There are 3–5 million cases of seasonal influenza globally, every year, giving rise to severe illness and 250,000–500,000 deaths. More than half of Saudi hospital admissions from the 2 million pilgrims attending Hajj each year are due to acute respiratory infections, the majority of which is caused by influenza. Influenza viruses spread easily by droplets and aerosols, directly from person to person, or by the transfer of the virus from contaminated surfaces to the eyes, nose, or mouth.
Influenza viruses belong to the family Orthomyxoviridae. They have a layer that protects the segmented negative-sense RNA genome when traveling between hosts. Types A, B, and C based on their core proteins are the three types of influenza viruses. Types A and B, the most common, cause seasonal influenza epidemics. Type C is less severe and causes mild infection.
Seasonal influenza causes symptoms of cough, sore throat, fever, headache, muscle and joint pain, severe malaise, and a runny nose. Influenza usually causes epidemics with significant disease and mortality within high-risk populations. These groups include pregnant women, young children of <5 years, older adults (aged 65 or more), and individuals with chronic medical conditions, as well as healthcare workers (HCWs).
Influenza vaccination reduces the population’s risk to infection, prevents nosocomial infections, and reduces morbidity and mortality of patients. For example, the likelihood of dying from pneumococcal diseases decreases by 50% in the vaccinated elderly. This risk is reduced even further (80%) for influenza-related complication deaths. The intramuscularly administered vaccine comprising an inactivated vaccine is the most common type. Complications of the influenza vaccines include influenza-like symptoms, the most common of which are fever and soreness at the site of the injection. Headache, nausea, muscle aches, and chills can also occur. Vaccination is not recommended for those with documented anaphylaxis from a previous influenza vaccine.
Vaccinations for individuals 6 months and older (including high-risk groups) are recommended by the World Health Organization and the United States’ Centers for Disease Control and Prevention. The United States Advisory Committee on Immunization Practices recommends vaccination for HCWs to reduce healthcare influenza-related morbidity.
Despite the higher rates of vaccination in developed countries, there is the reluctance to take the influenza vaccine. Vaccination coverage in the United States during the 2016–2017 influenza season was 43.3% in adults and 59% in children (6 months to 17-years-old). While high-risk groups and HCWs are generally more inclined to be vaccinated, in Saudi Arabia, a survey of six major hospitals showed that influenza vaccination rates in HCWs was 38%. To understand this reluctance, it is necessary to identify the motivational factors, attitudes, and cultural differences.
Poor uptake of influenza vaccination is often due to low knowledge levels and a negative attitude to influenza vaccines, including the fear of an adverse reaction. Pregnant women are often hesitant because of the fear of harming the fetus or increasing their chances of miscarriage.
The goal of this research was to assess comprehension, beliefs, and mindsets regarding influenza vaccination in the adult population in Riyadh city and identify the reasons for accepting or declining immunization.
Materials and Methods
This cross-sectional questionnaire-based study was conducted at Princess Norah Bint Abdurrahman University, King Abdullah Bin Abdulaziz University Hospital, shopping malls and parks in Riyadh from December 15, 2017 to January 30, 2018. Participants included students, HCWs and the general population. All were residents of Riyadh city aged 18-year-old and above. Residents outside Riyadh city and those younger than 18-year-old were excluded from the study. Previous literature has shown that 46.5% of the general population has an acceptable level of influenza vaccine knowledge. Using a power of 80% (beta = 20%) and a level of confidence of 95% (alpha = 0.05) and a margin of error of 6%, the minimal sample size needed was 426. This was increased to 500 participants to adjust for missing or incomplete data. Participants in this study were selected by the convenient sampling technique. Ethical approval was obtained from the Institutional Review Board of Princess Nourah Bint Abdulrahman University vide Letter No. IRB-17-0217 dated 13/12/2017 and informed written consent was taken from all participants.
