ABSTRACT
Background: Vaccination of primary healthcare workers (PHCWs) help to prevent the spread of influenza among at-risk patients.
Objectives: To assesses seasonal influenza vaccination (SIV) coverage and the factors affecting SIV’s utilization among PHCWs in Abha city, southwestern Saudi Arabia.
Methods: A cross-sectional survey was carried out between June 2018 and August 2018 in all primary healthcare centers in Abha city. It targeted physicians, nurses, technicians, and pharmacists. A self-administered questionnaire was used to collect data regarding SIV status during the 2017–2018 season, obtain knowledge regarding SIV and influenza disease, and identify potential motivators for and barriers to SIV.
Results: Of 312 PHCWs, the SIV coverage rate was 45.5% in the 2017–2018 vaccination season. A multivariable logistic regression model showed that the risk groups for non-vaccination were PHCWs less than 40 years old (adjusted Odds Ratio (aOR) = 4.07, 95% CI: 1.50–11.03), technicians (aOR = 3.73, 95% CI: 1.20–11.54), single PHCWs (aOR = 2.36, 95% CI:1.20–4.62), and PHCWs lacking adequate influenza vaccine knowledge (aOR = 4.22, 95% CI: 2.13–8.35). Approximately 23% and 32% of PHCWs were found to have inadequate knowledge about SIV and influenza disease, respectively. PHCWs’ awareness about their risk of infection and their need for protection was found to be the most common motivator (77.5%), and a fear of side effects was found to be the most frequent barrier (40%).
Conclusion: SIV coverage rate is suboptimal. Knowledge gaps and misconceptions about the influenza vaccine are the main barriers to an adequate coverage.
KEYWORDS: Seasonal influenza vaccination, primary healthcare workers, motivators, barriers, knowledge
Introduction
Seasonal influenza is an infectious respiratory disease that causes a worldwide public health problem due to its complications and high subsequent mortality rate particularly among at risk patients. These have caused all levels of health services to be overburdened during severe epidemics.1–3 A systematic review and meta-analysis found that healthcare workers (HCWs) are at a significantly greater risk of influenza infection compared to adults working in non-healthcare settings.4 Furthermore, primary healthcare workers (PHCWs) who provide care to patients may help to transmit the infection to their patients, friends, and family members.5
Influenza vaccination is an essential tool for the prevention of influenza. Vaccination of HCWs is an important strategy for reducing the transmission of influenza from health care staff to their patients and families.6 Moreover, PHCWs can positively motivate their patients by following self-prevention procedures and receiving the vaccination themselves.7 The prevention of influenza among PHCWs via vaccination provides additional protection to patients with chronic disease who access primary healthcare centers and are at risk of complications from influenza.8 Therefore, it is highly recommended that healthcare facilities adopt adequate policies and perform actions to encourage influenza vaccinations for HCWs.9 However, the vaccination coverage among HCWs remains suboptimal in many countries. In the 2017–2018 influenza season, the coverage rate among HCWs was 40.2% in Greece,10 68.7% in England,11 78.4% in the United States,12 and low in most countries of the Eastern Mediterranean Region.13
Although the Saudi Ministry of Health provides a seasonal influenza vaccine to all PHCWs and patients free-of-charge,14 the vaccination rate among HCWs in the 2017–2018 influenza season was low (55.9%).15
Studying the obstacles to, and motivators of, vaccination among PHCWs is important to enhancing seasonal influenza vaccination (SIV) coverage. The most-reported motivators include self-protection and the protection of family members,16 while the most commonly reported obstacles are inadequate knowledge about the vaccine and misconceptions about the vaccine’s effectiveness and adverse effects.17
There are few data on the SIV coverage rate and its determinants among PHCWs in southwestern Saudi Arabia. This survey assessed the SIV coverage rate and the factors affecting SIV’s utilization among PHCWs in southwestern Saudi Arabia. It also explores the barriers to and motivators of SIV uptake.
