Assessing and bridging the gap in vaccinology education: insights from Romanian medical universities

Abstract

Background

Vaccinology education forms a cornerstone of effective public health strategies, particularly in the face of global challenges such as vaccine hesitancy. This study investigates the current state of vaccinology education within Romanian medical universities, compares it against European standards, and identifies potential gaps in the curriculum.

Methods

We created a survey that aimed to determine the prevalence of vaccinology concepts within current curricula and to perform a gap analysis against the desired competency levels recommended by the European Society of Vaccinology.

The survey was distributed to faculty heads and independently to students across 14 medical universities in Romania. The survey focused on nine key areas of vaccinology.

Results

Of the fourteen Romanian medical faculties in which we distributed the questionnaire, seven gave at least one reply and three meeting the inclusion criteria based on response rates. The study revealed that while certain areas of vaccinology, such as the historical context of immunization and key aspects of immunology, were well covered, practical aspects of vaccine administration were less emphasized. The survey also revealed a disparity between faculty and student perceptions of the importance of a specialized vaccinology curriculum.

Conclusions

The findings underscore a significant convergence between the current curriculum and desired educational standards yet highlight the need for curricular revisions to address less-covered areas. We advocate for the integration of specialized vaccinology courses at advanced stages of medical education. Aligning educational content with the needs perceived by students and faculty can help optimize the curriculum to better prepare medical professionals for public health challenges.

Introduction

Vaccination is a critical public health intervention with a significant impact on saving lives, as affirmed by the World Health Organization.

Despite this, we have witnessed a global decline in vaccine coverage, particularly in childhood vaccinations, that preceded the COVID- 19 pandemic. It only intensified during the pandemic, with the WHO reporting 25 million unvaccinated children, a surge from pre- 2020 figures [1]. Relatively stable vaccine coverage across Europe, disparities persist among countries. For instance, Eastern European nations such as Romania report lower vaccination rates, with figures around 40% compared to 70–80% in Western European countries for both primary and booster COVID- 19 doses [2]. This trend extends beyond COVID- 19; for example, human papillomavirus vaccine uptake remains insufficient, with only 66% coverage for the first dose and 44% for the full series [3, 4]. In Europe, other vaccine uptake rates are low: 89% for diphtheria, tetanus, and pertussis and 85% for meningococcal conjugate vaccines [5]. In Romania, as of February 2022, vaccination coverage for two doses of measles, mumps, and rubella at age 5 was 71.4%, and for diphtheria, tetanus, and pertussis at age 14, it was 63.4%, with nonattendance cited as the primary reason for these shortfalls [6].

The phenomenon of vaccine hesitancy among the public and healthcare workers poses a significant challenge to immunization efforts. Healthcare workers'reluctance to receive or recommend vaccines, stemming from concerns about safety, efficacy, and adverse effects, is well documented [7]. This hesitancy undermines public confidence, a crucial determinant of vaccine acceptance [8, 9].

Students'and medical professionals’ attitudes toward vaccinations are shaped by their vaccinology education. Addressing the gaps in vaccinology education within healthcare training programs has become increasingly urgent. Current medical curricula often lack comprehensive coverage of vaccinology, leaving healthcare professionals inadequately prepared to address vaccine-related concerns [10]. The need for structured vaccinology education is underlined by studies highlighting the positive correlation between targeted training and vaccine uptake [3, 11].

Recent initiatives, such as the VACSATC project and IMMUNION [10], have sought to standardize vaccinology curricula across European medical schools, emphasizing the inclusion of core vaccination concepts for healthcare professionals [12].

In Romania's undergraduate medical education, vaccinology concepts, such as immunology and immunopathology, epidemiology, family medicine, primary health care, nursing, medical ethics, clinical pharmacology, public health, pediatrics, infectious and tropical diseases, microbiology, and medical law, have been conveyed across various disciplines throughout the years of study.

The residency curriculum for family medicine notably includes a specialized module in vaccinology, preparing family doctors—who serve as the main vaccinators in the national health system—with advanced skills. Other specializations do not extend this in-depth vaccinology training beyond the undergraduate level, leaving the foundational knowledge acquired during the college years as the basis for professional practice.

