ABSTRACT
Patients with asthma are at increased risk of respiratory infections, especially from seasonal influenza. Vaccination is critical for disease management, but uptake remains low, particularly in low- and middle-income countries. Vaccine literacy (VL) may influence vaccination behavior. This study aimed to assess VL among asthmatic adults in Jordan and examine its relationship with influenza vaccination, considering demographic, attitudinal, and clinical factors. A cross-sectional survey was conducted with 400 adults with asthma. Participants completed the Arabic version of the Vaccine Literacy Assessment tool (HLVa-Ar), a vaccine attitude scale, a vaccination practices survey, a sociodemographic sheet, and the GINA asthma symptoms test. Binary logistic regression identified predictors of influenza vaccination. The results indicated that only 29.1% of participants reported receiving the influenza vaccine. The median VL score was 34 (IQR: 27–41) out of a maximum score of 56. Regression analysis showed that higher VL scores were significantly associated with increased odds of vaccination (OR = 1.053, 95% CI: 1.024–1.083, p <.001). A more positive attitude toward vaccination also predicted higher vaccination rates (OR = 1.286, 95% CI: 1.167–1.418, p <.001). Conversely, participants earning less than 500 JOD per month were less likely to be vaccinated (OR = 0.450, 95% CI: 0.257–0.787, p = .005). The results confirmed that VL significantly influences vaccination practices. Public health strategies should focus on improving VL, especially among socioeconomically disadvantaged groups, to enhance vaccine uptake and asthma control.
KEYWORDS: Asthma, patient education, vaccine, health literacy, Jordan
Introduction
Asthma is a chronic inflammatory disease of the airways that requires timely medical intervention and proper patient management to prevent serious outcomes, including hospitalization and asthma-related death.1 It can affect individuals of any age and typically presents with symptoms such as coughing, chest tightness, wheezing, and shortness of breath.2 Like other chronic diseases, it poses a significant burden worldwide, affecting patients, their families as well as health care systems.3 Acute respiratory viral infections, especially influenza, are among the most common triggers of asthma exacerbations.4 Influenza epidemics result in considerable morbidity and mortality, particularly among individuals with asthma.4 Therefore, annual influenza vaccination is strongly recommended by the global lung initiative guidelines (GINA) for asthmatic patients.1 Vaccination remains a cornerstone of public health. However, vaccine hesitancy/refusal is a growing challenge, that negatively impacts public health by increasing infection rates, especially among unvaccinated individuals.5 Improving influenza vaccination rates in asthmatic individuals could enhance disease management.6 Despite studies identifying knowledge gaps and attitudes among different groups, limited research has addressed actual adherence to influenza vaccination among people with asthma.7 Health literacy (HL) is the ability to access, understand, and use health-related information.8 HL has been shown to influence healthcare outcomes, including vaccine acceptance.9 Low HL contributes to poor decision-making and distrust in healthcare, while high HL supports informed choices and better vaccine adherence.10 This has led to the development of the concept of vaccine literacy (VL), defined as the ability to find, understand, evaluate, and apply immunization-related information to make informed decisions.8 VL goes beyond factual knowledge, encompassing the motivation and skills necessary to engage with vaccine-related content and make appropriate choices for oneself and one’s family.10,11 Many studies have drawn attention to this aspect by showing that VL not only reflects awareness of vaccines but also includes the ability to apply this knowledge in health-related decision-making.12 Other studies have further defined VL as a multidimensional concept that spans personal, community, and organizational levels.13
The public health relevance of VL is evident, particularly in the context of preventing vaccine-preventable diseases. Both the general population and healthcare professionals need to be “vaccine literate” to make responsible vaccination decisions and to understand the benefits and potential side effects of vaccines.
Studies evaluating VL in asthmatic patients as a predictor of vaccine acceptance are limited. Therefore, this study was designed to evaluate VL among adults with asthma in Jordan and explore its association with influenza vaccination practices. Jordan was selected as the study setting due to its notably low influenza vaccination coverage14,15 and the limited availability of research on vaccine literacy within Middle Eastern populations.16 Although vaccines are included in the national immunization program for children in Jordan, this program does not cover the influenza vaccine. Moreover, vaccine uptake among adults, particularly for influenza, remains markedly low. A cross-sectional study evaluating perceptions of the influenza vaccine among Jordanian adults found that only 9.9% of participants reported being vaccinated during the study period.14 Similarly, studies involving patients with chronic diseases such as asthma have reported low vaccination rates, suggesting gaps in awareness and access to vaccine-related information.17 This highlights the broader issue of limited vaccine literacy across populations and reinforces the importance of examining vaccine literacy as a potential predictor of vaccination practices. Understanding this relationship may inform targeted interventions to improve vaccination uptake, potentially enhancing asthma management and reducing the risk of exacerbations and related complications.
Materials and methods
This investigation employed a cross-sectional design targeting adult patients with asthma who were receiving care at the pulmonary outpatient clinic of Jordan University Hospital, situated in Amman, Jordan. Data collection was conducted between November 2024 and April 2025. Eligibility criteria specified individuals aged 18 years or older with a clinical diagnosis of asthma for a minimum duration of one year, and who were willing to participate. Potential participants were identified through a systematic review of clinical records and approached during their scheduled clinic visits. Prior to participation, individuals received a concise overview of the study objectives, assurances of data confidentiality, and were informed of their right to withdraw at any point without consequence. The self-administered survey was estimated to require approximately ten minutes to complete.
The study adhered to the ethical principles outlined in the Declaration of Helsinki. Ethical approvals were obtained from both Al-Zaytoonah University of Jordan (Reference No. 47/14/2023–2024) and the University of Jordan Hospital (Reference No. 10/2024/15816).
Data collection and survey instruments
The primary data collection instrument was the Arabic version of the Vaccine Literacy Assessment tool (HLVa-Ar),16 a validated scale developed for Arabic-speaking populations to evaluate vaccine-related literacy. The questionnaire is composed of two sections; the first, functional VL, consists of five four-point Likert-type items with response options ranging from “never” (scored as 4) to “often” (scored as 1). The second part of the HLVa-Ar includes nine four-point Likert scale items that evaluate both interactive and critical components of VL (Table Q3 and Q4).
In addition to the HLVa-Ar questionnaire, the study instrument included a sociodemographic sheet that asked about patients’ age, income and education level, marital status, and disease duration. Furthermore, the instrument included a section assessing patients’ attitudes toward influenza vaccination practices (Table Q1 and Q2). This section contained six Likert-scale questions, with responses ranging from “strongly disagree” (scored as 1) to “strongly agree” (scored as 5) for positive statements. The items “I think that vaccinations are causing me complications/problems” and “I think I’m going to get sick from vaccines” were reverse-coded. Asthma control status was assessed using the GINA asthma symptoms test (GINA-AST).1 The final section assessed participants’ vaccination practices for influenza and other recommended vaccines.
Sample size calculation
To explore the factors associated with influenza vaccination practices, a binary logistic regression analysis was carried out. In determining the adequacy of the sample size for this model, the well-established rule of thumb concerning Events Per Variable (EPV) was utilized,18 specifying that a minimum of ten outcome events should be available for each predictor included in the model. Given that the analysis included nine independent variables, this benchmark translated into a requirement for at least 90 participants within the smaller of the comparison groups. The current study included 115 patients in the smaller group.
Statistical analysis
Data were presented as medians and interquartile ranges (IQR) for continuous variables and frequencies with percentages (%) for categorical variables. To assess internal consistency, Cronbach’s alpha was computed for the two HLVa-Ar scales and for the vaccine attitude scale. A binary logistic regression model was applied to assess factors associated with influenza vaccine practice (never vaccinated vs previously vaccinated patients). The model included age, VL, sex, education level, monthly income, marital status, asthma control status, attitude score, and disease duration. Multicollinearity was assessed by computing VIF. Significance was determined at p-values < 0.05. The Statistical Package for the Social Sciences (SPSS), version 26, was used to analyze the data. SPSS version 26 was used to analyze the data.
