|Year : 2020 | Volume
| Issue : 1 | Page : 59-65
Knowledge, attitude, and practice of influenza vaccineamong health-care employees in Sultan Bin Abdulaziz Humanitarian City
Mariam H Alghamdi1, Sulaiman Abdullah Alshammari2
1 Health Promotion Unit, Sultan Bin Abdulaziz Humanitarian City, Riyadh, Saudi Arabia
2 Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
|Date of Submission||30-Jun-2019|
|Date of Decision||22-Sep-2019|
|Date of Acceptance||12-Oct-2019|
|Date of Web Publication||06-Jan-2020|
Sulaiman Abdullah Alshammari
Department of Family and Community Medicine, College of Medicine, King Saud University Medical City, P.O. Box 2925, Riyadh 11461
Source of Support: None, Conflict of Interest: None
Objectives: This study aimed to investigate the knowledge, attitudes, and practices (KAP) of health-care employees (HCEs) in Sultan Bin Abdulaziz Humanitarian City (SBAHC) toward influenza vaccine. Methodology: We conducted this cross-sectional study between November and December 2018. The study population included all HCEs. We recruited eligible participants through stratified random sampling. Data collection was done using a validated questionnaire, comprising 19 questions and designed to explore the KAP of influenza vaccine among HCEs. Results: A total of 391 HCEs completed the electronic questionnaire. Overall, 66% of them had received the influenza vaccine and 44.8% of them had received the vaccine from SBAHC. The number of participants who reported direct involvement with patient care was 292 (74.7%). The primary reasons attributable for not receiving the influenza vaccine at all over the past years ranged from a belief that it was not effective, to the unavailability of the vaccine during the night shift. The primary reasons for not receiving it annually, among those who had been vaccinated at least once in the same period, ranged from lack of time to being away during the vaccination campaigns. Participants who were planning to get the vaccine in the present year accounted for 30.7% of the sample. Conclusion: The low number of participants intending to get the vaccine in the present year can be attributed to inadequate knowledge, false beliefs, and fears regarding the vaccine efficacy and safeness. An extensive campaign aimed at promoting vaccination is recommended. Although physicians are quite clear about the importance of vaccine, aggressive educational campaign to increase vaccination rate is still needed for nurses, allied health professionals, and support staff.
Keywords: Health education campaign, health-care institutions, health-care workers, influenza vaccination
|How to cite this article:|
Alghamdi MH, Alshammari SA. Knowledge, attitude, and practice of influenza vaccineamong health-care employees in Sultan Bin Abdulaziz Humanitarian City. J Nat Sci Med 2020;3:59-65
|How to cite this URL:|
Alghamdi MH, Alshammari SA. Knowledge, attitude, and practice of influenza vaccineamong health-care employees in Sultan Bin Abdulaziz Humanitarian City. J Nat Sci Med [serial online] 2020 [cited 2020 Apr 6];3:59-65. Available from: http://www.jnsmonline.org/text.asp?2020/3/1/59/272326
| Introduction|| |
As a public health problem, influenza is responsible for severe mortality and morbidity among high-risk groups, particularly the elderly. It is a year-round disease burden infecting 7%–18% of the general population, with 3–5 million severe cases and deaths., Seasonal influenza can be effectively prevented by vaccination, including a reduction in the infection rate of 70%–90% among healthy adults younger than 65 years old., For older adults aged 65 years and above, getting the influenza vaccine reduces the risk for hospital admission and death, and it prevents secondary complications related to influenza. Although the vaccine is available and safe, it has been reported that the uptake of the vaccine among health-care employees (HCEs) is low in many countries.,, HCEs are exposed to different patients' diseases and immunity levels, and the vaccination of HCEs can protect both HCEs and their patients. Unvaccinated HCEs could be a source of nosocomial influenza.
In addition to the prevention of influenza, HCEs' vaccination reduces HCEs' disability absenteeism related to influenza. These major influenza complications of sickness absenteeism result in lack of health workers, additional financial burden, and strain on the delivery of health care. In some parts of the world, sickness absenteeism accounts for 30%–40% of the affected individuals during influenza outbreaks. The World Health Organization and the Advisory Committee on Immunization Practices of Centers for Disease Control and Prevention (CDC) stated that health-care workers should be vaccinated annually. Furthermore, health-care organizations should implement supportive policies and procedures to promote HCEs' vaccination. The Saudi Immunization program was started by the Saudi Ministry of Health, and they utilize international experience to help their program in recommending the vaccination of HCEs against influenza. Furthermore, during the pilgrimage season, there is an increased risk of influenza infection transmission, causing a considerable health threat to airport workers, HCEs, security staff, and ordinary individuals. The Saudi Thoracic Society guideline recommends strict vaccination strategies in this regard. Several previous studies have reported low overall rates of influenza vaccination in Saudi Arabia,,,,, but some recent studies found that the rate of vaccination has increased and improved.
