INTRODUCTION

Seasonal influenza is caused by airborne influenza viruses affecting the respiratory system seasonally, from fall extending through winter until early spring. The virus is highly contagious, with infection symptoms ranging from mild or moderate to severe, potentially leading to serious complications [1].

Healthcare workers constitute a high-risk group for influenza infection, as they can contract the virus from their patients and subsequently transmit it to other patients, visitors, and family members. Influenza vaccine uptake by physicians and other healthcare workers is thus essential for controlling the spread of influenza infection and preventing associated morbidity and mortality [2].

A report by the Centers for Disease Control and Prevention highlighted the importance of healthcare professionals (HCPs) receiving annual influenza vaccination to decrease morbidity and mortality among themselves and their patients [3]. Despite the proven efficacy of influenza vaccines in reducing clinical burden, vaccine hesitancy among physicians persists and is a growing source of concern [4]. Influenza vaccine uptake among healthcare workers varies globally and remains a worldwide issue. In European countries, vaccination uptake remains comparatively low; a meta-analysis of 92 studies comprising 125 vaccination data points from 26 countries revealed an overall vaccination rate of 41.7% among healthcare workers [5]. A study from the Middle East also reported variations in influenza vaccine uptake among HCPs; among 993 respondents, vaccination rates were 24.7%, 67.2%, and 46.4% in the United Arab Emirates, Kuwait, and Oman, respectively [6].

Efforts have been made to understand factors influencing HCPs’ attitudes towards vaccination, exploring their individual beliefs, institutional policies, and the complex effects these factors have on vaccination practices [7]. Studies have revealed that the attitudes and beliefs of HCPs towards influenza vaccination significantly predict their decision-making regarding recommending the vaccine to their patients [8].

A study from Jordan found that influenza infections accounted for 9% of total hospital admissions with severe acute respiratory infections [9]. In Jordan, the influenza vaccine is recommended by the Ministry of Health’s vaccination program for physicians and is offered free of charge to physicians working in the public sector [10]. Another cross-sectional study from Jordan, conducted following the 2015–2016 influenza season, reported that only 51.9% of HCPs received the influenza vaccine in the preceding 3 years [11]. A more recent study from Jordan conducted during the coronavirus disease 2019 (COVID-19) pandemic found that 47.1% of HCPs had received the vaccine at least once; however, this study included only 55 physicians, of whom 69.1% reported having ever been vaccinated [11].

The health belief model (HBM) has been utilized to guide assessments of physicians’ perceptions and attitudes toward influenza vaccination [12]. Developed in the 1950s based on 2 theories—the theory of cues to action (CTA) and cognitive theory—the HBM explores various health-related behaviors. This model proposes that an individual will take preventive action if they believe they are susceptible to a disease or health issue, perceive that the disease occurrence would negatively affect their life, believe that taking preventive measures would mitigate the severity or prevent the disease altogether, and perceive minimal barriers or limitations to performing the action. The model was further reformulated to include 2 additional categories: cues to action and health motivation or self-efficacy [13,14].

HBM has been widely used to study influenza vaccine uptake in the general population and among high-risk groups, including healthcare workers [12]. It has provided valuable insights into reasons influencing healthcare workers’ decisions to accept or reject influenza vaccination [15,16] and has facilitated data generation for intervention programs aimed at improving influenza vaccine uptake among healthcare workers [17].

Given the critical importance of influenza vaccine uptake by physicians, as well as the need for updated data and a comprehensive assessment of physicians’ knowledge, attitudes, and barriers regarding influenza vaccination, this national study was proposed, targeting physicians from various clinical settings and specialties.

METHODS

Design and Population

A cross-sectional study was conducted to investigate knowledge, attitudes, and barriers toward influenza vaccine uptake among physicians working at the Ministry of Health in Jordan between March 2023 and June 2023. Physicians were eligible for inclusion if they were Jordanian nationals permanently residing in the study areas. Physicians who did not reside permanently in these areas or who had contraindications to the influenza vaccine were excluded.

Study Setting

The study was conducted at multiple sites, ensuring diverse representation from both hospitals and comprehensive healthcare centers. Data collection took place at the following facilities: Al-Bashir Hospital, Amman; Princess Rahma Hospital for Pediatrics, Irbid; Princess Basma Hospital, Irbid; Princess Badiea Hospital for Obstetrics and Gynecology, Irbid; Zarqa Governmental Hospital; Karak Governmental Hospital; Amman Comprehensive Healthcare Center; Comprehensive health centers in Zarqa, Karak, and Irbid.

