Abstract
Background.
Influenza is an underestimated contributor to morbidity and mortality. Population knowledge regarding influenza and its vaccination has a key role in enhancing vaccination coverage.
Objectives.
This study aimed to identify the gaps of knowledge among Jordanian population towards influenza and its vaccine, and to identify the major determinants of accepting seasonal influenza vaccine in adults and children in Jordan.
Methods.
This was a cross-sectional study that enrolled 941 randomly selected adults in Amman, Jordan. A four-section questionnaire was used which included questions about the sociodemographic characteristics, knowledge about influenza and the factors that affect seasonal influenza vaccine acceptance and refusal.
Results.
Only 47.3% of the participants were considered knowledgeable. About half of the participants (51.9%) correctly identified the main influenza preventative measures. Lack of knowledge about the important role of seasonal influenza vaccine in disease prevention was observed. Low vaccination rate (20% of adults) was reported. The most critical barrier against vaccination in adults and children was the concern about the safety and the efficacy of the vaccine, while the most important predictors for future vaccination in adults and children were physician recommendation and government role. In children, the inclusion of the vaccine within the national immunization program was an important determinant of vaccine acceptance.
Conclusion.
Formulating new strategies to improve the population’s level of knowledge, assuring the population about the safety and the efficacy of the vaccine and the inclusion of the vaccine within the national immunization program are the essential factors to enhance vaccination coverage in Jordan.
Keywords: Adult immunization, children immunization, influenza, Jordan, knowledge, practice, seasonal influenza vaccine.
Introduction
Influenza is a contagious respiratory infection caused by influenza viruses, such as H1N1, H3N2 and corona viruses. The disease severity varies from mild upper respiratory symptoms such as sneezing and coughing to severe pneumonia (1). Current estimates indicate that seasonal influenza affects 5–10% of the world’s population resulting in an annual mortality rate of 250000–500000 (2). This is of particular importance for the high-risk groups including children at the age of 5 years and younger, pregnant women, elderly (≥65 year of age), individuals with chronic medical conditions and health care personnel (3).
Seasonal influenza vaccine is considered to be one of the effective tools in reducing disease severity, the associated complications and disease spread (1,2,4). The Centers for Disease Control and Prevention in America recommends annual seasonal influenza vaccination for any person older than 6 months to prevent influenza epidemics (5). However, influenza vaccination coverage was <1% in most parts of Africa and Asia (6). In Jordan, a Middle Eastern country that resides in Asia, vaccination rate is low (6). In addition, there is no national seasonal influenza vaccination policy in Jordan and influenza vaccine is not a scheduled vaccine in the national immunization program for children (6,7).
In relation to public awareness about influenza and its vaccine in Jordan, only a single report evaluated general vaccination acceptance for children, which showed that only 34% of the surveyed mothers thought that influenza vaccine is a mandatory vaccine for their children (7). Yet, there are no previous reports that have specifically addressed Jordanian adult population awareness about influenza and its vaccine. In other Middle Eastern countries, several studies were performed to assess knowledge about influenza vaccine and vaccine acceptance among health care professionals, but not knowledge about influenza illness and its vaccine among the general adult population or children (8–10). Other studies were implemented worldwide to assess knowledge about influenza and its vaccine acceptance in children (11,12), adults (13) and GPs (14–16). Concerns about the safety and the efficacy of influenza vaccine—and physician recommendation for having the vaccine—were the most commonly reported determinants of influenza vaccine acceptance (8–16). Despite the presence of many worldwide surveys addressing this topic, till date, we are not aware of any comprehensive study that has assessed the state of knowledge, awareness and practice of adult and children towards seasonal influenza and its vaccine in Jordan, or in the Middle East. Therefore, the current cross-sectional study aims to identify the major gaps in knowledge towards seasonal influenza, its routes of transmission and its preventative measures among the Jordanian population, and to identify the barriers against vaccine acceptance among adults and children in Jordan. The data generated from this study could help in formulating strategies to help increasing awareness and acceptance of the influenza vaccine in Jordan. These could include assuring the population about the safety and the efficacy of the vaccine through multimedia and physician recommendation, offering the vaccine for free, inclusion of the vaccine within the national immunization program for children and utilization of schools to provide the vaccine for children. Enhancing influenza vaccine acceptance among Jordanian population would result in national and global health benefits in reducing the emergence and the spread of new variants of influenza viruses.