Results
Table 1 presents the sociodemographic characteristics of the study sample, categorized by gender, education level, and asthma control status. More than half of the participants were female (54.8%), with a median age of 50 years (IQR: 38–61). Among males, 48.1% held a university or college degree, compared to 42.9% of females. In terms of asthma control, 33.8% of females and 38.7% of males had well-controlled asthma. Monthly income was less than 500 JOD for the majority of participants across all groups, particularly among those with only an elementary school education (87.4%) and those with uncontrolled asthma (73.8%). Most participants were married (72.1% of females and 81.2% of males) and had children (31.1% of females and 32.6% of males), although a higher proportion of individuals with uncontrolled asthma reported having no children (85.0%).
Table 1.
Sociodemographic characteristics of the study sample by gender, education level, and asthma control status.
| Gender |
Education Level |
Asthma Control Status |
|||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Female n = 54.8% |
Male n = 45.3% |
Elementary school |
High school |
University/college degree |
Well-controlled |
Partially controlled |
Uncontrolled |
||||
| Count (%) or median (IQR) | |||||||||||
| Age | 50 (38–61) | 54 (38–66) | 65 (56–71) | 55 (45–61) | 39 (30–49) | 44 (33–55) | 55 (40–66) | 60 (45–71) | |||
| Education | Elementary school | 83 (37.9%) | 52 (28.7%) | 28 (19.4%) | 63 (35.8%) | 44 (55.0%) | |||||
| High school | 42 (19.2%) | 42 (23.2%) | 35 (24.3%) | 36 (20.5%) | 13 (16.3%) | ||||||
| University/college degree | 94 (42.9%) | 87 (48.1%) | 81 (56.3%) | 77 (43.8%) | 23 (28.7%) | ||||||
| Monthly income | <500 | 156 (71.2%) | 115 (63.5%) | 118 (87.4%) | 68 (81%) | 85 (47%) | 92 (63.9%) | 120 (68.2%) | 59 (73.8%) | ||
| ≥500 | 63 (28.8%) | 66 (36.5%) | 17 (12.6%) | 16 (19%) | 96 (53%) | 52 (36.1%) | 56 (31.8%) | 21 (26.3%) | |||
| Marital | Other | 61 (27.9%) | 34 (18.8%) | 35 (25.9%) | 9 (10.7%) | 51 (28.2%) | 36 (25.0%) | 37 (21.0%) | 22 (27.5%) | ||
| Married | 158 (72.1%) | 147 (81.2%) | 100 (74.1%) | 75 (89.3%) | 130 (71.8%) | 108 (75.0%) | 139 (79.0%) | 58 (72.5%) | |||
| Children | No | 151 (68.9%) | 122 (67.4%) | 121 (89.6%) | 59 (70.2%) | 93 (51.4%) | 83 (57.6%) | 122 (69.3%) | 68 (85.0%) | ||
| Yes | 68 (31.1%) | 59 (32.6%) | 14 (10.4%) | 25 (29.8%) | 88 (48.6%) | 61 (42.4%) | 54 (30.7%) | 12 (15.0%) | |||
| CONTROL_STATUS | Well-controlled | 74 (33.8%) | 70 (38.7%) | 28 (20.7%) | 35 (41.7%) | 81 (44.8%) | |||||
| Partially controlled | 99 (45.2%) | 77 (42.5%) | 63 (46.7%) | 36 (42.9%) | 77 (42.5%) | ||||||
| Uncontrolled | 46 (21%) | 34 (18.8%) | 44 (32.6%) | 13 (15.5%) | 23 (12.7%) | ||||||
| How long have you been diagnosed with the disease? | 10 (4–20) | 14 (6–25) | 18 (6–30) | 10 (5–16) | 10 (4–15) | 6 (3–15) | 14 (6–20) | 20 (8.5–30) | |||
*Jordanian dinars (1 JOD = 1.4 USD).
Participants’ responses regarding their vaccination attitudes, categorized by gender, educational level, and asthma control status, are presented in Tables 2A1 and A2. Among the positive statements, the item “Infectious respiratory diseases such as influenza and COVID-19 increase my asthma symptoms” received the highest proportion of “agree” or “strongly agree” responses across all groups. This included both genders (63% of females and 66.3% of males), all educational levels (elementary, 58.5%; high school, 64.3%; and university or college degree, 69.1%), as well as asthma control categories (well-controlled, 66.7%; partially controlled, 67.1%; and uncontrolled, 55.1%).
Table 2.
Participants’ responses regarding their vaccination attitudes by gender.
| Gender |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Female |
Male |
|||||||||
| Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
Strongly disagree |
Disagree |
Neutral |
Agree |
Strongly agree |
|
| Count (%) | ||||||||||
| I think I should get the different vaccines | 5 (2.3%) | 47 (21.5%) | 69 (31.5%) | 92 (42%) | 6 (2.7%) | 0 (0%) | 37 (20.4%) | 71 (39.2%) | 69 (38.1%) | 4 (2.2%) |
| My doctor thinks I should get different vaccines. | 6 (2.7%) | 20 (9.1%) | 113 (51.6%) | 76 (34.7%) | 4 (1.8%) | 1 (0.6%) | 20 (11%) | 103 (56.9%) | 53 (29.3%) | 4 (2.2%) |
| Influenza vaccination prevents disease | 2 (0.9%) | 22 (10%) | 121 (55.3%) | 73 (33.3%) | 1 (0.5%) | 1 (0.6%) | 11 (6.1%) | 111 (61.3%) | 53 (29.3%) | 5 (2.8%) |
| Infectious respiratory diseases such as influenza and COVID-19 increase my asthma symptoms | 1 (0.5%) | 5 (2.3%) | 75 (34.2%) | 106 (48.4%) | 32 (14.6%) | 0 (0%) | 7 (3.9%) | 54 (29.8%) | 86 (47.5%) | 34 (18.8%) |
| I think that vaccinations are causing me complications/problems* | 2 (0.9%) | 37 (16.9%) | 145 (66.2%) | 31 (14.2%) | 4 (1.8%) | 0 (0%) | 30 (16.6%) | 127 (70.2%) | 21 (11.6%) | 3 (1.7%) |
| I think I’m going to get sick from vaccines* | 1 (0.5%) | 36 (16.4%) | 149 (68%) | 29 (13.2%) | 4 (1.8%) | 0 (0%) | 32 (17.7%) | 125 (69.1%) | 21 (11.6%) | 3 (1.7%) |
*Reversed scoring.
Among the negative statements, the item “I think that vaccinations are causing me complications/problems” received the lowest percentage of “disagree” or “strongly disagree” responses among females (17.8%). In contrast, participants with a university or college degree had the highest percentage of “disagree” or “strongly disagree” responses to the same item (61.9%). When analyzed by asthma control status, 20.8% of participants with well-controlled asthma, 15.4% with partially controlled asthma, and 15.1% with uncontrolled asthma responded with “disagree” or “strongly disagree” to this statement. The median attitude score was 19 (IQR: 18–21) out of a maximum possible score of 30. Cronbach’s alpha for the attitude scale was 0.77, indicating acceptable internal consistency.
Participants’ responses to the vaccination literacy questionnaire, categorized by educational level, are presented in Table A3. The item with the highest “Often” response among participants with a university or college degree was “Did you discuss what you understood about vaccinations with your doctor or other people?” (45.3%). Among those with a high school education, the highest “Often” response was for “Did you check whether the information was correct?” (35.7%). The same item received the highest “Often” response among those with an elementary school education (28.1%). In contrast, the item with the highest “Never” response among university or college graduates was “Did you need much time to understand them?” (35.4%). For high school participants, this item also received the highest “Never” response (42.9%). Among elementary school participants, the item with the highest “Never” response was “Have you considered the credibility of the sources?” (37%).