Methods
Survey design and setting
A cross-sectional survey was carried out at primary healthcare centers (PHCCs) in Abha city, southwestern Saudi Arabia. There are 11 PHCCs in Abha City. They provide primary health care services to approximately 421,921 persons.
Survey population
The survey targeted all physicians, nurses, technicians, dentists, and pharmacists working at the 11 PHCCs in Abha city. The survey was conducted between June 2018 and August 2018. All PHCWs working at the above-mentioned PHCCs were invited to participate in the survey.
Survey tools and data collection
A specially designed questionnaire was developed after the relevant literature was reviewed. Face content validity was assessed and approved by a panel of experts in Family Medicine, Community Medicine, Biostatistics, and Preventive Medicine. The questionnaire was composed of the areas: (a) personal and work characteristics, such as age, gender, job title, specialty, years of experience, qualifications, and the presence of chronic disease, such as diabetes mellitus, hypertension, ischemic heart disease, chronic respiratory disease, and chronic kidney disease; (b) influenza vaccine uptake in the 2017–2018 influenza season; (c) questions to evaluate knowledge regarding SIV and influenza disease; and (d) potential motivators for and barriers to influenza vaccination in the survey year.
Seven questions and six questions were used to assess knowledge about the influenza vaccine and disease, respectively. The vaccine knowledge questions included questions on the nature of the vaccine, the frequency of uptake, the vaccine’s effectiveness, possible side effects, and contraindications. The influenza knowledge questions covered the following areas: high risk groups, methods of transmission and prevention, and complications. A participant was considered to have adequate knowledge on the vaccine and the disease when they correctly answered at least four of the questions in each set. The anonymous questionnaire was self-reported by the participants. Only personnel who were vaccinated were asked about motivators for vaccination, and only personnel who were not vaccinated were asked about barriers to vaccination.
Participants from each PHCC were identified using human resources records. The authors disseminated the self-reported questionnaire among the participants in person.
Data entry and analysis
The obtained data were entered, double-checked, refined, and analyzed using SPSS version 22 (IBM, North Castle, NY, USA). Categorical variables are presented as a number and a percentage and compared by chi-squared test. A univariate analysis was carried out to calculate the crude odds ratio (cOR) of being unvaccinated and the 95% confidence intervals (95% CIs). A logistic regression model was used to evaluate the significant independent factors associated with participants’ seasonal influenza non-vaccination during the survey season. Adjusted odds ratios (aORs) of being unvaccinated and their 95% CI were calculated. The dependent variable was SIV status in the in the 2017–2018 influenza season (non-vaccinated = 1 and vaccinated = 0) The independent variables that were included in the model were: age, sex, job title, experience, level of education, marital status, smoking status, presence of chronic disease, vaccine knowledge, and influenza disease knowledge.
Results
Description of the survey participants
The survey involved 312 of the 390 primary healthcare workers (PHCWs) in Abha city. The overall response rate was 80.3% (77% for physicians, 86% for nurses, 83% for technicians, 75% for dentists, and 83% for pharmacists). The main reason for nonparticipation was absence at the time of the visit to the PHCC. The PHCWs’ age ranged from 22 to 65 years with a median of 31 years. More than half of the participants were females (181, 58.0%). The survey sample included 74 (23.7%) physicians, 123 (39.4%) nurses, 68 (21.8%) technicians, 30 (9.6%) pharmacists, and 17 (5.4%) dentists. Their years of experience ranged from 1 to 41 years with a median of 8 years. Most of the participants have a secondary school diploma (140, 44.9%) or a bachelor’s degree (139, 44.6%). A minority have a post graduate degree (33, 10.6%). A majority of the participants were married (230, 73.7%), nonsmokers (276, 88.5%), and did not suffer from a chronic disease (272, 87.2%).
Seasonal influenza vaccination coverage rate
Less than half (n = 142) of the survey participants were vaccinated against seasonal influenza in the 2017–2018 vaccination season (a coverage rate of 45.5%).