The information was collected from adult participants using a 4-part closed-ended, interviewer-based questionnaire, adapted from previous studies. The questionnaire consisted of 32 questions, the 1st part of which had nine questions on the sociodemographic characteristics. The 2nd part with 12 questions assessed influenza knowledge; part three consisting of 3 questions assessed vaccine knowledge and the 4th comprised 8 questions on the attitude toward influenza vaccination. The content validity of the questionnaire was evaluated by a focus group composed of a microbiologist, an internal medicine physician, an epidemiologist, and an infection control specialist.
A pilot study was conducted on 15 participants from the general population, students, and HCWs who gave verbal consent. The questionnaire was distributed in person and collected after completion. Participants were asked if they comprehended the questionnaire and whether they felt comfortable participating.
Descriptive statistics were used to describe the sample. Statistical analyses were performed using t-tests and Chi-squared tests. A statistically significant result was noted when the P value was under 0.05. According to microbiologists and biostatisticians, 60% was considered a good knowledge score for the general population (including students). For HCWs, 70% was defined as a good knowledge score.
The 500 participants in the study consisted of 124 HCWs (24.8%), 195 students (39%), and 181 participants from the general population (36.2%). Ages ranged from 18 to 76 with a mean of 28 ± 9.67 [Table 1]. Most responders were in the 18–29 age group (63.2%), most (436) were female (87.2%), were Saudi (85.2%), 40% were married, and 47.4% were university educated.
Participants’ knowledge scores ranged from 5 to 35 with a mean of 18 ± 5.85. The highest mean knowledge score was observed in people aged 40 and older. The lowest mean knowledge score was in people aged between 18 and 29 and was statistically significant (P = 0.03) [Table 2].
For gender, almost the same mean knowledge score was observed with statistical insignificance (P = 0.165). NonSaudis had a higher mean knowledge score (21.4 ± 6.94) than Saudis (17.4 ± 5.44), and was statically significant (P < 0.001). The mean knowledge score for married (18.26 ± 6.34) was higher than for nonmarried but was not statistically significant (P = 0.460). Postgraduate participants had the highest mean knowledge score (23.05 ± 6.63). Participants with middle school certificate had the lowest score (13.35 ± 6.14), which was statistically significant (P < 0.001). The mean knowledge score of HCWs was 21.07 ± 6.44, which was higher than that of the students (17.56 ± 5.16) and the general population (16.43 ± 5.35) with statistical significance (P < 0.001). Physicians had the highest mean knowledge score of all subgroups. Although the mean knowledge score for health science students was higher than that of non-health sciences students; it was statistically insignificant (P = 0.161).
Sixty participants (12%) were considered high-risk for influenza: 31 (51.7%) participants had chest disease; 19 (31.7%) had diabetes mellitus; 6 (10%) had heart disease; 5 (8.3%) had neurological disease, and 2 (3.3%) had liver disease. The mean knowledge score for this group was 17.38 ± 5.40.
A knowledge score of 60% was considered good for the general population and students, whereas 70% was considered good knowledge for HCWs. Most participants in all groups had poor knowledge; only 62 (12.4%) had good knowledge. The lowest percentage of good knowledge was the general population (16 participants, 8.8%), followed by students (23, 11.8%) and HWCs (23, 18.5%). Of the HCWs, 47% of physicians (16 participants), 16.7% of nurses, (6) and 1.9% of other HCWs (1) had good knowledge. Of the students, 13% in health science (14) and 10.2% in non-health science (9) had good knowledge. The main sources of knowledge were the social media (35%) and doctors and health educators in hospitals (33%). Only 3% of participants had no information.
Table 2 shows the vaccination rates of the different groups. Surprisingly, the vaccination rate of HCWs was the lowest (12.9%), followed by students (15.9%), and the general population (17.1%), and statistically insignificant (P = 0.602). All students had similar vaccination rates and were statistically insignificant (P = 0.88). Of the 60 high-risk participants, 31.7% (19 participants) had been vaccinated this year.