Currently, the extent to which basic vaccinology concepts are covered in Romanian medical school curricula is unknown. This study evaluates the prevalence and gap in the analysis of vaccinology concepts within Romanian medical undergraduate programs, fulfilling a recognized international need for robust vaccinology education.

Methodology

Between April and June 2023, we conducted a survey aimed at comparing the teachings of vaccinology in Romanian faculties with European recommendations in this field. To achieve this goal, we distributed a questionnaire to the heads of departments responsible for vaccinology-related classes in medical faculties, as specified in the respective faculties'syllabi, and to the students in the same faculties.

Our questionnaire consisted of three parts. The first part collected general information about each faculty, including details on the discipline, teaching methods, and the time allocated to vaccinology concepts. We analyzed the collected data using SPSS 21.0. Descriptive statistics are presented as the mean and standard deviation (SD) for normally distributed data and as the median and interquartile range (IQR) for nonnormally distributed data.

The second part included the translation of the eight fundamental areas outlined in the European Consensus for Vaccinology Curricula curricula into Romania. These areas were considered educational standards and encompassed both theoretical and practical knowledge that medical students should acquire during their training. The translation was performed via a consensus approach to convene a panel of bilingual medical experts. The questions were detailed, fixed response, and the same questions were used for both professors and students.

Each response was registered and analyzed, and it was considered positive if there was more than one positive responder per category, professor, or student.

Each faculty member in Romania has its own curriculum with certain general guidelines, so we consulted professors from nine specialty groups focused on vaccinology, including primary health care, infectious diseases, family medicine, epidemiology, pediatrics, basic medical sciences (pharmacology, immunology, microbiology), ethics and communication, and nursing and community medicine.

Only faculties with a teacher response rate exceeding 85% were included in our analysis to ensure that the data collected were representative. A high response rate reduces the risk of nonresponse bias, where the opinions of those who do not respond could systematically differ from those who do.

To evaluate the gap between the Desired Level, Expected Level, and Acquired Level of Vaccinology Knowledge, we employed a gap analysis template. This template included a"current state"column that quantitatively assessed the degree of achievement for each field within each faculty, considering both professors'and students'perspectives. The ideal standard was based on recommendations from the European Society of Vaccinology, and the Gap Description column highlighted any differences between the desired, expected, and acquired levels. Negative gaps in the professor segment indicated inadequately explored aspects of vaccinology, while negative gaps in the student segment suggested lower retention than expected.

We used SPSS to compare the desired, expected, and acquired levels of knowledge, evaluate the degree of coverage for notions taught by various specialties, and identify gaps or discrepancies between the three levels.

Furthermore, we analyzed specific areas that were underdeveloped or overlooked from both theoretical and practical standpoints. Each identified gap was assessed in terms of its impact on the importance of future doctors'knowledge and skills.

The third part of the questionnaire aimed to collect suggestions for improving the teaching of vaccinology concepts. This section allowed teachers to propose changes to vaccine curricula and discuss plans to bridge identified gaps through new teaching strategies and methodologies. Descriptive statistics were employed.

Results

Of the fourteen medical universities in Romania to which we distributed the questionnaire, seven responded: University of Medicine and Pharmacy Carol Davila Bucharest, Faculty of Medicine Brasov, University of Medicine and Pharmacy Craiova, University of Medicine and Pharmacy Cluj, University of Medicine and Pharmacy Iasi, University of Medicine and Pharmacy Timisoara, and Faculty of Medicine Sibiu. The survey received responses from 62 individuals representing nine discipline groups, including Public Health and Health Promotion, Primary Care of the State of Health, Infectious Diseases, Family Medicine and Community Medical Care, Other Specialties, Epidemiology, Pediatrics, Basic Medical Sciences (Pharmacology, Immunology, Microbiology), and Ethics and Communication.

Three centers, namely, the University of Medicine and Pharmacy"Carol Davila"Bucharest, University of Medicine Craiova, and Faculty of Medicine Brasov, exceeded the 85% response threshold and were included in the detailed analysis (Table 1).

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In these centers, all seminars and lectures on vaccinology were mandatory.

