Abstract
Background:
The important role of vaccination and preventive health care has been shown in several studies conducted worldwide. Despite the annual high infection rate of influenza, there are still many people who opt not to get vaccinated and be protected. We conducted this study to explore the knowledge, practices, and barriers of a Saudi Arabian population toward influenza vaccination.
Methods:
We conducted a community-based cross-sectional study using a questionnaire that was distributed online through social media to adult males and females aged 18 years old and above in Riyadh, Saudi Arabia.
Results:
A total of 778 individuals responded to the survey, 193 (24.8%) males and 585 (75.2%) females. Male respondents tended to have a better knowledge of influenza and flu vaccine than females. However, there were more females who have been vaccinated. More males believed that they do not belong to the high-risk group compared to females (P < 0.001). The younger age group of respondents significantly had a better knowledge of flu vaccine and influenza (P < 0.05). On the other hand, the older age group of respondents (age 45–60 and age >60 years old) have more reasons and barriers to have the vaccine.
Conclusion:
Knowledge of influenza and flu vaccine is relatively high, but the translation of this knowledge into practice is poor. The paradigm shift should be focused not only on knowledge of vaccines and vaccination but to attitudes and practices that will address barriers to getting the vaccine.
Keywords: Adherence, barriers, influenza vaccine, knowledge, practice
Introduction
Influenza is the commonest infection that can be transmitted through airborne which affects around 5%–10% of the world's population leading to an annual mortality rate of 250 000–500 000.[1,2] According to the World Health Organization (WHO), vaccination toward influenza is recommended for high-risk population such as children, hospitalized patients, pregnant women, and health care workers.[3] Furthermore, the American Center for Disease Control and Prevention (ACDCP) recommend annual vaccination for people older than 6 months.[4] In Saudi Arabia, influenza vaccines are offered free of charge for all population.[5]
The important role of vaccination and preventive health care has been shown in several studies conducted worldwide. Self-protection has been one of the most important reasons for vaccination compliance among health care workers in a German university hospital.[6] Because of the advent of new influenza strains, many countries have initiated mass immunizations.[7] Apart from the emergence of new strains, the annual epidemics of seasonal influenza pose a significant burden on the society including hospitalizations, absences at work, and even fear from the general population.[8]
Despite the annual high infection rate of influenza, there are still many people who opt not to get vaccinated and be protected. Several factors and reasons have come into play for people who do not get them vaccinated. For one is lack of knowledge and attitude toward the vaccine.[9] In one study, half of the pregnant women were not aware of the recommendations for vaccination during pregnancy, and 80% believed that the vaccine can cause birth defects, whereas another study showed a very low 13.1% of pregnant women who were aware that they have to be vaccinated and safe to receive a vaccine for influenza.[10,11] Among health care workers, the knowledge of influenza vaccine was reported to be low from 52% to 81%.[12,13,14] Compared to individuals working in a health care facility or individuals who have some medical background, knowledge and awareness of the importance of vaccination for influenza among the general population is relatively low at 23.6%.[15]
Another barrier for influenza vaccination is the lack of time. A study conducted in the Eastern Mediterranean countries showed that the lack of time to get vaccinated is the main factor for not receive the influenza vaccine among health care worker.[16] A study in Saudi Arabia showed that health care workers avoid getting vaccinated for influenza because of their misconception that vaccine itself causes influenza and concept about efficiency.[17] Other identified barriers for influenza vaccination include pain/discomfort,[18] previous side effects,[18] psychological factors,[19] belief that they are not at risk,[20] and misinformation or unawareness of the importance of vaccination from their doctors or health care workers.[21,22,23]
Because of the compendium of factors and barriers toward influenza vaccination, our aim of this study was to explore the knowledge, practices, and barriers of a Saudi Arabian population toward influenza vaccination.
Method
We conducted a community-based cross-sectional study using a questionnaire in http://surveymonkey.com that was distributed online through social media applications - Twitter, WhatsApp and Snapchat to individuals in Riyadh, Saudi Arabia. All adult males and females aged 18 years old and above were invited to participate in the study. Individuals less than 18 years old and non-residents of Riyadh city were excluded from the study.
The questionnaire consisted of three sections (demographic profile including age, gender, marital status, education, place of residence, employment, smoking and presence of chronic illness, 13 questions on knowledge of influenza vaccine, 3 questions on practice toward influenza vaccine, and 13 questions on barriers for not taking influenza vaccine). The questionnaire was developed using questions from the previous similar studies in English then translated to Arabic, and a pilot study was conducted on 20 volunteers to determine the validity and reliability of the questionnaire.[5,24,25]
Sample size was calculated based on 95% confidence level, 3% margin of error, and a prevalence of 9.5% (based on the lowest proportion of knowledge among Saudi population regarding safety of the vaccine in pregnant women according to Alqahtani et al.),[5] and a non-response rate of 50%. The calculated target sample size was 734.
Data was entered into a computer using standardized entry codes. For all tests, statistical significance was set at P < 0.05. Descriptive statistics were used to present means and standard deviation (for continuous variables), and numbers and percentages (for categorical variables). Independent t-test and analysis of variation (ANOVA) were used to determine significant differences between continuous variables and chi-square tests to compare age groups and other categorical demographic variables. All analyses were conducted using the Statistical Package for Social Sciences (SPSS) version 23.0 (SPSS, IBM, Armonk, New York, USA).
All participants were informed about the aim of the study in the first page of the electronic survey. To ensure confidentiality, responses were collected anonymously, with no personal information such as names, IDs, contact numbers, or e-mails required. The study was approved by an institutional review board of King Fahad Medical City, Riyadh, Saudi Arabia [IRB:H-01-R-012].
Results
The link was sent to 860 adults and 778 had responded to the survey with a response rate of 91% and 193 (24.8%) males and 585 (75.2%) females. There were 767 (98.6%) Saudi nationals, and 11 (1.4%) were of other nationalities. Table 1 shows the demographic characteristics of the respondents.
Table 1.