Factors associated with influenza non-vaccination
Table 1 describes the univariate analysis the and multivariable analysis for the factors associated with influenza non-vaccination. The multivariable analysis shows that the risk of non-vaccination was higher among participants less than 40 years old (aOR = 4.07, 95% CI: 1.50–11.03), technicians (aOR = 3.73, 95% CI: 1.20–11.54), single PHCWs (aOR = 2.36, 95% CI: 1.20–4.62), and those lacking adequate influenza vaccine knowledge (aOR = 4.22, 95% CI: 2.13–8.35). On the other hand, influenza disease knowledge and presence of chronic disease were not associated with vaccination uptake among the survey participants.
Table 1.
Univariate analysis and multivariable analysis for factors associated with seasonal influenza non-vaccination in the survey participants (n = 312).
| Factors | Total No. (%) |
Vaccinated No. (%) | Non-vaccinated No. (%) |
cOR(95%CI) | aOR(95%CI) |
|---|---|---|---|---|---|
| Age (years) | |||||
| <40 | 264(84.6) | 108(40.9) | 156(59.1) | 3.51(1.80–6.85) | 4.07(1.50–11.03) |
| ≥40 | 48(15.4) | 34(70.8) | 14(29.2) | Ref | Ref |
| Sex | |||||
| Male | 131(42.0) | 73(55.7) | 58(44.3) | Ref | |
| Female | 181(58.0) | 69(38.1) | 112(61.9) | 2.04(1.29–3.22) | 1.61 (0.84–3.08) |
| Job title | |||||
| Physician | 74(23.7) | 46(62.2) | 28(37.8) | Ref | Ref |
| Pharmacist | 30(9.6) | 6(20.0) | 24(80.0) | 6.57(2.39–18.05) | 1.54(0.67–3.54) |
| Nurse | 123(39.4) | 52(42.3) | 71(57.7) | 2.24(1.24–4.05) | 2.09(0.87–5.00) |
| Technician | 68(21.8) | 29(42.6) | 39(57.4) | 2.21(1.13–4.33) | 3.73(1.20–11.54) |
| Dentist | 17(5.4) | 9(52.9) | 8(47.1) | 1.46(0.50–4.22) | 1.32(0.41–4.24) |
| Experience (years) | |||||
| ≤10 | 231(74.0) | 99(42.9) | 132(57.1) | Ref | Ref |
| >10 | 81(26.0) | 43(53.1) | 38(46.9) | 0.663(0.40–1.10) | 1.11(0.57–2.18) |
| Level of education | |||||
| Diploma | 140(44.9) | 61(43.6) | 79(56.4) | Ref | Ref |
| Bachelor | 139(44.6) | 61(43.9) | 78(56.1) | 0.99(0.62–1.58) | 0.90(0.48–1.71) |
| Postgraduate degree | 33(10.6) | 20 (60.6) | 13(39.4) | 0.50(0.23–1.09) | 1.27(0.46–3.56) |
| Marital status | |||||
| Married | 230(73.7) | 121(52.6) | 109(47.4) | Ref | Ref |
| Single | 82(26.3) | 21(25.6) | 61(74.4) | 3.22(1.84–5.64) | 2.36(1.20–4.62) |
| Smoking status | |||||
| Smoker | 36(11.5) | 17(47.2) | 19(52.8) | Ref | Ref |
| Non-smoker | 276(88.5) | 125(45.3) | 151(54.7) | 1.081(0.54–2.17) | 1.08(0.47–2.50) |
| Chronic disease | |||||
| No | 272(87.2) | 119(43.8) | 153(56.2) | Ref | Ref |
| yes | 40(12.8) | 23(57.5) | 17(42.5) | 0.57(0.29–1.12) | 0.63(0.28–1.41) |
| Vaccine Knowledge | |||||
| Adequate | 238(76.3) | 125(52.5) | 113(47.5) | Ref | |
| Inadequate | 74(23.7) | 17(23.0) | 57(77.0) | 3.7(2.04–6.75) | 4.22(2.13–8.35) |
| Influenza disease Knowledge | |||||
| Adequate | 210(67.3) | 96(45.7) | 114(54.3) | Ref | Ref |
| Inadequate | 102(32.7) | 46(45.1) | 56(54.9) | 1.02(0.64–1.65) | 0.61(0.35–1.07) |
cOR, Crude Odds Ratio; aOR, Adjusted Odds Ratio; 95% CI, 95% Confidence Interval; Bold: 95% CIs is statistically significant; Ref., Reference group.