Sampling and Sample Size

Previous studies have shown that influenza vaccine uptake rates among physicians in Jordan vary between 50% and 69% [9,11]. The number of physicians practicing in Jordan was estimated at approximately 42 000 [18]. Therefore, a sample size of 380 physicians was targeted, considering a 5% margin of error and a confidence level of 95%.

A representative sample of physicians across various specialties from Ministry of Health facilities in Amman, Irbid, and Karak was selected. The number of physicians included per site was proportional to the total number of physicians at each respective location. Simple random sampling was utilized based on a comprehensive list of physicians at each site. Interviews were scheduled on different days and times to maximize availability and participation. Probability sampling techniques were implemented at each location to avoid convenience sampling and to ensure representativeness of the study population.

Data Collection

Data were collected using a structured questionnaire specifically developed for this study. The questionnaire was adapted from previously validated instruments [12,19,20] and translated into Arabic using a rigorous backward-forward translation process conducted by public health experts.

The first section of the questionnaire gathered demographic information, medical and drug histories, vaccination histories, and socioeconomic factors. The second section assessed influenza vaccine uptake and knowledge related to the vaccine. The final section consisted of close-ended questions organized around the HBM, specifically addressing perceived susceptibility, severity, benefits, and barriers to influenza vaccination. The HBM is a well-established behavioral framework for predicting vaccine uptake and attitudes toward vaccination [21].

HBM framework

The following components of the HBM were assessed: perceived risk of contracting influenza (perceived susceptibility), perceived severity of influenza consequences, perceived benefits of vaccination, perceived barriers to vaccination, vaccine availability, factors prompting action (CTA), and modifying factors (individual characteristics).

According to the HBM, a physician’s readiness to act (to receive the influenza vaccine or recommend it to patients) depends on several beliefs and conditions: personal susceptibility to influenza, the seriousness of the influenza threat, the belief that vaccination benefits outweigh barriers, confidence in the ability to obtain vaccination successfully, and the presence of CTA motivating vaccination.

Questionnaire development and pilot testing

To ensure clarity, acceptability and relevance, the questionnaire was piloted with 30 delegates from representative groups within the study areas. These pilot interviews helped refine the questionnaire’s format and content for clarity, length and participant comprehension. The final version comprised close-ended questions organized into key areas based on the HBM, including perceived susceptibility, severity, benefits, and barriers to influenza vaccination.

Reliability assessment using Cronbach’s alpha yielded an average score of 0.82, with results ranging from 0.77 for perceived susceptibility to influenza infection to 0.87 for perceived barriers to vaccination. Face and content validity were ensured by comprehensively covering all HBM components along with vaccine uptake assessment. Items were developed based on the HBM framework, relevant previous studies, and expert experience in the field.

Construct validity was assessed using exploratory factor analysis (EFA), employing principal component analysis with varimax rotation. The minimum factor loading criterion was set at 0.50. Scale communalities, indicating variance explained in each dimension, were also evaluated, with all items demonstrating communalities above 0.50.

Statistical Analysis

Data analysis was conducted using SPSS version 28.0 (IBM Corp., Armonk, NY, USA), including descriptive and multivariate analyses. Chi-square analysis was conducted to assess associations between socio-demographic variables and vaccine uptake. Multivariate logistic regression analyses were employed to explore associations with various socio-demographic characteristics. Additionally, chi-square tests were utilized to examine relationships between baseline parameters, knowledge levels, and vaccination status. Binary logistic regression analysis was used to identify predictors of vaccine uptake and vaccine recommendation to patients.

Ethics Statement

The study was conducted in accordance with the Declaration of Helsinki. Approval was obtained from the Institutional Review Committee of the Ministry of Health Ethics Committee (No. MOH/REC/2022/328, dated October 26, 2022). Verbal informed consent was obtained from the participants who were eligible to participate in this study. Prior to obtaining the consent form, all participants were provided with relevant information about this study. Those who did not consent were not enrolled.

RESULTS

Demographic Characteristics

A total of 389 physicians were enrolled, with an acceptance rate of 93.0%. The mean age of participants was 37.04 years. Approximately two-thirds of participants were male (n=253, 65.0%). Regarding professional designation, 83 (21.3%) were consultants, 102 (26.2%) were general practitioners, and 204 (52.4%) were specialists. In terms of practice settings, 47.0% worked in both outpatient clinics and hospitals, 39.9% worked exclusively in hospitals, and 13.1% practiced exclusively in clinics. The mean±SD number of influenza vaccinations received by participants was 3.82±3.93.