Participants’ responses to the vaccination literacy questionnaire, categorized by gender, are presented in Table 3. The item with the highest “Often” response was “Did you check whether the information was correct?” (32.9% of females and 41.4% of males), while the item with the highest “Never” response was “Did you need much time to understand them?” (36.5% of females and 37% of males). The median VL score was 35 (IQR: 27–41) out of a maximum possible score of 56. Cronbach’s alpha was 0.91 for the functional VL scale and 0.93 for the interactive and critical VL scale.
Table 3.
Participants’ responses to the vaccination literacy questionnaire categorized by gender.
| Gender |
||||||||
|---|---|---|---|---|---|---|---|---|
| Female |
Male |
|||||||
| Never |
Rarely |
Sometimes |
Often |
Never |
Rarely |
Sometimes |
Often |
|
| Count (%) | ||||||||
| Functional VL | ||||||||
| Did you find that the material as a whole (texts and/or images) was difficult to read? | 70 (32%) | 64 (29.2%) | 81 (37%) | 4 (1.8%) | 58 (32%) | 54 (29.8%) | 60 (33.1%) | 9 (5%) |
| Did you find words you didn’t know? | 68 (31.1%) | 85 (38.8%) | 61 (27.9%) | 5 (2.3%) | 59 (32.6%) | 73 (40.3%) | 36 (19.9%) | 13 (7.2%) |
| Did you find that the texts were difficult to understand? | 66 (30.1%) | 63 (28.8%) | 82 (37.4%) | 8 (3.7%) | 59 (32.6%) | 35 (19.3%) | 78 (43.1%) | 9 (5%) |
| Did you need much time to understand them? | 80 (36.5%) | 65 (29.7%) | 66 (30.1%) | 8 (3.7%) | 67 (37%) | 58 (32%) | 45 (24.9%) | 11 (6.1%) |
| Did you or would you have needed someone to help you understand them? | 60 (27.4%) | 67 (30.6%) | 86 (39.3%) | 6 (2.7%) | 46 (25.4%) | 70 (38.7%) | 55 (30.4%) | 10 (5.5%) |
| Interactive and critical VL | ||||||||
| Have you consulted more than one source of information? | 54 (24.7%) | 30 (13.7%) | 71 (32.4%) | 64 (29.2%) | 40 (22.1%) | 29 (16%) | 56 (30.9%) | 56 (30.9%) |
| Did you find the information you were looking for? | 53 (24.2%) | 41 (18.7%) | 50 (22.8%) | 75 (34.2%) | 42 (23.2%) | 30 (16.6%) | 42 (23.2%) | 67 (37%) |
| Did you understand the information found? | 57 (26%) | 41 (18.7%) | 45 (20.5%) | 76 (34.7%) | 38 (21%) | 28 (15.5%) | 50 (27.6%) | 65 (35.9%) |
| Have you had the opportunity to use the information? | 66 (30.1%) | 38 (17.4%) | 56 (25.6%) | 59 (26.9%) | 40 (22.1%) | 32 (17.7%) | 63 (34.8%) | 46 (25.4%) |
| Did you discuss what you understood about vaccinations with your doctor or other people? | 60 (27.4%) | 36 (16.4%) | 45 (20.5%) | 78 (35.6%) | 41 (22.7%) | 24 (13.3%) | 52 (28.7%) | 64 (35.4%) |
| Did you consider whether the information collected was about your condition? | 66 (30.1%) | 39 (17.8%) | 46 (21%) | 68 (31.1%) | 40 (22.1%) | 29 (16%) | 56 (30.9%) | 56 (30.9%) |
| Have you considered the credibility of the sources? | 68 (31.1%) | 38 (17.4%) | 47 (21.5%) | 66 (30.1%) | 48 (26.5%) | 34 (18.8%) | 34 (18.8%) | 65 (35.9%) |
| Did you check whether the information was correct? | 70 (32%) | 36 (16.4%) | 41 (18.7%) | 72 (32.9%) | 39 (21.5%) | 35 (19.3%) | 32 (17.7%) | 75 (41.4%) |
| Did you find any useful information to make a decision on whether or not to get vaccinated? | 63 (28.8%) | 34 (15.5%) | 61 (27.9%) | 61 (27.9%) | 38 (21%) | 25 (13.8%) | 53 (29.3%) | 65 (35.9%) |
Participants’ responses to the vaccination literacy questionnaire, categorized by educational level, are displayed in Table A3. The item with the highest “Often” response among participants with a university or college degree was “Did you discuss what you understood about vaccinations with your doctor or other people?” (45.3%). Among those with a high school education, the highest “Often” response was for “Did you check whether the information was correct?” (35.7%). The same item also received the highest “Often” response among participants with an elementary school education (28.1%). In contrast, the item with the highest “Never” response among university or college graduates was “Did you need much time to understand them?” (35.4%). This item also had the highest “Never” response among high school participants (42.9%). Among elementary school participants, the highest “Never” response was for “Have you considered the credibility of the sources?” (37%).
Participants’ responses to the vaccination literacy questionnaire, categorized by asthma control status, are presented in Table A2. Among participants with well-controlled asthma, the item with the highest “Often” response was “Did you check whether the information was correct?” (47.2%). The same item also received the highest “Often” response in the partially controlled group (35.8%). In the uncontrolled asthma group, the items “Did you understand the information found?” and “Have you had the opportunity to use the information?” both had the highest “Often” response rates (27.5%).
The item with the highest “Never” response in the well-controlled group was “Did you need much time to understand them?” (39.6%). This item also had the highest “Never” response in the partially controlled group (34.7%). In the uncontrolled asthma group, the highest “Never” response was for “Have you considered the credibility of the sources?” (42.5%).
Participants’ uptake of vaccines varied across different vaccine types and was influenced by gender, educational level, and asthma control status, as shown in Table 4. For the tetanus vaccine, a substantial portion of participants (51.6% of females and 48.3% of males) reported never having been vaccinated. Influenza vaccination uptake was consistently low across all groups, with approximately 70.9% of participants indicating they had never received the vaccine. Most participants reported receiving two doses of the COVID-19 vaccine (64.5% of females and 75.3% of males), with higher uptake observed among those with a university or college degree (76.4%) and those with well-controlled asthma (78%). Pneumococcal vaccination was extremely limited, with the majority of participants reporting no history of vaccination (94.9% of females and 92.7% of males).
Table 4.
Participants’ responses to vaccination practices categorized by gender, educational level, and asthma control status.