Methods
Study subjects
This study was conducted in Amman, the capital of Jordan. A target sample of 1107 adults (aged 18 and older) was estimated based on power calculation as previously shown (11). This was based on estimates that 50% of the respondents knew the main preventative measures, with a 95% level of confidence. Accordingly, a sample size of 1049 participants were needed to be invited, and was approximated to 1107. This study was conducted in the following sites: the out-patient clinics of the University of Jordan Hospital, several health care centres and public places such as parks in the vicinity of Amman. Subjects available at the previous sites, at the time of data collection, were invited to participate in the study.
Study design and data collection
This cross-sectional study was carried out over the period from December 2015 to April 2016. Participants were asked for verbal consent to participate in the study, and consenting participants were administered the questionnaire through 5–10 minutes semi-structured interview. Approval of the study protocol and the questionnaire was obtained from the Institutional Review Board (IRB) at the University of Jordan hospital.
The questionnaire was developed after reviewing related surveys in the literature (11–13). The questionnaire was reviewed by several colleagues in the field for content and face validity and was then piloted to a sample of 50 adults and was adjusted accordingly.
The questionnaire was structured to include four sections. The first section included demographics and general characteristics of the participants. The second section addressed participants’ knowledge about influenza, its mode of transmission and its preventative measures. The third part addressed participants’ practice of having influenza vaccine, factors that affected their practices and factors that would affect their future decision of having the vaccine. Participants were asked to choose as many factors that applied to them. The fourth part assessed the attitude of the participants—who were parents for children at the age of 5 and younger—towards administering influenza vaccine to their children, factors affecting their practice and factors that would affect their future decision of administering the vaccine to their children. Parents were asked to choose as many factors that applied to them.
Statistical analysis
Statistical analysis was carried out using SPSS version 20.0 (SPSS Inc., Chicago, IL). Descriptive statistics were used to describe demographic and general characteristics of participants. Percentages and frequencies were used to describe categorical variables, while median and inter-quartile range (IQR) were calculated to describe continuous variables, as specified in the Results section. Participants’ responses regarding knowledge were measured using ‘yes’, ‘no’, and ‘I do not know’ choices. A score of 1 was given for a ‘yes’ response and a score of 0 was given to either of ‘no’ or ‘I do not know’ responses. Participants’ knowledge scores were assessed using the number of correct responses they gained out of 17 knowledge items. The participant was considered adequately knowledgeable if his knowledge score for all knowledge questions was higher than the median knowledge score of all participants. Our data were non-parametric; therefore, non-parametric statistical analysis tests were used. Mann–Whitney, Kruskal–Wallis and Pearson’s chi-square tests were used to test the differences among the variables that affect the knowledge score and the variables that affect the practice of having the influenza vaccine (bivariate analysis). Mann–Whitney test was used to compare medians of two independent groups (males and females). Kruskal–Wallis test was used to compare medians of more than two independent groups (unemployed, part time and full time). Finally, Pearson’s chi-square test was used to find the correlation between two categorical variables (the practice of having influenza vaccine and working in the medical field). Factors that were found to be significantly associated with high-knowledge score through bivariate analysis, entered into backward-stepwise-multivariate linear regression analysis to determine the strength of association of each of the variables. All hypothesis testing were two-sided. A P-value of <0.05 was considered to be significant. Responses regarding the factors that affect the future decision of having the vaccine were measured using 5-point Likert scale which is composed of strongly agree, agree, neutral, strongly disagree and disagree responses. ‘Strongly agree’ and ‘agree’ choices were considered as a single answer and the rest of the choices were categorized as disagree. Descriptive frequencies were calculated for this part.
Results
General characteristics of participants
The sociodemographic characteristics of the participants are shown in Table 1 (first two columns). Of the 1107 adults approached, a total of 941 responded (85% response rate) with a mean age of 36.63±12.82 years.
Table 1.