Vaccination Status With Professional and Demographic Characteristics

Among the 389 physicians participating in the study, 183 (47.0%) received the influenza vaccine during the season of data collection. Several characteristics showed significant associations with vaccination status during the study period (Table 1). The mean age of vaccinated physicians was higher compared to non-vaccinated physicians (38.24 vs. 35.93 years, p=0.013). Geographic location influenced vaccination rates; the northern region showed the highest rate (57.5% vaccinated), compared to the central (44.6%) and southern (34.9%) regions (p=0.020). Professional designation was also significantly associated with vaccination uptake; consultants exhibited the highest rate of vaccine uptake (62.7%) compared to specialists (47.5%) and general practitioners (33.3%) (p<0.001).

Knowledge and Attitude of Medical Doctors About Influenza and Influenza Vaccination

Table 2 presents physicians’ knowledge about the influenza virus. Overall, the participants demonstrated good knowledge regarding influenza symptoms and transmission routes, though there were notable gaps. Approximately 74.1% incorrectly believed that individuals “with influenza can transmit the infection only after symptoms appear,” and similarly, a substantial proportion mistakenly thought “HCPs are less susceptible to influenza infections than other people.”

Significant differences in knowledge and attitudes toward influenza vaccination were observed based on vaccination status (Supplemental Material 1). Vaccinated physicians showed stronger support for integrating influenza vaccination into standard medical practice (85.8 vs. 62.1%, p<0.001) and more frequently believed healthcare workers should receive vaccination unless contraindicated (77.1 vs. 53.4%, p<0.001). Additionally, vaccinated physicians more often recognized the effectiveness of influenza vaccines in preventing complications and mortality (78.1 vs. 60.2%, p=0.001), and placed greater importance on preventing influenza symptoms in high-risk groups such as elderly individuals (80.9 vs. 65.5%, p=0.003) and patients with chronic conditions (85.8 vs. 71.8%, p=0.001).

Supplemental Material 2 describes physicians’ vaccine-related knowledge, attitudes, training participation, and practice patterns, stratified by vaccination status. Physicians who received the influenza vaccine were significantly more aware of the availability of free influenza vaccination for HCPs compared to those who did not receive the vaccine (84.7 vs. 73.3%, p=0.014). Physicians who recently participated in influenza vaccine training were more likely to be vaccinated compared to those without recent training (22.6 vs. 12.8%, p=0.014). These physicians also reported greater awareness of national or international influenza preventive guidelines (36.6 vs. 24.3%, p=0.011), higher adherence to these guidelines (35.0 vs. 22.8%, p=0.010), and showed greater interest in future influenza vaccine training (69.5 vs. 55.5%, p=0.010). Additionally, vaccinated physicians were significantly more likely to provide their patients with influenza vaccination compared to their non-vaccinated colleagues (69.9 vs. 47.7%, p<0.001).

Reasons for and Barriers to Influenza Vaccination

Table 3 summarizes physicians’ reasons for and against influenza vaccination. Among the reasons for receiving vaccination, the most frequently cited was the belief that vaccination reduces the risk of contracting influenza (63.5%), followed by the belief that vaccination decreases the risk of transmitting influenza to high-risk patients (47.0%). Conversely, primary reasons given for not receiving the vaccine included forgetting to vaccinate (31.1%), believing oneself not at risk for influenza (24.7%), and doubts regarding vaccine efficacy (11.6%). Additional noteworthy reasons included perceived immunity due to repeated exposure (19.8%) and concerns about potential adverse effects (16.4%).

The main barriers to providing patients with the influenza vaccine included the cost of vaccination (48.6%), fear of side effects (35.5%), previous history of side effects (35.5%), lack of awareness about vaccine availability (21.1%), and perceptions that the vaccine is not beneficial (24.1%).

Factors Influencing Physicians’ Uptake of Influenza Vaccine

Table 4 presents the results of regression analysis identifying predictors of influenza vaccine uptake during the current influenza season. Physicians in the northern region were significantly more likely to be vaccinated compared to those in the middle region (odds ratio [OR], 2.06, p=0.023). Vaccination history was another strong predictor; those with a higher lifetime vaccination frequency were more likely to be vaccinated during the current season (OR, 1.60, p<0.001). Factors derived from the HBM also significantly predicted influenza vaccine uptake. Physicians who believed that vaccination was essential for routine medical practice (self-efficacy) or who expressed fewer concerns regarding vaccine side effects (perceived barriers) were significantly more likely to be vaccinated. Recent participation in influenza vaccine-related training was an additional positive predictor of vaccine uptake; physicians with recent training were 2.17 times more likely to receive vaccination compared to those without training. Furthermore, positive perceptions regarding adequate staffing were positively associated with vaccine uptake.

