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Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia
Journal of Hospital Infection xxx (2017) 1e8 Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia H.K. Haridi a, b, *, K.A. Salman b, E.A. Basaif b, D.K. Al-Skaibi a a b
General Directorate of Health Affairs, Hail Region, Saudi Arabia King Abdulla Medical City, Makkah, Saudi Arabia
A R T I C L E
I N F O
Article history: Received 12 December 2016 Accepted 5 February 2017 Available online xxx Keywords: Vaccine Influenza Healthcare workers Compliance Barriers
S U M M A R Y
Background: Influenza vaccination of healthcare workers (HCWs) is essential for patient safety, their own safety, and hospital operation. However, despite its strong recommendation, studies indicates a low rate of vaccine uptake. Aim: To assess rates of, and factors affecting, influenza vaccine uptake among HCWs. Methods: A cross-sectional survey was carried out during October 1st to 16th, 2015, among HCWs in King Abdullah Medical City in Makkah, Saudi Arabia. A self-administered, anonymous questionnaire was distributed to HCWs; this included questions on demographic characteristics, vaccine uptake, and knowledge, beliefs, attitude, and concern about influenza vaccine. Findings: Out of 500 HCWs approached, 447 returned valid self-reported questionnaires with response rate 89.4%. Overall, 88.3% of the participants reported receiving vaccination during the 2014/15 season, higher than during the 2013/14 (61.2%) and 2012/13 (54.5%) seasons. Self-protection (81.5%) was the main reason for vaccination, whereas 73.4% of HCWs reported vaccination to protect patients. The main reasons for vaccination avoidance were misconception that the vaccine causes influenza (38.5%) and concern about vaccine efficacy (32.7%). Logistic regression analysis revealed that the following were independently associated with vaccine receipt among HCWs: awareness of vaccine guidelines; intention to receive the vaccine next season; nurses and other HCWs compared to physicians; longer practice; and age >40 years. Conclusion: A good uptake of influenza vaccine was achieved during the 2014/15 season following adoption of mandatory vaccination policy. Awareness programmes are needed to correct HCWs’ misconceptions about the vaccine. Efforts need to focus especially on physicians, younger staff and new recruits. ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Address: General Directorate of Health Affairs, Hail Region, P.O. Box, 2510, Hail, 81461, Saudi Arabia. Tel.: þ96 6507114741. E-mail address: [email protected] (H.K. Haridi).
Seasonal influenza is an acute viral infection caused by influenza viruses; infected individuals are highly contagious and can transmit influenza for 24 h before they are symptomatic.1 Influenza causes significant morbidity and mortality;
http://dx.doi.org/10.1016/j.jhin.2017.02.005 0195-6701/ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8
indeed, on a worldwide basis, influenza as a contributor or cause of death outpaces all the other vaccine-preventable diseases combined. Hospitalized patients are frequently more vulnerable to influenza than members of the general population.2,3 Healthcare workers (HCWs) can be central to influenza transmission in hospitals as they are exposed to both infected patients and patients in high-risk groups.1 Influenza outbreaks in hospitals cause morbidity among patients and HCWs; they also interfere with normal function of healthcare systems, for example by impacting on HCW numbers and workload and on hospital income as a result of fewer elective admissions and operations.4 In Saudi Arabia, our hospital in Makkah experienced an influenza outbreak in January 2016, with 12 confirmed cases of whom eight were among HCWs.5 An outbreak of influenza A (H1N1) in a long-term care facility at Taief in 2010 affected 21 residents (an attack rate of 47.7%), with two deaths.6 In Riyadh, two outbreaks occurred at a tertiary hospital in early August and late October 2009 with 526 HCWs confirmed H1N1 influenza positive.7 Large outbreaks have also been reported in other countries. For example, an influenza outbreak in a Japanese general hospital in December 2014 affected more than 100 individuals (41 patients and 62 staff), with two deaths among elderly patients.8 Seasonal influenza vaccination of HCWs is a core component of infection control policy and patient safety programmes.9,10 Such programmes can reduce patient morbidity and mortality, increase patient safety, and reduce work absenteeism among healthcare workers.11e13 Vaccination coverage among HCWs varies substantially between different studies and countries, with lower rates of uptake mostly reported. In a cross-sectional survey in 27 European countries vaccination coverage in HCWs ranged between 13% and 89%, with uptake rates in different centres frequently being <35%, sometimes <25%.13 In the USA, the Centers for Disease Control and Prevention influenza season report from 2014/15 showed that 77.3% of all HCWs reported having had an influenza vaccination, an increase of 13.8% compared with the 2010/11 season estimate. This improvement in vaccine coverage was attributed mainly to more hospitals adopting mandatory vaccination policies.14 Influenza vaccine uptake rates among HCWs in Saudi Arabia have previously been reported to be low. In 2014 Alshammari et al. reported 38% coverage in six major hospitals, and in 2010 Rehmani and Memon reported 34.4% coverage; both of these are substantially better than the 5.9% coverage reported among HCWs employed in Hajj healthcare facilities in 2007.15e17 In neighbouring countries, uptake of influenza vaccine among HCWs has also been reported to be low: 24.7% in the Emirates, 46.4% in Oman, 67.2% in Kuwait, and 19.4% in Qatar.18,19 HCWs and healthcare systems have an ethical and moral duty to protect vulnerable patients from influenza.20 Owing to the failure of voluntary immunization programmes for HCWs, mandatory polices are being increasingly adopted by healthcare institutions and public health authorities.9 In Saudi Arabia, healthcare institutions dealing with pilgrims during Hajj seasons provide emergency care for a high-risk group of patients, who are predominantly elderly with comorbid conditions.20 Being exposed to stressful physical conditions puts them at risk of complicated and/or serious
influenza.21,22 In response, the Saudi Ministry of Health has mandated influenza vaccination for all HCWs in settings providing healthcare for pilgrims. Few previously published studies were identified exploring influenza vaccination among HCWs in healthcare facilities serving Hajj pilgrims.17 Moreover, there is a need to assess the impact of the recent mandatory vaccination policy. The aims of this work were to assess the uptake rates of seasonal influenza vaccine among HCWs, and to identify determinants of compliance with the vaccine uptake and reasons that inhibit or motivate vaccination.
Methods Study design and setting The study was a cross-sectional survey carried out between October 1st and 16th, 2015 among HCWs in King Abdulla Medical City, which is a tertiary care, 550-bed hospital, located in holy Makkah, Saudi Arabia. The hospital has more than 3150 staff, including 574 physicians, more than 900 nurses, and 720 other HCWs directly involved in patient care. The hospital admitted 11,329 inpatients and received 155,204 outpatient visits during 2014. Like other hospitals in Saudi Arabia, the hospital provides influenza vaccine free of charge to all HCWs.