Demographic characteristics of 778 survey respondents
| Demographic variables | n | % |
|---|---|---|
| Gender | ||
| Male | 193 | 24.8 |
| Female | 585 | 75.2 |
| Nationality | ||
| Saudi | 767 | 98.6 |
| Non-Saudi | 11 | 1.4 |
| Age groups, in years | ||
| 18-30 | 353 | 45.4 |
| 30-45 | 237 | 30.5 |
| 45-60 | 171 | 22.0 |
| >60 | 17 | 2.2 |
| Years as resident of Riyadh | ||
| <1 year | 38 | 4.9 |
| 1-5 years | 51 | 6.6 |
| >5 years | 689 | 8.6 |
| Marital status | ||
| Single | 291 | 37.4 |
| Married | 487 | 62.6 |
| Education | ||
| Primary | 110 | 14.1 |
| High level | 112 | 14.4 |
| University | 556 | 71.5 |
| Employment | ||
| Employed | 393 | 50.5 |
| Unemployed | 385 | 49.5 |
| Presence of chronic disease | ||
| None | 668 | 85.9 |
| Asthma | 53 | 6.8 |
| Heart disease | 10 | 1.3 |
| COPD Diabetes | 6 | 0.8 |
| Mellitus | 41 | 5.3 |
| Smoking | ||
| Yes | 69 | 8.9 |
| No | 709 | 91.1 |
Table 2 shows the responses to the questions on the general knowledge about influenza vaccine. A larger number of respondents believe that flu is highly contagious (86.9%), that the infection can be serious that needs hospitalization of the patient (82.6%), flu vaccine is recommended for all individuals with chronic disease (60.0%), 61.8% said flu vaccine is the best way for protection and 58.0% mentioned that it will avoid complications against influenza, and that it is safe and effective (53.6%). However, 54.8% of respondents believe that flu vaccine weakens the immune system and can render anyone susceptible to infections. On the other hand, 44.2% respondents did not know that pregnant women should take the vaccine, 57.1% was unaware that it was recommended for children 6 months of age and above, and 48.1% for adults >65 years of age respectively. Less than half (n = 325, 41.8%) of the respondents are planning to have the vaccine this year, whereas 428 (55.0%) had already been vaccinated majority through Hajj permit requirement (n = 121, 15.6%) and through physician recommendation (n = 120, 15.4%). The most common reason/barrier for not having the flu vaccine was bad experience with the previous flu vaccination (n = 618, 79.4%), followed by the notion that they do not belong to the group of individuals that needs to have flu vaccination (n = 410, 52.7%), and fear of injections (n = 402, 51.7%).
Table 2.
Responses to questions on knowledge, practice, and barriers to influenza vaccination among 778 respondents according to gender and age groups, n (%)
| Questions on knowledge, practice, and barriers/reasons for influenza vaccination | Yes | No/Do not know |
|---|---|---|
| Knowledge | ||
| Flu infection is highly contagious | 676 (86.9) | 102 (13.1) |
| Flu infection can sometimes be serious that a person must be admitted to the hospital | 643 (82.6) | 135 (17.4) |
| All pregnant women are advised to take the flu vaccine | 292 (37.5) | 486 (62.5) |
| Seasonal influenza vaccine is recommended to be given to all individuals with chronic disease | 467 (60.0) | 311 (40.0) |
| Annual vaccination is the best way to protect one from influenza | 481 (61.8) | 297 (38.2) |
| The best way to avoid the complications of influenza is by having seasonal vaccination | 451 (58.0) | 327 (42.0) |
| Influenza vaccine is safe and effective | 417 (53.6) | 361 (46.4) |
| Influenza vaccine is given during winter | 540 (69.4) | 238 (30.6) |
| Seasonal influenza vaccine is freely provided in every primary healthcare facility | 270 (34.7) | 508 (65.3) |
| Flu vaccine can cause influenza | 131 (16.8) | 647 (83.2) |
| Seasonal influenza vaccine weakens the immune system and renders one susceptible to infections | 426 (54.8) | 352 (44.2) |
| Influenza vaccine is recommended for children 6 months of age and above | 231 (29.7) | 547 (70.3) |
| Influenza vaccine is recommended for elderly individuals aged >65 years old | 332 (42.7) | 446 (57.3) |
| Practice | ||
| I am planning to take influenza vaccine this year | 325 (41.8) | 453 (58.2 |
| I have been vaccinated with influenza vaccine | 428 (55.0) | 350 (45.0) |
| I have been vaccinated because: | ||
| Recommended by a doctor | 120 (15.4) | |
| Recommended by family/friend | 70 (9.0) | |
| Job demand | 77 (9.9) | |
| Hajj requirement | 121 (15.6) | |
| Media campaign | 40 (5.1) | |
| Barriers/Reasons | ||
| Avoid medications | 270 (34.7) | 508 (65.3) |
| Thinks that flu is a simple disease and there is no need to prevent or vaccinate against it | 296 (38.0) | 482 (62.0) |
| Concerned about the side effects | 259 (33.3) | 519 (66.7) |
| Risk of acquiring the disease is low | 158 (20.3) | 620 (79.7) |
| Do not believe that the vaccine is effective | 107 (13.8) | 671 (86.2) |
| Do not believe that the vaccine is safe | 349 (44.9) | 429 (55.1) |
| The flu shot will make them sick | 196 (25.2) | 582 (74.8) |
| Do not know where to go and get vaccinated | 333 (42.8) | 445 (57.2) |
| Bad experience with the previous flu vaccine | 618 (79.4) | 160 (20.6) |
| Do not think that they belong to a group that is recommended to get vaccinated | 410 (52.7) | 368 (47.3) |
| Fear of injections | 402 (51.7) | 376 (48.3) |
| Forgot | 333 (42.8) | 445 (57.2) |
| The Ministry of Health had not made vaccination obligatory | 315 (40.5) | 463 (59.4) |
Table 3 shows the percentage of responses to questions on knowledge, practice, and barriers according to gender and age groups. Males significantly believe that annual vaccination protects from flu (68.9% vs. 59.5%, P = 0.019), that vaccination prevents flu complications (65.3% vs. 55.3%, P = 0.018), that flu vaccine is given in winter (76.2% vs. 67.2%, P = 0.019). However, there were significantly more females who were vaccinated (60.5% vs. 49.2%, P = 0.006), and more females avoid medications (36.9% vs. 28.0%, P = 0.024), think that flu is a simple disease and no need to have vaccination (40.5% vs. 30.6%, P = 0.014), that flu vaccine increases the risk of acquiring flu (22.2% vs. 14.5%, P = 0.021), do not believe that flu vaccine is safe (48.5% vs. 33.7%, P < 0.001), that a flu shot makes them sick (29.7% vs. 11.4%, P < 0.001). On the other hand, there were more males who believe that they do not belong to the high-risk group compared to females (64.8% vs. 48.7%, P < 0.001). The younger age group of respondents significantly have a better knowledge of flu vaccine and influenza (P < 0.05), and planning to have the vaccine (P = 0.007). On the other hand, the older age group of respondents (age 45–60 and age >60 years old) have more reasons and barriers to have the vaccine.