Participants aged between 18 and 29 had the highest vaccination rate (16.1%), with statistical insignificance (P = 0.170). Saudis had a higher vaccination rate (16.7%) than non-Saudis (9.5%), but was statistically insignificant (P = 0.115). Two hundred and five participants (41%) intend to have an influenza vaccination in the future; however, 59% had no intention of doing so.A statistically insignificant (P = 0.165) higher proportion of males were vaccinated (22.2%) than females (14.8%); 14.5% of married participants were vaccinated this year, with no statistical significance (P = 0.85). Participants with a middle school certificate had the highest vaccination rate (25%), but postgraduate degree holders had the lowest vaccination rate (13.5%). These results were statistically insignificant (P = 0.668).
Most studied participants (88.6%) knew that a virus causes influenza 44%; 33% thought it was bacteria, and 25% did not know the cause. Most of the population knew that the incubation period was 1–4 days, and 70.8% considered influenza a potentially severe disease [Table 3]. Most participants (84.6%) considered inhalation of infected droplets in the air as a mode of transmission; 44% considered touching their eyes, nose, or mouth with contaminated hands as the mode of transmission. Also, 23.4% believed that influenza and the common cold were the same, and 50.8% thought antibiotics were suitable treatment for influenza. Most participants thought of fever, sore throat, fatigue, headache, and cough as symptoms of influenza (76.4%, 60.8%, 59.8%, 56%, 50.2% respectively) and 70% of participants thought of sinus and ear infections as complications. 61.6% were aware that high-risk influenza-related complications affected young children (under 5) but only 36.4% knew that elderly people (65 and older) were also vulnerable. Most participants had had a cough with a fever this year: 33% had had it once; 26.6% twice; 21.6% more than twice, but 18.8% had no cough. 77.2% believed that influenza could be prevented by social distancing, while 71.4% and 66.2% respectively considered vaccination and hand washing as preventive methods. 73.4% believed children should be vaccinated, while 38.2% considered HCW vaccinations necessary.
The study showed that most participants had not had the vaccine this year (60.8%). Moreover, 43.4% of the population had never been vaccinated [Table 4].
Figure 1 shows the reasons why people would take the influenza vaccination. The primary incentive was advice by their doctors and the recommendation by the Ministry of Health (MOH) (77.8% for each). The least common reason (20.8%) was vaccination campaign incentives such as coffee and sweets. Figure 2 shows the studied population’s justifications for not getting vaccinated. The most common reason given was that influenza was uncommon (66.2%), followed by the belief that the vaccine would make them sick; 42.4% said they did not have the time to be vaccinated.
Child vaccination rates were better with 34.4% of participants indicating their children were vaccinated this year. A statistically significant (P = 0.024) 38.4% of students, 35.4% of HCWs and 29.2% of the general population had vaccinated children in their families. The most important reason reported for child vaccinations was protection from influenza complications (80.6%), followed by doctors’ recommendations. The least common reason was chronic conditions. Most families (59%) believed the vaccine would make their children sick, followed by 42.8% who gave the lack of time as the excuse for nonvaccination.
The present study was done to determine the level of knowledge and perception of both the general population and HCWs as it pertains to influenza and associated vaccines. Most participants had poor knowledge of both. The HCWs had the highest knowledge score; they were followed by students, and then the general population. Physicians had the best knowledge score among HCWs. The mean knowledge score of HCWs was 21.07 ± 6.44 (54% of the total score), which is comparable to the Haridi et al’s study done at King Abdullah Medical City in Makkah, Saudi Arabia. There, the mean knowledge score for the HCWs was 16.03 ± 5.86 out of 33 points (48.6% of the total score). In the latter study, 42.2% of healthcare participants reported that they had insufficient knowledge of the vaccine.
