neuroimmune interactions, this review aims to support the development of precision-based diagnostics and targeted therapies for long COVID-related neurological dysfunction. Emerging approaches include immune-modulatory agents (e.g., anti-IL-6), neuroprotective drugs, and strategies for repurposing antiviral or anti-inflammatory compounds in neuro-COVID. Given the high prevalence of comorbidities, personalized therapies guided by biomarkers and patient-specific immune profiles may be essential. Advancements in vaccine technologies and targeted biologics may also hold promise for prevention and disease modification. Finally, continued interdisciplinary research is needed to clarify the complex virus–immune–brain axis in long COVID and inform effective clinical management. Full article

Coronavirus disease 2019 (COVID-19) resulted in significant morbidity and mortality globally. Despite the efficacy of COVID-19 vaccines in reducing morbidity and mortality, uptake in South Africa was sub-optimal due to a number of factors which remain not fully understood, particularly in mandatory vaccination workplace settings. This quantitative, cross-sectional study aimed to understand determinants of COVID-19 vaccination uptake among clinical and non-clinical workers, aged 18 years and older, employed at a large organisation with a mandatory workplace COVID-19 vaccination policy in South Africa. Workers completed a one-off, self-administered, online questionnaire that explored determinants of COVID-19 vaccination, barriers and enablers to accessing vaccines, and perspectives regarding the mandatory workplace vaccine policy. Among the 88 workers enrolled in the study, the frequent reasons for COVID-19 vaccination included preventing the spread of COVID-19 (71%, n = 62), fear of contracting COVID-19 (64%, n = 56), protecting colleagues and patients (63%, n = 55), and the mandatory workplace policy (65%, n = 57). Just under two-thirds of workers (63%, n = 55) were supportive/very supportive of the mandatory COVID-19 vaccine policy. Reasons for support included the fact that vaccination would create a safer work environment, protecting oneself/others from acquiring COVID-19, and receiving support from their employer. Only 15% (n = 13) of workers were not supportive/against the policy. The findings of this study could inform occupational health policy and counselling and support in workplaces in future pandemics. Full article

Background/Objectives: Influenza vaccination plays a crucial role in reducing morbidity and mortality among older adults; however, uptake remains suboptimal, particularly in the post-COVID-19 pandemic. In many settings, countries have not recovered their influenza vaccine coverage rates to the same level as pre-COVID. Therefore, this scoping review systematically identified the behavioral and social drivers (BeSD) influencing influenza vaccination among older adults using the BeSD framework. Methods: A systematic search across five databases included quantitative, qualitative, and mixed-methods studies involving individuals aged 60 years and older. Data were charted across four BeSD domains: thinking and feeling, social processes, motivation, and practical issues. Results: Thirty-nine studies from 24 countries were included. Key barriers encompassed safety concerns, misinformation, financial burdens, logistical challenges, and cultural and language barriers. While motivation was positively associated with vaccination intentions, the transition from intention to behavior remains underexplored, and practical issues have received comparatively limited research attention. Conclusions: These findings underscore the need for multifaceted, behaviorally informed interventions and greater inclusion of under-resourced settings to support equitable influenza vaccination strategies for healthy aging. Full article

Psoriasis is a chronic immune-mediated inflammatory skin disorder characterized by keratinocyte hyperproliferation, impaired epidermal barrier function, and immune dysregulation. The Th17/IL-23 axis plays a central role in its pathogenesis, promoting the production of key pro-inflammatory cytokines such as IL-17, IL-23, and TNF-α, which sustain chronic inflammation and epidermal remodeling. Emerging evidence suggests that SARS-CoV-2 may trigger new-onset or exacerbate existing psoriasis, likely through viral protein-induced activation of toll-like receptors (TLR2 and TLR4). This leads to NF-κB activation, cytokine release, and enhanced Th17 responses, disrupting immune homeostasis. Erythrodermic psoriasis (EP), a rare and severe variant, presents with generalized erythema and desquamation, often accompanied by systemic complications, including infection, electrolyte imbalance, and hemodynamic instability. In a murine model of SARS-CoV-2 infection, we found notable cutaneous changes: dermal collagen deposition, hair follicle destruction, and subcutaneous adipose loss. Parallel findings were seen in a rare clinical case (only the third reported case) of EP in a patient with refractory psoriasis, who developed erythroderma after off-label initiation of dupilumab therapy. The patient’s histopathology closely mirrored the changes seen in the SARS-CoV-2 model. Histological evaluations also reveal similarities between psoriasis flare-ups following dupilumab treatment and cutaneous manifestations of COVID-19, suggesting a shared inflammatory pathway, potentially mediated by heightened type 1 and type 17 responses. This overlap raises the possibility of a latent connection between SARS-CoV-2 infection and increased psoriasis severity. Since the introduction of COVID-19 vaccines, sporadic cases of EP have been reported post-vaccination. Although rare, these events imply that vaccine-induced immune modulation may influence psoriasis activity. Our findings highlight a convergence of inflammatory mediators—including IL-1, IL-6, IL-17, TNF-α, TLRs, and NF-κB—across three triggers: SARS-CoV-2, vaccination, and dupilumab. Further mechanistic studies are essential to clarify these relationships and guide management in complex psoriasis cases. Full article