Table 3.
Frequency distribution and association between gender and age groups with questions on knowledge, attitudes, and practices toward flu vaccination among 778 respondents
| Questions | Gender | P | Age groups | P | ||||
|---|---|---|---|---|---|---|---|---|
| Male Yes/No n (%) | Female Yes/No n (%) | 18-30 Yes/No n (%) | 30-45 Yes/No n (%) | 45-60 Yes/No n (%) | >60 Yes/No n (%) | |||
| General knowledge | ||||||||
| Flu is highly contagious | 168/25 (87.0/13.0) | 508/168 (86.8/13.2) | 0.941 | 306/47 (86.7/13.3) | 209/28 (88.2/11.8) | 147/24 (86.0/14.0) | 14/3 (82.4/17.6) | 0.850 |
| Flu can be serious/patient admitted to hospital | 158/35 (81.9/18.1) | 485/100 (82.9/17.1) | 0.741 | 302/51 (85.6/14.4) | 192/45 (81.0/19.0) | 139/32 (81.3/18.7) | 10/7 (58.8/41.2) | 0.024* |
| Pregnant women should take the vaccine | 69/124 (35.8/64.2) | 223/362 (38.1/61.9) | 0.556 | 158/195 (4.8/55.2) | 78/159 (32.9/67.1) | 53/11 (31.0/69.0) | 3/14 (17.6/82.4) | 0.001* |
| Flu vaccine is recommended to people with chronic disease | 109/84 (56.5/43.5) | 358/227 (61.2/38.8) | 0.246 | 203/150 (57.5/42.5) | 140/97 (59.1/40.9) | 114/57 (66.7/33.3) | 10/7 (58.8/41.2) | 0.243 |
| Annual vaccination protects from flu | 133/60 (68.9/31.1) | 348/237 (59.5/40.5) | 0.019* | 235/18 (66.6/33.4) | 132/105 (55.7/44.3) | 103/68 (60.2/39.8) | 11/6 (64.7/35.3) | 0.061 |
| Vaccination prevents flu complications | 126/67 (65.3/34.7) | 325/260 (55.6/44.4) | 0.018* | 227/126 (64.3/35.7) | 120/117 (50.6/49.4) | 95/76 (55.6/44.4) | 9/8 (52.9/47.1) | 0.009* |
| Flu vaccine is effective and safe | 111/82 (57.5/42.5) | 306/279 (52.3/47.7) | 0.209 | 162/191 (45.9/54.1) | 128/109 (54.0/46.0) | 112/59 (65.5/34.5) | 15/2 (88.2/11.8) | <0.001* |
| Flu vaccine is given in winter | 147/46 (76.2/23.8) | 393/192 (67.2/32.8) | 0.019* | 254/99 (72.0/28.0) | 160/77 (67.5/32.5) | 117/54 (68.4/31.6) | 9/8 (52.9/47.1) | 0.292 |
| Flu vaccine is free | 74/119 (38.3/61.7) | 196/389 (33.5/66.5) | 0.221 | 144/209 (40.8/59.2) | 77/160 (32.5/67.5) | 47/124 (27.5/72.5) | 2/15 (11.8/88.2) | 0.003* |
| Flu vaccine can cause influenza | 27/166 (14.0/86.0) | 104/481 (17.8/82.2) | 0.223 | 51/302 (14.4/85.6) | 48/189 (20.3/79.7) | 31/140 (18.1/81.9) | 1/16 (59/94.1) | 0.166 |
| Flu vaccine weakens the immune system | 117/76 (60.6/39.4) | 309/276 (52.8/47.2) | 0.059 | 191/162 (54.1/45.9) | 122/115 (51.5/48.5) | 103/68 (60.2/39.8) | 10/7 (58.8/41.2) | 0.351 |
| Flu vaccine is recommended for children 6 months of age and above | 67/126 (34.7/65.3) | 164/421 (28.0/72.0) | 0.078 | 124/229 (35.1/64.9) | 65/172 (27.4/72.6) | 40/131 (23.4/76.6) | 2/15 (11.8/88.2) | 0.010* |
| Flu vaccine is recommended for elderly >65 years | 83/110 (43.0/57.0) | 249/336 (42.6/57.4) | 0.914 | 141/212 (39.9/60.1) | 94/143 (39.7/60.3) | 89/82 (52.0/48.0) | 8/9 (47.1/529) | 0.042* |
| Practice | ||||||||
| Planning to have the vaccine this year | 72/121 (37.3/62.7) | 253/332 (43.2/56.8) | 0.147 | 124/229 (35.1/64.9) | 109/128 (46.0/54.0) | 84/87 (49.1/50.9) | 8/9 (47.1/52.9) | 0.007* |
| Have been vaccinated | 95/98 (49.2/50.8) | 54/231 (60.5/39.5) | 0.006* | 175/178 (49.6/50.4) | 160/77 (67.5/32.5) | 107/64 (62.6/37.4) | 7/10 (41.2/58.8) | <0.001* |
| Reasons/Barriers | ||||||||
| Avoid medications | 54/139 (28.0/72.0) | 216/369 (36.9/63.1) | 0.024* | 99/254 (28.0/72.0) | 98/139 (41.4/58.6) | 67/104 (39.2/60.8) | 6/11 (35.3/64.7) | 0.005* |
| Thinks flu is a simple disease/no need for vaccine | 59/134 (30.6/69.4) | 237/348 (40.5/59.5) | 0.014* | 90/263 (25.5/74.5) | 122/115 (51.5/48.5) | 77/94 (45.0/55.0) | 7/10 (41.22/58.8) | <0.001* |
| Concerned with side effects | 54/139 (28.0/72.0) | 205/380 (35.0/65.0) | 0.071 | |||||
| Risk of acquiring influenza is low | 28/165 (14.5/85.5) | 130/455 (22.2/77.8) | 0.021* | 94/259 (26.6/73.4) | 101/136 (42.6/57.4) | 59/112 (34.5/65.5) | 5/12 (29.4/70.6) | 0.001* |
| Do not believe vaccine is effective | 28/165 (14.5/85.5) | 79/506 (13.5/86.5) | 0.726 | 78/275 (22.1/77.9) | 52/185 (21.9/78.1) | 25/146 (14.6/85.4) | 3/14 (17.6/82.4) | 0.205 |
| Do not believe that vaccine is safe | 65/128 (33.7/66.3) | 284/301 (48.5/51.5) | <0.001* | 54/299 (15.3/84.7) | 35/202 (14.8/85.2) | 15/156 (8.8/91.2) | 3/14 (17.6/82.4) | 0.194 |
| Flu shot makes them sick | 22/171 (11.4/88.6) | 174/411 (29.7/70.3) | <0.001* | 140/213 (39.7/60.3) | 118/119 (49.8/50.2) | 85/86 (49.7/50.3) | 6/11 (35.3/64.7) | 0.038* |
| Do not know where to go | 82/111 (42.5/57.5) | 251/334 (42.9/57.1) | 0.919 | 74/279 (21.0/79.0) | 73/164 (30.8/69.2) | 48/123 (28.1/71.9) | 1/16 (5.9/94.1) | 0.010* |
| Bad experience with the previous vaccine | 151/42 (78.2/21.8) | 467/118 (79.8/20.2) | 0.635 | 174/179 (49.3/50.7) | 90/147 (38.0/62.0) | 60/111 (35.1/64.9) | 9/8 (52.9/47.1) | 0.004* |
| Do not think they do not belong to the high-risk group | 125/68 (64.8/35.2) | 285/300 (48.7/51.3) | <0.001* | 256/97 (72.5/27.5) | 202/35 (85.22/14.8) | 145/26 (84.8/15.2) | 15/2 (88.2/11.8) | <0.001* |