The vaccine used in the Sultan Bin Abdulaziz Humanitarian City (SBAHC) was trivalent which agrees with the Northern Hemisphere recommendation from CDC Atlanta.
The extent of the awareness, attitude, and practice of influenza vaccination in the SBAHC is not known, and finding the gaps in the knowledge, attitudes, and practices (KAP) related to influenza vaccination may help in designing health education programs that positively influence the rates of vaccine coverage. Against this backdrop, the current study was designed to explore KAP toward influenza vaccination among HCEs in SBAHC. The finding of the study may support the development of future interventions and policies aimed at increasing influenza vaccination uptake among HCEs.
| Methodology|| |
We conducted a cross-sectional study in SBAHC, Riyadh, between November and December 2018. A total of 1948 HCEs were employed in SBAHC. We recruited eligible participants through stratified random sampling, using computer-generated random numbers. The population details were obtained from the Human Capital Department, including a list of HCEs, stratified by profession according to qualifications approved by the Saudi Commission for Health Specialties. The categories of HCEs were physicians, nurses, allied health professionals, and support staff. The Human Capital Department at SBAHC provided us with the list of HCEs, stratified by profession according to qualifications approved by the Saudi Commission for Health Specialties. The categories of HCEs were physicians, nurses, allied health professionals, and support staff. Allied health professionals are those staff who were qualified from the colleges of applied medical sciences. Supporting staff are other staff not categorized as physicians, nurses, and allied health professionals. The eligibility criteria were SBAHC employees for at least 1 year.
A total of 1948 HCEs are employed in SBAHC. We estimated the sample size based on the assumption that 50% of the HCEs have the requisite KAP to receive annual seasonal influenza vaccinations. The chosen degree of precision was 0.05 at the 95% level of confidence, with a design effect of 1. Based on these assumptions, the minimum estimated sample size was 322 HCEs.
We used a known questionnaire which was developed and validated by Bali et al. after obtaining author's permission.
It consisted of 19 questions designed to explore the KAP toward seasonal influenza vaccination among HCEs. The items collected information on age and professional categories of the participants and importance of the influenza vaccine; whether a person had been vaccinated in the past 1–5 years; how many times they had received vaccine in the past 5 years; and what prevent HCEs from getting vaccinated. It also consisted of questions on the kind of knowledge HCEs needed, including high-risk groups for which influenza vaccination is strongly recommended, and the best ways to reach these high-risk categories. The general beliefs of vaccination were illustrated by asking participants to rank their agreement statements using a 5-point Likert scale (1 = agree, 5 = disagree). These responses were recorded as "agree" (1 or 2 on the Likert scale), "neutral," and "disagree" (4 or 5). Further, we conducted a pilot study on twenty HCEs who were excluded from the main study. This self-administered paper questionnaire was distributed to selected participants personally face to face.
In terms of ethical considerations, the participants were informed of the goals or methods of the study; the participation was voluntary and the participants had the right to withdraw from the study without negative repercussions. All information received from the participants remained strictly confidential, and their responses were anonymized. The participants voluntarily signed an informed consent before their inclusion in the investigation. The study was approved by the Institutional Review Boards of King Saud University (Research project No. E-18-3473) and SBAHC Project number 036/2018/November 7, 2018.
Data analysis was conducted using SPSS, version 21.0 (SPSS Inc., Chicago, IL, USA). Chi-square tests were used to compare categorical variables. P < 0.05 and 95% confidence intervals were used to report the statistical significance of the results.
| Results|| |
A total of 391 HCEs completed the electronic questionnaire. Out of all the participants, 66% had received influenza vaccinations in the preceding 5 years; 44.8% received the vaccine from SBAHC. HCEs who reported direct involvement with patient care accounted for 292 (74.7%). Occupations included physicians (n = 18, 4.6%), nurses (n = 114, 29.2%), allied health professionals (n = 66, 16.9%), and support staff (n = 193, 49.4%). The age distribution of the respondents was 26–39 years (67.8%), 40–49 years (18.9%), 18–25 years (8.7%), and older than 50 years (4.6%). HCEs without direct patient contact took part in the investigation as they often continue working while suffering from influenza and may transmit the diseases to patients or other employees who are in direct contact with patients.
