INTRODUCTION

Influenza is a respiratory disease caused by the influenza virus, which often presents symptoms similar to those of the common cold. The virus originates from zoonotic reservoirs, including aquatic birds and bats, and possesses the ability to mutate and challenge the immune system. This necessitates regular updates to vaccines. Due to these mutations, there is a constant risk of a flu pandemic occurring before new medications can be developed [1,2].

Influenza poses a global threat, leading to significant morbidity and mortality. It is estimated that seasonal influenza results in 30 000 to 60 000 deaths annually [3]. Historical pandemics, such as the Spanish flu, H2N2 Asian flu, H3N2 Hong Kong flu, and H1N1 swine flu, have also led to considerable health impacts [1,2,4]. Vaccination remains the most effective measure against influenza pandemics, safeguarding lives and decreasing the rates of morbidity and mortality [5].

Based on comprehensive clinical trials and post-marketing surveillance, the influenza vaccine is considered a very safe medical intervention [6,7]. The reported side effects are generally mild and temporary, such as fever and pain at the injection site [6,7]. Serious adverse events are extremely rare, and there is no confirmed evidence that the vaccine increases the risk of autoimmune disorders like Guillain-Barré syndrome (GBS) or other chronic conditions. In fact, the risk of developing GBS is higher following an influenza virus infection than from the vaccine itself [8]. Overall, the benefits of the vaccine in preventing morbidity and mortality outweigh its minor side effects [6-8].

Although healthy adult healthcare workers are not at high risk for influenza-related complications, they can be a source of nosocomial infections for patients. Research has shown that vaccinating healthcare workers is associated with a reduced incidence of nosocomial influenza cases. Conversely, unvaccinated healthcare workers have been identified as potential sources of influenza transmission [9]. Therefore, the World Health Organization has recommended including healthcare workers in the target group for seasonal influenza vaccination [10].

In Saudi Arabia, the Ministry of Health (MOH) has identified healthcare workers as a priority group for the annual seasonal influenza vaccine [11]. The MOH has also required healthcare facilities to promote the influenza vaccine. Priority was given to outreach programs for healthcare workers in high-risk areas such as intensive care units, emergency rooms, hemodialysis units, and organ transplant units. A study conducted in Saudi Arabia found that during the 2008-2009 influenza season, only 34.4% of healthcare workers received the influenza vaccine. The predominant reason for not getting vaccinated was the belief that the vaccine was ineffective in preventing the disease. Conversely, the main motivation for those who chose to get vaccinated was to protect themselves from the disease [12].

To the best of our knowledge, there is no recent data on the knowledge, attitudes, and practices (KAP) regarding the influenza vaccine among healthcare workers in Saudi Arabia for the 2021-2022 influenza season. Therefore, this study aimed to investigate the KAP toward influenza vaccination among healthcare workers in Saudi Arabia during 2021.

This study aimed to (1) assess the level of KAP toward influenza vaccine among healthcare workers at MOH facilities in Saudi Arabia and (2) explore organizational factors that could influence the uptake of influenza vaccine among healthcare workers in Saudi Arabia.

METHODS

Study Design

A cross-sectional study was conducted from September 2021 to October 2021, by the MOH, which distributed an online questionnaire to healthcare workers.

Study Population and Setting

The study was conducted at MOH facilities including the MOH office, directorates, hospitals, and primary healthcare centers (PHCCs). It targeted general practitioners, nurses, pharmacists, and laboratory technicians. The study included both Saudi and non-Saudi healthcare workers, as well as both male and female participants.

Sample Size and Sampling Technique

The proportion of vaccinated healthcare workers was reported as 48.6%, based on the findings of a previous study [13]. To calculate the minimum required sample size, the Cochran formula was utilized, resulting in 384 participants. This calculation was based on a Z-value of 1.96, corresponding to a 95% confidence interval, and an acceptable margin of error of 0.05. Data collection was conducted using a convenience sampling method, where participants were sent an online questionnaire via email.

Data Collection Instrument and Recruitment of Participants

A self-administered questionnaire was developed following a review of relevant literature. The face validity of the questionnaire was established through a review process involving experts from the MOH. It comprised 5 distinct sections, totaling 32 questions.

The first section collected demographic data from the participants, including age, sex, nationality, profession, educational level, and type of workplace setting. The second section consisted of 11 questions related to knowledge about the influenza vaccine. The third section included 7 statements designed to assess participants’ attitudes toward influenza vaccination. The fourth section examined the participants’ practices regarding influenza vaccines, featuring 4 specific questions in this area. Finally, the fifth section comprised 4 questions that investigated organizational determinants and factors that might influence the uptake of the influenza vaccine among participants.