Supplemental Material 3 details predictors of lifetime influenza vaccine uptake. Compared to consultants, general practitioners had significantly lower lifetime (OR, 0.12, p=0.001) and current-year vaccination rates (OR, 0.05, p<0.001). Physicians working in the southern region had lower vaccination rates both historically (OR, 0.30, p=0.028) and during the current season (OR, 0.23, p=0.013). Physicians disagreeing with routine influenza vaccination were substantially less likely to receive the vaccine historically (OR, 0.23, p=0.023) and currently (OR, 0.04, p<0.001). Participation in influenza vaccine-related training during the past year (cues to action) was positively correlated with vaccination uptake (OR, 9.80, p=0.010). Offering influenza vaccination to patients was similarly associated with increased vaccination rates (OR, 3.69, p=0.003).

Factors Affecting the Probability of Physicians’ Offering Patients the Influenza Vaccine

Table 5 shows the results of regression analysis examining predictors of physicians recommending influenza vaccination to patients. HBM components significantly predicted physicians’ likelihood of recommending vaccination. Personal vaccination status, medical specialty, practice setting, attitudes toward vaccine efficacy, and recent training were important determinants influencing whether physicians recommended the influenza vaccine to their patients.

Physicians vaccinated during the current influenza season demonstrated significantly higher likelihood of recommending vaccination to patients (OR, 2.17, p=0.039). Physicians practicing in the northern region were also more likely to recommend vaccination compared to those in other regions (OR, 2.87, p=0.026). Additionally, obstetricians were significantly more likely to offer influenza vaccines compared to physicians of other specialties (OR, 0.26, p=0.039), whereas physicians practicing in both clinics and hospitals were less likely to offer vaccination compared to those practicing exclusively in clinics. Physicians who recently participated in influenza vaccination training were also significantly more likely to recommend vaccination (cues to action; OR, 3.62, p=0.018). In contrast, those who disagreed that influenza vaccination prevents complications among high-risk patients (perceived benefits) had significantly lower likelihood of recommending vaccination (OR, 0.06, p=0.042).

DISCUSSION

This study revealed a low influenza vaccination uptake rate of 47% among physicians, which also corresponded to low rates of recommending vaccination to their patients. Despite several initiatives aimed at improving influenza vaccine uptake among HCPs, the findings indicate that further efforts are necessary to enhance vaccination rates in Jordan [9,11,18]. The study also highlighted significant knowledge gaps among physicians regarding influenza vaccination, underscoring the need for targeted educational interventions. Despite extensive evidence supporting the benefits of influenza vaccination, our findings suggest that many physicians lack a comprehensive understanding of critical aspects related to influenza and its vaccine. Such knowledge deficits may impede physicians’ ability to effectively recommend and administer the vaccine, ultimately affecting public health outcomes [8]. One key barrier identified was physicians’ perception of themselves as not being at high risk of influenza infection. This finding aligns with other studies conducted in the Middle East and warrants increased attention from healthcare organizations [22,23].

The low influenza vaccination rate among physicians reported in this study mirrors findings from previous studies [9,11,18]. A prior report from Jordan similarly highlighted significant gaps in influenza vaccine uptake among HCPs, including physicians, nurses, and pharmacists, with 52.9% of participants reporting never receiving the vaccine. Older age and physician status were primary predictors of receiving influenza vaccination, whereas underestimating influenza severity and concerns regarding vaccine safety were major reasons cited for vaccine refusal [11].

Consistent with previous research from Jordan and the broader region [23–29], the low vaccination rate among physicians in our study was associated with factors such as lack of awareness, vaccine cost, limited knowledge regarding high-risk groups requiring vaccination, and mistrust regarding vaccine efficacy. The identified knowledge gaps are particularly concerning given physicians’ crucial role in promoting vaccination and managing vaccine hesitancy among patients. Indeed, patient confidence in vaccination often depends significantly on recommendations and guidance provided by HCPs [30–32].