| Fear of injections | 89/104 (46.1/53.9) | 313/272 (53.5/46.5) | 0.075 | 202/151 (57.2/42.8) | 108/129 (45.6/54.4) | 89/82 (52.0/48.0) | 11/6 (64.7/35.3) | 0.033* |
| Forgot to get vaccinated | 83/110 (43.0/57.0) | 250/335 (42.7/57.3) | 0.876 | 154/199 (43.6/56.4) | 134/103 56.5/43.5) | 104/67 (60.8/39.2) | 10/7 (58.8/41.2) | 0.001* |
| The MoH have not made vaccination obligatory | 103/90 (53.4/46.6) | 212/373 (36.2/63.8) | <0.001* | 160/193 (45.3/54.7) | 83/154 (35.0/65.0) | 63/108 (36.8/63.2) | 9/8 (52.9/47.1) | 0.038* |
*Significant
Table 4 shows the percentage of responses to questions on knowledge, practice, and barriers according to marital status, level of education, and employment status. Single individuals, individuals with higher level of education (high school and college level/university), and those employed tend to have a better knowledge of influenza and flu vaccine (P < 0.05). 46.4% married respondents received the vaccine than 34.0%single individuals (P = 0.001) significantly more married individuals avoid medications, who thinks that flu is a simple disease, who thinks that flu shot makes them sick, had bad experiences with flu vaccine, and has fear of injections (P < 0.05). Respondents who have a lower level of education (primary level) tend to get vaccinated (P = 0.004); however, they think that flu is a simple disease and there is no need for vaccination (P < 0.001), risk of acquiring influenza is low (P = 0.011), that flu shot makes them sick (P < 0.001), and has fear of injections (P = 0.002).
Table 4.
Frequency distribution and association between marital status, level of education, and employment with questions on knowledge, attitudes, and practices toward flu vaccination among 778 respondents
| Questions | Marital status | P | Level of education | P | Employment | P | ||||
|---|---|---|---|---|---|---|---|---|---|---|
| Single Yes/No n (%) | Married Yes/No n (%) | Primary Yes/No n (%) | Higher school Yes/No n (%) | College/Univ Yes/No n (%) | Employed Yes/No n (%) | Unemployed Yes/No n (%) | ||||
| General knowledge | ||||||||||
| Flu is highly contagious | 257/34 (88.3/11.7) | 419/68 (86.0/14.0) | 0.362 | 87/23 (79.1/20.9) | 106/6 (94.6/5.4) | 483/73 (86.9/13.1) | 0.003* | 326/59 (84.7/15.3) | 350/43 (89.1/10.9) | 0.070 |
| Flu can be serious/patient admitted to hospital | 248/43 (85.2/14.8) | 395/92 (81.1/18.9) | 0.143 | 78/32 (70.9/29.1) | 102/10 (91.1/8.9) | 463/93 (83.3/16.7) | <0.001* | 319/66 (82.9/17.1) | 324/69 (82.4/17.6) | 0.879 |
| Pregnant women should take the vaccine | 130/11 (44.7/55.3) | 162/325 (33.3/66.7) | 0.001* | 29/81 (26.4/73.6) | 52/50 (55.4/44.6) | 201/355 (36.2/63.8) | <0.001* | 130/255 (33.8/66.2) | 162/231 (41.2/58.8) | 0.032* |
| Flu vaccine is recommended to people with chronic disease | 164/127 (56.4/43.6) | 303/184 (62.2/37.8) | 0.106 | 55/55 (50/50) | 87/25 (77.7/22.3) | 325/231 (58.5/41.5) | <0.001* | 211/174 (54.8/45.2) | 256/137 (65.1/34.9) | 0.003* |
| Annual vaccination protects from flu | 193/98 (66.3/33.7) | 288/199 (59.1/40.9) | 0.046* | 56/54 (50.9/49.1) | 81/31 (72.3/27.7) | 344/212 (61.9/38.1) | 0.005* | 232/153 (60.3/39.7) | 249/144 (63.4/36.6) | 0.374 |
| Vaccination prevents flu complications | 189/102 (64.9/35.1) | 262/225 (53.8/46.2) | 0.002* | 50/60 (45.5/54.5) | 84/28 (75.0/25.0) | 317/239 (57.0/43.0) | <0.001* | 207/178 (53.8/46.2) | 244/149 (62.1/37.9) | 0.019* |
| Flu vaccine is effective and safe | 129/162 (44.3/55.7) | 288/199 (59.1/40.9) | <0.001* | 64/46 (58.2/41.8) | 72/40 (64.3/35.7) | 281/275 (50.5/49.5) | 0.017* | 178/207 (46.2/53.8) | 239/154 (60.8/39.2) | <0.001* |
| Flu vaccine is given in winter | 201/90 (69.1/30.9) | 339/148 (69.6/30.4) | 0.875 | 69/41 (62.7/37.3) | 84/28 (75.0/25.0) | 387/169 (69.6/30.4) | 0.137 | 256/129 (66.5/33.5) | 284/109 (72.3/27.7) | 0.081 |
| Flu vaccine is free | 122/169 (41.9/58.1) | 148/339 (30.4/69.6) | 0.001* | 30/80 (27.3/72.7) | 40/72 (35.7/64.3) | 200/356 (36.0/64.0) | 0.210 | 138/247 (35.8/64.2) | 132/261 (33.6/66.4) | 0.509 |
| Flu vaccine can cause influenza | 38/253 (13.1/86.9) | 93/394 (19.1/80.9) | 0.029* | 24/86 (21.8/78.2) | 8/104 (7.1/92.9) | 99/457 (17.8/82.2) | 0.007* | 71/314 (18.4/81.6) | 60/333 (15.3/84.7) | 0.237 |
| Flu vaccine weakens the immune system | 157/134 (5.0/46.0) | 269/218 (55.2/44.8) | 0.728 | 52/58 (47.3/52.7) | 73/39 (65.2/34.8) | 301/255 (54.1/45.9) | 0.024* | 198/187 (51.4/48.6) | 228/165 (58.0/42.0) | 0.065 |
| Flu vaccine is recommended for children 6 month of age and above | 98/193 (33.7/66.3) | 133/354 (27.3/72.7) | 0.060 | 23/87 (20.9/79.1) | 56/56 (50/50) | 152/404 (27.3/72.7) | <0.001* | 86/299 (22.3/77.7) | 145/248 (36.9/63.1) | <0.001* |
| Flu vaccine is recommended for elderly >65 years | 116/175 (39.9/60.1) | 216/271 (44.4/55.6) | 0.220 | 42/68 (38.2/61.8) | 69/43 (61.6/38.4) | 221/335 (39.7/60.3) | <0.001* | 135/250 (35.1/64.9) | 197/196 (50.1/49.9) | <0.001* |