To test the clarity and understanding of the questionnaire, a pilot study was conducted by administering it to 10 healthcare workers. Their feedback and responses were analyzed to ensure the questionnaire’s suitability for the study’s objectives. Subsequently, data collection took place from September 16, 2021 to October 16, 2021. The questionnaire was distributed to eligible healthcare workers through the Internal Communication Department of the MOH.

Knowledge, Attitudes, and Practices Scores and Categorization Criteria

The overall KAP scores for the participants were calculated based on their responses to the questions in each section, which included 11 knowledge-related questions, 7 attitude-related questions, and 4 practice-related questions. In the knowledge section, each correct answer earned 1 point, and each incorrect answer received 0 points. These scores were then summed to determine the total knowledge score for each participant, which could range from 0 to 11.

In the attitude section, a Likert scale was employed to evaluate participants’ attitudes toward the influenza vaccine. Responses indicating a positive attitude were assigned 2 points, neutral responses received 1 point, and negative responses were given 0 points. Subsequently, these scores were aggregated to calculate a total score, which ranged from 0 to 14.

In the practice section, each “yes” response was assigned a score of 1 point, and each “no” response was assigned a score of 0 points. These scores were then summed to obtain a total score, which ranged from 0 to 4.

The overall KAP score, which assessed participants’ KAP regarding the influenza vaccine, was derived by summing the total scores from the KAP sections. This composite KAP score varied from a minimum of 0 to a maximum of 29.

Categorization of knowledge, attitude, and overall KAP scores was conducted using percentile thresholds. Practice was categorized based on the median into 2 groups: poor practice (<3) and good practice (≥3), as detailed in Table 1.

Statistical Analysis

The statistical analysis was conducted by 2 investigators using Jamovi version 2.3 (https://www.jamovi.org/). The Shapiro-Wilk test was used to assess the normality of the variables. Continuous variables were described using the median and interquartile range (IQR). Frequencies and proportions were employed to represent categorical variables.

The chi-square test was used to examine the relationships between categorical demographic and organizational factors that could influence the uptake of the influenza vaccine. The independent t-test was utilized to assess the differences in knowledge and attitude scores related to vaccine uptake. All relevant and statistically significant factors identified in the bivariate analyses—including nationality, age group, profession, workplace setting, organizational factors, participation in influenza vaccine training programs, awareness of influenza vaccine guidelines, participants’ perception of no need for the vaccine, beliefs about vaccine effectiveness, and disbelief in the severity of the disease—were incorporated into a binomial logistic regression model. Odds ratios (ORs) were used to examine the association between the dependent variable (uptake of influenza vaccine) and independent variables (demographic and organizational factors), with the level of significance set at 5%.

Ethics Statement

Ethical approval for the study was granted by the MOH Ethics Committee (No. 21-7M). Informed consent was obtained from each participant following a comprehensive explanation of the study. To protect confidentiality and privacy, the data were exclusively used for the purposes of this study. The results were analyzed, summarized, and published, ensuring that no personal information of the participants was disclosed.

RESULTS

A total of 1278 participants initially responded to the questionnaire. However, after data cleaning, 5 participants were excluded, resulting in 1273 participants being included in the study. The majority of these participants were aged between 30 years and 39 years (48.1%). The predominant nationality was Saudi (85.8%), with males comprising 63.8% of the sample. Professionally, nurses represented more than a quarter of the participants (28.4%), followed by physicians (23.7%). In terms of educational attainment, 41.6% of the participants held a bachelor’s degree, while 33.6% had a diploma. Approximately 2-thirds of the participants were employed in hospitals, with the remaining 21.6% working in PHCCs, as shown in Table 2.

Table 1 presents the levels of KAP, as well as the overall KAP regarding the influenza vaccine among participants. The median knowledge score was 7 (IQR, 2.0), with over one-third of the participants (37.1%) demonstrating a high level of knowledge. The median attitude score was 11 (IQR, 3.0), showing that a significant portion (41.2%) of the participants held a positive attitude toward the influenza vaccine. Additionally, the median practice score was 3 (IQR, 1.0), revealing that the majority of participants (80.2%) practiced good behaviors related to the vaccine.