Only 229 participants (58.6%) received the vaccine between one and three times in the past 5 years; 133 (34%) had not been vaccinated at all in that period and 29 (7.4%) participants were vaccinated four or five times in the past 5 years. The main reasons reported by the respondents for not receiving the influenza vaccination in the past 1–5 years [Table 1] ranged from believing that it was not effective in preventing influenza, to unavailability of the vaccine during the night shift. The leading reasons for not receiving the influenza vaccination annually among those who had been vaccinated in the same period [Table 2] ranged from lack of time to being away during the vaccination campaigns.
|Table 1: Reasons for not getting vaccinated in the previous 5 years (n=133)|
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|Table 2: Reasons for not getting vaccinated 1.3 times in the previous 5 years (n=229)|
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The vaccine was considered safe by 255 (65.2%) respondents, whereas 136 (34.8%) perceived it unsafe. The reasons reported for perceiving the vaccine unsafe included a belief that it could harm the immune structure (17.6%) or the central nervous system (2%). Of the 136 participants who considered it unsafe, 10 (2.6%) respondents reported knowing someone who had been harmed by vaccination, 6 (1.5%) were concerned about vaccine-related joint problems, and 12 (3.1%) avoided vaccination because of allergies. With regard to attitudes on immunization in general, there is an increasing agreement on the benefit of vaccination programs and decreasing agreement of the harm of vaccines on the immune system or whether it can cause unknown illnesses. However, 32% of the respondents thought that vaccination programs are directed and inspired by profit and 32% perceived that side effects due to vaccinations are underinvestigated in the medical literature.
A total of 258 respondents (66%) had received the influenza vaccine in the preceding 5 years. All the 18 participants aged 50 years or older were vaccinated, along with 145 (54.7%) respondents in the 26–39 years' age group. Out of all the participants, 120 (30.7%) intended to be vaccinated against influenza in 2019. Only 5.9% of the respondents between the ages of 18 and 25 years and 83.3% aged 50 years and above intended to receive an influenza vaccine this year. Out of all the respondents, 65.2% regarded the vaccine to be safe [Table 3].
|Table 3: Participants' age versus receiving vaccine, receiving vaccine this year, and vaccine safety (n=391)|
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A total of 258 participants (66%) had received the influenza vaccine in their lifetime; the proportion of physicians in this group was high (100%), whereas that of support staff was low (58%). The number of participants who intended to get an influenza vaccine this year was 120 (30.7%). This rate was the lowest among allied health professionals (15.2%), and the highest among physicians (100%). Further, 51.5% of the allied health professionals, 76.3% of nurses, and 60.1% of support staff regarded the vaccine to be safe [Table 4].
|Table 4: Participants' occupation versus receiving vaccine, receiving vaccine this year, and vaccine safety (n=391)|
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Our results show decreasing agreement that vaccines cause unknown illnesses, with 78.6% of the participants aged 26–39 years agreeing that this is the case. Among the same age group, 80% of the participants agreed that vaccines weaken the immune system. There was an increasing agreement that adverse effects of vaccination are underreported; 76.3% of those who agreed with this statement were from the 26 to 39 years' age group and 0.59% were aged 50 years or older. There was a decreasing agreement that vaccine programs are motivated by profit, with 55.8% of the respondents agreed with this statement in the 26–39 years' age group and 8.5% in the 50 years' and above age group [Table 5].
In terms of profession, we found a decreasing agreement that vaccines cause unknown illnesses, with 47.9% of the support staff agreeing with this statement. From the same group, 45.7% agreed that vaccines weaken the immune system. There was an increasing agreement that the adverse effects of vaccines are underreported, with 57.4% of the support staff and 21.3% of the nurses agreeing with this. We found an increasing agreement that vaccine programs are motivated by profit, with 49.5% of support staff in agreement. However, 10.9% of the physicians disagreed with this statement [Table 6].
Among all the 391 respondents, 52.9% (n = 207) believed that influenza vaccinations should be mandatory on annual bases or a condition for employing HCEs in risky wards or clinics such as pediatrics. The reason for not participating in yearly vaccination campaigns included doubts about the effectiveness and safeness of the vaccine; the perception of efficacy was the predominant reason among support staff. However, 30.7% of the participants intended to get vaccinated in the current year.