| Practice | ||||||||||
| Planning to have the vaccine this year | 99/192 (34.0/66.0) | 226/261 (46.4/53.6) | 0.001* | 65/45 (59.1/40.9) | 30/82 (26.8/73.2) | 230/326 (41.4/58.6) | <0.001* | 169/216 (43.9/56.1) | 156/237 (39.7/60.3) | 0.235 |
| Have been vaccinated | 140/151 (48.1/51.9) | 309/178 (63.4/36.6) | <0.001* | 74/36 (67.3/32.7) | 51/61 (45.5/54.5) | 324/232 (58.3/41.7) | 0.004* | 227/158 (59.0/41.0) | 222/171 (56.5/43.5) | 0.485 |
| Reasons/Barriers | ||||||||||
| Avoid medications | 80/211 (27.5/72.5) | 190/297 (39.0/61.0) | 0.001* | 55/55 (50/50) | 25/87 (22.3/77.7) | 190/366 (34.2/65.8) | <0.001* | 136/249 (35.3/64.7) | 134/259 (34.1/65.9) | 0.719 |
| Thinks flu is a simple disease/no need for vaccine | 73/218 (25.1/74.9) | 223/264 (45.8/54.2) | <0.001* | 62/48 (56.4/43.6) | 25/87 (22.3/77.7) | 209/347 (37.6/62.4) | <0.001* | 144/241 (37.4/62.6) | 152/241 (38.7/61.3) | 0.714 |
| Concerned with side effects | 86/205 (29.6/70.4) | 173/314 (35.5/64.5) | 0.087 | 46/64 (41.8/58.2) | 24/88 (21.4/78.6) | 189/367 (34.0/66.0) | 0.004* | 129/256 (33.5/66.5) | 130/263 (33.1/66.9) | 0.899 |
| Risk of acquiring influenza is low | 71/220 (24.4/75.6) | 87/400 (17.9/82.1) | 0.028* | 29/81 (26.4/73.6) | 12/100 (10.7/89.3) | 117/439 (21.0/79.0) | 0.011* | 97/288 (25.2/74.8) | 61/332 (15.5/84.5) | 0.001* |
| Do not believe vaccine is effective | 47/244 (16.2/83.8) | 60/427 (12.3/87.7) | 0.133 | 13/97 (11.8/88.2) | 9/103 (8.0/92.0) | 85/471 (15.3/84.7) | 0.103 | 51/334 (13.2/86.8) | 56/337 (14.2/85.8) | 0.685 |
| Do not believe that vaccine is safe | 118/173 (40.5/59.5) | 231/256 (47.4/52.6) | 0.062 | 53/57 (48.2/51.8) | 39/73 (34.8/65.2) | 257/299 (46.2/53.8) | 0.065 | 183/202 (47.5/52.5) | 166/227 (42.2/57.8) | 0.138 |
| Flu shot makes them sick | 60/231 (20.6/79.4) | 136/351 (27.9/72.1) | 0.023* | 41/69 (37.3/62.7) | 11/101 (9.8/90.2) | 144/412 (25.9/74.1) | <0.001* | 118/267 (30.6/69.4) | 78/315 (19.8/80.2) | 0.001* |
| Do not know where to go | 143/14 (49.1/50.9) | 190/297 (39.0/61.0) | 0.006* | 49/61 (44.5/55.5) | 43/69 (38.4/61.6) | 241/315 (43.3/56.7) | 0.579 | 189/196 (49.1/50.9) | 144/249 (36.6/63.4) | <0.001* |
| Bad experience with previous vaccine | 214/77 (73.5/26.5) | 404/83 (83.0/17.0) | 0.002* | 85/25 (77.3/22.7) | 92/20 (82.1/17.9) | 441/115 (79.3/20.7) | 0.663 | 309/76 (80.3/19.7) | 309/84 (78.6/21.4) | 0.573 |
| Do not think they do not belong to the high-risk group | 165/126 (56.7/43.3) | 245/242 (50.3/49.7) | 0.084 | 54/56 (49.1/50.9) | 77/35 (68.8/31.2) | 279/277 (50.2/49.8) | 0.001* | 182/203 (47.3/52.7) | 228/165 (58.0/42.0) | 0.003* |
| Fear of injections | 128/163 (44.0/56.0) | 274/213 (56.3/43.7) | 0.001* | 68/42 (61.8/38.2) | 43/69 (38.4/61.6) | 291/265 (52.3/47.7) | 0.002* | 213/172 (55.3/44.7) | 189/204 (48.1/51.9) | 0.044* |
| Forgot to get vaccinated | 164/127 (56.4/43.6) | 264/223 (54.2/45.8) | 0.563 | 60/51 (53.6/46.4) | 80/32 (71.4/28.6) | 289/267 (52.0/48.0) | 0.001* | 187/198 (48.6/51.4) | 241/152 (61.3/38.7) | <0.001* |
| The MoH have not made vaccination obligatory | 128/163 (44.0/56.0) | 187/300 (38.4/61.6) | 0.124 | 41/69 (37.3/62.7) | 58/54 (51.8/48.2) | 216/340 (38.8/61.2) | 0.030* | 140/245 (36.4/63.6) | 175/218 (44.5/55.5) | 0.020* |
*Statistical significance at 5% level
Logistic regression showed that being employed was the most significant factor for knowledge (Beta = 0.180, t = 4.647, P < 0001). Married women were the most significant factors to practice vaccination (Beta = 0.100, t = 2.678, P = 0.008, and Beta = 0.155, t = 3.404, P = 0.001). For barriers, male gender, unemployment, and being single were the most significant factors for not getting vaccinated (Beta = 0.122, t = 3.257, P = 0.001, Beta= - 0.146, t = -3.786, P < 0.001, and Beta = -0.090, t = -1.979, P = 0.048).
Discussion
This study aimed to explore the knowledge, practices, and barriers of a Saudi Arabian population toward influenza vaccination. Considering that our respondents were taken from the general population, the knowledge of influenza and flu vaccination (with percentages above 50%) in most of the questions that were asked was encouraging which showed that a larger percentage of our respondents have a very good knowledge and understanding of flu vaccine and the importance of vaccination to prevent the disease. Our results are significantly higher than those reported from the previous studies in which knowledge ranged from 23.1% to 52%.[12,13,14,15]
It was identified that 5 to 6 in ten respondents had flu vaccination because it is a requirement for Hajj pilgrimage, and only 1 to 2 of ten respondents had vaccination because of doctor's recommendation. This suggests that people in this region do get vaccinated because of their need to fulfill a requirement, but not because of their need to be protected from a contagious disease. In fact, more than half of the respondents believed that there is no need for them to have the vaccine because “they do not belong” to the group of individuals that needs to have flu vaccination. The statement that “getting flu vaccine will make you sick” has been mongered by a lot of individuals and this created the misconception toward vaccines in general. In fact, the US Center for Disease Control (CDC) has argued on this statement that “getting the flu vaccine is better than getting the flu.”[26]