Regarding the allocation of lecture time to vaccinology, significant variations were observed across disciplines in these three centers. Pediatrics dedicated a substantial lecture time mean of 35.7%, while family medicine allocated 10% of their lecture time. Epidemiology contributed 16% of their lecture time, and basic medical sciences accounted for 13.2%. Ethics and communication comprised a relatively small portion, with a median of 1.7%, and other medical and surgical specialties allocated no time for lectures on vaccinology (Table 2).

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In addition to lecture time allocation, we also assessed the percentage of seminar and practical skills dedicated to vaccinology relative to the overall time. Here, epidemiology had a median of 16.6%, Basic Medical Sciences had a mean of 15.6%, Public Health and Health Promotion had a median of 10.7%, and Family Medicine had a median of 8.8% (Table 3).

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Fifty-three students from the 3 included centers voluntarily responded to our survey.

We found a high convergence of the perceived vaccine curricula in the three centers included in the analysis. Students have achieved a high level of coverage and acquisition of knowledge across various aspects of vaccinology, and their understanding often exceeds the expected and desired levels.

The findings for each section are detailed in Annex 1:

1. I.

Rationale, context, and history of immunization: 100% coverage and acquisition by the students, meeting the desired and expected levels.

2. II.

Key aspects of immunology: 100% coverage and acquisition by the students, aligning with the desired and expected levels.

3. III.

Key aspects of vaccines: Students have acquired knowledge regarding the stages of vaccine development and quality management, which were not covered by the teachers in 2 of the 3 faculties.

4. IV.

Vaccine-preventable diseases: 100% coverage and acquisition by the students, meeting the desired and expected levels.

5. V.

Immunization policy and schedules: Students can name factors influencing immunization coverage that were not covered by one of the faculty, but they acquired this knowledge.

6. VI.

Future prospects: Students have discussed new methods of vaccine administration, which were not covered by one of the faculties but were acquired by them.

7. VII.

Communication: Students have acquired a comprehensive understanding of various issues affecting and influencing vaccination decisions and communication strategies.

They have also gained insights into addressing vaccine hesitancy, avoiding categorization, and applying principles of effective communication in vaccination.

1. VIII.

Professional commitment: Students are committed to offering the best professional advice on vaccination, although this knowledge was covered but not fully acquired in one of the faculties.

2. IX.

Practical skills: Students have acquired understanding and practical skills related to different immunization techniques, surpassing the expected level.

When asked to rate, on a scale of 1 to 5, with 1 being least important and 5 being most important, which knowledge or skills from the provided list should be prioritized in teaching students about vaccination, the professors identified an understanding of vaccine-preventable diseases and communication skills as the most crucial (Table 4).

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The student target knowledge of vaccine preventable disease, communication development and practical skills to be the most important (Table 5).

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The survey, which was conducted to assess perceptions of the necessity of a specialized vaccinology course, yielded divergent findings among professors and students. Among the professors surveyed, 47% deemed the specialized course unnecessary. Conversely, 23% of the professors advocated for its essentiality, recommending its integration into the curriculum during the 5 th or 6 th academic year. Thirty percent abstained from responding to the survey question.

The student cohort exhibited a greater inclination toward the necessity of a specialized vaccinology course, with 68% affirming its importance. Twenty percent of the student respondents disagreed with the necessity of such a course. Additionally, a segment of the student responses, accounting for 11%, remained unrecorded due to nonresponse.

Discussion

Our study aimed to evaluate the coverage of vaccinology concepts in Romanian university centers. Our findings reveal an alignment between the delivered curriculum and the educational standards recommended by the European consensus for vaccinology curricula. Students demonstrated substantial knowledge acquisition, often exceeding both the desired and expected competency levels, particularly in areas such as the historical context of immunization and key aspects of immunology.

Out of 14 medical universities in Romania solicited for participation, responses were received from seven, of which only three universities presented a sufficient response rate to be included in the analysis, minimizing the risk of response bias.

Vaccinology lectures and seminars were mandatory across these universities, with significant engagement from the departments of epidemiology, pediatrics, and family medicine. The frequency of responses from faculty within these departments was notably greater, which could reflect a heightened awareness and direct involvement with the outcomes of vaccination practices, as well as the observed effects of vaccine noncompliance.

