Assessing prevalence, knowledge, attitude, and practices associated with influenza vaccination among the people residing in Jazan Province, Saudi Arabia

ABSTRACT

Objectives:

To understand the attitude and knowledge regarding influenza vaccine is crucial for developing effective vaccination strategies to improve public health outcomes. Seasonal influenza is a widespread, preventable infection caused by influenza viruses, particularly affecting vulnerable populations.

Methods:

We conducted a community-based cross-sectional study to assess the prevalence, knowledge, attitudes, and practices regarding influenza vaccination in Jazan Province, Saudi Arabia.

Results:

A total of 402 participants were surveyed, with the majority being female (80.3%) and Saudi nationals (97.3%). Our results revealed that 69.4% of the participants had been vaccinated, yet significant gaps remained in knowledge, especially regarding high-risk groups and vaccine side effects. Although 97% had heard of the influenza vaccine, only half of the participants were aware of its side effects. Moreover, 58.8% of the unvaccinated believed that their immune systems could naturally fight off the infection. Attitudes towards vaccination were generally positive, with 76.2% adhering to preventive measures. However, misconceptions persisted, particularly regarding vaccine safety and the perceived severity of influenza. Marital status being widowed was a significant predictor (estimate; 95% confidence interval; p-value) for low knowledge score (-1.46; -2.54, -0.38; p=0.008) whereas, having already taken the influenza vaccine was a significant predictor for higher score (1.15; 0.73, 1.56; p<0.001). For every unit increase in the knowledge score, the influenza vaccination hesitancy odds increased by 1.83 times, which was statistically significant.

Conclusion:

Our study demonstrates that while awareness of influenza and its vaccine is relatively high, significant misconceptions remain, highlighting the need for targeted health education initiatives to address these gaps and increase regional vaccination coverage.

Seasonal influenza, commonly known as the flu, is a virulent respiratory infection caused by influenza viruses that affects all age groups of individuals worldwide. Seasonal influenza remains a global health burden as the epidemics are considered to cause about 3–5 million cases of severe illness and lead to the death of 290,000–650,000 individuals throughout the world.¹ Among the four variants of influenza viruses, the influenza A and B viruses spread quickly from person to person through air droplets. In areas with temperate climates, seasonal influenza occurs mostly during winter, whereas in tropical areas, influenza is reported throughout the year, resulting in frequent irregular outbreaks.^1-3

While most individuals with seasonal influenza recover without any treatment, influenza may increase the risk of morbidity and mortality in certain high-risk individuals. Individuals who are at a higher risk of developing influenza may include pregnant women, children below the age of 5 years, elderly people, individuals with chronic medical conditions, and healthcare professionals. To avoid any potential complications, influenza can be prevented by vaccination.¹ It is recommended to receive the influenza vaccine every year, as the immunity against the disease reduces due to emerging mutations in the influenza virus.⁴ According to the recommendations by the Saudi Thoracic Society in 2015, all individuals over the age of 6 months must be vaccinated for seasonal influenza annually, unless contraindicated.⁵ Despite the easy availability and proven efficacy of influenza vaccines, the vaccination rate remains suboptimal in many countries, including Saudi Arabia. Although influenza vaccines are provided free of cost to the public, numerous studies have investigated the influenza vaccination rate in the kingdom and consistently reported a relatively low vaccination rate in the general population.^{4, 6,7,8} A nationwide cross-sectional study in Saudi Arabia reported that only 31.5% of the study participants received an influenza vaccination in 2019–2020.⁷ Similarly, a cross-sectional study in Jazan Province, Saudi Arabia reported that only 13% of the study participants received the vaccination.⁴ According to study conducted in Saudi Arabia (2019), the vaccination rates were relatively higher, especially among well-educated individuals; however, the overall vaccination rates remain low.⁸ About 46% of the individuals who were not vaccinated believed the influenza vaccine was unnecessary. A 2020 study on the knowledge and practices towards seasonal influenza reported that a major proportion of the residents of Saudi Arabia, particularly in the city of Riyadh, do not opt for influenza vaccine mainly due to previous negative experiences with influenza vaccination, followed by the belief that they are not among the groups that require vaccines, and have a fear of injections. Other factors influencing vaccination behavior included cultural beliefs, perceived risk of influenza, lack of confidence in the vaccine’s effectiveness and safety, and lack of knowledge to access the vaccination services.⁶