Another peculiar finding in this study is why there are significantly more males who believe that flu vaccination protects one from influenza and its complications, but on the other hand, more females actually get vaccinated despite that some of them avoid vaccinations and several other barriers that prevent them from vaccination. In some countries, the increase in annual flu vaccination among men significantly increased because of the increase in Medicare coverage among men than women.[27] On the other hand, in contrast to other reports, there are more women who have the intention to get vaccinated during pregnancy and even get their children vaccinated.[28] Females may not have the intention to get vaccinated because they have a lower antibody response compared to males and cross-reactivity of antibodies might be higher among females than males, and local adverse reactions were reportedly high among females than males.[29]
This study also showed that young adults have the tendency to acquire knowledge and learn about the vaccine and influenza compared to older people. The reason for this was that most of our respondents who have knowledge of influenza and flu vaccine were educated either in their higher levels of education or at university level. However, this did not translate to actually having the vaccine. Our results showed that among our respondents who actually planned to have the vaccine was significantly lower among age groups 18–30 and 30–45 (35.1% and 46.0%) compared to the older age groups 45–60 and >60 (49.1% and 47.1%).
The other hand, there were more males who believe that they do not belong to the high-risk group compared to females (64.8% vs. 48.7%, P < 0.001). The younger adults significantly have a better knowledge of flu vaccine and influenza (P < 0.05), planning to have the vaccine (P = 0.007). But the older adults (age 45–60 and age >60 years old) had more reasons and barriers to take the vaccine. Young adults get vaccinated because they perceive the vaccine as effective, safe, and consider themselves as susceptible to the disease.[30]
Barriers of vaccination correlated to the male gender, the unemployed, and being single. Surprisingly as mentioned earlier, our male respondents had good knowledge of the vaccine and influenza but in reality does not get themselves vaccinated. This may have something to do with the males' assumption of them not being at risk for influenza (64.8%). This is similar to the findings of Abalkhail et al., where the assumption of not being at risk was a significant barrier toward vaccination. However, in contrast to our study, their study showed that males had lower knowledge scores and at the same time had lower vaccination rate than females.[1] The unemployed and those with low level of education together with religious and cultural beliefs were found to be the most commonly cited obstacles to vaccination acceptance.[31] Being single (unmarried) has been found to be a risk factor for lower immunization rates because single individuals are less likely to frequently utilize health care services, and they are most likely to live with their parents, brothers, and sister who are most likely to be vaccinated.[32]
With regards to the implementation of vaccination programs and evade the low vaccine acceptance and utilization, there is a need to address the fears of people toward vaccines and increase awareness of their health status particularly among those who are at risk for severe influenza illness.[33] A large-scale influenza vaccination promotion using text messaging was found to increase vaccination by 23.2%, although individuals responded more to messages that highlighted rewards to be received for obtaining a flu shot.[34] Furthermore, primary care physicians should intensively promote vaccination because vaccination recommendation by a physician and information dissemination regarding vaccines and vaccination to patients significantly increase vaccination rates.[35]
The relevance of this prevalence study to primary care practice is that it gives us an idea and understanding on how the general population, particularly among Saudis, knows influenza vaccine and how they perceive the importance of vaccination and how many of individuals actually get themselves vaccinated. Furthermore, this study also helps primary care physicians to institute practice measures to deliver optimal care and prevention of communicable disease such as influenza, and also prevent complications brought about by the disease.