Subjects The eligible participants were HCWs who are engaged in direct patient care, including physicians, nurses and other healthcare workers (pharmacists, laboratory personnel, therapists, technicians, and other staff directly involved in patient care.
Sample The investigators received a complete list of the eligible HCWs. A representative stratified random sample was taken from the eligible population. Sample size was determined before study initiation and calculated conservatively to allow for maximum sample size, assuming a 50% influenza vaccination uptake among the respondents with a margin of error of 5% at 95% confidence level. Consequently, a sample of 327 HCWs was sought. Anticipating 60e70% response rate, 500 questionnaires were distributed taking into consideration a balanced proportion of HCWs according to assignment, departmental affiliations, and work shifts.
Survey instrument and administration An anonymous structured questionnaire was constructed based on a review of the literature and previous research findings.1,9,16,23,24 The questionnaire included demographic, professional, and work practice characteristics of the respondents; uptake of seasonal influenza vaccine during 2014/ 15, 2013/14, and 2012/13 seasons; vaccine availability, provision of instructions and guidelines; beliefs, attitudes, and concerns about influenza vaccine. Included in the last section, questions sought to assess respondents’ knowledge about influenza disease, vaccine facts, and uptake recommendations. The instrument was reliable for internal consistency with
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8 calculated Cronbach’s alpha coefficient at 0.78. The consenting subjects self-completed the questionnaire after distribution to the eligible HCWs with a briefing for the study objectives by trained co-ordinators who did not have medical or administrative responsibilities in the hospital during the study.
Pilot study The questionnaire was pre-tested and piloted with a convenience sample of 20 HCWs with professional and demographic characteristics similar to those of the study population to ensure clarity and ease of administration. Based on respondents’ recommendations, some changes were incorporated to simplify and improve the final questionnaire.
Ethics The Ethical Committee of King Abdulla Medical City approved the study protocol and the final questionnaire, with approval number 15-216.
Statistical analysis Statistical analysis was undertaken using the EpiInfo 7 programme. Descriptive statistics were generated for all survey items. A binary outcome variable was created to reflect compliance of the subject with seasonal influenza vaccine uptake. A compliant subject was defined as ‘the subject who received seasonal influenza vaccine regularly without interruption for the last three seasons; 2014/15, 2013/14, and 2012/ 13’. A bivariate analysis with c2-test and t-test as appropriate was performed to explore factors associated with HCWs’ receipt of the vaccine with demographic, professional, and practice characteristics, as well as knowledge and attitude towards influenza vaccine. A multivariate logistic regression model with backward selection and threshold of <0.2 was developed to capture predictors independently associated with the compliant behaviour of seasonal influenza vaccine receipt. Odds ratios (ORs) and their 95% confidence intervals (CIs) were reported as measures of association between predictors and outcome of interest. All statistical tests were twotailed and P 0.05 was considered statistically significant.
Results Respondent data and influenza vaccine uptake In all, 447 of the 500 questionnaires that were distributed were returned (response rate 89.4%). Respondents were comparable to the surveyed population (P ¼ 0.207). The characteristics of the respondents are summarized in Table I. Overall, 394/447 (88.3%) of the respondents reported receiving a vaccination in the 2014/15 season, higher than in the 2013/14 season (61.2%, 273/447) and in the 2012/13 season (54.5%, 243/447) (Figure 1). Uptake was significantly higher in the last season (2014/15) among nurses (93.3%) compared to physicians (86.9%) and other health professionals (83.1%) (P ¼ 0.012). For the previous seasons, nurses also had higher vaccine uptake compared to physicians for the 2013/14 season [68.9% vs 51.5%; odds ratio
3
(OR): 2.09; 95% confidence interval (CI): 1.27e3.43; P ¼ 0.004] and for 2012/13 season (61.1% vs 42.4%; OR: 2.14 95% CI: 1.31e3.49; P ¼ 0.003). There was no significant difference in the demographic characteristics of the vaccinated or unvaccinated respondents in 2014/15 season. The mean ages of respondents for the two groups were 32.35 7.78 and 32.50 7.89 years, respectively, and the lengths of practice were 7.46 6.17 and 7.61 6.24 years, respectively (P ¼ 0$185), for the two groups respectively.
Beliefs, attitudes and concerns about influenza vaccine Nearly three-quarters of the participants (73.6%) believed that influenza vaccine is valuable in prevention of the disease. Nurses were more convinced (81.5%) of the vaccine efficacy than physicians (64.6%) or other HCWs (71.0%) (P ¼ 0.016). The majority of participants agreed that they recommended influenza vaccine to the target groups (81.0%) and to their family members (82.3%). Over half (55.0%) expressed their concern/ worry about the vaccine; 38.9% were concerned about the vaccine efficacy, and 16.1% about vaccine side-effects; there was no significant difference between HCWs according to their employment designations (P ¼ 0.675). Most participants (83.7%) expressed their belief that all HCWs should receive the vaccine, 11.6% were uncertain and only 4.7% disagreed. The agreement was more pronounced among nurses than physicians (91.7% vs 73.7%) with less contradiction (2.1% vs 8.1%). In all, 83.7% of participants responded that they strongly agreed or agreed with the mandatory vaccination policy; 7.4% were uncertain and just 9.0% rated disagree/strongly disagree. Nurses were more likely to agree (90.2% strongly agree/agree vs 82.8% for physicians and 76.1% for other HCWs; P ¼ 0.024). The participants had suboptimal knowledge about influenza and influenza vaccine, with a mean SD knowledge score of 16.03 5.86 out of 33 points. There was a significant difference between mean knowledge scores of physicians, nurses, and other HCWs (17.38 5.53, 16.35 5.76, and 14.73 5.971, respectively; P ¼ 0.001); 42.2% of the participants reported themselves that they had insufficient knowledge about the vaccine.