Regarding the overall KAP, the median score was 21 (IQR, 4.0), indicating a relatively even distribution among participants. Specifically, 36.8% demonstrated a high KAP level, 30.9% a moderate KAP level, and 32.3% a low KAP level towards the influenza vaccine. Further details about participants’ KAP regarding the influenza vaccine can be found in Supplemental Material 1.

Regarding influenza vaccine uptake, approximately half of the participants (50.8%) had received the influenza vaccine in the past 12 months, while 85.3% reported receiving the vaccine in the past 5 years. Among different age groups, the highest uptake was observed in individuals aged 60 and older during both periods, with 85.7% reporting vaccination in the previous 12 months and 100% in the previous 5 years. However, individuals aged 40-49 years reported the lowest vaccine uptake, with only 47.8% having been vaccinated in the past 12 months.

In terms of sex, males reported a higher vaccination rate compared to females, with 52.3% indicating they had been vaccinated in the previous 12 months and 87.7% in the previous 5 years. Additionally, non-Saudis reported a relatively higher vaccination uptake compared to Saudi participants in both time periods, with 62.4% in the previous 12 months and 95.0% in the previous 5 years, versus 48.9% and 83.7%, respectively for Saudi participants.

Physicians and nurses reported the highest vaccine uptake rates, with 55.6% and 55.0%, respectively, in the past 12 months, and 87.1% and 90.6%, respectively, over the past 5 years. In contrast, laboratory specialists demonstrated the lowest uptake rates, with 40.0% in the past 12 months and 75.3% in the past 5 years. Additionally, vaccine uptake rates varied across different educational levels. Specifically, individuals with a PhD. exhibited the highest uptake rates for both periods, at 57.7% and 86.6% respectively, compared to those with diploma and bachelor’s degrees. However, those holding bachelor’s degrees showed relatively lower uptake rates, at 47.3% in the past 12 months and 85.3% in the past 5 years.

In terms of different workplace settings, individuals employed at PHCCs generally reported higher vaccine uptake rates, with 54.9% in the previous 12 months and 91.3% over the past 5 years. In contrast, those working in directorates exhibited lower uptake rates, with 41.1% in the previous 12 months and 83.0% in the previous 5 years. However, vaccine uptake varied among participants employed at the Ministry’s Office. Specifically, they reported the highest uptake rate in the previous 12 months at 56.9%, but the lowest rate over the past 5 years at 78.5, as detailed in Table 3.

The logistic regression analyses identified significant factors influencing vaccination uptake among participants over the past 12 months, as detailed in Table 4. The primary predictors of vaccine uptake included having been vaccinated within the last 5 years (OR, 2.19; 95% CI, 1.49 to 3.23; p<0.001), availability of the influenza vaccine at workplace settings (OR, 2.35; 95% CI, 1.56 to 3.52; p<0.001), knowledge of influenza vaccine guidelines for healthcare workers (OR, 1.68; 95% CI, 1.31 to 2.14; p<0.001), participation in training programs or continuing education on the influenza vaccine (OR, 1.95; 95% CI, 1.47 to 2.58; p<0.001), employment at the MOH office (OR, 2.14; 95% CI, 1.12 to 4.09; p=0.021), and positive attitudes toward the vaccine (OR, 1.51; 95% CI, 1.09 to 2.09; p=0.014). Conversely, the most common reason for not getting vaccinated was the perception of being at low risk and believing vaccination to be unnecessary (OR, 0.53; 95% CI, 0.32 to 0.86; p=0.011).

DISCUSSION

The present study sheds light on KAP related to the influenza vaccine, the vaccine uptake rate, and factors influencing vaccine uptake among healthcare workers in Saudi Arabia during 2021. The findings indicate that a majority of healthcare workers had an appropriate extent of knowledge, with 37.1% demonstrating a high level and 26.6% demonstrating a moderate level. These findings are consistent with a previous study, where 50.4% of healthcare workers reported good knowledge [14].

A near-majority of participants in the current study (41.2%) reported positive attitudes. These findings align with those of a previous study, in which 65.5% of healthcare workers had positive attitudes toward the influenza vaccine [15]. Moreover, other studies support these consistent findings [14,16].

This study revealed that 80.2% of the participants demonstrated good practices regarding the influenza vaccine, with a majority (90%) recommending the vaccine to their patients. This finding is consistent with a previous study in which 75% of healthcare workers advised their patients to get vaccinated [17]. However, the vaccination coverage among the participants was 50.8% over the past 12 months and 85.3% over the past 5 years. These figures are within the range of previously reported prevalence estimates for influenza vaccine uptake among healthcare workers, which varied widely from a low of 15.3% to a high of 88.3% [12,14,17-27].