These findings reflect a significant gap in the vaccination rates, warranting further investigation and intervention. Hence, understanding the attitude and knowledge of the public and raising awareness regarding the need for influenza vaccination is crucial for developing effective vaccination strategies to improve public health outcomes.⁸

Although a previous cross-sectional study has assessed the prevalence, knowledge, attitude, and practices towards influenza vaccination among healthcare workers in Jazan Province, Saudi Arabia,⁹ there is a dearth of data on these factors in the general population of this region. Given the widespread misconceptions about influenza and its vaccines among the people and the lack of data among the general population, we aimed to estimate the influenza vaccination rates and evaluate the knowledge, attitudes, and practices regarding influenza vaccination among individuals residing in Jazan Province, Saudi Arabia.

Methods

We conducted a community-based cross-sectional study from April to September 2024 in Jazan Province, Saudi Arabia. According to the 2024 Population and Housing Census, the total population of the region is estimated to be around 1.4 million.¹⁰

Individuals residing in Jazan Province who consented to participate in this study were included by systematic random sampling and those who refused to provide consent were excluded. The study questionnaire was distributed among the eligible population by the study team.

Data were collected using a self-administered validated questionnaire. MA, AK, SJ, and RR have evaluated the face and content validity and assessed the questionnaire for clarity, comprehensiveness and style - the framed questionnaire comprised of 19 questions from 3 domains. We used the Fleiss’ kappa statistic to assess the interrater agreement among the selected experts, demonstrating an excellent agreement (0.82). Additionally, the reliability analysis was done using the Cronbach’s alpha method, and all domains have demonstrated a high degree of internal consistency with a value range between 0.81-0.90.

Participants were allowed to choose one option for each question of the questionnaire. The first part of the questionnaire collected sociodemographic characteristics such as age, gender, nationality, education level, occupation, and marital status. The second part centered on knowledge regarding the influenza vaccine with 8 items: severity of the virus, accepting the vaccine, reasons for accepting the vaccine, and reasons for refusing the vaccine. Each question carried 1 point. The third part consisted of questions concerning the attitude towards influenza vaccination (4 items). The fourth part included questions regarding influenza prevention methods and their efficacy.

We collected the sociodemographic characteristics namely age, gender, nationality, marital status, and education level. The vaccination rate, knowledge, attitude, and practice regarding influenza vaccination were estimated.

Raosoft¹¹ was used to estimate the sample size. Assuming an influenza vaccination rate of 50% based on previous studies a 5% absolute precision level, and a 5% standard normal deviation, 385 participants were required.^7,12,13 The data are presented as frequencies and percentages or the mean and standard deviation (SD), as appropriate. A composite score for knowledge was calculated by assigning 1 point to each correct response on the knowledge questions, so the total score ranged from 0 to x points. Predictors of the total knowledge score and vaccine hesitancy (that is, those who had not received the influenza vaccine before) were identified using regression models. All predictors with a p-value <0.02 in the univariate analysis were subjected to multivariable analysis. A p-value <0.05 was considered to indicate statistical significance in the final model. All analyses were conducted using SPSS Statistics, version 23 (IBM Corp., Armonk, NY, USA).

The Standing Committee for Sabbatical Leave and Practices Publication Research Ethics approved this study (Reference N0:REC-45/09/1021) prior to its commencement. The study was conducted in accordance with the Declaration of Helsinki and the Saudi Arabian guidelines on ethical conduct and publication of health research.

Results

We included a total of 402 participants in the study. Table 1 shows the sociodemographic characteristics. The majority of the participants were female, Saudi, and had a university degree, and the largest portion of the participants were 18-25 years old, married, and employed.

Table 1.

- Demographic characteristics of the study participants (N=402).