The respondents expressed an urgent need for convenient dissemination of information on various aspects of influenza vaccination, including details on the current year's vaccine, differences between influenza and the common cold, information on outbreaks, and effectiveness of the vaccine. The preferred methods for dissemination ranged from E-mails (79.8%) to campaigns (57.3%) and the staff's Intranet server (my city) (50.4%). For the provision of vaccinations, 49.4% of the respondents preferred the organization of department-specific clinics on specific days and at specific times, followed by visiting employees in their departments (36.8%) and offering appointments (33.2%).
| Discussion|| |
Out of all participants in this study, 30.7% intended to be vaccinated against influenza in 2019. Our findings indicate a higher uptake rate than that of the UAE (24.7%) but lower uptake rate than Oman (46.4%) and Kuwait (67.2%). Previous Saudi studies reported slightly higher vaccination rates of between 34% and 38% among HCEs,, but the uptake rates reported by Al-Tawfiq et al. (51%) and Alshammari et al. (67.6%) were clearly higher than our findings., The attitude and practice toward influenza vaccination by HCEs in Saudi Arabia appears to have markedly improved.
We found an association between age and vaccination status, with a vast majority of vaccinated participants in the age ranges of 26–39 years and 50 years and older. Omani studies reported a significant association between age and vaccination status, where most unvaccinated individuals were younger than 25 years, and the vast majority of those who were vaccinated were in the age range of 36–45 years. Studies conducted in the UAE and Kuwait, however, found no association between age and vaccination status. Our explanation of these findings would be as follows: young age groups may not perceive themselves as susceptible or to suffer from serious complication as their older age group counterpart.
Multiple reasons were reported to influence the attitudes and practices toward influenza vaccination uptake among HCEs in SBAHC, ranging from a belief that the vaccination is not effective in preventing influenza to the misconception that it can harm their health. Other reasons included perceived low efficacy and high adverse effects of the vaccine, as well as the belief that they have low susceptibility to influenza. Only about a third of the participants (30.7%) intended to get vaccinated in the current year due to a previous flu shot, making them feel unwell. Nearly 26% of the participants believed that vaccination causes unknown illnesses and 31% believed that vaccines weaken the immune system. Low vaccination uptake in the face of the widespread perceptions that influenza is a potentially severe disease indicates a huge gap between beliefs and practice and calls for educational campaigns aimed at promoting compliance and removing the barriers that limit vaccination.
Nearly 31% (n = 133) of the participants did not believe that the flu shot is effective in preventing influenza. The influenza vaccines' efficacy against confirmed influenza-infected adults is 70%–90% when vaccine strains match circulating strains. Vaccination has proved to significantly reduce influenza and upper respiratory diseases and accordingly absenteeism due to influenza among HCEs and other working individuals. Such important health information needs to be continually disseminated among HCEs to improve vaccination rates.
In a study conducted in three Arabian countries, it was found that profession was not associated with vaccination status. This result is in line with our findings, as well as the findings of other studies., The health authority should regularly monitor influenza vaccination among HCEs. Giving incentives for being vaccinated, reinforced announcement campaigns, and providing the individuals with a choice of vaccinations have been shown to increase vaccination uptake in the workplace., There was a high degree of agreement on the need for influenza vaccination among those working in high-risk department among our participants; this finding may be useful in emphasizing the high-risk status of HCEs in general. Further, our findings emphasize the need for clear policy and procedure by all health facilities on routine influenza vaccinations as a standard policy for all HCEs. Our participants indicated a need for convenient workplace access to influenza vaccinations, through the facilitation of clinics, vaccination in employees' offices, and scheduling of appointments for vaccination.
Limitations of the study
There are limitations of the study. We depended on participants' self-reporting of influenza vaccination status, not subjected to independent verification. Recall bias is another potential limitation.
| Conclusion|| |
The reasons for the small number of workers who were planning to get vaccinated in the present year were ranging from poor knowledge to misbelief and fears of vaccine's effectiveness and safety. We found an association between age and vaccination rates. The acceptance of the influenza vaccination among HCEs was moderate, with higher rejection among vaccinated participants. Decision makers at health facilities should embark on comprehensive educational campaigns aimed at removing the barriers to vaccination. Furthermore, influenza vaccination is considered crucial for patient safety and the ethical responsibility of HCEs.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]