| Gender |
Educational Level |
Asthma Control Status |
|||||||
|---|---|---|---|---|---|---|---|---|---|
| Female |
Male |
Elementary school |
High school |
University/college degree |
Well-controlled |
Partially controlled |
Uncontrolled |
||
| Count (%) | |||||||||
| Have you been vaccinated against tetanus? | Never at all | 112 (51.6%) | 86 (48.3%) | 74 (55.2%) | 45 (54.2%) | 79 (44.4%) | 74 (52.5%) | 87 (49.7%) | 37 (46.8%) |
| Yes, more than 10 years ago | 81 (37.3%) | 67 (37.6%) | 38 (28.4%) | 28 (33.7%) | 82 (46.1%) | 57 (40.4%) | 66 (37.7%) | 25 (31.6%) | |
| Yes, in the last 10 years | 24 (11.1%) | 25 (14%) | 22 (16.4%) | 10 (12%) | 17 (9.6%) | 10 (7.1%) | 22 (12.6%) | 17 (21.5%) | |
| Have you ever been vaccinated against influenza? | Never at all | 152 (70%) | 128 (71.9%) | 108 (80.6%) | 63 (75.9%) | 109 (61.2%) | 98 (69.5%) | 127 (72.6%) | 55 (69.6%) |
| Yes | 65 (30%) | 50 (28.1%) | 26 (19.4%) | 20 (24.1%) | 69 (38.8%) | 43 (30.5%) | 48 (27.4%) | 24 (30.4%) | |
| How many times have you previously received the COVID-19 vaccine? | I never received the vaccine | 33 (15.2%) | 15 (8.4%) | 27 (20.1%) | 10 (12%) | 11 (6.2%) | 7 (5%) | 16 (9.1%) | 25 (31.6%) |
| One | 33 (15.2%) | 14 (7.9%) | 20 (14.9%) | 16 (19.3%) | 11 (6.2%) | 10 (7.1%) | 24 (13.7%) | 13 (16.5%) | |
| Two | 140 (64.5%) | 134 (75.3%) | 84 (62.7%) | 54 (65.1%) | 136 (76.4%) | 110 (78%) | 127 (72.6%) | 37 (46.8%) | |
| Three | 11 (5.1%) | 14 (7.9%) | 3 (2.2%) | 3 (3.6%) | 19 (10.7%) | 14 (9.9%) | 7 (4%) | 4 (5.1%) | |
| More than three times | 0 (0%) | 1 (0.6%) | 0 (0%) | 0 (0%) | 1 (0.6%) | 0 (0%) | 1 (0.6%) | 0 (0%) | |
| Have you been vaccinated against pneumococcus? | Never at all | 206 (94.9%) | 165 (92.7%) | 123 (91.8%) | 78 (94%) | 170 (95.5%) | 139 (98.6%) | 163 (93.1%) | 69 (87.3%) |
| Yes | 11 (5.1%) | 13 (7.3%) | 11 (8.2%) | 5 (6%) | 8 (4.5%) | 2 (1.4%) | 12 (6.9%) | 10 (12.7%) | |
A binary regression model was used to identify the variables significantly associated with patients vaccinated against influenza (see Table 5). The binary logistic regression analysis demonstrated that higher VL scores were significantly associated with increased odds of vaccination (OR = 1.053, 95% CI: 1.024–1.083, p <.001). A more positive attitude toward vaccination also predicted higher vaccination rates (OR = 1.286, 95% CI: 1.167–1.418, p <.001). On the other hand, participants earning less than 500 JOD per month were less likely to be vaccinated (OR = 0.450, 95% CI: 0.257–0.787, p = .005).
Table 5.
Binary logistic regression of variables associated with participants’ influenza vaccination status.
| OR | p-value | 95% C.I. for OR |
|||
|---|---|---|---|---|---|
| Lower | Upper | ||||
| Age | 1.001 | 0.922 | 0.978 | 1.025 | |
| VL | 1.053 | <0.001 | 1.024 | 1.083 | |
| Sex | Female vs. male | 1.427 | 0.188 | 0.840 | 2.423 |
| Education | Elementary school | 0.621 | 0.249 | 0.276 | 1.396 |
| High school | 0.768 | 0.487 | 0.365 | 1.615 | |
| University/college degree | (REF) | ||||
| Monthly income | <500 JOD vs. ≥500 JOD | 0.450 | 0.005 | 0.257 | 0.787 |
| Marital status | Married vs others | 0.915 | 0.784 | 0.485 | 1.726 |
| Asthma control status | Well-controlled | 0.685 | 0.331 | 0.320 | 1.468 |
| Partially controlled | 0.601 | 0.153 | 0.299 | 1.209 | |
| Uncontrolled | (REF) | ||||
| Attitude score | 1.286 | <0.001 | 1.167 | 1.418 | |
| How long have you been diagnosed with the disease? | 1.015 | 0.208 | 0.991 | 1.040 | |
*Jordanian dinars (1 JOD = 1.4 USD).
Discussion
This study evaluated VL among adults with asthma in Jordan and investigated its association, among other variables, with vaccination practices. Our findings revealed low levels of VL among participants when assessed using both functional VL and interactive and critical VL. Furthermore, the study identified several factors associated with vaccination acceptance, including VL, vaccination attitudes, and income level. The regression analysis clearly demonstrated that individuals with higher VL scores had significantly greater odds of being vaccinated. This highlights a strong association between improved understanding and use of vaccine-related information and increased vaccine uptake in our sample. The results add to the growing body of evidence that literacy-specific competencies may shape real-world preventive health behaviors. While studies specifically assessing VL in asthmatic patients as a predictor of vaccine acceptance are limited, several studies have confirmed the significance of related aspects of VL, such as knowledge and attitudes toward vaccination among individuals with asthma, which aligns with our results. A study conducted on asthmatic adults and parents of 102 children with asthma found low vaccine rates that were strongly attributed to misconceptions about vaccine effectiveness and possible adverse effects.19 The second part of the study assessed vaccination practices among pediatricians and pulmonary physicians and found that many had neither received the vaccine themselves nor recommended it to their patients. This highlights the need for improved education for both physicians and patients.
The low uptake observed in our study must be considered within the broader context of national vaccination trends. While influenza continues to be a major risk factor for asthma exacerbations20 and vaccination is considered of high value for patients with chronic conditions21 especially in respiratory diseases such as asthma and Chronic Obstructive Pulmonary Disease (COPD), influenza vaccine coverage in Jordan remains notably low. A cross-sectional study assessing Jordanians’ attitudes toward the use of influenza vaccines revealed that only 9.9% of participants reported having received the vaccine during the period covered by the study.14 Many studies have explored the underlying factors behind the significantly low acceptance of vaccines. The most prevalent factor was found to be insufficient knowledge regarding asthma, influenza vaccine and the association between them.22 Recent studies suggest that vaccine awareness has a significant influence on vaccine acceptance among patients. For instance, a study conducted in Jordan showed that patients with greater knowledge about vaccines were more likely to accept vaccination, highlighting the substantial impact of awareness on vaccination decisions.22 Additionally, a cross-sectional study among Jordanian adults assessing the attitudes toward the role of the influenza vaccine during COVID-19 pandemic found that receiving information about the vaccine, its safety, and possible side effects was among the key predictors of influenza vaccine uptake.15
Despite some general awareness of respiratory risks, our findings indicate that this does not necessarily translate into action. Our findings suggest that vaccine literacy among adults with asthma in this study was generally low, as indicated by scores across both functional and interactive/critical domains. This limited literacy was evident in participants’ responses to vaccine-related items, where many did not reject misconceptions about vaccine safety. At the same time, a majority appeared to recognize the health risks posed by respiratory infections such as influenza and COVID-19, particularly in relation to asthma exacerbations. This indicates a disconnect between awareness of infection risks and the adoption of preventive behaviors like vaccination – likely linked to insufficient vaccine literacy. A study conducted in Italy indicated that improving vaccine literacy could positively influence vaccination rates among healthcare professionals.23 Similar associations have been observed in the general public. For example, a cross-sectional study conducted among 614 Chinese adults found a significant positive correlation between interactive-critical VL and vaccination intention.24
The awareness – action gap reinforces the importance of targeted, skill-based interventions. The gap highlighted by our findings between awareness and literacy-informed actions reinforces the need for educational strategies in healthcare that go beyond raising awareness. Such approaches should focus on strengthening patients’ capacity to critically evaluate and act on vaccine-related information. Evidence from a community-based intervention conducted among racially and ethnically minoritized individuals in the United States supports the effectiveness of this approach, showing improved vaccine literacy and greater acceptance of influenza vaccination.25 In the Jordanian context, adopting similar educational interventions could be highly valuable and could be delivered through educational programs in schools and universities, by healthcare providers, and via social media platforms. Strengthening practical skills to evaluate vaccine-related information, address misconceptions, and effectively access vaccination services within the healthcare system could empower the Jordanian population, especially individuals with asthma, to make informed, proactive decisions. This, in turn, could improve vaccine uptake and enhance asthma management.
