Original Article
Influenza Vaccination Hesitancy among Health Care Workers at the Tertiary Care Hospital, Buraydah, Qassim, Saudi
Arabia
Osama Al Wutayd1*, Amna Rehana Siddiqui2, Fahad Al-Jasser3,Mohammed S.
Alkathlan4, Weam K. Almasaud5, Rola A. Alsalamah5, Ola A. Alotaibi5, Khuzama K. Alkhalaf5, Modhi S. Alotaibi5, Ghadah M. Alharbi5, Norah I. Albahli5
1Department of Family and Community Medicine, Unaizah College of Medicine, Unaizah, Qassim University, Saudi Arabia. 2Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan. 3Prevention and Control of Infection Administration, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia.
4Department of Medicine, Infectious Diseases section, King Fahad Specialist Hospital, Buraydah, Saudi Arabia. 5Unaizah College of Medicine, Qassim University, Saudi Arabia.
*Corresponding Author: [email protected]
Abstract
Background: Vaccine hesitancy (VH) refers to reluctance or refusal to vaccinate despite the availability of vaccines against contagious diseases. The World Health Organization recommends healthcare workers (HCWs) to receive the influenza vaccine annually to protect them and prevent the spread of influenza to patients.
Objective: This study aimed to determine factors contributing to influenza VH among HCWs at the tertiary care King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia.
Participants and Methods: This cross-sectional study involved 369 HCWs that provided informed consents. Data were collected using a self-administered questionnaire that covered demographic data, personal health history, and factors that may influence the decision not to vaccinate. HCWs that did not receive the influenza vaccine the previous season and had no intention of being vaccinated the next season were considered as VH group – the outcome of interest.
Results: Participants’ mean age was 30 ± 7 years and median work duration was 6 years. In total, 11% of participants were classified as VH. The most common reasons for VH were: “I do not need it,” being in good health, and “it doesn’t have any benefit”
(8/41, 19.5%). Factors associated with VH included age >30 years (adjusted odds ratio [AOR] 3.18; 95% confidence interval [CI] 1.44, 7.05), and, a low level of confidence in information provided by the Ministry of Health (AOR 7.41; 95% CI 1.56, 35).
Conclusion: Despite the low VH among participating HCWs, more effort should be directed toward high-risk HCWs with VH through ongoing educational and vaccination programs to ensure a safe healthcare setting for both patients and HCWs.
Keywords: Influenza, Vaccine hesitancy, Healthcare workers, Saudi Arabia.
Citation: Al Wutayd O, Siddiqui AR, Al-Jasser F, Alkathlan MS, Almasaud WK, Alsalamah RA, Alotaibi OA, Alkhalaf KK, Alotaibi MS, Alharbi GM, Albahli NI.
Influenza Vaccination Hesitancy among Health Care Workers at the Tertiary Care Hospital, Buraydah, Qassim, Saudi Arabia. JUMJ 2018, September 1, 5(3): 33-39.
Introduction
Vaccine hesitancy (VH) refers to the reluctance or refusal to vaccinate despite the availability of vaccines. The World Health Organization (WHO) recognized
VH as a top 10 global threat to public health in 2019(1). VH has been defined as a behavior influenced by factors such as convenience, complacency, and confidence(2). Influenza or seasonal flu is
. an airborne contagious and common
respiratory infection caused by the influenza virus. Its spread is related to a seasonal epidemic, which is associated with significant consequences, including complications such as pneumonia and related hospitalization and mortality. As the health effects of influenza infection are important, the Centers for Disease Control and Prevention (CDC) analyzed its consequences during pandemics and found that up to 49.0 million illnesses, up to 960,000 hospitalizations, and up to 79,000 related mortalities were attributed to influenza since 2010(3). Influenza outbreaks in hospitals can result in significant morbidity and mortality, especially in those with compromised immune systems, including older adults and patients with chronic illnesses(4,5). WHO and the Saudi Thoracic Society recommend that individuals, including healthcare workers (HCWs), who may transmit influenza should receive the vaccine annually(6,7). A study conducted in France among general practitioners randomly selected from the private health sector found that the prevalence of VH decreased if there was trust in the source of information or when there was sufficient knowledge of the benefits and risks of the vaccine(8). Another prospective cohort study was conducted in Canada among HCWs aged 18–69 years in an acute care hospital. That study found that vaccine uptake differed according to the HCW’s previous vaccination history. They also found that the highest odds ratio (OR) was for those that were vaccinated many times previously (OR 156; 95% CI 98, 248).