Sociodemographic characteristics of all participants (n = 941) and their association with knowledge score
| Variable | %a (n) | Knowledge score | P-value |
|---|---|---|---|
| Median (inter-quartile range) | |||
| Age | 0.002* | ||
| <30 | 37.6 (341) | 12 (4) | |
| 30–60 | 58.5 (531) | 12 (3) | |
| >60 | 3.9 (35) | 13 (4) | |
| Genderb | 0.534 | ||
| Females | 63.2 (593) | 12 (3) | |
| Males | 36.8 (345) | 12 (3) | |
| Marital statusc | |||
| Married | 64.7 (609) | 12 (3.0) | 0.006* |
| Widow | 2.6 (24) | 10 (4.0) | |
| Divorced | 1.3 (12) | 11 (3.5) | |
| Single | 31.4 (296) | 12 (4.0) | |
| Educationc | |||
| <12 years | 5.3 (50) | 10.5 (5.0) | <0.005* |
| High school | 17.4 (163) | 12 (4.0) | |
| Some college or technical school | 14.4 (135) | 12 (3.0) | |
| Bachelor degree | 50.8 (476) | 13 (3.0) | |
| Graduate degree | 12.1 (113) | 13 (3.0) | |
| Incomeb | |||
| ≤500 JD | 42.9 (393) | 12 (3.0) | <0.005* |
| >500 JD | 57.1 (523) | 13 (3.0) | |
| Employmentc | |||
| Unemployed | 45.2 (425) | 12 (4.0) | 0.712 |
| Part time | 9.8 (92) | 13 (3.0) | |
| Full time | 45 (423) | 12 (3.0) | |
| Work in medical fieldb | |||
| Yes | 12.9 (121) | 14 (2.5) | <0.005* |
| No | 87.1 (820) | 11.8 (4.0) | |
| Chronic illnessc | |||
| Asthma | 3.1 (29) | 13 (2.0) | 0.583 |
| COPD | 0.3 (3) | 13 | |
| Heart disease | 4 (38) | 13 (3.0) | |
| Diabetes | 7.5 (70) | 12 (3.0) | |
| None | 78.3 (737) | 13 (3.0) | |
| Others | 6.8 (64) | 12 (4.0) | |
| Having children at the age of 5 years or youngerb | 0.484 | ||
| Yes | 33.7 (317) | 12 (3.0) | |
| No | 66.3 (624) | 12 (3.0) | |
| Medical insuranceb | 0.002* | ||
| Yes | 69.5 (653) | 13 (3.0) | |
| No | 30.5 (281) | 12 (4.0) | |
| Smokersb | 0.08 | ||
| Yes | 19.8 (186) | 12 (4.0) | |
| No | 80.2 (731) | 12 (3.0) |
COPD, chronic obstructive pulmonary disease; JD, Jordanian dinar.
aValid percent.
bMann–Whiteny U test.
cKruskal–Wallis.
*Significant at P-value <0.05.
Knowledge about influenza
Evaluation of the level of knowledge among the participants showed very low proportion of the study population (2%, n = 19) correctly answered the nine general information questions about influenza and its vaccine. Most of the participants (89.6%) were familiar with the definition of influenza and more than half of the participants (56%, n = 527) identified the high-risk groups for influenza-associated complications. However, only 8.7% (n = 82) knew the major information related to H1N1 influenza (the three questions together). Only 15.2% (n = 143) knew that influenza vaccine is given annually and does not cover corona virus. Considering mode of transmission, the majority of the population (78.7%, n = 741) correctly distinguished the three major modes of influenza transmission. More than half of the sample (51.9%, n = 488) correctly identified the main influenza preventative measures. However, only 63% of them believed that influenza vaccine is one of the major influenza preventative measures. Overall, only 1.4% (n = 13) correctly answered the 17 knowledge questions. Table 2 shows detailed frequencies for individual items.
Table 2.