Our results also demonstrated substantial misconceptions among physicians regarding influenza symptoms and transmission. A significant proportion of respondents incorrectly believed that influenza transmission occurs only after symptoms appear. Vaccinated physicians demonstrated greater awareness of influenza symptoms and complications, and were more likely to offer vaccination to high-risk patients. These findings align with previous studies from Jordan and other developing countries [2,8]. Additionally, approximately one-quarter of physicians in our study were unaware that they constitute a high-risk group eligible for influenza vaccination, and roughly one-third reported simply forgetting to get vaccinated. Physicians’ intention to receive influenza vaccination was also influenced by their perceived severity of the disease for themselves and other healthcare workers. Earlier research similarly found that reduced perception of disease severity constituted a significant barrier to seasonal influenza vaccine uptake among healthcare providers [33,34]. Thus, emphasizing local vaccination guidelines is crucial for enhancing vaccine uptake among HCPs [35]. It is also essential for occupational health units or healthcare management to regularly monitor influenza vaccine uptake [36].

Our findings underscore the importance of influenza vaccination training, as physicians who received specialized training had significantly higher vaccination rates. Educational programs and targeted vaccination campaigns aimed at physicians have consistently been shown to improve adherence to vaccination guidelines [22]. To address these identified knowledge and practice gaps, tailored educational initiatives specifically targeting physicians should be developed. Integrating regular updates on influenza vaccination guidelines into continuing medical education programs and clinical resources could substantially improve physicians’ knowledge and attitudes [37]. Furthermore, healthcare facilities could adopt policies that mandate routine influenza vaccine training as part of annual credentialing procedures. Organizational barriers identified in this study could also be addressed through structured vaccination programs that ensure vaccine availability and easy accessibility, coupled with regularly updated records tracking vaccine uptake. Educational materials that simplify complex topics—such as vaccine efficacy across different populations or the importance of annual vaccination—could further enhance comprehension and retention of vaccination information [38].

The strengths of this study include its multicentric design, encompassing major population centers in Jordan, the use of a validated questionnaire, and achieving an excellent response rate. Nonetheless, several limitations should be acknowledged. First, vaccination history relied on self-reported data without verification through vaccination cards or official vaccination records. Second, this study did not specifically target certain medical specialties managing particular patient groups, and the limited number of general practitioners and family physicians included represents an additional limitation. Lastly, the absence of a universally recognized gold-standard method for assessing physicians’ knowledge, attitudes, and practices regarding influenza vaccination limits construct and convergent validity.

In conclusion, influenza vaccination uptake among physicians in Jordan remains low. This study is the first in Jordan to comprehensively assess physicians’ perceptions toward influenza vaccination and to identify the primary barriers influencing vaccine uptake among healthcare providers and their patients. Key findings indicated that a lack of specialized training aimed at improving adherence to annual influenza vaccination guidelines, along with limited awareness regarding common influenza presentations, constituted significant obstacles to achieving optimal vaccine coverage among physicians. Therefore, it is strongly recommended that infection control teams, occupational health departments, employee health clinics, and public health awareness initiatives collaborate to increase influenza vaccine uptake among physicians in Jordan. This study provides valuable data on perceptions and barriers that can guide the development of targeted intervention programs. Additionally, proactive outreach efforts should be undertaken to remind unvaccinated physicians of vaccine availability—offered free of charge—and to address any existing concerns they may have about vaccination.

Supplemental Materials

Notes

Data Availability

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.

Conflict of Interest

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

Funding

None.

Acknowledgements

We thank the management of Al-Bashir Hospital, Amman; Princess Rahma Hospital for Pediatrics, Irbid; Princess Basma Hospital, Irbid; Princess Badiea Hospital for Obstetrics and Gynecology, Irbid; Zarqa Governmental Hospital; Karak Governmental Hospital; Amman Comprehensive Healthcare Center and the comprehensive health centers in Zarqa, Karak, and Irbid for their great support.

Author Contributions

Conceptualization: Abu-Helalah M. Data curation: Darweesh RM, Alshurman M, Ja’far Al Mughrabi F L, Ja’far Al Mughrabi F Y, Ghanem N. Formal analysis: Alshraideh H, Al-Hanaktah M. Funding acquisition: None. Methodology: Abu-Helalah M. Project administration: Abu-Helalah M, Al-Hanaktah M. Visualization: Alshraideh H, Al-Hanaktah M. Writing – original draft: Abu-Helalah M, Gharibeh TR, Al-Hanaktah M. Writing – review & editing: Abu-Helalah M, Gharibeh TR, Al-Hanaktah M, Alshraideh H, Darweesh RM, Alshurman M, Ja’far Al Mughrabi F L, Ja’far Al Mughrabi F Y, Ghanem N.

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