There was also variation in vaccine uptake according to occupation (higher among physicians and support services staff) and ethnicity (higher among those with European ancestry) (9).
A multicenter cross-sectional study conducted in south-east Turkey that investigated factors contributing to HCWs receiving the influenza vaccine reported the overall regular vaccination uptake was 9.2%, with higher adherence among physicians than nurses. Several factors were found to play a role in increasing vaccine uptake namely, male sex, being
an internist, having a chronic disease, and living with older adults(10). A study, focused on influenza vaccine uptake and associated factors (e.g., awareness, and barriers) was conducted among medical students at a university hospital in central Saudi Arabia. The study concluded that both awareness about and uptake of the vaccine were inadequate. Barriers that affected vaccination adherence included:
thinking there was no risk for developing influenza (37.90%), worrying about vaccine side-effects (28.90%), and concern about efficacy the vaccine (14.50%)(11). Another study conducted at a tertiary care hospital in Riyadh among parents, adult patients, and HCWs reported that influenza VH was 17%.
Reasons for refusal included participants’
perceptions that vaccination was not necessary because they were healthy and no positive effect would be achieved from vaccination, and worry about adverse effects of the vaccine(12).
It is important to clarify the rate of VH among HCWs and determine factors associated with VH to increase the vaccination uptake rate. To our knowledge, no such study has been conducted among HCWs in Qassim region. This study aimed also to determine factors that contributed to influenza VH among HCWs at the tertiary care King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia.
Participants and Methods A quantitative cross-sectional study was conducted on 369 HCWs that were registered at King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia during 2019. This is the only governmental tertiary referral hospital in Qassim region, and has a total of 500 beds [13]. Doctors and nurses were approached on specific days for data collection during the study period from different departments. Those who were absent or on vacation were excluded from this study. The sample size was calculated using a sample equation for cross- sectional studies with a precision of 5%
and 95% level of confidence. Given a reported VH prevalence of 13% among HCWs based on a previous study conducted in Saudi Arabia(12) and
assuming a 20% non-response rate, the required sample size was 209 HCWs.
Before providing informed consent, participants received an explanation of the purpose of this study and their rights regarding confidentiality, to withdraw at any time without any obligation, and to contact the study team with any queries.
Participants’ anonymity was assured by assigning each participant a code number for the purpose of analysis. No incentives or rewards were given to participants.
Ethical approval was obtained from the Regional Ethical Committee in Ministry of Health (MOH), Qassim, before this study started.
Data were collected from participating HCWs using a self-administered questionnaire. Team leaders and department secretaries were responsible for distributing and collecting questionnaires, and checking they were complete. The validated questionnaire(12) included three sections: 1) demographic data (e.g., age, sex, nationality, work sector, job title, and years of work experience); 2) personal health history (age, sex, nationality, educational level, working sector, work experience, history of comorbid conditions, job title); and 3) data about the flu vaccine (have you ever received flu vaccine before, do you intend to get vaccinated in future, reasons for vaccine hesitancy, level of confidence in doctors' information, MOH, and social media, and duration of vaccine efficacy).
A pilot study was conducted with a sample of 30 HCWs to test the logistics of data collection and clarity of the data collection tool, and estimate the timing for data collection - their results were not included in the study.
Participants who had not been vaccinated in the previous season and did not intend to be vaccinated in future were classified as the VH group (outcome of interest),
and those who had been
vaccinated/planned to be vaccinated were classified as another category.