Variables associated with respondents’ vaccination uptake The potential predictors for compliance of seasonal influenza vaccine uptake were examined on the basis of the compliance definition postulated in the present study as the subject who received seasonal influenza vaccine regularly without interruption for the last three seasons: 2014/15, 2013/ 14, and 2012/13). Table II presents the results of logistic regression analysis. In the univariate logistic regression analysis with the potential predictors we found that nurses were significantly more compliant to receive vaccination regularly than were physicians (OR: 2.29; 95% CI: 1.37e3.84; P < 0.01); respondents with longer length of practice (5e9 years) compared to those with <5 years practice (1.80; 1.15e2.83; P < 0.05); intention to receive the vaccine next season (5.02; 2.32e10.87; P < 0.001); reading Ministry of Health vaccine circulars/guidelines (2.47; 1.67e3.63; P < 0.001); self-efficacy of having sufficient
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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Table I Characteristics of the participants, influenza vaccination and knowledge score among 447 healthcare workers (HCWs) in King Abdulla Medical City, Makkah, KSA, 2015 Overall
Vaccination status 2014/2015 season Vaccinated
Assignment Physician Nurse Other HCWs Gender Male Female Age (years) 25 26e30 31e35 36e40 >40 Median (mean SD) Education (highest degree) Less than Bachelor Bachelor Postgraduate (Diploma/Master) Postgraduate (Board/PhD/MD) Length of practice (years) <5 5e9 10 Median (mean SD) Marital status Single Married Others (divorced, widowed) Have children aged <16 years Yes No Have any chronic disease No Yes Vaccinated 2013/2014 season Yes No Vaccinated 2012/2013 season Yes No Intend to receive the vaccine next season Yes No Knowledge score about influenza and vaccine [median (mean SD)]
P
Unvaccinated
0.0121 99 (22.1%) 193 (43.2%) 155 (34.7%)
86 (86.9%) 180 (93.3%) 128 (83.1%)
13 (13.1%) 13 (6.7%) 26 (16.9%)
221 (49.4%) 226 (50.6%)
200 (90.5%) 194 (86.2%)
21 (9.5%) 31 (13.8%)
53 197 80 62 55 30
(11.9%) (44.1%) (17.9%) (13.9%) (12.3%) (32.35 7.78)
46 174 65 59 50 30
(86.8%) (88.8%) (81.3%) (95.2%) (90.9%) (32.50 7.89)
7 22 15 3 5 29
(13.2%) (11.2%) (18.8%) (4.8%) (9.1%) (31.29 6.96)
27 262 80 78
(6.0%) (58.6%) (17.9%) (17.4%)
22 235 67 70
(81.5%) (90.0%) (83.8%) (89.7%)
5 26 13 8
(18.5%) (10.0%) (16.3%) (10.3%)
168 152 127 6
(37.6%) (34.0%) (28.4%) (7.46 6.17)
143 137 114 6
(85.6%) (90.1%) (89.8%) (7.61 6.24)
24 15 13 5
(914.4%) (9.9%) (10.2%) (6.40 5.54)
0.160
0.125
0.294 0.290
0.384
169 (37.8%) 269 (60.2%) 9 (2.0%)
147 (87.5%) 241 (89.6%) 6 (66.7%)
21 (12.5%) 28 (10.4%) 3 (33.3%)
179 (40.0%) 268 (60.0%)
162 (90.5%) 232 (86.9%)
17 (9.5%) 35 (13.1%)
385 (85.9%) 63 (14.1%)
337 (87.5%) 57 (93.4%)
48 (12.5%) 4 (6.6%)
273 (61.2%) 173 (38.8%)
251 (63.7%) 143 (36.3%)
22 (42.3%) 30 (57.7%)
243(54.5%) 203 (45.5%)
223 (56.6%) 171 (43.4%)
20 (38.5%) 32 (61.5%)
383 (86.8%) 58 (13.2%) 16 (16.03 5.86)
353 (90.5%) 30 (58.8%) 16 (15.80 5.98)
37 (9.5%) 21 (41.2%) 16 (15.80 5.98)
0.185 0.099
0.244 0.181
0.003
0.014
<0.001 0.315
HCWs, healthcare workers.
knowledge about the vaccine (1.63; 1.11e2.41; P < 0.05); recommending the vaccine to family members (1.95; 1.14e3.33; P < 0.05); and participants’ agreement with regard to mandating vaccination for all HCWs. In the multivariate logistic regression analysis intended to capture predictors that were independently associated with the compliance of vaccine uptake, the model identified
reading Ministry of Health influenza vaccine circulars/guidelines (OR: 1.94; 95% CI: 1.29e2.93; P < 0.01) and intention to receive the vaccine next season (4.45; 2.00e9.91; P < 0.001). Compared to physicians, nurses (3.54; 1.76e7.71; P < 0.01) and other HCWs (2.65; 1.30e5.40; P < 0.01), longer length of practice (5e9 years) compared to those with <5 years’ practice (1.85; 1.14-3.00; P < 0.05), and age >40 years (2.69;
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8
2014/2015
2013/2014
100 Influenza vaccine uptake (%)
90
5
2012/2013
93.3
88.3
86.9
83.1
80 70 60
68.9 61.1
61.2 54.5
57.8
51.5
50
53.9
42.4
40 30 20 10 0
Overall
Physicians
Nurses
Other HCWs
Figure 1. Influenza vaccine uptake (%) for influenza vaccination seasons 2014/15, 2013/14 and 2012/13 among healthcare workers (HCWs) in King Abdulla Medical City, Makkah, Saudi Arabia.