In addition to VL, systemic and policy-related issues may influence uptake. In our study, vaccination practices varied substantially across different vaccine types. COVID-19 vaccine uptake was notably higher than that of influenza and pneumococcal vaccines. These disparities may be explained by the mandatory nature of the COVID-19 vaccine, in contrast to the voluntary status of the others. Limited vaccine literacy among participants, along with inconsistencies in how public health information is communicated, also appear to have influenced uptake. These inconsistencies include conflicting advice from healthcare practitioners and a lack of clear guidelines. Although conducted in the United States, a large cross-sectional study involving 19,420 adults found that exposure to inconsistent information from unreliable sources such as social media was associated with lower influenza vaccine uptake.26 While the cultural context differs, these findings suggest that conflicting messaging can undermine vaccine confidence more broadly. In Jordan, where influenza vaccination rates are already low and there is a disconnect between infection awareness and preventive behaviors,19 similar patterns may contribute to vaccine hesitancy. Addressing this requires a coordinated effort to improve public health communication by ensuring that vaccine-related information is clear, consistent, and comes from trusted sources. Although many patients acknowledged their susceptibility to respiratory infections, the observed low levels of vaccine literacy suggest that most still lacked the knowledge and skills necessary to act on vaccine-related information. Despite these low literacy levels, the tools used to assess vaccine literacy demonstrated excellent internal consistency, with Cronbach’s alpha values of 0.91 and 0.93 for the Functional and Interactive VL subscales, respectively.
Socioeconomic factors further compound these challenges. Demographic factors such as age, education level, and monthly income were found to be associated with influenza vaccine uptake among asthma patients. Our findings indicated that individuals with lower income levels were significantly less likely to have received the influenza vaccine. This is consistent with previous studies examining the influence of socioeconomic status on vaccination behaviors. For example, research conducted in the United States has shown that individuals with lower income levels have reduced access to and uptake of influenza vaccination.27 This highlights the role of socioeconomic factors in vaccine access and highlights the need for targeted interventions like vaccination programs for low-income populations, given the fact that contrasting findings have been proposed for the role of health literacy in bridging gaps in vaccine uptake in resource-limited settings.28 Conversely, higher vaccine literacy was associated with a greater likelihood of having received the influenza vaccine. This finding aligns with other studies that emphasize the important role of vaccine literacy in reducing vaccine hesitancy. A cross-sectional study conducted in China found that individuals with higher overall vaccine literacy were less hesitant to receive the influenza vaccine,29 reinforcing the idea that, beyond basic knowledge, the ability to critically engage with and apply vaccine-related information plays a crucial role in shaping health behaviors such as vaccination. Our study found that only 29.1% of asthma patients reported receiving the influenza vaccine. While this is within the general range reported for the Jordanian population in some older studies (9.9% to 27.5%),14 it’s slightly higher than the more recent figures for adults with chronic diseases (10.4%).17 This suggests that while overall influenza vaccination rates are low in Jordan, even among those with a higher risk condition like asthma, the rate in our study population is not dramatically different from the general population. This highlights that low influenza vaccination coverage is a widespread issue in Jordan, regardless of specific health conditions, and points to broader systemic and awareness challenges, highlighting the need for broader public health solutions.
Strengths, limitations, and future directions
The current study has a number of limitations. The cross-sectional design limits the ability to establish causality; longitudinal and interventional studies are warranted to explore the causal relationships between VL and vaccination practices among asthmatic patients. Moreover, self-reported data on vaccination status and VL may be subject to recall and social biases. Additionally, the study was conducted in a single healthcare setting, which may limit its generalizability; a multicenter study would likely yield more representative results. Finally, the participants were recruited from an asthma clinic, which may also limit the generalizability of our results. Individuals who attend a specialized asthma clinic may have received consistent counseling on vaccines and their importance. This, in turn, could result in higher vaccine literacy and uptake among the study participants compared to individuals with asthma who do not regularly attend such clinics. To account for this limitation, which may have led to an overestimation of VL in the asthma population, future research should recruit a more diverse sample from multiple settings. On the other hand, our study has several strengths. To the best of our knowledge, this is the first study in Jordan assessing the association between VL and influenza vaccine uptake among asthmatic patients. The sample size was adequate, enhancing the statistical power and reliability of our findings. Additionally, this study provides a foundation for future longitudinal and intervention studies to examine the causal relationship between VL and vaccination behaviors, thereby paving the way for exploring more effective interventions to improve vaccine literacy and vaccination coverage in asthmatic patients.
Conclusion
Our study highlights the significant role of VL and demographic variables such as age and income level in shaping vaccination decisions and practices among asthmatic patients. Enhancing VL and addressing socioeconomic barriers are key to improving vaccine coverage and reducing asthma exacerbations as well as other infection-related complications. This could be achieved by focusing on developing educational campaigns and vaccination programs particularly targeting low-income populations to empower patients’ informed decision-making, ultimately reducing influenza-related complications in this population.
Supplementary Material
Acknowledgements
Conceptualization, W.Q., and A.J.; methodology, W.Q., and M.K.; software, J.E.; validation, K.O., and A.J.; formal analysis, W.Q.; investigation, M.K.; writing – original draft preparation, L.S, L.A.S., and M.K.; writing – review and editing, W.Q., J.E., and A.J.; visualization, W.Q., K.O., and A.J.; supervision, A.J. All authors have read and agreed to the published version of the manuscript.
Biography
Judith Eberhardt is Professor of Psychology and Public Health Equity at Teesside University and a Chartered Psychologist. She is an Associate Fellow of the British Psychological Society, a Fellow of the Higher Education Academy, and a member of the American Psychological Association. Her research focuses on preventative health behaviours, health inequalities in ethnic minority populations, and the psychosocial aspects of long-term conditions, particularly within the fields of health psychology and public health. Her research has been supported by funding from organisations such as the NIHR, Public Health England, and Prostate Cancer Research, and she has published extensively in leading journals in psychology and public health. In addition, she regularly reviews for over 50 scientific journals and funding bodies. Judith holds a PhD in Psychology from Teesside University and a Vordiplom in Psychology from Heidelberg University.
Appendices.
Table A1.
Participants’ responses regarding their vaccination attitudes by educational level.
| Education Level |
|||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Elementary school |
High school |
University/college degree |
|||||||||||||
| Strongly disagree | Disagree | Neutral | Agree | Strongly agree | Strongly disagree | Disagree | Neutral | I agree | Strongly agree | Strongly disagree | Disagree | Neutral | Agree | Strongly agree | |
| I think I should get the different vaccines | 1 (0.7%) | 39 (28.9%) | 51 (37.8%) | 41 (30.4%) | 3 (2.2%) | 0 (0%) | 18 (21.4%) | 32 (38.1%) | 32 (38.1%) | 2 (2.4%) | 4 (2.2%) | 27 (14.9%) | 57 (31.5%) | 88 (48.6%) | 5 (2.8%) |
| My doctor thinks I should get different vaccines. | 2 (1.5%) | 23 (17%) | 79 (58.5%) | 30 (22.2%) | 1 (0.7%) | 0 (0%) | 3 (3.6%) | 54 (64.3%) | 25 (29.8%) | 2 (2.4%) | 5 (2.8%) | 14 (7.7%) | 83 (45.9%) | 74 (40.9%) | 5 (2.8%) |
| Influenza vaccination prevents disease | 2 (1.5%) | 12 (8.9%) | 95 (70.4%) | 26 (19.3%) | 0 (0%) | 0 (0%) | 6 (7.1%) | 49 (58.3%) | 29 (34.5%) | 0 (0%) | 1 (0.6%) | 15 (8.3%) | 88 (48.6%) | 71 (39.2%) | 6 (3.3%) |
| Infectious respiratory diseases such as influenza and Corona increase my asthma symptoms | 0 (0%) | 4 (3%) | 52 (38.5%) | 62 (45.9%) | 17 (12.6%) | 0 (0%) | 3 (3.6%) | 27 (32.1%) | 45 (53.6%) | 9 (10.7%) | 1 (0.6%) | 5 (2.8%) | 50 (27.6%) | 85 (47%) | 40 (22.1%) |
| I think that vaccinations are causing me complications/problems* | 0 (0%) | 11 (8.1%) | 100 (74.1%) | 18 (13.3%) | 6 (4.4%) | 0 (0%) | 14 (16.7%) | 62 (73.8%) | 8 (9.5%) | 0 (0%) | 2 (1.1%) | 110 (60.8%) | 26 (14.4%) | 1 (0.6%) | 0 (0%) |
| I think I’m going to get sick from vaccines* | 0 (0%) | 10 (7.4%) | 101 (74.8%) | 18 (13.3%) | 6 (4.4%) | 0 (0%) | 15 (17.9%) | 63 (75%) | 6 (7.1%) | 0 (0%) | 1 (0.6%) | 110 (60.8%) | 26 (14.4%) | 1 (0.6%) | 0 (0%) |
*Reversed scoring.