Statistical Package for the Social Sciences (SPSS) program version 21 was used for data entry, management, and analysis. We first calculated the frequencies of all studied variables, followed by cross tabulation and Chi-square and Fisher’s
exact tests. The effects of the independent variables on the dependent variable were evaluated with univariate and multivariate logistic regression modeling. Independent variables with a p value ≤0.10 in the univariate analysis were included in the multivariate analysis.
Results
Analysis of participants’ descriptive characteristics showed that 77% were nurses, 56% were aged ≤30 years, and 82% were female. 83% of them were non- Saudi and 80% had a bachelor’s level education. Regarding main duties, 72% of participants worked in the medical departments and the remainder was distributed between surgical and other positions in the hospital (laboratory and radiology department). Around 38% had 5–9 years of work experience, 39% had less than 5 years of experience, and only 23% had ≥10 years of experience. Most participants (89%) were free of comorbidities, but the remaining 11% had one or more comorbidities, such as bronchial asthma, diabetes mellitus, or hypertension (Table 1). The response rate for this study was 92%, which was satisfactory.
In total, 41 (11%) participants had VH towards influenza vaccination, whereas 328 (89%) were planning to be vaccinated in future or had been vaccinated in the past. The most common reason for VH was that the participant believed they did not need it because they were healthy (19.5%), followed by the perception that vaccination did not have any benefit (19.5%). The least common reason for VH was thinking the vaccine caused serious side-effects (5%; Figure 1).
A crude analysis showed that VH was more common among participants older than 30 years, males, Saudi nationals, physicians, those working in the surgical area, and those with a low level of confidence in information provided by MOH or physicians. Multivariable analyses showed that HCWs older than 30 years and those with a low level of confidence in information provided by MOH had greater odds of VH (Table 2).
.
Table 1: Participants’ characteristics (n = 369).
Characteristics Number %
Age, years >30 163 44
≤30 206 56
Sex Male 66 18
Female 303 82
Nationality Saudi 64 17
Non Saudi 305 83
Educational level Bachelor’s degree 294 80
Diploma 34 9
Postgraduate/Board certified 41 11
Work sector Medical 266 72
Surgical 50 14
Other (laboratory and radiology department) 53 14 Work experience,
years
<5 143 39
5–9 140 38
≥10 86 23
History of comorbid conditions
None 327 89
Yes 42 11
Job title Physicians 86 23
Nurses 283 77
Figure 1: Reasons for influenza vaccine hesitancy among Healthcare workers at King Fahad Specialist Hospital, Buraydah, Qassim, Saudi Arabia (n = 41).
Discussion
The overall level of influenza VH among HCWs in this study was 11%. The most common reasons for VH were that the HCWs did not think they needed to be vaccinated because they were healthy, and that the vaccine did not have any positive effects or benefits. Relatively few participants were concerned about the safety of the vaccine. The rate of influenza VH in this study is lower or nearly similar to rates reported by other studies from Saudi Arabia(12,14). A study conducted among 100 HCWs in Saudi
arabia showed that influenza VH was 13%; with the most common reasons being perceptions that the vaccine did not have any positive effects or benefits, and that they did not need the vaccine because they were healthy(12). These reasons were similar to those reported in our study.
Another study conducted in Al-Ahsa, Saudi Arabia, in 2009 reported low influenza vaccine coverage among HCWs; with the most common reason for not being vaccinated being the belief that vaccination was not effective in preventing the disease(14).
Table 2: Factors associated with influenza vaccine hesitancy among healthcare workers at the tertiary care King Fahad Specialist Hospital, Buraydah, Qassim, Saudi. OR = Odds ratio, CI = Confidence interval, MOH = Ministry of Health.