Table II Logistic regression analysis of demographic, professional, and institutional factors associated with compliance with seasonal influenza vaccine uptake among 447 healthcare workers in King Abdulla Medical City, Makkah, KSA, 2015 Variables
Vaccination compliancea No
Assignment Physicians 70 Nurses 99 Other HCWs 96 Gender Male 133 Female 132 Age (years) <40 229 40 36 Length of practice in years <5 112 <5e9 80 10 73 Marital status Single 108 Married/Others 157 Education (highest) Less than Bachelor 20 Bachelor 142 Postgraduate degree 103 Have a chronic medical condition No 233 Yes 33 Have children aged <16 years No 163 Yes 102 Intend to receive the vaccine next season No 50 Yes 213
Univariate OR (95% CI)
Adjusted OR (95% CI)
1 3.54 (1.76e7.12)** 2.65 (1.30e5.40)**
Yes
(70.7%) (51.3%) (61.9%)
29 (29.3%) 94 (48.7%) 59 (38.1%)
1 2.29 (1.37e3.84)** 1.48 (0.86e2.55)
(60.2%) (58.4%)
88 (39.8%) 94 (41.6%)
1 1.08 (0.74e1.57)
(61.2%) (49.3%)
145 (38.8%) 37 (50.7%)
1 1.62 (0.98e2.69)
1 2.69 (1.30e5.58)**
(66.7%) (52.6%) (57.5%)
56 (33.3%) 72 (47.4%) 54 (42.5%)
1 1.80 (1.15e2.83)* 1.48 (0.92e2.38)
1 1.85 (1.14e3.00)* 1.56 (0.86e2.84)
(63.9%) (56.5%)
61 (36.1%) 121 (43.5%)
1 1.37 (0.92e2.02)
(74.1%) (54.2%) (65.2%)
7 (25.9%) 120 (45.8%) 55 (34.8%)
1 2.42 (0.99e5.90) 1.53 (0.61e3.83)
(60.5%) (52.4%)
152 (39.5%) 30 (47.6%)
1 1.39 (0.82e2.38)
(60.8%) (57.0%)
105 (39.2%) 77 (43.0%)
1 0.85 (0.58e1.25)
(86.2%) (55.5%)
8 (13.8%) 171 (44.5%)
1 5.02 (2.32e10.87)***
1 4.45 (2.00e9.91)***
(continued on next page) Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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Table II (continued ) Variables
Vaccination compliancea No
The vaccine is available at my workplace all the time No 89 (63.1%) Yes 172 (57.3%) Read/offered Ministry of Health circular/guidelines No 170 (68.8%) Yes 94 (47.2%) Feel have sufficient vaccine knowledge No 124 (66.0%) Yes 140 (54.3%) Believe the vaccine is valuable in influenza prevention No 75 (64.1%) Yes 189 (57.8%) I recommend the vaccine to the target groups No 56 (65.9%) Yes 209 (57.7%) I recommend the vaccine to my family members No 56 (71.8%) Yes 209 (56.6%) All HCWs should receive the vaccine (agreement) Uncertain/Not agree/Strongly disagree 51 (69.9%) Strongly agree/Agree 214 (57.2%) I have concern about the vaccine side-effects or efficacy No 119 (59.2%) Yes 146 (59.3%) Knowledge of influenza disease 16 (15.80 5.98) and vaccine score (out of 32 points) [median (mean SD)]
Univariate OR (95% CI)
Adjusted OR (95% CI)
Yes
52 (36.9%) 128 (42.7%)
1 1.27 (0.84e1.93)
77 (31.2%) 105 (52.8%)
1 2.47 (1.67e3.63)***
64 (34.0%) 118 (45.7%)
1 1.63 (1.11e2.41)*
42 (35.9%) 138 (42.2%)
1 1.30 (0.84e2.02)
29 (34.1%) 153 (42.3%)
1 1.41 (0.86e2.32)
22 (28.2%) 160 (43.4%)
1 1.95 (1.14e3.33%)*
22 (30.1%) 160 (42.8%)
1 1.73 (1.01e2.98%)*
82 (40.8%) 100 (40.7%) 16 (16.37 5.66)
1 0.99 (0.68e1.45) 1.07 (0.98e1.05)
1 1.94 (1.29e2.93)**
OR, odds ratio; CI, confidence interval; HCWs, healthcare workers. *P < 0.05; **P < 0.01; ***P < 0.001. Final model: e2*log-likelihood: 534.09; interactions: 5; c2 ¼ 55.80; df: 7; P < 0.001. a Received vaccination in the last three seasons.
1.30e5.58; P < 0.01) were factors independently associated with vaccine uptake.
Reasons for acceptance or avoidance to receive seasonal influenza vaccine Table III presents the most frequent reasons cited by the respondents for having or not having seasonal influenza vaccine. The most cited reasons for being vaccinated were: selfprotection (81.5%), to protect patients (74.4%), as an institutional requirement (55.6%), to prevent cross-infection (45.7%), and having contact with household children (32.2%). The most cited reasons for not getting the vaccine were: the misconception that the vaccine causes influenza (38.5%), concerns about vaccine efficacy (32.7%), trust in/wish to challenge natural immunity (21.2%), the vaccine was not available (11.5%), not all strains of the virus are covered (9.6%), and experience of severe localized reaction in previous vaccination (9.6%).
Discussion Our study was a cross-sectional survey among healthcare workers in King Abdulla Medical City, a tertiary care hospital,
located in holy Makkah, Saudi Arabia, that opened in 2010. The hospital serves pilgrims among other patients during Hajj and Omra seasons for Muslims, which host the largest annual mass gatherings of people in the world. In the first two years after the hospital opened, vaccine uptake by HCWs was low (23e29%), despite the vaccine being strongly recommended and provided free of charge. Subsequently, campaigns were implemented every season to encourage staff to accept vaccination including awareness sessions and easy accessibility to the vaccine. These campaigns at best merely convinced only half of the staff to be vaccinated. In response to low rates of voluntary uptake of influenza vaccine by HCWs, and the high vulnerability of many pilgrims during the Hajj seasons, in 2013 the Ministry of Health in Saudi Arabia adopted a mandatory vaccination policy for HCWs in all healthcare facilities in Makkah and Madinah. The aim was to ensure an acceptable level of vaccination to ensure patient safety and prevent any impact on hospital activities.2 There were no penalties for unvaccinated staff. The observed effect size of this change in policy was modest, vaccination coverage increasing only by 6.7%, from 54.5% in 2012/13 to 61.2%. In the following season, 2014/15 (the year of the study), mandatory vaccination was associated with a consequence of not permitting the unvaccinated staff to participate in the Hajj
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8 Table III Most frequent reasons cited by healthcare workers for accepting or declining to receive seasonal influenza vaccine in King Abdulla Medical City, Holy Makkah, 2015 Reasons for vaccine uptake or avoidance
Uptake (N ¼ 394) Protect myself Protect patients Required by my institution Prevent cross-infection Having children contact at home Avoidance (N ¼ 52) Vaccine causes influenza Concern about vaccine efficacy Trust in/wish to challenge my natural immunity The vaccine was not available Not all stains are covered Prior experience of severe localize reaction a
Frequencya
321 293 219 180 127
(81.5%) (74.4%) (55.6%) (45.7%) (32.2%)
20 17 11 6 5 5
(38.5%) (32.7%) (21.2%) (11.5%) (9.6%) (9.6%)
A respondent could mention more than one reason.