Table A2.
Participants’ responses regarding their vaccination attitudes by asthma control status.
| Asthma Control status |
|||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Well-controlled |
Partially controlled |
Uncontrolled |
|||||||||||||
| Strongly disagreed | Disagree | Neutral | Agree | Strongly agree | Strongly disagree | Disagree | neutral | Agree | Strongly agree | Strongly disagree | Disagree | Neutral | Agree | Strongly agree | |
| I think I should get the different vaccines | 2 (1.4%) | 30 (20.8%) | 44 (30.6%) | 67 (46.5%) | 1 (0.7%) | 2 (1.1%) | 29 (16.5%) | 72 (40.9%) | 68 (38.6%) | 5 (2.8%) | 1 (1.3%) | 25 (31.3%) | 24 (30%) | 26 (32.5%) | 4 (5%) |
| My doctor thinks I should get different vaccines. | 2 (1.4%) | 13 (9%) | 79 (54.9%) | 49 (34%) | 1 (0.7%) | 2 (1.1%) | 13 (7.4%) | 100 (56.8%) | 59 (33.5%) | 2 (1.1%) | 3 (3.8%) | 14 (17.5%) | 37 (46.3%) | 21 (26.3%) | 5 (6.3%) |
| Influenza vaccination prevents disease | 0 (0%) | 12 (8.3%) | 79 (54.9%) | 50 (34.7%) | 3 (2.1%) | 1 (0.6%) | 12 (6.8%) | 105 (59.7%) | 55 (31.3%) | 3 (1.7%) | 2 (2.5%) | 9 (11.3%) | 48 (60%) | 21 (26.3%) | 0 (0%) |
| Infectious respiratory diseases such as influenza and COVID-19 increase my asthma symptoms | 0 (0%) | 7 (4.9%) | 41 (28.5%) | 80 (55.6%) | 16 (11.1%) | 1 (0.6%) | 0 (0%) | 57 (32.4%) | 83 (47.2%) | 35 (19.9%) | 0 (0%) | 5 (6.3%) | 31 (38.8%) | 29 (36.3%) | 15 (18.8%) |
| I think that vaccinations are causing me complications/problems* | 0 (0%) | 30 (20.8%) | 95 (66%) | 19 (13.2%) | 0 (0%) | 1 (0.6%) | 26 (14.8%) | 125 (71%) | 22 (12.5%) | 2 (1.1%) | 1 (1.3%) | 11 (13.8%) | 52 (65%) | 11 (13.8%) | 5 (6.3%) |
| I think I’m going to get sick from vaccines* | 0 (0%) | 30 (20.8%) | 99 (68.8%) | 15 (10.4%) | 0 (0%) | 1 (0.6%) | 26 (14.8%) | 125 (71%) | 22 (12.5%) | 2 (1.1%) | 0 (0%) | 12 (15%) | 50 (62.5%) | 13 (16.3%) | 5 (6.3%) |
*Reversed scoring.
Table A3.
Participants’ responses to the vaccination literacy questionnaire were categorized by educational level.
| Educational Level |
||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Elementary school |
High school |
University/college degree |
||||||||||
| Never |
Rarely |
Sometimes |
Often |
Never |
Rarely |
Sometimes |
Often |
Never |
Rarely |
Sometimes |
Often |
|
| Count (%) | ||||||||||||
| Functional VL | ||||||||||||
| Did you find that the material as a whole (texts and/or images) was difficult to read? | 41 (30.4%) | 49 (36.3%) | 43 (31.9%) | 2 (1.5%) | 27 (32.1%) | 19 (22.6%) | 34 (40.5%) | 4 (4.8%) | 60 (33.1%) | 50 (27.6%) | 64 (35.4%) | 7 (3.9%) |
| Did you find words you didn’t know? | 41 (30.4%) | 59 (43.7%) | 30 (22.2%) | 5 (3.7%) | 24 (28.6%) | 31 (36.9%) | 25 (29.8%) | 4 (4.8%) | 62 (34.3%) | 68 (37.6%) | 42 (23.2%) | 9 (5%) |
| Did you find that the texts were difficult to understand? | 44 (32.6%) | 33 (24.4%) | 54 (40%) | 4 (3%) | 23 (27.4%) | 20 (23.8%) | 37 (44%) | 4 (4.8%) | 58 (32%) | 45 (24.9%) | 69 (38.1%) | 9 (5%) |
| Did you need much time to understand them? | 47 (34.8%) | 45 (33.3%) | 37 (27.4%) | 6 (4.4%) | 36 (42.9%) | 19 (22.6%) | 25 (29.8%) | 4 (4.8%) | 64 (35.4%) | 59 (32.6%) | 49 (27.1%) | 9 (5%) |
| Did you or would you have needed someone to help you understand them? | 34 (25.2%) | 48 (35.6%) | 49 (36.3%) | 4 (3%) | 22 (26.2%) | 27 (32.1%) | 30 (35.7%) | 5 (6%) | 50 (27.6%) | 62 (34.3%) | 62 (34.3%) | 7 (3.9%) |
| Interactive and critical VL | ||||||||||||
| Have you consulted more than one source of information? | 40 (29.6%) | 22 (16.3%) | 42 (31.1%) | 31 (23%) | 26 (31%) | 11 (13.1%) | 23 (27.4%) | 24 (28.6%) | 28 (15.5%) | 26 (14.4%) | 62 (34.3%) | 65 (35.9%) |
| Did you find the information you were looking for? | 40 (29.6%) | 25 (18.5%) | 38 (28.1%) | 32 (23.7%) | 24 (28.6%) | 14 (16.7%) | 15 (17.9%) | 31 (36.9%) | 31 (17.1%) | 32 (17.7%) | 39 (21.5%) | 79 (43.6%) |
| Did you understand the information found? | 40 (29.6%) | 27 (20%) | 37 (27.4%) | 31 (23%) | 22 (26.2%) | 16 (19%) | 15 (17.9%) | 31 (36.9%) | 33 (18.2%) | 26 (14.4%) | 43 (23.8%) | 79 (43.6%) |
| Have you had the opportunity to use the information? | 46 (34.1%) | 25 (18.5%) | 35 (25.9%) | 29 (21.5%) | 22 (26.2%) | 20 (23.8%) | 20 (23.8%) | 22 (26.2%) | 38 (21%) | 25 (13.8%) | 64 (35.4%) | 54 (29.8%) |
| Did you discuss what you understood about vaccinations with your doctor or other people? | 40 (29.6%) | 23 (17%) | 35 (25.9%) | 37 (27.4%) | 28 (33.3%) | 14 (16.7%) | 19 (22.6%) | 23 (27.4%) | 33 (18.2%) | 23 (12.7%) | 43 (23.8%) | 82 (45.3%) |
| Did you consider whether the information collected was about your condition? | 43 (31.9%) | 30 (22.2%) | 30 (22.2%) | 32 (23.7%) | 23 (27.4%) | 16 (19%) | 19 (22.6%) | 26 (31%) | 40 (22.1%) | 22 (12.2%) | 53 (29.3%) | 66 (36.5%) |
| Have you considered the credibility of the sources? | 50 (37%) | 27 (20%) | 27 (20%) | 31 (23%) | 28 (33.3%) | 14 (16.7%) | 15 (17.9%) | 27 (32.1%) | 38 (21%) | 31 (17.1%) | 39 (21.5%) | 73 (40.3%) |
| Did you check whether the information was correct? | 47 (34.8%) | 30 (22.2%) | 20 (14.8%) | 38 (28.1%) | 25 (29.8%) | 15 (17.9%) | 14 (16.7%) | 30 (35.7%) | 37 (20.4%) | 26 (14.4%) | 39 (21.5%) | 79 (43.6%) |
| Did you find any useful information to make a decision on whether or not to get vaccinated? | 40 (29.6%) | 26 (19.3%) | 37 (27.4%) | 32 (23.7%) | 25 (29.8%) | 12 (14.3%) | 23 (27.4%) | 24 (28.6%) | 36 (19.9%) | 21 (11.6%) | 54 (29.8%) | 70 (38.7%) |
Appendix 2.