Knowledge about the influenza vaccine and influenza disease
Approximately one-fourth of the survey participants (74, 23.05%) were inadequately knowledgeable about the influenza vaccine. Inadequate knowledge was higher among pharmacists (10, 33.3%), technicians (21, 30.9%), nurses (36, 29.3%), and dentists (4, 23.5%) compared to physicians (3, 4.1%). On the other hand, non-significant relationships were observed for age, sex, experience, marital status, qualifications, and health status (Table 2).
Table 2.
Factors associated with non-satisfactory knowledge of influenza vaccine and disease in the survey participants (n = 312).
| Non-satisfactory vaccine knowledge |
Non-satisfactory influenza disease knowledge |
||||
|---|---|---|---|---|---|
| Factors | Total | No. (%) | p-value | No. (%) | p-value |
| Age (years) | 0.50 | 0.40 | |||
| <40 | 148 | 38(25.7%) | 52(35.1%) | ||
| ≥40 | 164 | 36(22.0%) | 50(30.5%) | ||
| Sex | 0.98 | 0.39 | |||
| Male | 131 | 31(23.7%) | 39(29.8%) | ||
| Female | 181 | 43(23.8%) | 63(34.8%) | ||
| Job title | 0.001 | 0.001 | |||
| Physician | 74 | 3(4.1%) | 9(12.2%) | ||
| Pharmacist | 30 | 10(33.3%) | 11(36.7%) | ||
| Nurse | 123 | 36(29.3%) | 51(41.5%) | ||
| Technician | 68 | 21(30.9%) | 28(41.2%) | ||
| Dentist | 17 | 4(23.5%) | 3(17.6%) | ||
| Experience (years) | 0.71 | 0.68 | |||
| ≤10 | 231 | 56(24.2%) | 74(32.0%) | ||
| >10 | 81 | 18(22.2%) | 28(34.6%) | ||
| Level of education | 0.18 | 0.03 | |||
| Diploma | 140 | 38(27.1%) | 54(38.6%) | ||
| Bachelor | 139 | 32(23.0%) | 43(30.9%) | ||
| Postgraduate degree | 33 | 4(12.1%) | 5(15.2%) | ||
| Marital status | 0.29 | 0.78 | |||
| Married | 230 | 51(22.2%) | 74(32.2%) | ||
| Single | 82 | 23(28.0%) | 28(34.1%) | ||
| Smoking status | 0.03 | 0.70 | |||
| Smoker | 36 | 14(38.9%) | 13(36.1%) | ||
| Non-smoker | 276 | 60(21.7%) | 89(32.2%) | ||
| Chronic disease | 0.85 | 0.07 | |||
| No | 272 | 65(23.9%) | 94(34.6%) | ||
| yes | 40 | 9(22.5%) | 8(20.0%) | ||
One-third of the participants (102, 32.7%) were inadequately knowledgeable about influenza disease. Non-satisfactory knowledge was higher among diploma (54, 38.6%) and bachelor (43, 30.9%) graduates as compared to postgraduates (5, 15.2%). Also, nurses (51, 41.5%), technicians (28, 41.2%), and pharmacists (11, 36.7%) reported higher non-satisfactory knowledge compared to dentists (3, 17.6%) and physicians (9, 12.2%). On the other hand, non-significant relations were observed for age, sex experience, marital status, and health status (Table 2).