programme in which participants receive a financial and nonfinancial incentives. A good coverage rate (88.3%) was achieved, with an increase of 33.8% compared to the 2012/13 season before adoption of this strategy, a coverage rate approaching US standards (90%) and exceeding the EU goal (75%).25,26 This strategy was shown to be effective in other reports and to have a rational and ethical justification.14,27e30 The mandatory vaccination policy in the last season 2014/ 2015, masked almost all predictors of voluntary vaccination found in the previous seasons, which entail that this approach defeated the barriers of suboptimal vaccination among HCWs. However, relying on mandatory vaccination policy to reach a satisfactory level of influenza vaccine uptake among HCWs does not eliminate the need to understand and deal with factors that enhances voluntary vaccine uptake. As seen from our results, despite the good vaccine coverage triggered by the mandatory vaccination policy, important misconceptions and inadequate knowledge about influenza vaccine remained. Moreover, a considerable number of HCWs also had concerns about the vaccine efficacy and side-effects, as in previous research.16,23 Thus orientation programmes may be crucial to correct misconceptions and close the knowledge gap of the HCWs. Good knowledge about influenza vaccine is not only important for sustaining good vaccine uptake, but is also important for commitment of the HCWs to prescribe the vaccine to the vulnerable target groups of patients and high-risk people. Vaccination of physicians together with their opinions on the effectiveness of the vaccine was a predictor of vaccination coverage in their patients.31,32 Our study also examined the potential predictors of voluntary influenza vaccination among HCWs. Awareness of HCWs with influenza vaccine guidelines was an independent driver for vaccination (OR: 1.94; P < 0.01), which implies the importance of supplying HCWs with evidence-based guidelines and ensuring that these guidelines are accessed and comprehended. A major independent driver for the voluntary vaccine uptake was the intention to receive the vaccine next season (OR: 4.45; P < 0.001). This finding supports the results of other
7
studies which showed that intention to be vaccinated is a good predictor of the behaviour to get vaccinated.33 In contrast with several previous studies that have reported that influenza vaccination uptake is higher among physicians than among other HCWs e including nurses24 e physicians in our study were less likely to voluntarily get vaccinated compared to nurses and other HCWs. Consistent with other studies, older age (>40 years) was independently associated with voluntary influenza vaccine uptake in our study.23,24,31 This could be explained by old age being a risk factor for influenza complications and chronic disease onset. Longer duration of practice in our study was also found to be an independent predictor of influenza vaccination uptake, which could be explained by superior professional experience and scientific knowledge, thus becoming more aware of the increased risk of the disease and more convinced of the vaccine efficacy. The most frequent motivating reasons cited by HCWs of getting vaccinated in our study were dominated by ‘self-protection’ (81.5%), which other studies have noted, followed by ‘patient protection’ (74.4%).18,23 This imply the importance to focus attention of HCWs on the top priority of culture of patient safety. Other cited motivating factors to receive the vaccine were: ‘required by my institution’, ‘prevent cross-infection’ and ‘having children contact at home’; these motivating factors that influenced HCWs’ decision to take influenza vaccine were also demonstrated by other studies.11,16,19,23 On the other hand, concerns about the vaccine efficacy and side effects were the most important reasons cited by the participants for vaccination avoidance; a findings consistent with prior research.15,16,18,19,23,24 The large sample size, high response rate, accurate representation of the hospital HCWs, and the large number of items explored through the questionnaire represent strengths of our study. The cross-sectional nature of the study design, HCWs’ self-reporting of vaccine uptake which was not cross-checked with records due to anonymity of the questionnaire, and possible recall bias are the main limitations. In conclusion, our results show a good uptake of seasonal influenza vaccine during the 2014/15 season, after adoption of mandatory vaccination policy. Awareness programmes are needed to supply evidencebased information about nosocomial influenza and influenza vaccine guidelines, and to address concerns about vaccine efficacy and side-effects. It may be of value to focus efforts on HCWs whoo are less compliant to receive vaccination, especially younger HCWs and physicians. Based on large effect size, high acceptance, and minimal contradiction, we recommend extension of mandatory vaccination policy to other health facilities.
Acknowledgement We thank the study participants, who devoted their time to give valuable information. Conflict of interest statement None declared. The views in this paper are the personal views of the authors and do not necessarily represent the views of the institutions of which we are members.
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8 Funding sources None.
References 1. Centers for Disease Control and Prevention (CDC). Prevention strategies for seasonal influenza in healthcare settings. Available at: http://www.cdc.gov/flu/professionals/acip/clinical.htm [last accessed December 2015]. 2. Salgado CD, Farr BM, Hall KK, Hayden FG. Influenza in the acute hospital setting. Lancet Infect Dis 2002;2:145e155. 3. BC Center for Disease Control. BC influenza prevention policy: a discussion of the evidence, 2013. Available at: http://www.bccdc. ca/resource-gallery/Documents/Statistics%20and%20Research/ Statistics%20and%20Reports/Immunization/Vaccine%20Info/ Influenza_prevention_policy_evidence_discussionFINAL.pdf [last accessed December 2015]. 4. Simeonsson K, Summers-Bean C, Connolly A. Influenza vaccination of healthcare workers: institutional strategies for improving rates. North Carolina Med J 2004;65:323e329. 5. Anonymous. Eight Makkah hospital staff infected with swine flu. Arab News (January 22nd, 2016). Available at: http//www. arabnews.com/Saudi-arabia/news/868761 [last accessed February 2017]. 6. Affifi RM, Omar SR, El Raggal AA. A novel influenza A (H1N1) outbreak experience among residents of long term-care facility in Saudi Arabia during 2010 seasonal flu circulation. Infect Dis Rep 2012;4:e23. 7. Balkhy HH, El-Saed A, Sallah M. Epidemiology of H1N1 (2009) influenza among healthcare workers in a tertiary center in Saudi Arabia: a 6-month surveillance study. Infect Control Hosp Epidemiol 2010;31:1004e1010. 8. Herriman R. Influenza outbreak strikes Japanese hospital. Outbreak News Today (December 28th, 2014). Available at: http:// outbreaknewstoday.com/influenza-outbreak-strikes-japanesehospital-66423/ [last accessed February 2017]. 9. World Health Organization (WHO). Vaccines against influenza. WHO position paper. Wkly Epidemiol Rec 2012;87:461e476. Available at: http://www.who.int/wer/2012/wer8747.pdf?ua¼1 [last accessed December 2015]. 10. Fiore AE, Shay DK, Broder K, et al. Centers for Disease Control and Prevention: Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2009. Morb Mortal Wkly Rep 2009;58:1e52. 11. Centers for Disease Control and Prevention (CDC). Immunization of health-care personnel. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep 2011;60:8e10. 12. Thomas RE, Jefferson TO, Demicheli V, Rivetti D. Influenza vaccination for health-care workers who work with elderly people in institutions: a systematic review. Lancet Infect Dis 2006;6:273e279. 13. Mereckiene J, Cotter S, D’Ancona F, et al., on behalf of the VENICE project gatekeepers group. Differences in national influenza vaccination policies across the European Union, Norway and Iceland 2008e2009. Euro Surveill 2010;15(44); pii¼19700. 14. Centers for Disease Control and Prevention (CDC). Influenza vaccination coverage among health care personnel e United States, 2014e15 influenza season. Morb Mortal Wkly Rep 2015;64:993e999. 15. Alshammari TM, AlFehaid LS, AlFraih JK, Aljadhey HS. Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination. Vaccine 2014;32:5957e5961.