Table Q1.
Items assessing attitudes toward vaccination.
| Item | I strongly disagree | I disagree | Neutral | I agree | I strongly agree |
|---|---|---|---|---|---|
| I think I should get the different vaccines | |||||
| My doctor thinks I should get different vaccines. | |||||
| Influenza vaccination prevents disease | |||||
| Infectious respiratory diseases such as influenza and COVID-19 increase my asthma symptoms | |||||
| I think that vaccinations are causing me complications/problems* | |||||
| I think I’m going to get sick from vaccines* |
Table Q2.
Items assessing attitudes toward vaccination – Arabic version.
| موافق بشدة | موافق | محايد | غير موافق | غير موافق بشدة | |
|---|---|---|---|---|---|
| أعتقد أنني يجب أن أتلقى اللقاحات المختلفة | |||||
| يعتقد طبيبي أنني يجب أن أتلقى اللقاحات المختلفة | |||||
| التطعيم ضد الأنفلونزا يمنع الإصابة بالامراض | |||||
| لاصابة بالامراض التنفسية المعدية مثل الانفلونزا وكورونا يزيد من اعراض مرض الربو لدي | |||||
| اعتقد انه يتسبب لي تطعيم المطاعيم مضاعفات/مشاكل* | |||||
| أعتقد أنه سوف أمرض مرضت بسبب اللقاحات |
Table Q3.
Vaccination literacy questionnaire.
| Never | Rarely | Sometimes | Often | |
|---|---|---|---|---|
| Did you find that the material as a whole (texts and/or images) was difficult to read? | ||||
| Did you find words you didn’t know? | ||||
| Did you find that the texts were difficult to understand? | ||||
| Did you need much time to understand them? | ||||
| Did you or would you have needed someone to help you understand them? | ||||
| Have you consulted more than one source of information? | ||||
| Did you find the information you were looking for? | ||||
| Did you understand the information found? | ||||
| Have you had the opportunity to use the information? | ||||
| Did you discuss what you understood about vaccinations with your doctor or other people? | ||||
| Did you consider whether the information collected was about your condition? | ||||
| Have you considered the credibility of the sources? | ||||
| Did you check whether the information was correct? | ||||
| Did you find any useful information to make a decision on whether or not to get vaccinated? |
Table Q4.
Vaccination literacy questionnaire – Arabic version.
| غالباً | أحياناً | نادراً | أبدا | |
|---|---|---|---|---|
| هل وجدت هذه المنشورات أو الملصقات(النصوص و/أو الصور) صعبة القراءة؟ | ||||
| هل وجدت كلمات لا تعرفها؟ | ||||
| هل وجدت أن النصوص كانت صعبة الفهم؟ | ||||
| هل كنت بحاجة إلى الكثير من الوقت لفهمها ؟ | ||||
| هل احتجت إلى شخص ما لمساعدتك على فهمها؟ | ||||
| هل سبق لك أن فكرت أو تم نصحك بتلقي اللقاح ضد أي مرض؟ | ||||
| هل استشرت أو بحثت في أكثر من مصدر للمعلومات؟ | ||||
| هل وجدت المعلومات التي كنت تبحث عنها؟ | ||||
| هل فهمت المعلومات التي وجدتها؟ | ||||
| هل أتيحت لك الفرصة لاستخدام المعلومات؟ | ||||
| هل ناقشت ما فهمته عن التطعيمات مع طبيبك أو مع أشخاص آخرين؟ | ||||
| هل فكرت فيما إذا كانت المعلومات التي تم جمعها تتعلق بحالتك؟ | ||||
| هل تحققت من مصداقية المصادر؟ | ||||
| هل تأكدت من صحة المعلومات؟ |
Funding Statement
This research received no funding.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
The dataset supporting the findings of this article is available in Zenodo at https://doi.org/10.5281/zenodo.16206724.
Ethics approval
The study was conducted according to the ethical principles of the Declaration of Helsinki. The authors have obtained ethical approval from Al-Zaytoonah University of Jordan (Ref. No. 47/14/2023–2024), and the University of Jordan Hospital (Ref. No. 10/2024/15816). Written informed consent has been obtained from all participants.
Supplementary Information
Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2025.2552062
References
- 1.2023 GINA main report–Global Initiative for Asthma–GINA [Internet]. [accessed 2023 May 10]. https://ginasthma.org/2023-gina-main-report/.