Background/Objectives: Seasonal influenza vaccination is crucial for reducing morbidity, mortality, and healthcare burdens. The 2023/2024 Ligurian vaccination campaign (Italy) utilized an inclusive model involving local health authorities, general practitioners, pediatricians, and pharmacies to enhance accessibility. Our study aimed at focusing on factors influencing vaccine uptake, public attitudes and access to preventive healthcare services. Methods: A cross-sectional survey was conducted among adults (≥18 years) in Ligurian pharmacies visitors during the vaccination campaign. A self-administered structured questionnaire gathered data on demographics, vaccination history, healthcare access, and awareness. Results: The study included 30,499 participants, and the median age with P25–P75 (years) was 62.0 [47.0–74.0]; 54.6% were female. Considering determinants of accepting influenza vaccination, age was identified as a strong independent predictor. Each one-year increase in age was associated with a 3.8% increase in the odds of influenza vaccination (OR 1.03, 95% CI 1.03–1.04, p < 0.001). Compared to individuals who never visited their general practitioners, those who visited “sometimes”, “often”, or “very often” had significantly higher odds of influenza vaccination (OR 1.54, 1.97, and 1.98, respectively; p < 0.001 for all categories). The strongest predictor of influenza vaccination in the 2023/2024 season was having received the influenza vaccine in the previous season (2022/2023) (OR 71.73, 95% CI 65.38–78.78, p < 0.001). Consistent with increasing age predicting higher influenza vaccination uptake, older age was associated with lower odds of refusing the vaccine due to the belief that “getting or transmitting influenza does not matter” or due to “other or unspecified reasons”. In contrast, receipt of the COVID-19 vaccination significantly increased the odds of holding these opinions. Among individuals who cited reasons such as fear of side effects, concerns about vaccine safety, fear of injections, general opposition to vaccines, or doubts about vaccine effectiveness, having received the COVID-19 vaccine was associated with lower odds of citing these as barriers to influenza vaccination. Conclusions: Fear of side effects and perceived unnecessary vaccination are key barriers. Targeted education and the involvement of general practitioners could enhance vaccine acceptance, particularly among hesitant groups. Full article

Background: Maternal vaccination is a critical primary preventive approach and an integral part of life-course immunization strategy, influencing the infection-associated morbidity and mortality in pregnant women, foetuses, and young infants. Despite clear guidelines for the administration of vaccines against tetanus, diphtheria, pertussis (Tdap), influenza, and COVID-19 during pregnancy, maternal vaccination rates remain suboptimal in Ireland as per the National Immunisation Office of the Health Service Executive (HSE). Aim: This review explores the prevailing status, uptake factors, and maternal immunization-specific vaccine hesitancy in Ireland. Method: A scoping review was conducted, searching nine electronic databases, including the Irish health research repository Lenus. The search strategy utilised a Population–Concept–Context framework (pregnant women—vaccine uptake/hesitancy—Ireland). Key factors identified and categorised according to the 5A framework: access, affordability, awareness, acceptance, and activation. Results: Searches yielded 2457 articles, and 12 eligible studies were included for review. Influencing factors were identified in each of the 5A dimensions, with the majority relating to acceptance and awareness. Positively associated factors included healthcare provider (HCP) recommendation and knowledge of vaccine safety. Potential antenatal barriers were maternal lack of knowledge of vaccine-preventable illness severity, infection risks, and vaccine safety concerns. A pregnant woman’s primary motivation for antenatal immunization was protection of her infant; however, the reluctance of HCPs to prescribe all recommended antenatal vaccines, inadequate immunization-specific discussion during antenatal consultations, and suboptimal knowledge of pregnancy-specific vaccine safety hampered potential positive influences. The Irish national immunization policy was a facilitator of affordability. Activation can be achieved through public health awareness campaigns and interdisciplinary promotion of maternal vaccination uptake. Conclusions: Maternal vaccination uptake in Ireland remains suboptimal, and a coordinated, targeted approach updating HCP recommendations, enhancing maternal awareness, and highlighting vaccine safety in pregnancy would be required to meet the life-course immunization goals recommended by WHO. By adopting a life-course immunization approach for healthy living, with maternal vaccination as the pivotal central point, vaccination programmes could close immunity gaps at various life stages. Full article