Participants’ knowledge about influenza, its mode of transmission and its preventative measures
| Question | Correctly answered % (n) |
|---|---|
| General knowledge about influenza and its vaccine | |
| Influenza is a contagious respiratory infection that might cause a range of mild illness to serious pneumonia, and is caused by respiratory viruses such as H1N1 virus and coronavirus. | 89.6 (843) |
| Swine influenza is one type of influenza caused by H1N1 virus. | 79.8 (750) |
| Every H1N1 infected person will experience complications that need hospitalizationa. | 23.9 (225) |
| Every H1N1 infected person will die because of ita. | 65.4 (615) |
| Medications are available for the treatment of serious cases of influenza. | 45.2 (425) |
| People with chronic illness (such as asthma, COPD, heart diseases or diabetes) are at higher risk to develop more serious influenza illness. | 67.6 (636) |
| Elderly (≥65 years of age) and children (≤5 years of age) are at higher risk to develop serious influenza illness. | 73.3 (690) |
| Influenza vaccine covers H1N1 virus but not corona virus. | 23.8 (224) |
| Influenza vaccine should be given annually. | 45.5 (428) |
| Mode of transmission | |
| Influenza can spread through close unprotected contact with respiratory droplets. | 91.9 (865) |
| Influenza can spread through droplets made when people with Influenza cough, sneeze or talk. | 94.7 (891) |
| Influenza can spread through touching mouth or nose after contact with contaminated objects. | 85.3 (803) |
| Preventative measures | |
| Wearing mask can prevent the spread of Influenza. | 85.7 (806) |
| Covering your nose or mouth when sneezing can prevent the spread of influenza. | 89.1 (839) |
| Washing hands with water and soap after coughing/sneezing can prevent the spread of influenza. | 91.4 (860) |
| Avoiding crowded places helps to prevent the spread of influenza. | 92.0 (866) |
| Having influenza vaccine. | 63.2 (595) |
COPD, chronic obstructive pulmonary disease.
aThe correct answer for the question is ‘No’.
The median knowledge score for the participants was 12 (IQR: 3), with those having a median score higher than 12 were considered knowledgeable. Accordingly, 47.3% (n = 445) of the participants were considered knowledgeable.
As presented in Table 1 (last two columns), the age, marital status, level of education, income and working in the medical field were associated with a significantly higher knowledge score.
Sources of information about influenza and its vaccine
In inquiring about the participant source of information about influenza, our results showed that the most commonly used source was newspapers (52.1%, n = 487) followed by health fairs (19.4%, n = 181), while much lower proportions of participants used brochures (10.7%, n = 100), physician office (9.6%, n = 90) or TV (8.2%, n = 77). However, a significantly higher knowledge score (P-value < 0.005) was associated with using physician office (score = 13), brochures (score = 13) or health fairs (score = 13) as sources of information.
Practice of participants towards having seasonal influenza vaccine
When assessing the participants’ practice of having seasonal influenza vaccine, 20.4% (n = 192) of the participants have ever had the vaccine. This practice was associated with a significantly higher knowledge score (a score of 13 [IQR: 4]) as compared to those who have not had the vaccine before (a score of 12 [IQR: 4]) (Mann–Whitney test, P-value <0.005).
Our results revealed that participants’ practice towards influenza vaccine was not associated with any of the sociodemographic characteristics studied except for the field of work and for the source of information. The practice of having influenza vaccine was observed more frequently among those who did not work in the medical field as compared to those working in the medical field (80.7% versus 19.3%, respectively, P-value = 0.004 and Pearson’s chi-square test). In addition, a higher vaccination rate was observed among participants who used newspapers as a source for their information about influenza (40%, P-value < 0.005 and Pearson’s chi-square test).
Table 3 presents the assessment of the reasons that contributed to the practice of receiving influenza vaccine. Accordingly, the most commonly reported reason for having influenza vaccine was compliance with physician recommendations followed by worries about catching H1N1 influenza and becoming severely ill after infection.
Table 3.