Motivators for and barriers to seasonal influenza vaccination
Table 3 shows the motivators for seasonal influenza vaccination (SIV) and barriers to vaccination in the survey participants. The most commonly reported motivators for SIV were awareness about the risk of influenza infection (110, 77.5%), a tendency to avoid disease transmission to family members (89, 62.7%), and in response to infection control instructions (86, 60.6%). Among PHCWs reporting a chronic disease (n = 23), 69.6% cited this as a motivation for receiving an influenza vaccine. As to barriers, a fear of side effects (40%), a false perception that vaccination is not important (24.1%), and unsatisfactory past experience (17.6%) were the most frequently stated barriers among unvaccinated participants.
Table 3.
Motivators for and barriers to seasonal influenza vaccination in the survey participants (n = 312).
| Total |
|
|---|---|
| Motivators/Barriers | No % |
| Motivators for vaccination (n = 142) # | |
| PHCWs at greater risk for influenza infection | 110 (77.5) |
| Presence of chronic disease (n = 23) | 16 (69.6) |
| To avoid disease transmission to family members | 89 (62.7) |
| Response to infection control instructions | 86 (60.6) |
| To avoid disease transmission to patients | 73 (51.4) |
| Vaccine is free and accessible | 39 (27.5) |
| Barriers to vaccination (n = 170) # | |
| Fear of side effects | 68 (40) |
| Vaccination is not important | 41 (24.1) |
| Unsatisfactory past experience | 30 (17.6) |
| Vaccination is ineffective | 27 (15.9) |
| Fear of needle shot | 20 (11.8) |
| Difficult to access | 15 (8.8) |
PHCWs, Primary healthcare workers; # Data is not mutually exclusive.
Discussion
The findings of the present survey provide us with insight into the SIV status among primary healthcare workers (PHCWs) in southwestern Saudi Arabia. They show that less than half (45.5%) of the PHCWs were vaccinated in the 2017–2018 vaccination season. This result reveals an increasing trend regarding the SIV coverage rate among healthcare professionals in Saudi Arabia. It is higher than that reported among healthcare workers for the 2012–2013 vaccination season (38%)18 and for the 2008–2009 vaccination season (34%).14 Compared to the vaccination coverage reported from other gulf regions, it is higher than that reported from Qatar (35%) in 201419 and United Arab Emirates (24.7%)20 but lower than that reported from Kuwait (67.2%)20 and close to that reported from Oman (46.4%).20 The findings of a previous study suggest that a coverage rate of 80% of HCWs may be adequate to minimize disease transmission and maintain herd immunity at a safe level in health care settings.21 Although, SIV is available and accessible to, and free-of-charge for, all PHCWs in Saudi Arabia, the uptake rate is still lower than the proposed target of 80%. A strategy of compulsory influenza vaccination as a condition of work in health care settings could improve SIV uptake.22 Also, the Task Force on Community Preventive Services recommends on-site, free, and actively promoted vaccinations to increase the coverage rate among HCWs.23
Our survey suggests that the risk of non-vaccination is higher among younger PHCWs (less than 40 years old). This result is in accordance with the findings of studies conducted in Oman,20 Qatar,24 Malaysia,25 Belgium,16 Hungary,26 Spain,27 and Saudi Arabia.15 Older age is one of the important predictors of influenza uptake among HCWs. Older HCWs tend to protect themselves via influenza vaccine. They are aware of their vulnerability to influenza and appreciate the benefits of the vaccine.28
In the current survey, technicians were found to be less likely to vaccinate compared to physicians. A similar result was reported among HCWs in the United States in the 2014–2015 influenza season.29 Technicians reported lower level of knowledge about both influenza disease and the influenza vaccine and that appears to be a risk factor for non-vaccination.