Background: Antibodies to galactose-alpha-1,3-galactose (alpha-gal), particularly the IgM and IgG isotypes, are abundant in human sera. These antibodies are known to be an important xenotransplantation barrier, but the full implications of these antibodies to health and disease remain incompletely understood. By contrast, IgE to alpha-gal is uncommon in the population but has been associated with tick bites and causally linked with mammalian meat allergy, often now known as alpha-gal syndrome (AGS). To date, there have been few population-based studies that have investigated alpha-gal IgG levels in relation to demographic factors, diet, tick bites, and mammalian meat allergy. Methods: Adults, predominantly healthcare workers, were recruited for a COVID-19 vaccine study. At least one serum sample was collected, and subjects completed questionnaires to provide demographic, diet, and tick exposure data. Alpha-gal IgG, IgE, and total IgG were measured using the ImmunoCAP platform, and blood group was assessed via reverse typing using stored serum. We also assessed alpha-gal IgG levels among subjects with AGS, recruited from an allergy clinic. Results: The median age of the 267 subjects in the vaccine cohort was 42 years, and median alpha-gal IgG levels were 3.0 μg/mL. Alpha-gal IgG levels were higher among the 43 (16.1%) subjects who had alpha-gal IgE sensitization (≥0.1 IU/mL) and among subjects lacking the B blood group antigen (blood groups A and O). Alpha-gal IgG levels did not differ between the subjects who had asymptomatic alpha-gal IgE sensitization and those who had meat allergy. However, both groups had higher alpha-gal IgG levels than subjects who lacked alpha-gal IgE sensitization. Subjects who reported prior tick or chigger bites had higher alpha-gal IgG levels than those without a bite history, regardless of alpha-gal IgE sensitization status. Conclusions: In a population-based cohort, alpha-gal IgG antibodies were found to be prevalent, and levels were increased in subjects with blood groups A and O, subjects who were alpha-gal IgE sensitized, and those who reported a history of tick bites. Full article

Background/Objectives: Vaccination hesitancy remains a global challenge, especially after the COVID-19 pandemic. We aimed to assess the prevalence of hesitancy towards regular COVID-19 vaccinations, including booster doses (additional doses beyond the primary to sustain or improve immunity), among university students and its associated factors. Methods: We conducted a cross-sectional study involving 190 university students from Hellenic Mediterranean University in Crete, Greece. Data were collected through an electronic survey distributed from July to October 2024. The survey included socio-demographic characteristics, health status factors, prior COVID-19 infection and vaccination history (general and for COVID-19), attitudes about COVID-19 vaccination, and the Attitude Towards Adult Vaccination (ATAVAC) scale. Qualitative data were also collected by addressing themes regarding ways to overcome vaccine hesitancy. Results: The study found that 64% of participants expressed hesitancy towards receiving COVID-19 booster doses. Factors contributing to this hesitancy were female gender, current smoking, pregnancy, concerns about vaccine side effects, a lack of confidence in vaccine efficacy, COVID-19 infection history, low perceived susceptibility to infection, and reliance on media information. Additionally, increased trust in the value of adult vaccination, adhering to recommendations of treating physician/scientist opinions, and prior adherence to vaccination were positively associated with regular COVID-19 vaccinations. A thematic analysis of the qualitative data identified four key strategies to overcome student vaccine hesitancy: enhancing health literacy, validating vaccine safety through further research, alleviating pandemic-related fears, and addressing distrust in authorities and opposition to mandatory vaccination. Conclusions: Our findings provide insights into the intricate factors and barriers of COVID-19 vaccination hesitancy among university students, thus emphasizing the need for more targeted interventions. Full article