Gap analysis

The ideal education model (desired state of education), as recommended by the European consensus, encompasses a comprehensive understanding of immunology, vaccine development, communicable disease epidemiology, policy, and practical vaccination skills [13]. The gap analysis revealed that certain aspects of vaccinology, such as the practical implications of vaccination and communication strategies to address vaccine hesitancy, were not uniformly covered. The disparities in the professors'responses may indicate variability in how these topics are valued and taught across institutions. The students diminish the gaps by completing the missing information by themselves, which may implicate a high interest in vaccinology at a pregraduate level.

The factors contributing to these educational gaps may include curricular limitations and insufficient faculty training in specific vaccinology areas. The coverage of vaccinology topics could affect the preparedness of future healthcare providers in responding to vaccine hesitancy and managing immunization programs effectively. Education seems to be the most important changeable factor in increasing vaccine adherence among professionals [14, 15].

While our survey indicates that students feel confident in their general knowledge of vaccination, we interpret these results with caution due to the self-reported nature of the data and the fact that a portion of the knowledge that students possess has been acquired through non-official channels, rather than through structured curriculum paths. Notably, students'satisfaction with their training seems to reflect a superficial confidence which may not fully encompass the depth required for practical application, particularly in handling vaccine hesitancy and communication during crises such as the COVID- 19 pandemic. For example, similar studies in Europe have demonstrated a gap in student preparedness. A German survey indicated that while there was a general satisfaction with the education on vaccine-preventable diseases, dissatisfaction was prevalent concerning training on vaccine hesitancy and effective communication strategies [16] Similarly, a survey in France highlighted that about 60% of healthcare students felt unprepared to address vaccine side effects and hesitancy, perceiving the lectures as insufficient [17].

Given these findings, our recommendations for European societies involve strengthening the curriculum to better cover the practical aspects of vaccination, including the management of vaccine hesitancy and the development of robust communication strategies [18, 19].

Evaluating the success of these interventions would require ongoing monitoring of curricular changes, assessments of student knowledge, and possibly correlating these metrics with public health outcomes related to vaccination.

There are limitations to our study. The survey method relies on the assumption that department heads and students are knowledgeable and honest in their self-reports. There is a potential for bias in the responses, which could affect the validity of the results. Furthermore, the 85% threshold for inclusion might have excluded faculties with less engagement in vaccinology education, potentially skewing the representation of the current state.

Our study included information on the perceived importance of various areas of vaccinology education from both professors'and students'perspectives. Both groups prioritized vaccine-preventable diseases and communication, suggesting that a curriculum focused on these areas could be well received. There is a recognized need for practical skills, which are essential for the application of theoretical knowledge.

The significant number of missing responses from professors could suggest potential areas for curricular improvement or the need for targeted professional development.

There are divided opinions among professors, with a slight majority acknowledging the importance of a specialized curriculum in vaccinology. The students show a clearer preference for specialized courses, indicating a perceived gap in their current education or a desire for more in-depth knowledge.

The findings underscore the need to enhance the curriculum related to vaccine-preventable diseases and to improve communication skills within the educational framework. To address these needs, we propose several pedagogical enhancements to the existing vaccinology curriculum as integration of case studies, group discussions, role-playing, and digital literacy training [17]. Additionally, future research is needed to align teaching methods with health outcomes and to enhance the curriculum addressing vaccine hesitancy [20].

Future research should aim to track the impact of educational interventions over time, assess the causality between specific curriculum components and vaccination rates, and explore the applicability of our findings across different cultural and health system contexts. It would also be valuable to investigate the role of continuous professional development in maintaining and updating the vaccinology knowledge of healthcare workers postgraduation.

Conclusions

In conclusion, the results of the study indicate that students'competence in vaccinology is high. This suggests a good degree of effectiveness in the current educational frameworks. However, there remains room for curricular enhancement, particularly in the domain of communication and vaccine administration—areas identified as insufficiently addressed by some faculties. The incorporation of dedicated vaccinology modules within the medical school curriculum can align with students’ needs and interests.

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files. The SPSS datasets are available from the corresponding author upon request.

Abbreviations

WHO:

World Health Organization

SD:

Standard deviation

IQR:

Interquartile range

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