16. Rehmani R, Memon JI. Knowledge, attitudes and beliefs regarding influenza vaccination among healthcare workers in a Saudi hospital. Vaccine 2010;28:4283e4287. 17. Madani TA, Ghabrah TM. Meningococcal, influenza virus, and hepatitis B virus vaccination coverage level among health care workers in Hajj. BMC Infect Dis 2007;7:80e85. 18. Abu-Gharbieh E, Fahmy S, Rasool BA, Khan S. Influenza vaccination: healthcare worker’s attitude in three Middle East countries. Int J Med Sci 2010;7:319e325. 19. Shahbic HE, Said HA. Flu vaccine among health workers in Qatar. Saudi Med J 2010;31:1157e1160. 20. Gautret P, Soula G, Delmont J, Parola P, Brouqui P. Common health hazards in French pilgrims during the Hajj of 2007: a prospective cohort study. J Travel Med 2009;16:377e381. 21. Mandourah Y, Ocheltree A, Al Radi A, Fowler R. The epidemiology of Hajj-related critical illness: lessons for deployment of temporary critical care services. Crit Care Med 2012;40:829e834. 22. Balkhy HH, Memish ZA, Bafaqeer S, Almuneef MA. Influenza a common viral infection among Hajj pilgrims: time for routine surveillance and vaccination. J Travel Med 2004;11:82e86. 23. Hollmeyer HG, Hayden F, Poland G, Buchholz U. Influenza vaccination of health care workers in hospitals e a review of studies on attitudes and predictors. Vaccine 2009;27:3935e3944. 24. Cohen DL, Casken J. Why are healthcare workers so resistant to the acceptance of influenza vaccine? A review of the literature to examine factors that influence vaccine acceptance. Int J Caring Sci 2012;5:26e35. 25. Office of Disease Prevention and Health Promotion. Healthy people 2020. Immunization and infectious diseases. Available at: https://www.healthypeople.gov/2020/topics-objectives/topic/ immunization-and-infectious-diseases/objectives [last accessed December 2015]. 26. EU Council Recommendation of 22 December 2009 on seasonal influenza vaccination. (2009/1019/EU); L:348e71. Available at: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri¼CELEX: 32009H1019:EN: HTML [last accessed December 2015]. 27. Nowalk MP, Lin CJ, Raymund M, Bialor J, Zimmerman RK. Impact of hospital policies on health care workers’ influenza vaccination rates. Am J Infect Control 2013;41:697e701. 28. Quan K, Tehrani DM, Dickey L, et al. Voluntary to mandatory: evolution of strategies and attitudes toward influenza vaccination of healthcare personnel. Infect Control Hosp Epidemiol 2012;33:63e70. 29. Committee on Infectious Diseases. Influenza immunization for all health care personnel: keep it mandatory. Pediatrics 2015;136:809e818. 30. Ottenberg AL, Wu JT, Poland GA, Jacobson RM, Koenig BA, Tilburt JC. Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate. Am J Public Health 2011;101:212e216. 31. Godoy P, Castilla J, Mayoral JM, et al. Influenza vaccination of primary healthcare physicians may be associated with vaccination in their patients: a vaccination coverage study. BMC Fam Pract 2015;16:44. 32. Schwarz Cha ´varri H, Pedrera Carbone V, Ortun ˜o Lo ´pez JL, Orozco Beltra ´n D, Gil Guille ´n V, Pastor Climent MA. Influence of physician and physician list characteristics on influenza vaccination rates in older people in a health care area in the community of Valencia, Spain. Aten Primaria 2004;34:336e342. 33. Lehmann BA, Ruiter RA, Chapman G, Kok G. The intention to get vaccinated against influenza and actual vaccination uptake of Dutch healthcare personnel. Vaccine 2014;32:6986e6991.
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia H.K. Haridi a, b, *, K.A. Salman b, E.A. Basaif b, D.K. Al-Skaibi a a b
General Directorate of Health Affairs, Hail Region, Saudi Arabia King Abdulla Medical City, Makkah, Saudi Arabia
A R T I C L E
I N F O
Article history: Received 12 December 2016 Accepted 5 February 2017 Available online xxx Keywords: Vaccine Influenza Healthcare workers Compliance Barriers
S U M M A R Y
Background: Influenza vaccination of healthcare workers (HCWs) is essential for patient safety, their own safety, and hospital operation. However, despite its strong recommendation, studies indicates a low rate of vaccine uptake. Aim: To assess rates of, and factors affecting, influenza vaccine uptake among HCWs. Methods: A cross-sectional survey was carried out during October 1st to 16th, 2015, among HCWs in King Abdullah Medical City in Makkah, Saudi Arabia. A self-administered, anonymous questionnaire was distributed to HCWs; this included questions on demographic characteristics, vaccine uptake, and knowledge, beliefs, attitude, and concern about influenza vaccine. Findings: Out of 500 HCWs approached, 447 returned valid self-reported questionnaires with response rate 89.4%. Overall, 88.3% of the participants reported receiving vaccination during the 2014/15 season, higher than during the 2013/14 (61.2%) and 2012/13 (54.5%) seasons. Self-protection (81.5%) was the main reason for vaccination, whereas 73.4% of HCWs reported vaccination to protect patients. The main reasons for vaccination avoidance were misconception that the vaccine causes influenza (38.5%) and concern about vaccine efficacy (32.7%). Logistic regression analysis revealed that the following were independently associated with vaccine receipt among HCWs: awareness of vaccine guidelines; intention to receive the vaccine next season; nurses and other HCWs compared to physicians; longer practice; and age >40 years. Conclusion: A good uptake of influenza vaccine was achieved during the 2014/15 season following adoption of mandatory vaccination policy. Awareness programmes are needed to correct HCWs’ misconceptions about the vaccine. Efforts need to focus especially on physicians, younger staff and new recruits. ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction * Corresponding author. Address: General Directorate of Health Affairs, Hail Region, P.O. Box, 2510, Hail, 81461, Saudi Arabia. Tel.: þ96 6507114741. E-mail address: [email protected] (H.K. Haridi).