A 2016 study conducted in Jordan reported a higher mean knowledge score in the studied population (12.6 ± 0.2 out of 16; 78.8% of the total score). The mean knowledge score for HCWs (13.72 ± 0.14; 85.8% of total score) was significantly higher than non-HCWs (10.41 ± 0.34; 65% of total score) although both were higher than those reported in this study. In the current study, no correlation was found between the knowledge score and the rate of vaccination. Like these results, the Haridi et al’s study reported that there was no statistical significance in the knowledge score and the vaccination status. This contrasts with a study done in Lebanon which showed a correlation between higher knowledge of influenza and vaccination and higher vaccination rates
In this study, participants aged 40 years and older, non Saudis, and postgraduate participants had higher knowledge scores, which was statistically significant. However, the knowledge scores grouped by marital status and gender were statistically insignificant. This is consistent with the Haridi et al’s study, which determined statistical significance in the knowledge scores according to age, marital status, education, income, and healthcare occupation.
The participants’ main source of knowledge in this study was the social media followed by doctors and health educators in hospitals. In accordance with these results, is the finding of a previous study conducted in 2017 in Saudi Arabia that explored the knowledge and attitudes of Saudi nationals on influenza vaccinations, which identified physicians and HCWs as the main source of information, and formal brochures and medical websites. The lack of communication between the physicians and the community might be one of the main causes of poor knowledge in the majority of the population.
Participation of the studied population in vaccinations was poor. HCWs had the lowest rate of vaccination compared to students and the general population. The fear of unproven vaccine side effects is thought to be a reason for the low vaccination rate in HCWs. Most were vaccinated at a governmental hospital followed by the university/workplace. There was no statistical significance in vaccination rates by age, gender, education, or occupation. This was comparable to a study of the adult population in Turkey, which reported low vaccination rates. The explanation this study posits for the low vaccination rates is that there are knowledge gaps and misconceptions about the vaccine. In contrast, a previous survey of HCWs in primary healthcare centers in Abha reported a higher vaccination rate (28.2%). A similar higher rate (27.6%) in the general population of Lebanon was also reported. The high rate of vaccination in the latter study was due to a vaccination program carried out by physicians to improve knowledge about vaccinations.
The prime reason for consenting to influenza vaccination in the current study was MOH and doctors’ recommendations. These same factors had positively affected vaccination rates in previous studies conducted on HCWs in King Abdullah Medical City in Makkah and University Hospitals in the South-Eastern Region of Turkey in 2015. In a study conducted in Abha, personal protection was the main reason for HCWs’ desire to be vaccinated. Of the physicians, 86.3% believed their contribution to getting their patients vaccinated was significant and that administering vaccines could be one of their functions (80.6%).
The most important barrier to vaccination in our study was poor previous rates of vaccination, followed by the belief that vaccines would make them sick. The same factors were reported as barriers to vaccination in a previous study in Turkey. The 2015 Turkish survey reported the misperception that regular influenza immunization was unnecessary.
The current study showed a better rate of vaccination of children in the surveyed families. The primary motivation was to protect them from complications. The most important barrier was the belief that the vaccine would make their children sick. A lower rate of vaccination of children was reported in a Spanish National Health Survey study in 2006 in which only 6.8% of children had the influenza vaccination. It is recommended that campaigns to increase awareness of influenza and the importance of vaccination should be held in health-care settings, shopping malls, and workplaces. An important limitation of our use of the convenient sampling technique is that the sample selected for this study is not representative of Riyadh city, thereby restricting representation and generalizability of our findings.