Factors that affect adult participants’ practice towards seasonal influenza vaccinea
| Reason/factor | %b (n) |
|---|---|
| Reasons for getting vaccinated (as specified by those who have ever had the vaccine) | |
| Compliance with physician recommendation | 48.4 (93) |
| Worries about catching H1N1 influenza | 25.0 (48) |
| Worries of becoming severely ill because of influenza | 22.9 (44) |
| To prevent infecting other family members | 20.8 (40) |
| Having a chronic medical condition | 3.6 (7) |
| Reasons for not getting vaccinated (as specified by those who have never had the vaccine before) | |
| Fear of contracting illness | 22.3 (165) |
| Not considering influenza as a threat | 22.0 (163) |
| Doubts about the efficacy of the vaccine | 19.4 (144) |
| Doubts about the safety of the vaccine | 18.9 (140) |
| Cannot find time to go to the physician | 17.1 (127) |
| Cost of the vaccine | 6.1 (45) |
| Factors that would encourage the participants to get vaccinated in the future (as specified by all the participants regardless of vaccination status) | |
| Recommendation by the physician | 81.2 (752) |
| If the vaccine was more tested for safety and efficacy | 74.8 (692) |
| If the government encouraged the vaccination | 72.9 (669) |
| If it is offered by the government for free | 70.0 (752) |
aParticipants were asked to select as many factors that applied to them.
bValid percent.
On the other hand, almost equal proportions of the participants reported that the most common reasons for not getting vaccinated were fear of contracting illness because of vaccine administration and not considering influenza as a threat. Other reasons which were reported in almost equal frequencies were participants’ doubts about the efficacy and the safety of the vaccine. Most of the participants were more willing to get vaccinated if it is recommended by the physician, if the vaccine was further tested for safety and efficacy, if the government encouraged the vaccination and if it is offered by the government for free (Table 3).
Attitude of parents towards giving seasonal influenza vaccine to their children
Of the total 317 parents, 67.3% (n = 213) had positive attitude to vaccinate their children. As presented in Table 4, the most common factors that discouraged parents to get their children vaccinated were concerns about vaccine safety followed by concerns about vaccine efficacy.
Table 4.
Factors that affect the practice of the parents for children at the age of five or less towards seasonal influenza vaccinea
| Reason/factor | %b (n) |
|---|---|
| Reasons for not getting vaccinated (as specified by the parents who have never vaccinate their children before, n = 213) | |
| Worries about the safety of the vaccine | 48.0 (36) |
| Doubts about the efficacy of the vaccine | 27.0 (15) |
| Fear of contracting illness | 12.0 (9) |
| Not considering influenza as a threat | 10.7 (8) |
| Cost of the vaccine | 8.0 (6) |
| Cannot find time to go to the physician | 1.3 (1) |
| Factors that would encourage the participants to get vaccinated in the future (as specified by all parents regardless of their children vaccination status) | |
| Inclusion of the vaccine within the national immunization program | 87.6 (275) |
| If it is recommended by the physician | 87.1 (263) |
| If the vaccine was tested more for safety and efficacy | 87.0 (260) |
| If the government strongly encouraged vaccination | 82.0 (246) |
| If the vaccine was given at child’s school | 79.2 (237) |
| If it is offered by the government for free | 77.2 (234) |
aParents were asked to select as many factors that applied to them.
bValid percent.
Parents were willing to vaccinate their children against influenza if the vaccine is included within the national immunization program, if it is recommended by the physician and if the vaccine was tested further for safety and efficacy. The role of the government and the school was also important (Table 4).
Multivariate linear regression model for the factors associated with higher knowledge score
As described above, several sociodemographic factors (indicated by asterisks in Table 1), the source of information and the practice of having influenza vaccine (as presented above under ‘Practice of participants towards having seasonal influenza vaccine’) were associated with higher knowledge score as found though bivariate analysis. These factors were further analysed through multivariate linear regression analysis (backward method). As presented in Table 5, the results of this analysis (R2 = 0.108 and P-value < 0.0001) showed that several sociodemographic characteristics and the practice of having influenza vaccine were associated with higher level of knowledge.
Table 5.
Results of multivariate linear regression analysis for covariates associated with higher level of knowledge (score > 12)
| Variables | SE | Ba | T | P-value |
|---|---|---|---|---|
| Marital status | 0.069 | 0.006 | 0.162 | 0.871 |
| Insurance | 0.177 | −0.032 | −0.962 | 0.336 |
| Income | 0.172 | 0.115 | 3.338 | 0.001* |
| Working in medical field | 0.243 | −0.209 | −6.313 | 0.000* |
| Level of education | 0.080 | 0.111 | 3.187 | 0.001* |
| Source of medical information | 0.072 | 0.054 | 1.655 | 0.098 |
| Have you ever had seasonal influenza vaccine | 0.188 | −0.119 | −3.708 | 0.000* |
| Age | 0.008 | 0.079 | 2.002 | 0.046* |
aStandardized coefficient.