Characteristics	n	%
Gender
Male	79	19.7
Female	323	80.3
Nationality
Saudi	391	97.3
Non-Saudi	11	2.7
Age group (years)
18-25	161	40.0
26-35	129	32.1
36-45	53	13.2
46-55	47	11.7
>55	12	3.0
Level of education
High school or less	65	16.2
University degree	326	81.1
Postgraduate degree	11	2.7
Marital status
Single	187	46.5
Married	197	49.0
Separated	10	2.5
Widowed	8	2.0
Occupations
Student	112	27.9
Employee	183	45.5
Non-employee	107	26.6

The mean (SD) knowledge score was 6.08 (1.53) points. Of the participants, 97% said that they heard about the influenza vaccine, and 92.1% correctly identified the appropriate age for receiving the vaccine. Moreover, 50.3% of the participants were unaware of the side effects of influenza vaccination and 78.3% identified those who are at high risk for influenza (Table 2).

Table 2.

- Knowledge about influenza vaccination among the study participants (N=402).

Questions	Correct answers
	n	%
Do you know that the influenza virus can cause a high-risk respiratory infection?	314	77.3
Who is at high risk of influenza?	206	78.3
Have you heard about the influenza vaccine before?	390	96.6
What is the appropriate age to receive the vaccine?	370	92.1
Do you know that you should receive the vaccine annually?	329	79.8
Can pregnant women receive the vaccine?	242	63.05
Do you know the benefits of receiving the vaccine?	310	70.4
Do you know the side effects of the influenza vaccine?	223	50.3

Of the participants, 69.4% stated they had received the influenza vaccine before. Among the unvaccinated, the most common reason for not getting vaccinated was believing that the immune system can fight the infection (58.8%), followed by thinking that influenza is not harmful (15.2%), and that vaccination is unsafe (12.8%) (Table 3).

Table 3.

- Attitudes and practices toward influenza vaccination and preventive measures (N= 402).

Variables	n	%
Have you received the vaccine before?
No	123	30.6
Yes	279	69.4
Reason for not receiving the vaccine
Influenza is not that harmful	32	15.2
Unsafe vaccine	27	12.8
Believe that the immune system can fight the infection	124	58.8
The vaccine can cause the disease	28	13.3
Do you think that the awareness is clear and sufficient for the influenza?
No	230	57.2
Yes	172	42.8
Do you know what the influenza prevention methods are?
No	68	16.9
Yes	334	83.1
Do you apply influenza prevention methods?
No	93	23.8
Yes	298	76.2

As shown in Figure 1, 42.8% of the participants thought that the awareness was adequate for influenza vaccination, 83.1% said that they knew about influenza prevention methods, and 76.2% declared that they followed influenza prevention measures.

Figure 1.

- Attitude regarding awareness and preventive measures related to influenza vaccination.

Next, we used linear regression to evaluate predictors of the knowledge score (Table 4). We found two significant predictors: Being widowed (compared with being married) was a significant predictor for a low knowledge score (estimate = -1.46; 95% confidence interval [CI] -2.54, -0.38; p=0.008). Having received the influenza vaccine was a significant predictor for a higher score (estimate=1.15; 95% CI 0.73, 1.56; p<0.001).

Table 4.

- Socio-demographic predictors of influenza vaccination related knowledge.

Variables	Estimate	CI lower limit	CI upper limit	P-value	Estimate	CI lower limit	CI upper limit	P-value
Gender					NOT INCLUDED IN THE ANALYSIS
Female
Male	0.04	-0.59	0.68	0.896
Nationality
Non-Saudi
Saudi	-0.51	-1.67	0.65	0.386
Age (years)
18-25
26-35	-0.01	-0.53	0.52	0.980	0.10	-0.47	0.68	0.729
36-45	0.08	-0.61	0.77	0.813	0.36	-0.40	1.11	0.351
46-55	0.04	-0.57	0.65	0.904	0.41	-0.32	1.14	0.271
56-65	-1.28	-2.66	0.11	0.071	-1.10	-2.46	0.26	0.113
66-75	1.26	-0.51	3.02	0.163	1.19	-0.53	2.91	0.175
Education
Bachelor
Doctorate	1.18	-0.36	2.71	0.132	0.73	-0.68	2.15	0.308
High school	-0.07	-0.67	0.52	0.805	-0.14	-0.69	0.42	0.627
Master	-0.07	-2.23	2.08	0.946	-0.12	-2.10	1.86	0.904
Middle school	-0.41	-2.17	1.36	0.649	0.03	-1.59	1.65	0.974
Primary grade	-0.07	-2.23	2.08	0.946	-0.64	-3.05	1.78	0.604
Marital status
Married
Separated	0.32	-0.93	1.56	0.618	0.75	-0.69	2.18	0.307
Single	0.26	-0.18	0.70	0.241	0.41	-0.15	0.97	0.155
Widow	-1.45	-2.60	-0.29	0.015	-1.46	-2.54	-0.38	0.008*
Occupation					NOT INCLUDED IN THE ANALYSIS
Employee
Non-employee	-0.03	-0.54	0.49	0.921
Student	-0.10	-0.61	0.42	0.711
Received vaccine
No
Yes	1.26	0.86	1.67	<0.001	1.15	0.73	1.56	<0.001*