Conclusion
Knowledge of influenza and flu vaccine is relatively high, but the translation of this knowledge into practice is poor. The paradigm shift should be focused not only on knowledge of vaccines and vaccination but to attitudes and practices that will address barriers to getting the vaccine particularly among the unemployed, single individuals, and male members of the Saudi population. There is a need for health authorities and researchers to further investigate this disparity why saudi population does not get vaccinated despite their knowledge of influenza and flu vaccine.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
- 1.Abalkhail MS, Alzahrany MS, Alghamdi KA, Alsoliman MA, Alzahrani MA, Almosned BS, et al. Uptake of influenza vaccination, awareness and its associated barriers among medical students of a University Hospital in Central Saudi Arabia. J Infect Public Health. 2017;10:644–8. doi: 10.1016/j.jiph.2017.05.001. [DOI] [PubMed] [Google Scholar]
- 2.Abu-Rish EY, Elayeh ER, Mousa LA, Butanji YK, Albsoul-Younes AM. Knowledge, awareness and practices towards seasonal influenza and its vaccine:Implications for future vaccination campaigns in Jordan. Fam Pract. 2016;33:690–7. doi: 10.1093/fampra/cmw086. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Influenza [Internet]. World Health Organization. World Health Organization; 2018. [cited 2019 Feb 01]. Available from: https://www.who.int/influenza/en/ [Google Scholar]
- 4.Grohskopf LA, Sokolow LZ, Olsen SJ, Bresee JS, Broder KR, Karron RA. Prevention and control of influenza with vaccines:Recommendations of the advisory committee on immunization practices, United States 2015-16 influenza season. Am J Transplant. 2015;15:2767–75. doi: 10.1111/ajt.13505. [DOI] [PubMed] [Google Scholar]
- 5.Alqahtani AS, Althobaity HM, Aboud DA, Abdel-Moneim AS. Knowledge and attitudes of Saudi populations regarding seasonal influenza vaccination. J Infect Public Health. 2017;10:897–900. doi: 10.1016/j.jiph.2017.03.011. [DOI] [PubMed] [Google Scholar]
- 6.Wicker S, Rabenau HF, Doerr HW, Allwinn R. Influenza vaccination compliance among health care workers in a German university hospital. Infection. 2009;37:197–202. doi: 10.1007/s15010-008-8200-2. [DOI] [PubMed] [Google Scholar]
- 7.Black S, Eskola J, Siegrist CA, Halsey N, MacDonald N, Law B, et al. Importance of background rates of disease in assessment of vaccine safety during mass immunisation with pandemic H1N1 influenza vaccines. Lancet. 2009;374:2115–22. doi: 10.1016/S0140-6736(09)61877-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Carrillo-Santisteve P, Ciancio BC, Nicoll A, Luigi Lopalco P. The importance of influenza prevention for public health. Hum Vaccin Immunother. 2012;8:89–95. doi: 10.4161/hv.8.1.19066. [DOI] [PubMed] [Google Scholar]
- 9.Lino M, Giuseppe GD, Albano L, Angelillo IF. Parental knowledge, attitudes and behaviours towards influenza A/H1N1 in Italy. Eur J Public Health. 2011;22:568–72. doi: 10.1093/eurpub/ckr115. [DOI] [PubMed] [Google Scholar]
- 10.Yudin MH, Salaripour M, Sgro MD. Pregnant women's knowledge of influenza and the use and safety of the influenza vaccine during pregnancy. J Obstet Gynaecol Can. 2009;31:120–5. doi: 10.1016/s1701-2163(16)34095-6. [DOI] [PubMed] [Google Scholar]
- 11.Mayet AY, Al-Shaikh GK, Al-Mandeel HM, Alsaleh NA, Hamad AF. Knowledge, attitudes, beliefs, and barriers associated with the uptake of influenza vaccine among pregnant women. Saudi Pharm J. 2017;25:76–82. doi: 10.1016/j.jsps.2015.12.001. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Loulergue P, Moulin F, Vidal-Trecan G, Absi Z, Demontpion C, Menager C, et al. Knowledge, attitudes and vaccination coverage of healthcare workers regarding occupational vaccinations. Vaccine. 2009;27:4240–3. doi: 10.1016/j.vaccine.2009.03.039. [DOI] [PubMed] [Google Scholar]
- 13.Bali NK, Ashraf M, Ahmad F, Khan UH, Widdowson MA, Lal RB, et al. Knowledge, attitude, and practices about the seasonal influenza vaccination among healthcare workers in Srinagar, India. Influenza Other Respir Viruses. 2013;7:540–5. doi: 10.1111/j.1750-2659.2012.00416.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Zhang J, While AE, Norman IJ. Nurses'knowledge and risk perception towards seasonal influenza and vaccination and their vaccination behaviours:A cross-sectional survey. Int J Nurs Stud. 2011;48:1281–9. doi: 10.1016/j.ijnurstu.2011.03.002. [DOI] [PubMed] [Google Scholar]
- 15.Torre GL, Semyonov L, Mannocci A, Boccia A. Knowledge, attitude, and behaviour of public health doctors towards pandemic influenza compared to the general population in Italy. Scand J Public Health. 2012;40:69–75. doi: 10.1177/1403494811424612. [DOI] [PubMed] [Google Scholar]
- 16.Zaraket H, Melhem N, Malik M, Khan WM, Dbaibo G, Abubakar A. Review of seasonal influenza vaccination in the Eastern Mediterranean Region:Policies, use and barriers. J Infect Public Health. 2019;12:472–8. doi: 10.1016/j.jiph.2018.10.009. [DOI] [PubMed] [Google Scholar]