Our results revealed that single PHCWs are also less likely to obtain the vaccine compared to married PHCWs. Previous studies have shown that subjects who live alone and are not married form a risk group for seasonal influenza vaccination.30,31
Our results also reveal that PHCWs who lack adequate influenza vaccine knowledge form a risk group for low vaccine uptake. This confirms the results obtained in previous studies that reported a low vaccination rate among HCWs with insufficient knowledge about the influenza vaccine.32,33 One of the important findings of the present survey that could help to explain the relatively low uptake of the vaccine is the considerable gap in knowledge about the influenza vaccine and influenza disease among the studied PHCWs. This result is consistent with the findings of previous studies.14,32 Therefore, it is worth enhancing HCWs’ knowledge about their role in disease transmission and the value of the influenza vaccine in order to correct misconceptions and ensure vaccine safety.32
Our results reveal that the most commonly reported motivators for seasonal influenza vaccination are: PHCWs’ awareness that they are at risk of influenza infection and need protection (77.5%), the presence of chronic disease (69.6%), and a tendency to protect family members (62.6%). These results are similar to those reported in studies from Saudi Arabia15 and other countries.20,34 Also, response to infection control instructions was found to be an important motivator for vaccine uptake in the present survey. According to the Saudi Ministry of Health’s infection control guidelines, an influenza vaccine should be recommended and provided free-of-charge to all HCWs.14 Motivators are the main predictors of vaccine acceptance and uptake. Expanding the number of PHCWs who have these motivators by educational campaigns as part of a multi-component intervention is important to increasing the vaccination rate.32,35
As to barriers, our results show that a fear of side effects (40%) and a false perception that vaccination is not important (24.1%) were the most frequently stated barriers among unvaccinated participants. These barriers are based on misconceptions and a lack of knowledge.18,24,27 Misconceptions can be reduced through a well-planned educational program. Overcoming misperceptions by clarifying the facts about SIV could improve its uptake.16
The present survey provides important information about the SIV coverage rate and factors that affect it. It also highlights the most important motivators for and barriers to vaccination among PHCWs in Saudi Arabia. This information could be generalized to similar populations to enhance vaccination coverage.
This survey has some limitations that are linked to its design. First, vaccination uptake was self-reported by participants and not verified by vaccination records, this tends to overestimate vaccination coverage rate. Second, information recall bias is possible; however, the survey was conducted between June 2018 and August 2018 during the same influenza season. This limited amount of time could minimize the probability of a wrong report. Another limitation is related to the cross-sectional nature of the survey. This design reflects the current SIV status and does not describe changes across time. In addition, the findings are not representative of all Saudi PHCWs, as we included only those in one region of the country.
In conclusion, the influenza vaccination coverage rate among PHCWs in southwestern Saudi Arabia remains suboptimal. Knowledge gaps and misconceptions about the influenza vaccine are the main barriers to an adequate SIV coverage rate. The role of improving HCWs’ knowledge in enhancing vaccination coverage should be examined by interventional studies. Also, a strategy of compulsory influenza vaccination as a condition of work in primary health care settings could be attempted to improve the uptake.
Funding Statement
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.No funds were requested or obtained to carry out this survey.
Abbreviations
- SIV
Seasonal influenza vaccination
- aOR
Adjusted odds ratio
- cOR
Crude odds ratio
- CIs
Confidence intervals
- HCW
Health care workers
- PHCCs
Primary healthcare centers
- PHCWs
Primary healthcare workers
Disclosure of potential conflicts of interest
The authors declare no conflicts of interest.
Ethical approval
The survey was conducted in accordance with the Declaration of Helsinki. The research proposal was approved by the Ethics and Research Committee of the College of Medicine of King Khalid University (ERC# 2018-04-07). Approval was attained from the directorate of the Health sector in Abha City prior to data collection. Oral consent was obtained from each PHCW after a warranty was provided on the confidentiality of the reported data.
Ethical considerations
The survey was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics and Research Committee of the College of Medicine of King Khalid University
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