- 2.O’Conor R, Wolf MS, Smith SG, Martynenko M, Vicencio DP, Sano M, Wisnivesky JP, Federman AD.. Health literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest. 2015;147(5):1307–15. doi: 10.1378/chest.14-0914. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Vollset SE, Ababneh HS, Abate YH, Abbafati C, Abbasgholizadeh R, Abbasian M, Abbastabar H, Abd Al Magied AHA, Abd elhafeez S, Abdelkader A, et al. Burden of disease scenarios for 204 countries and territories, 2022–2050: a forecasting analysis for the global burden of disease study 2021. Lancet. 2024;403(10440):2204–2256. doi: 10.1016/S0140-6736(24)00685-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Busse WW, Lemanske RF, Gern JE. Role of viral respiratory infections in asthma and asthma exacerbations. Lancet [Internet]. 2010. [accessed 2025 Apr 12]. 376(9743):826. https://pmc.ncbi.nlm.nih.gov/articles/PMC2972660/. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Krastev S, Krajden O, Vang ZM, Juárez F-G, Solomonova E, Goldenberg MJ, Weinstock D, Smith MJ, Dervis E, Pilat D, et al. Institutional trust is a distinct construct related to vaccine hesitancy and refusal. BMC Public Health. 2023;23(1):2481. doi: 10.1186/s12889-023-17345-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Vasileiou E, Sheikh A, Butler C, El Ferkh K, Von Wissmann B, McMenamin J, Ritchie L, Schwarze J, Papadopoulos NG, Johnston SL, et al. Effectiveness of influenza vaccines in asthma: a systematic review and meta-analysis. Clin Infect Dis [Internet]. 2017. [accessed 2025 Apr 12]. 65(8):1388. https://pmc.ncbi.nlm.nih.gov/articles/PMC5850022/. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Lyn-Cook R, Halm EA, Wisnivesky JP. Determinants of adherence to influenza vaccination among inner-city adults with persistent asthma. Prim Care Respir J. 2007;16(4):229–235. doi: 10.3132/pcrj.2007.00056. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bello CB, Akinwale OD, Elemile MG. Understanding the concept of health literacy: a strategy to improve nursing practice. J Educ Chang Integrative Nursing [Internet]. 2024. [accessed 2025 Apr 12]. 6(4):241–249. https://journals.lww.com/jinm/fulltext/2024/06040/understanding_the_concept_of_health_literacy__a.9.aspx. [Google Scholar]
- 9.Lorini C, Santomauro F, Donzellini M, Capecchi L, Bechini A, Boccalini S, Bonanni P, Bonaccorsi G. Health literacy and vaccination: a systematic review. Hum Vaccin Immunother [Internet]. 2017. [accessed 2025 Apr 12]. 14(2):478. https://pmc.ncbi.nlm.nih.gov/articles/PMC5806657/. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Biasio LR, Zanobini P, Lorini C, Monaci P, Fanfani A, Gallinoro V, Cerini G, Albora G, Del Riccio M, Pecorelli S, et al. COVID-19 vaccine literacy: a scoping review. Hum Vaccin Immunother. 2023;19(1):2176083. doi: 10.1080/21645515.2023.2176083. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Cadeddu C, Regazzi L, Bonaccorsi G, Rosano A, Unim B, Griebler R, Link T, De Castro P, D’Elia R, Mastrilli V, et al. The determinants of vaccine literacy in the Italian population: results from the health literacy survey 2019. Int J Environ Res Public Health. 2022;19(8):4429. doi: 10.3390/ijerph19084429. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Zhang E, Dai Z, Wang S, Wang X, Zhang X, Fang Q. Vaccine literacy and vaccination: a systematic review. Int J Public Health. 2023;68:68. doi: 10.3389/ijph.2023.1605606. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chiara L, Marco DR, Patrizio Z, Roberto BL, Paolo B, Duccio G, Valerio FA, Andrea G, Olfa M, Vieri L, et al. Vaccination as a social practice: towards a definition of personal, community, population, and organizational vaccine literacy. BMC Public Health. 2023. 23. 23(1). doi: 10.1186/s12889-023-16437-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Assaf AM, Hammad EA, Haddadin RN. Influenza vaccination coverage rates, knowledge, attitudes, and beliefs in Jordan: a comprehensive study. Viral Immunol. 2016;29(9):516–525. doi: 10.1089/vim.2015.0135. [DOI] [PubMed] [Google Scholar]
- 15.Zalloum WA, Elayeh ER, Ali BAH, Zalloum N. Perception, knowledge and attitude towards influenza vaccine during COVID-19 pandemic in Jordanian population. Eur J Integr Med. 2022;49:49. doi: 10.1016/j.eujim.2022.102100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Al-Qerem W, Jarab A, Al Bawab AQ, Eberhardt J, Alasmari F, Hammad A, Obidat R, Al-Sa’di L, Zumot R. Validation of an Arabic tool for assessing vaccination literacy: a factor and rasch analysis. Hum Vaccin Immunother. 2024;20(1):20. doi: 10.1080/21645515.2024.2381297. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Abu-Helalah M, Gharibeh T, Al-Hanaktah M, Khatatbeh I, Batarseh F, Asfour A, Okkeh O, Dalal A, Alhendi A, Ababneh H, et al. Knowledge, attitudes, barriers and uptake rate of influenza virus vaccine among adults with chronic diseases in Jordan: a multicentric cross-sectional study. Front Public Health. 2025;13:1603482. doi: 10.3389/fpubh.2025.1603482. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Peduzzi P, Concato J, Feinstein AR, Holford TR. Importance of events per independent variable in proportional hazards regression analysis II. Accuracy and precision of regression estimates. J Clin Epidemiol. 1995;48(12):1503–1510. doi: 10.1016/0895-4356(95)00048-8. [DOI] [PubMed] [Google Scholar]
- 19.Kaya A, Altınel N, Karakaya G, Çetinkaya F. Knowledge and attitudes among patients with asthma and parents and physicians towards influenza vaccination. Allergol Immunopathol (Madr). 2017;45(3):240–243. doi: 10.1016/j.aller.2016.08.003. [DOI] [PubMed] [Google Scholar]
- 20.Xiong X, Wei Y, Lam HCY, Wong CKH, Lau SYF, Zhao S, Ran J, Li C, Jiang X, Yue Q, et al. Association between cold weather, influenza infection, and asthma exacerbation in adults in Hong Kong. Sci Total Environ. 2023;857:159362. doi: 10.1016/j.scitotenv.2022.159362. [DOI] [PubMed] [Google Scholar]
- 21.de Bacurau AGM, Francisco PMSB. Prevalence of influenza vaccination in adults and elderly with chronic respiratory diseases. Cad Saude Publica. 2018;34(5). doi: 10.1590/0102-311x00194717. [DOI] [PubMed] [Google Scholar]
- 22.Al-Qerem W, Alassi A, Jarab A, Al Bawab AQ, Hammad A, Alasmari F, Alazab B, Husein DA, Momani NAL, Eberhardt J. Examining influenza vaccination patterns among young adults with asthma: insights into knowledge, attitudes, and practices. Patient Prefer Adherence. 2023;17:2899–2913. doi: 10.2147/PPA.S436622. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Lorini C, Collini F, Gasparini F, Paolini D, Grazzini M, Ierardi F, Galletti G, Zanobini P, Gemmi F, Bonaccorsi G. Health literacy, vaccine confidence and influenza vaccination uptake among nursing home staff: a cross-sectional study conducted in Tuscany. Vaccines (Basel). 2020;8(2):154. doi: 10.3390/vaccines8020154. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gao S, Li Y, Wang X, Li S, Chen M, Yue B. Vaccine literacy, vaccination intention, and their correlation among adults in mainland China: a cross-sectional study. J Health Popul Nutr [Internet]. 2024. [accessed 2025 Jul 16]. 43(1). https://pubmed.ncbi.nlm.nih.gov/39127762/. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Abdul-Mutakabbir JC, Abdul-Mutakabbir R, Casey SJ. Utilizing an educational intervention to enhance influenza vaccine literacy and acceptance among minoritized adults in Southern Californian vulnerable communities in the post-COVID-19 era. Infect Dis Rep [Internet]. 2025;17(2):18. https://www.mdpi.com/2036-7449/17/2/18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Hwang J. Health information sources and the influenza vaccination: The mediating roles of perceived vaccine efficacy and safety. J Health Commun [Internet]. 2020. [accessed 2025 Jul 21]. 25(9):727–735. https://pubmed.ncbi.nlm.nih.gov/33186091/. [DOI] [PubMed] [Google Scholar]
- 27.Gaskin CM, Woods DR, Ghosh S, Watson S, Huber LR. The effect of income disparities on influenza vaccination coverage in the United States. Public Health Rep. 2023;138(1):85–90. doi: 10.1177/00333549211069190. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Zanobini P, Lorini C, Caini S, Lastrucci V, Masocco M, Minardi V, Possenti V, Mereu G, Cecconi R, Bonaccorsi G. Health literacy, socioeconomic status and vaccination uptake: a study on influenza vaccination in a population-based sample. Int J Environ Res Public Health. 2022;19(11):6925. doi: 10.3390/ijerph19116925. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Wang L, Guo M, Wang Y, Chen R, Wei X. The relationship between influenza vaccine hesitancy and vaccine literacy among youth and adults in China. Front Immunol. 2024;15:1444393. doi: 10.3389/fimmu.2024.1444393. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The dataset supporting the findings of this article is available in Zenodo at https://doi.org/10.5281/zenodo.16206724.