*Significant at P-value < 0.05.
Discussion
Knowledge about influenza and its vaccine
Influenza is an underestimated contributor to morbidity and mortality worldwide (2). Most of the research conducted to assess influenza knowledge and its vaccine acceptance has been undertaken among health care professionals (8–10,14–16). Only few studies were conducted in the general adult population and in children (11–13,16). This study is the first study performed in Jordan to assess adults’ and parents’ knowledge, attitude and practice towards influenza and its vaccine and the factors associated with their practice. This study provided interesting results that have implications on public health and provides valuable insights for policy makers. However, the results of this study should be interpreted cautiously since this study was conducted within a single city, Amman, in Jordan.
In the current study, assessment of the population knowledge showed that 47.3% of the participants were considered knowledgeable. However, critical gaps in knowledge were identified. In particular, most of the participants overestimated the perception of risk due to H1N1 infection and thought that H1N1 always lead to hospitalization-associated illness. Although more than half of the population correctly identified the three major influenza preventative measures in total, only 63% of them considered influenza vaccine as a major preventative measure as compared to frequencies >85% for the other preventative measures separately. Similar results were observed in a previous survey conducted in Italy, where most of the study population did not know that vaccine is one of the major influenza preventative measures (11). In addition, the majority of the participants did not know that seasonal influenza vaccine covers H1N1 virus and that it should be given annually (3). Such lack of knowledge about the important role of the seasonal vaccine in influenza prevention and its administration frequency could partially justify the low rate of vaccination observed in our study (~20% of the adults) and could explain the low vaccination coverage in our area as indicated by the WHO (2).
Multivariate linear regression analysis of the factors that were associated with significantly higher level of knowledge revealed that working in the medical field was associated with a high-knowledge score. Health care personnel mutually have a higher level of knowledge regarding health problems due to the nature of their work, having easy access to information resources, such as medical guidelines (9,14) and due to being categorized as high-risk groups by the WHO (3). Despite being associated with higher knowledge score, working in the medical field was not associated with high frequency of vaccine administration. This is consistent with the results of previous reports in Lebanon (9) and Italy (11,14), where low vaccination acceptance of health care workers was observed. Participants with higher level of education were more knowledgeable as shown in the results of this study; this probably attributes to the easier access to information resources. Also, the practice of previously having seasonal influenza vaccine and a monthly income >500 JD were also associated with the higher level of knowledge.
The media plays a key role in shaping population attitude towards vaccination as reported previously (17). Our results showed that newspapers were the primary source of information about influenza. Consequently, newspaper would be a useful target for advertisement and health massages about influenza and its vaccine in Jordan. Compared to a previous study performed in the UK, television was the most commonly used source of information about influenza followed by the internet (12). This difference probably reflects cultural differences between the different countries.
Practices of participants towards having seasonal influenza vaccine and determinants of that practice
In this survey, the practice of having influenza vaccine was observed in only 20.4% of the study population although 63% of the population believed that vaccine is an important influenza preventative measure and ~47% of the participants were considered knowledgeable. Hence, population beliefs and level of knowledge regarding influenza and its vaccine do not guarantee the practice of vaccination, as previously shown in a study that assessed vaccine acceptance among health care workers in Lebanon (9). In contrast to the level of knowledge, our data showed that the practice of having influenza vaccine was significantly more observed in those who were not working in the medical field rather than in health care personnel. This might be due to the low perception of risk about influenza among the surveyed health care personnel. The perception of risk about influenza was previously examined among GPs in France (16). It was reported that GPs who perceive the risk of influenza illness to outweigh the potential vaccine-associated risks (risk-averse attitude) had higher vaccination acceptance than risk-tolerant practitioners (16). Thus, working in the medical field also does not ensure the practice of getting vaccinated. This was in keeping with the results obtained in previous studies on health care workers conducted in our region such as in United Arab Emirates, Kuwait and Oman (8), in Lebanon (9) and in Saudi Arabia (10) or in studies conducted worldwide such as in Italy (14) and in France (16). The practice of getting vaccinated was also more significantly observed in those who used newspapers as their primary source of information about influenza.