- 17.Haridi H, Salman K, Basaif E, Al-Skaibi D. Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia. J Hosp Infect. 2017;96:268–75. doi: 10.1016/j.jhin.2017.02.005. [DOI] [PubMed] [Google Scholar]
- 18.Armstrong K, Berlin M, Schwartz JS, Propert K, Ubel PA. Barriers to influenza immunization in a low-income urban population. Am J Prev Med. 2001;20:21–5. doi: 10.1016/s0749-3797(00)00263-4. [DOI] [PubMed] [Google Scholar]
- 19.Schmid P, Rauber D, Betsch C, Lidolt G, Denker ML. Barriers of influenza vaccination intention and behavior-A systematic review of influenza vaccine hesitancy 2005-2016. PLoS One. 2017;12:e0170550. doi: 10.1371/journal.pone.0170550. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Eppes C, Wu A, You W, Cameron KA, Garcia P, Grobman W. Barriers to influenza vaccination among pregnant women. Vaccine. 2013;31:2874–8. doi: 10.1016/j.vaccine.2013.04.031. [DOI] [PubMed] [Google Scholar]
- 21.Silverman NS, Greif A. Influenza vaccination during pregnancy. Patients'and physicians'attitudes. J Reprod Med. 2001;46:989–94. [PubMed] [Google Scholar]
- 22.Mirza A, Subedar A, Fowler SL, Murray DL, Arnold S, Tristram D, et al. Influenza vaccine:Awareness and barriers to immunization in families of children with chronic medical conditions other than asthma. South Med J. 2008;101:1101–5. doi: 10.1097/SMJ.0b013e318182ee8d. [DOI] [PubMed] [Google Scholar]
- 23.Merrill RM, Kelley TA, Cox E, Layman AB, Layton BJ, Lindsay R. Factors and barriers influencing influenza vaccination among students at Brigham Young University. Med Sci Monit. 2010;16:PH 29–34. [PubMed] [Google Scholar]
- 24.AlMusailhi SA, AlShehri NM, AlHarbi WM. Knowledge, utilization and barriers of pregnant women to influenza vaccine in primary health care centers in Dammam and Al Khobar, Saudi Arabia 2017-2018. Int J Womens Health. 2019;11:207–11. doi: 10.2147/IJWH.S194061. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Sagor KH, AlAteeq MA. Beliefs, attitudes and barriers associated with the uptake of the seasonal influenza vaccine among patients visiting primary healthcare clinics. Saudi Med J. 2018;39:690–6. doi: 10.15537/smj.2018.7.22293. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.LaVito A. Here are some reasons why people don't get the flu shot-and why they're wrong. Health and Science, 11-2018. Available from: https://www.cnbc.com/2018/11/02/heres-why-people-dont-get-a-flu-shot-and-why-you-should.html .
- 27.Watson IW, Oancea SC. Does health plan type influence receipt of an annual influenza vaccination? J Epidemiol Community Health. 2020;74:57–63. doi: 10.1136/jech-2019-212488. doi:10.1136/jech- 2019-212488. [DOI] [PubMed] [Google Scholar]
- 28.Psarris A, Sindos M, Theodora M, Antsaklis P, Pergialiotis V, Loutradis D, et al. Routine immunizations during pregnancy, doctors'compliance and patient hesitancy:A two stage study on vaccination uptake. Eur J Obstet Gynecol Reprod Biol. 2019;243:36–40. doi: 10.1016/j.ejogrb.2019.10.012. [DOI] [PubMed] [Google Scholar]
- 29.Klein SL, Pekosz A. Sex-based biology and the rational design of influenza vaccination strategies. J Infect Dis. 2014;209(Suppl 3):S114–9. doi: 10.1093/infdis/jiu066. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Penţa MA, Crăciun IC, Băban A. The power of anticipated regret:Predictors of HPV vaccination and seasonal influenza vaccination acceptability among young Romanians. Vaccine. 2019 doi: 10.1016/j.vaccine.2019.11.042. doi:10.1016/j.vaccine 2019.11.042. [DOI] [PubMed] [Google Scholar]
- 31.Guzman-Holst A, DeAntonio R, Prado-Cohrs D, Juliao P. Barriers to vaccination in Latin America:A systematic literature review. Vaccine. 2019 doi: 10.1016/j.vaccine.2019.10.088. doi:10.1016/j.vaccine 2019.10.088. [DOI] [PubMed] [Google Scholar]
- 32.Chiatti C, Barbadoro P, Lamura G, Pennacchietti L, Di Stanislao F, D'Errico MM, et al. Influenza vaccine uptake among community-dwelling Italian elderly:Results from a large cross-sectional study. BMC Public Health. 2011;11:207. doi: 10.1186/1471-2458-11-207. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Reinders S, Romero C, Carcamo C, Tinoco Y, Valderrama M, La Rosa S, et al. A community-based survey on influenza and vaccination knowledge, perceptions and practices in Peru. Vaccine. 2019 doi: 10.1016/j.vaccine.2019.11.016. doi:10.1016/j.vaccine 2019.11.016. [DOI] [PubMed] [Google Scholar]
- 34.Lee WN, Stück D, Konty K, Rivers C, Brown CR, Zbikowski SM, et al. Large-scale influenza vaccination promotion on a mobile app platform:A randomized controlled trial. Vaccine. 2019 doi: 10.1016/j.vaccine.2019.11.053. doi:10.1016/j.vaccine 2019.11.053. [DOI] [PubMed] [Google Scholar]
- 35.Kizmaz M, Kurt BK, Kargin NÇ, Döner E. Influenza, pneumococcal and herpes zoster vaccination rates among patients over 65 years of age, related factors, and their knowledge and attitudes. Aging Clin Exp Res. 2019:1–9. doi: 10.1007/s40520-019-01423-z. doi:10.1007/s40520-019-01423-z. [DOI] [PubMed] [Google Scholar]