Seasonal influenza is an acute viral infection caused by influenza viruses; infected individuals are highly contagious and can transmit influenza for 24 h before they are symptomatic.1 Influenza causes significant morbidity and mortality;
http://dx.doi.org/10.1016/j.jhin.2017.02.005 0195-6701/ª 2017 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8
indeed, on a worldwide basis, influenza as a contributor or cause of death outpaces all the other vaccine-preventable diseases combined. Hospitalized patients are frequently more vulnerable to influenza than members of the general population.2,3 Healthcare workers (HCWs) can be central to influenza transmission in hospitals as they are exposed to both infected patients and patients in high-risk groups.1 Influenza outbreaks in hospitals cause morbidity among patients and HCWs; they also interfere with normal function of healthcare systems, for example by impacting on HCW numbers and workload and on hospital income as a result of fewer elective admissions and operations.4 In Saudi Arabia, our hospital in Makkah experienced an influenza outbreak in January 2016, with 12 confirmed cases of whom eight were among HCWs.5 An outbreak of influenza A (H1N1) in a long-term care facility at Taief in 2010 affected 21 residents (an attack rate of 47.7%), with two deaths.6 In Riyadh, two outbreaks occurred at a tertiary hospital in early August and late October 2009 with 526 HCWs confirmed H1N1 influenza positive.7 Large outbreaks have also been reported in other countries. For example, an influenza outbreak in a Japanese general hospital in December 2014 affected more than 100 individuals (41 patients and 62 staff), with two deaths among elderly patients.8 Seasonal influenza vaccination of HCWs is a core component of infection control policy and patient safety programmes.9,10 Such programmes can reduce patient morbidity and mortality, increase patient safety, and reduce work absenteeism among healthcare workers.11e13 Vaccination coverage among HCWs varies substantially between different studies and countries, with lower rates of uptake mostly reported. In a cross-sectional survey in 27 European countries vaccination coverage in HCWs ranged between 13% and 89%, with uptake rates in different centres frequently being <35%, sometimes <25%.13 In the USA, the Centers for Disease Control and Prevention influenza season report from 2014/15 showed that 77.3% of all HCWs reported having had an influenza vaccination, an increase of 13.8% compared with the 2010/11 season estimate. This improvement in vaccine coverage was attributed mainly to more hospitals adopting mandatory vaccination policies.14 Influenza vaccine uptake rates among HCWs in Saudi Arabia have previously been reported to be low. In 2014 Alshammari et al. reported 38% coverage in six major hospitals, and in 2010 Rehmani and Memon reported 34.4% coverage; both of these are substantially better than the 5.9% coverage reported among HCWs employed in Hajj healthcare facilities in 2007.15e17 In neighbouring countries, uptake of influenza vaccine among HCWs has also been reported to be low: 24.7% in the Emirates, 46.4% in Oman, 67.2% in Kuwait, and 19.4% in Qatar.18,19 HCWs and healthcare systems have an ethical and moral duty to protect vulnerable patients from influenza.20 Owing to the failure of voluntary immunization programmes for HCWs, mandatory polices are being increasingly adopted by healthcare institutions and public health authorities.9 In Saudi Arabia, healthcare institutions dealing with pilgrims during Hajj seasons provide emergency care for a high-risk group of patients, who are predominantly elderly with comorbid conditions.20 Being exposed to stressful physical conditions puts them at risk of complicated and/or serious
influenza.21,22 In response, the Saudi Ministry of Health has mandated influenza vaccination for all HCWs in settings providing healthcare for pilgrims. Few previously published studies were identified exploring influenza vaccination among HCWs in healthcare facilities serving Hajj pilgrims.17 Moreover, there is a need to assess the impact of the recent mandatory vaccination policy. The aims of this work were to assess the uptake rates of seasonal influenza vaccine among HCWs, and to identify determinants of compliance with the vaccine uptake and reasons that inhibit or motivate vaccination.
Methods Study design and setting The study was a cross-sectional survey carried out between October 1st and 16th, 2015 among HCWs in King Abdulla Medical City, which is a tertiary care, 550-bed hospital, located in holy Makkah, Saudi Arabia. The hospital has more than 3150 staff, including 574 physicians, more than 900 nurses, and 720 other HCWs directly involved in patient care. The hospital admitted 11,329 inpatients and received 155,204 outpatient visits during 2014. Like other hospitals in Saudi Arabia, the hospital provides influenza vaccine free of charge to all HCWs.
Subjects The eligible participants were HCWs who are engaged in direct patient care, including physicians, nurses and other healthcare workers (pharmacists, laboratory personnel, therapists, technicians, and other staff directly involved in patient care.
Sample The investigators received a complete list of the eligible HCWs. A representative stratified random sample was taken from the eligible population. Sample size was determined before study initiation and calculated conservatively to allow for maximum sample size, assuming a 50% influenza vaccination uptake among the respondents with a margin of error of 5% at 95% confidence level. Consequently, a sample of 327 HCWs was sought. Anticipating 60e70% response rate, 500 questionnaires were distributed taking into consideration a balanced proportion of HCWs according to assignment, departmental affiliations, and work shifts.
Survey instrument and administration An anonymous structured questionnaire was constructed based on a review of the literature and previous research findings.1,9,16,23,24 The questionnaire included demographic, professional, and work practice characteristics of the respondents; uptake of seasonal influenza vaccine during 2014/ 15, 2013/14, and 2012/13 seasons; vaccine availability, provision of instructions and guidelines; beliefs, attitudes, and concerns about influenza vaccine. Included in the last section, questions sought to assess respondents’ knowledge about influenza disease, vaccine facts, and uptake recommendations. The instrument was reliable for internal consistency with
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8 calculated Cronbach’s alpha coefficient at 0.78. The consenting subjects self-completed the questionnaire after distribution to the eligible HCWs with a briefing for the study objectives by trained co-ordinators who did not have medical or administrative responsibilities in the hospital during the study.
Pilot study The questionnaire was pre-tested and piloted with a convenience sample of 20 HCWs with professional and demographic characteristics similar to those of the study population to ensure clarity and ease of administration. Based on respondents’ recommendations, some changes were incorporated to simplify and improve the final questionnaire.
Ethics The Ethical Committee of King Abdulla Medical City approved the study protocol and the final questionnaire, with approval number 15-216.