CI: confidence interval

Table 5 shows the results of the univariate and multivariable analysis to identify the predictors of influenza vaccine hesitancy. For every unit increase in the knowledge score, the odds of vaccine hesitancy increased by 1.83 times, which was statistically significant.

Table 5.

- Factors influencing participants’ willingness to receive influenza vaccination in Jazan Province.

Logistic regression
Variables	Estimate	Odds ratio	CI lower limit	CI upper limit	P-value	Estimate	Odds ratio	CI lower limit	CI upper limit	P-value
Gender						NOT INCLUDED IN THE ANALYSIS
Female
Male	0.24	1.27	-0.62	1.18	0.592
Nationality
Non-Saudi
Saudi	-1.23	0.29	-4.18	0.57	0.261
Age
18-25
26-35	0.41	1.51	-0.30	1.14	0.263
36-45	0.39	1.48	-0.54	1.39	0.422
46-55	0.29	1.33	-0.53	1.14	0.497
56-65	0.04	1.04	-1.81	2.11	0.964
66-75	15.20	4005435.03	-94.33	NA	0.986
Education
Bachelor
Doctorate	14.94	3070833.53	-68.46	NA	0.984
High school	-0.17	0.84	-0.95	0.65	0.676
Master	-0.63	0.53	-3.87	2.61	0.659
Middle school	-1.32	0.27	-4.40	1.04	0.285
Primary grade	-0.63	0.53	-3.87	2.61	0.659
Marital status
Married
Separated	0.16	1.17	-1.52	2.16	0.859
Single	0.18	1.19	-0.43	0.79	0.567
Widow	-0.25	0.78	-1.81	1.42	0.754
Occupation
Employee
Non-employee	-0.53	0.59	-1.24	0.17	0.137	-0.60	0.55	-1.38	0.16	0.123
Student	-0.58	0.56	-1.28	0.12	0.106	-0.63	0.53	-1.41	0.13	0.106
Knowledge score	0.60	1.82	0.38	0.83	<0.001	0.61	1.83	0.39	0.84	<0.001*

CI: confidence interval

Discussion

We assessed the knowledge, attitudes, and practices related to influenza vaccination among 402 participants residing in Jazan Province, Saudi Arabia. Most of the participants were aware of the influenza vaccine, the appropriate age to receive it, that it should be received annually, and that influenza could cause a high-risk respiratory infection. However, only a few participants were aware of the vaccine’s side effects and that pregnant women could receive it. While 69.4% of the participants reported they were vaccinated, we found persistent and significant gaps in understanding regarding high-risk groups and vaccine safety. Over half of the participants who were not vaccinated thought vaccination was not needed because of the assumption that the immune system could fight the infection. A small proportion of the participants also that influenza is not harmful and vaccination is unsafe. Over 70% of the study subjects were aware of the benefits of the influenza vaccine, but more than 57% felt that awareness of influenza is not very clear and insufficient. Most of the participants genuinely engaged in influenza preventive measures.