As discussed above, knowledge and beliefs about influenza and its vaccine might only partially contribute to vaccine acceptance. Therefore, in this study, we examined other determinants that affect the decision of accepting or refusing vaccinations. In keeping with previous reports (18,19), our results showed that physician recommendation was the most important cause of accepting the vaccine in those participants who have been previously vaccinated. Other factors such as concerns of catching H1N1, becoming severely ill because of influenza and protecting other family members were almost equally important. These factors, which are associated with vaccine beneficial effects, were previously shown to be associated with higher vaccination rate among adults in the USA (18). On the other hand, fear of getting ill after administering the vaccine and not considering influenza as a threat were the most commonly reported barriers against vaccination, followed by doubts about the safety and efficacy of the vaccine. In line with that, Malosh et al. (18) reported that low perceived risk of infection and concern about vaccine safety and efficacy were the most common reasons for not getting vaccinated in the USA. Although vaccine cost was not an important cause for refusing the vaccine, most of the participants in this study were more willing to get vaccinated in the future if the vaccine is offered for free by the government. In keeping with that, the cost of the vaccine has been previously reported as a possible barrier against influenza vaccine acceptance (6,17).
Children at/or younger than 5 years of age are identified by the WHO as a risk group for influenza-associated complications (3). In addition, in an epidemiology study conducted in Jordan, it was shown that 57% of hospitalized influenza-positive patients with severe acute respiratory infection cases, during 2008–14, were children younger than 5 years (20). Hence, in this study, we examined parents’ attitude towards their children being vaccinated. Similar to adult results, concerns about the safety and the efficacy of the vaccine were the major barriers against child vaccination. In keeping with our results, a previous study conducted in Jordan, to assesses Jordanian mothers’ awareness of children vaccination in general, has been reported that ~40% of them were concerned about safety of child vaccination in general (7). In other Middle Eastern countries, concern about vaccine safety was also a major factor that prevents health care workers from recommending the vaccine for their patients (8). Furthermore, the results of previous surveys conducted in the UK (12) and the USA (18) were also in line with other results, where the safety and the efficacy of influenza vaccine were considered as the major factors that determine vaccine acceptance in children. The results of this survey revealed that the roles of both the physician and the government were also critical in increasing vaccination rate for this high-risk group. The government’s role in this regard would include the incorporation of the vaccine within the national immunization program, as it has not been a scheduled vaccine for children so far (6,7). The government’s role would also include assuring the population for the safety and the efficacy of the vaccine, offering the vaccine in the schools and for free. The critical role of the government and schools to improve vaccination of children was also emphasized in previous reports conducted in the UK (12).
Limitations
Our study has resulted in interesting findings, yet it has some limitations. First, it has inherent weakness due to the study design that implies general associations between the different variables rather than a cause-and-effect relationship. Second, the results were based on self-reported information about vaccination history rather than on verifying medical records. Third, since the participants were approached in Amman city only, the results of this study may not be necessarily representative of the general population in Jordan.
Conclusions
Our data revealed critical gaps of knowledge within the Jordanian population regarding seasonal influenza and more importantly regarding its vaccine. The major determinants of vaccine acceptance and the major barriers against vaccination in both adults and children were also identified. Hence, our study provided critical implications for health care policy makers. Optimizing vaccination coverage in adults and children in Jordan would ideally be achieved through the collaboration of physicians and the government. Implementation of educational programs and the utilization of newspapers are required for the dissemination of positive attitude towards influenza vaccine, for assuring the population about the safety and the efficacy of influenza vaccine and for educating the population about the risk groups that would highly benefit from vaccination. Child vaccination would also be improved through incorporating influenza vaccine within the national immunization program and offering the vaccine through schools.
Declaration
Funding: the Deanship of Academic Research at the University of Jordan.
Ethical approval: the Institutional Review Board at the University of Jordan hospital.
Conflict of interest: none.
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