These variations may be attributed to differences in study populations, settings, sample sizes, vaccine promotion, and time periods. Despite these factors, vaccination coverage among healthcare workers still falls short of the minimum 90% target recommended by the Healthy People 2020 goals [28].

The factors identified in this study that were associated with vaccine uptake included vaccination history, workplace practices such as encouraging and offering the vaccine, awareness of vaccination guidelines, participation in training programs about the influenza vaccine, type of workplace settings, and positive attitudes toward the vaccine. These findings are consistent with previous studies, which have consistently found that vaccination behavior in previous years is associated with vaccine uptake [23,25,29].

Organizational factors are crucial in promoting vaccine uptake among healthcare workers. Previous studies have indicated that the presence of standing orders or recommendations for vaccination significantly motivates healthcare workers to accept vaccines [19,26]. Furthermore, Rakita et al. [30] have demonstrated the effectiveness of mandatory influenza vaccination policies for healthcare workers.

Similarly, 2 studies have observed that healthcare workers’ awareness of vaccination guidelines is associated with increased vaccine uptake [19,22]. Additionally, participation in training programs about the influenza vaccine has been found to correlate with higher vaccine uptake [14].

Significant variation in influenza vaccine uptake was observed among participants based on their type of workplace. Specifically, participants employed at the MOH office were more than twice as likely to receive the vaccine than those working in the directorates. This finding aligns with previous research that highlighted the influence of workplace-related factors on vaccine uptake. Workplace support measures, including free vaccination, on-site vaccination services, and vaccination promotion, have been demonstrated to enhance vaccine uptake [31,32].

In 2018, the MOH initiated a seasonal influenza vaccination campaign at its Ministry’s Office, offering on-site vaccinations to its employees [33]. This initiative significantly increased the vaccination uptake rate among the individuals at the MOH office, underscoring the importance of proactive strategies by the central administrative body to promote vaccine uptake.

Furthermore, a study conducted by Madewell et al. [29] found a positive association between attitude scores and self-reported vaccination among healthcare workers. This finding is supported by Chen et al. [34], who reported that the attitudes of healthcare workers strongly influenced their practice regarding the influenza vaccine.

Conversely, the most common reason participants cited for not getting vaccinated was their perception of low risk, making vaccination unnecessary. This finding is consistent with several studies [14,18,23,26,35,36]. Overcoming this perception should be a central element of comprehensive vaccination strategies. It is crucial to implement targeted interventions that enhance vaccine accessibility, provide workplace support, and promote awareness campaigns in directorates and other healthcare settings across Saudi Arabia to improve vaccine uptake rates.

Since the current study was conducted at only MOH facilities, we recommend that future studies target a broader and more diverse sample of healthcare workers, including those from both government and private facilities. Additionally, for future research, we suggest gathering detailed data on healthcare workers’ vaccination histories and the side effects they experienced to enhance our understanding of their KAP toward influenza vaccination.

Limitations of the study include the use of a convenience sampling method, which may introduce selection bias and limit the generalizability of the findings to the broader population of healthcare workers in Saudi Arabia, as the study was limited to only healthcare workers at MOH facilities. Additionally, the study relied on self-reported data, which is subject to recall bias and social desirability bias. Participants may provide responses they believe are expected, potentially impacting the accuracy of the collected data.

The study findings reveal that healthcare workers at the MOH in Saudi Arabia demonstrate positive KAP regarding influenza vaccination. Despite this, the vaccine uptake rate remains below the desired coverage target. This discrepancy suggests a knowledge-behavior gap, where favorable knowledge and attitudes are not completely reflected in actual vaccine uptake. To address this issue, we recommend implementing interventions that enhance accessibility, provide workplace support, conduct awareness campaigns, and tackle barriers impeding vaccination, thereby improving uptake rates among healthcare workers in Saudi Arabia.

Supplemental Materials

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Author Contributions

Conceptualization: Almutairi LM, Albalawi AM. Data curation: Almutairi LM, Almusawi MA. Formal analysis: Almusawi MA, Alalweet RM. Funding acquisition: None. Methodology: Almutairi LM, Albalawi AM. Writing – original draft: Almusawi MA, Asiri AM. Writing – review & editing: Almutairi LM, Almusawi MA, Albalawi AM, Abu Hassan MY, Alotaibi AF, Almutairi TM, Alalweet RM, Asiri AM.

Acknowledgements

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Figure & Data

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