Our results are consistent with a previous study conducted in Riyadh, Saudi Arabia, in 2020, which indicated that 77.3% of the participants believed that influenza was a highly contagious illness and if serious could necessitate hospitalization.⁶ In our study, although a considerable proportion of the participants reported having received an influenza vaccine, most of them understood the benefits of influenza vaccination. A significant proportion (22.9%) needed to be made aware of it, leading to a markedly reduced rate of voluntary vaccination. However, there are contrasting reports in the literature. Other studies from Saudi Arabia have reported a lower rate of influenza vaccination (44.53%, 36.7%, and 55%).^14-16 The comparatively higher rate of influenza vaccination in our study suggests that public health efforts implemented by the Ministry of Health in Saudi Arabia have been effective.

Although 5.7% of the participants thought that vaccines were only for the elderly, about half of them stated that it was acceptable for pregnant women to get vaccinated. However, earlier studies reported that a low proportion of Saudi individuals were aware that pregnant women could receive an influenza vaccine.^16,17 The participants continue to hold false beliefs about the disease and vaccination despite an increased understanding of influenza and the necessity for vaccination.^18,19 For example, over half of the participants believed that their immune system could protect against influenza. In contrast, among the individuals who chose not to get vaccinated (30.6%), beliefs persisted that the vaccine could cause significant adverse effects and that they could protect themselves against influenza by other means.

The majority of the participants believed that receiving the influenza vaccine annually was essential, indicating a positive attitude toward vaccination. Additionally, the participants who had previously been vaccinated exhibited considerably higher knowledge and a favorable attitude toward vaccination. However, previous vaccine recipients demonstrated a limited understanding of influenza vaccination. Those less likely to receive vaccinations held unfavorable opinions and believed that vaccinations could weaken their immune system. The probability of receiving an influenza vaccine was higher among the participants who understood its necessity and believed it was safe, effective, and required at a certain time of year.

The observation that being a widow is related to a lower knowledge score is consistent with other studies conducted in the Middle East. These studies correlate social distress and the absence of a spouse’s presence to lower health literacy.²⁰ In Saudi Arabia and Jordan, those who are married can make decisions and access health information or knowledge through their spouses.^21,22 At the same time, however, the link between previous influenza vaccination and higher knowledge scores is explained by the need for awareness campaigns, as demonstrated in studies from Qatar and the United Arab Emirates^23,24 that reported the volume of vaccine uptake is directly related to increased levels of health education. This reinforces the need for targeted intervention with regard to culture to the most vulnerable—widowers—to narrow knowledge gaps. The findings of this study offer valuable information to enhance the vaccine uptake in the Jazan Province. As healthcare professionals remain the preferred and trusted source of information, it is important that they are involved in expanding health outcomes to address the common barriers and misconceptions. This study can help healthcare professionals and policymakers in Saudi Arabia to understand the need for the development of educational public health programs, campaigns, and strategies to improve vaccine uptake in Jazan Province.

Study limitations

The study recruited a sample size, which may affect the generalizability of the findings. The questionnaire required participants to read and respond independently, hence it could not be distributed to individuals with low literacy levels, thereby limiting the inclusivity of the sample. Since this was a cross-sectional study, the direction of relationships could not be determined. Additionally, response bias could not be eliminated. Hence, these limitations must be considered during the interpretation of results.

In conclusion, this study provides valuable insights into the knowledge, attitude, and practices knowledge, attitudes, and practices regarding influenza vaccination in an under-researched region, highlighting key areas for public health intervention. Our study demonstrates that while awareness of influenza and its vaccination is relatively high in Jazan Province, Saudi Arabia, significant misconceptions remain, particularly concerning the severity of the disease and vaccine safety. Efforts to improve vaccination rates must focus on addressing the existing misconceptions through public health campaigns. This can be carried out by encouraging healthcare professionals to actively engage in discussion about the importance of seasonal influenza vaccines, address any concerns and doubts of the patients, and correct misconceptions, if any. It is also necessary to explain the benefits of the vaccine, the need for the vaccine in high-risk/special populations, and why it is required to receive the vaccine annually, as clearly as possible. Additionally, the other barriers such as fear of injections and previous negative experiences can be addressed by educating the public about the potential side effects and providing reassurance regarding the efficacy and safety of vaccines. By increasing awareness and accessibility of the influenza vaccine, vaccine uptake can be enhanced, contributing to better public health outcomes in this area. Future studies in this region with a larger sample size can be beneficial to confirm our study’s findings and improve health outcomes.