Factor Vaccine Hesitancy Crude OR
(95% CI)
Adjusted OR (95% CI) Yes n (%) No n (%)
Age, years
≤30 16 (8) 190 (92) Reference Reference
>30 25 (15) 138 (85) 2.15
(1.11–4.18)
3.18 (1.44–7.05) Sex
Female 26 (9) 277 (91) Reference Reference
Male 15 (23) 51 (77) 3.13
(1.55–6.32)
1.77 (0.48–6.50) Nationality
Non Saudi 28 (9) 277 (91) Reference Reference
Saudi 13 (20) 51 (80) 2.52
(1.22–5.19)
1.53 (0.52–4.51) Job title
Nurse 22 (8) 261 (92) Reference Reference
Physician 19 (22) 67 (80) 3.36
(1.72–6.57)
1.85 (0.47-7.26)
Work sector
Medical 26 (10) 240 (90) Reference Reference
Surgical 11 (22) 39 (78) 2.6
(1.19–5.69)
2.24 (0.95–5.27)
Other 4 (8) 49 (92) 0.75
(0.25–2.26)
0.97 (0.30–3.13) Level of confidence in
MOH information
High 35 (10) 320 (90) Reference Reference
Low 6 (43) 8 (57) 6.86
(2.25–20.9)
7.41 (1.56–35.0) Level of confidence in
doctors’ information
High 35 (10) 317 (90) Reference Reference
Low 6 (35) 11 (65) 4.94
(1.72–14.18)
1.71 (0.41–7.20)
Education level
Bachelor 32 (11) 262 (89) Reference
Diploma 2 (6) 32 (94) 0.51
(0.12–2.24) Postgraduate/
Board-certified
7 (17) 34 (83) 1.69
(0.69–4.12)
Work experience, years
<5 18 (13) 125 (87) Reference
5–9 10 (7) 130 (93) 0.53
(0.24–1.2)
≥10 13 (15) 73 (85) 1.24
(0.57–2.67) History of comorbid
conditions
None 34 (10) 293 (90) Reference
Yes 7 (17) 35 (83) 1.72
(0.71–4.18) Level of confidence in
information from social media
High 13 (8) 143 (92) Reference
Low 28 (13) 185 (87) 1.67
(0.83–3.33) Duration of vaccine
efficacy
Know 33 (11) 272 (89) Reference
Not know 8 (13) 56 (88) 1.18
(0.52–2.69) The low VH among HCWs in our study
may be explained by the hospital infection and prevention control efforts and availability of infectious disease physicians. In this setting, person-to- person education is provided on the spot in all consultations and rounds, and lectures and campaigns are frequently arranged. Other strategies include easy access to an employees’ health clinic and establishment of satellite nurses to give
vaccines at different places in the hospital. In addition, the study hospital has experienced the implications of previous outbreaks of MERS-CoV, which resulted in increased awareness about infection and prevention control measures for staff. Finally, the MOH has made efforts to encourage HCWs and the general population to be vaccinated, with the influenza vaccine offered free-of- charge in all healthcare settings, and proactive campaigns focused on education
. and promoting vaccination before the start
of each vaccination season.
Although VH was low in our study, we found VH was more common among HCWs older than 30 years and with low confidence in information provided by MOH. However, the majority of HCWs (96%) had a high level of confidence in information provided by MOH, which was consistent with a previous study from Saudi Arabia(12).
Conclusion
Despite the low rate of VH among HCWs in the present study, being among HCWs, more effort should be directed toward high-risk HCWs with VH through ongoing educational and vaccination programs to ensure a safe health care setting for both patients and HCWs.
Limitations of the Study
The large participation numbers was one of the study strengths. However, there were some limitations of the present study. First, there was a possibility of selection bias, meaning that the sample might not have been fully representative of all HCWs. However, 400 questionnaires were distributed by team leaders and department secretaries to HCWs when they signed the attendance record at beginning or end of the day, and participants had 5 days to return their questionnaire. The response rate for this study was 92%, which was satisfactory.
Second, the results might have been affected by recall bias, as some HCWs might not have been able to remember their vaccination history. However, this was unlikely because they were able to select “don’t remember” in response to that item. Self-report of influenza vaccination status has also been found to be valid and reliable(15).
Funding
This study was supported by the authors' institutions as their employment duties.
Conflict of Interests
The authors declared no conflict of interests.
Acknowledgments
We would like to thank the physicians and nurses at King Fahad Specialist Hospital, Buraydah, Saudi Arabia, for
their participation in this study. We also thank Audrey Holmes, MA, from Edanz Group for editing a draft of this manuscript.
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