The knowledge about influenza and vaccinations in the studied populations, including HCWs was poor. Influenza vaccination was low in the different groups of the studied population. Few and infrequent attacks of influenza and the side effects were the most common barriers to acceptance of the vaccine. It is recommended that health education, dispelling misinformation and dissemination of facts could play a significant role in increasing the rate of acceptance.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
1. El Khoury G, Salameh P Influenza vaccination:A cross-sectional survey of knowledge, attitude and practices among the Lebanese adult population Int J Environ Res Public Health 2015 12 15486 97
2. Al-Tawfiq J, Benkouiten S, Memish Z A systematic review of emerging respiratory viruses at the Hajj and possible coinfection with Streptococcus pneumoniae Travel Medicine and Infectious Disease 2018 23 6 13
3. Ministry of Health Kingdom of Saudi Arabia 2014 Available from:https://www.moh.gov.sa/en/Flu/Pages/About.aspx
Last accessed on 2017 Nov 10
4. Patrick RM, Rosenthal KS, Pfaller MA Medical Microbiology E-book Elsevier Health Science, 2020
5. Mohammed O, Zeitouni M The Saudi Thoracic Society Guidelines for Influenza Vaccinations PubMed Central (PMC) 2017 Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652287/#sec1-9title
Last accessed on 2017 Dec 01
6. Influenza (Seasonal) 2018 Available from:https://www.who.12 int/news-room/fact-sheets/detail/influenza-(seasonal)
Last accessed on 2018 Nov 06
7. Barry MA, Aljammaz KI, Alrashed AA Knowledge, attitude, and barriers influencing seasonal influenza vaccination uptake Can J Infect Dis Med Microbiol 2020 2020 7653745
8. Choucair K, El Sawda J, Assaad S, El Chakhtoura NG, Hassouna H, Sidani N, et al. Knowledge, perception, attitudes and behavior on influenza immunization and the determinants of vaccination J Epidemiol Glob Health 2021 11 34 41
9. American Academy of Pediatrics Committee on Infectious Diseases Prevention of influenza:Recommendations for influenza immunization of children, 2006-2007 Pediatrics 2007 119 846 51
10. Comparison of Side Effects of the 2015-2016 High-Dose, inactivation Trivalent Influenza Vaccine
and Standard Dose, Inactivated, Trivalent Influenza in Adult ≥65 Years
11. Esposito S, Bosis S, Pelucchi C, Tremolati E, Sabatini C, Semino M, et al. Influenza vaccination among healthcare workers in a multidisciplinary University hospital in Italy BMC Public Health 2008 8 422
12. Flu Vaccination Coverage, United States, 2016-17 Influenza Season | FluVaxView | Seasonal Influenza (Flu) | CDC [Internet]. Cdc.gov.2017 Available from: https://www.cdc.gov/flu/fluvaxview/coverage-1617estimates.htm
Last accessed on 2017 Dec 01
13. Alqahtani AS, Althobaity HM, Al Aboud D, Abdel-Moneim AS Knowledge and attitudes of Saudi populations regarding seasonal influenza vaccination J Infect Public Health 2017 10 897 900
14. Tarrant M, Wu KM, Yuen CY, Cheung KL, Chan VH Determinants of 2009 A/H1N1 influenza vaccination among pregnant women in Hong Kong Matern Child Health J 2013 17 23 32
15. 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
16. Asma S, Akan H, Uysal Y, Poçan AG, Sucaklı MH, Yengil E, et al. Factors effecting influenza vaccination uptake among health care workers:A multi-center cross-sectional study BMC Infect Dis 2016 16 192
17. Santaularia J, Hou W, Perveen G, Welsh E, Faseru B Prevalence of influenza vaccination and its association with health conditions and risk factors among Kansas adults in 2013:A cross-sectional study BMC Public Health 2016 16 185
18. Haridi HK, Salman KA, Basaif EA, Al-Skaibi DK 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
19. Ozisik L, Calik Basaran N, Oz SG, Sain Guven G, Durusu Tanriover M Perceptions and attitudes of patients about adult vaccination and their vaccination status:Still a long way to go? Med Sci Monit 2017 23 3178 84
20. Alsaleem MA Acceptance of H1N1 vaccine
among healthcare workers at primary healthcare centres in Abha, KSA J Egypt Public Health Assoc 2013 88 32 9
21. Vora A, Shaikh A Awareness, attitude, and current practices toward influenza vaccination among physicians in India:A multicenter, cross-sectional study Front Public Health 2021 9 642636
22. Lopez-de-Andres A, Hernández-Barrera V, Carrasco-Garrido P, Gil-de-Miguel A, Jiménez-García R Influenza vaccination coverage among Spanish children, 2006 Public Health 2009 123 465 9