Statistical analysis Statistical analysis was undertaken using the EpiInfo 7 programme. Descriptive statistics were generated for all survey items. A binary outcome variable was created to reflect compliance of the subject with seasonal influenza vaccine uptake. A compliant subject was defined as ‘the subject who received seasonal influenza vaccine regularly without interruption for the last three seasons; 2014/15, 2013/14, and 2012/ 13’. A bivariate analysis with c2-test and t-test as appropriate was performed to explore factors associated with HCWs’ receipt of the vaccine with demographic, professional, and practice characteristics, as well as knowledge and attitude towards influenza vaccine. A multivariate logistic regression model with backward selection and threshold of <0.2 was developed to capture predictors independently associated with the compliant behaviour of seasonal influenza vaccine receipt. Odds ratios (ORs) and their 95% confidence intervals (CIs) were reported as measures of association between predictors and outcome of interest. All statistical tests were twotailed and P 0.05 was considered statistically significant.
Results Respondent data and influenza vaccine uptake In all, 447 of the 500 questionnaires that were distributed were returned (response rate 89.4%). Respondents were comparable to the surveyed population (P ¼ 0.207). The characteristics of the respondents are summarized in Table I. Overall, 394/447 (88.3%) of the respondents reported receiving a vaccination in the 2014/15 season, higher than in the 2013/14 season (61.2%, 273/447) and in the 2012/13 season (54.5%, 243/447) (Figure 1). Uptake was significantly higher in the last season (2014/15) among nurses (93.3%) compared to physicians (86.9%) and other health professionals (83.1%) (P ¼ 0.012). For the previous seasons, nurses also had higher vaccine uptake compared to physicians for the 2013/14 season [68.9% vs 51.5%; odds ratio
3
(OR): 2.09; 95% confidence interval (CI): 1.27e3.43; P ¼ 0.004] and for 2012/13 season (61.1% vs 42.4%; OR: 2.14 95% CI: 1.31e3.49; P ¼ 0.003). There was no significant difference in the demographic characteristics of the vaccinated or unvaccinated respondents in 2014/15 season. The mean ages of respondents for the two groups were 32.35 7.78 and 32.50 7.89 years, respectively, and the lengths of practice were 7.46 6.17 and 7.61 6.24 years, respectively (P ¼ 0$185), for the two groups respectively.
Beliefs, attitudes and concerns about influenza vaccine Nearly three-quarters of the participants (73.6%) believed that influenza vaccine is valuable in prevention of the disease. Nurses were more convinced (81.5%) of the vaccine efficacy than physicians (64.6%) or other HCWs (71.0%) (P ¼ 0.016). The majority of participants agreed that they recommended influenza vaccine to the target groups (81.0%) and to their family members (82.3%). Over half (55.0%) expressed their concern/ worry about the vaccine; 38.9% were concerned about the vaccine efficacy, and 16.1% about vaccine side-effects; there was no significant difference between HCWs according to their employment designations (P ¼ 0.675). Most participants (83.7%) expressed their belief that all HCWs should receive the vaccine, 11.6% were uncertain and only 4.7% disagreed. The agreement was more pronounced among nurses than physicians (91.7% vs 73.7%) with less contradiction (2.1% vs 8.1%). In all, 83.7% of participants responded that they strongly agreed or agreed with the mandatory vaccination policy; 7.4% were uncertain and just 9.0% rated disagree/strongly disagree. Nurses were more likely to agree (90.2% strongly agree/agree vs 82.8% for physicians and 76.1% for other HCWs; P ¼ 0.024). The participants had suboptimal knowledge about influenza and influenza vaccine, with a mean SD knowledge score of 16.03 5.86 out of 33 points. There was a significant difference between mean knowledge scores of physicians, nurses, and other HCWs (17.38 5.53, 16.35 5.76, and 14.73 5.971, respectively; P ¼ 0.001); 42.2% of the participants reported themselves that they had insufficient knowledge about the vaccine.
Variables associated with respondents’ vaccination uptake The potential predictors for compliance of seasonal influenza vaccine uptake were examined on the basis of the compliance definition postulated in the present study as the subject who received seasonal influenza vaccine regularly without interruption for the last three seasons: 2014/15, 2013/ 14, and 2012/13). Table II presents the results of logistic regression analysis. In the univariate logistic regression analysis with the potential predictors we found that nurses were significantly more compliant to receive vaccination regularly than were physicians (OR: 2.29; 95% CI: 1.37e3.84; P < 0.01); respondents with longer length of practice (5e9 years) compared to those with <5 years practice (1.80; 1.15e2.83; P < 0.05); intention to receive the vaccine next season (5.02; 2.32e10.87; P < 0.001); reading Ministry of Health vaccine circulars/guidelines (2.47; 1.67e3.63; P < 0.001); self-efficacy of having sufficient
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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Table I Characteristics of the participants, influenza vaccination and knowledge score among 447 healthcare workers (HCWs) in King Abdulla Medical City, Makkah, KSA, 2015 Overall
Vaccination status 2014/2015 season Vaccinated
Assignment Physician Nurse Other HCWs Gender Male Female Age (years) 25 26e30 31e35 36e40 >40 Median (mean SD) Education (highest degree) Less than Bachelor Bachelor Postgraduate (Diploma/Master) Postgraduate (Board/PhD/MD) Length of practice (years) <5 5e9 10 Median (mean SD) Marital status Single Married Others (divorced, widowed) Have children aged <16 years Yes No Have any chronic disease No Yes Vaccinated 2013/2014 season Yes No Vaccinated 2012/2013 season Yes No Intend to receive the vaccine next season Yes No Knowledge score about influenza and vaccine [median (mean SD)]
P
Unvaccinated
0.0121 99 (22.1%) 193 (43.2%) 155 (34.7%)
86 (86.9%) 180 (93.3%) 128 (83.1%)
13 (13.1%) 13 (6.7%) 26 (16.9%)
221 (49.4%) 226 (50.6%)
200 (90.5%) 194 (86.2%)
21 (9.5%) 31 (13.8%)
53 197 80 62 55 30
(11.9%) (44.1%) (17.9%) (13.9%) (12.3%) (32.35 7.78)
46 174 65 59 50 30
(86.8%) (88.8%) (81.3%) (95.2%) (90.9%) (32.50 7.89)
7 22 15 3 5 29
(13.2%) (11.2%) (18.8%) (4.8%) (9.1%) (31.29 6.96)
27 262 80 78
(6.0%) (58.6%) (17.9%) (17.4%)
22 235 67 70
(81.5%) (90.0%) (83.8%) (89.7%)
5 26 13 8
(18.5%) (10.0%) (16.3%) (10.3%)
168 152 127 6
(37.6%) (34.0%) (28.4%) (7.46 6.17)
143 137 114 6
(85.6%) (90.1%) (89.8%) (7.61 6.24)
24 15 13 5
(914.4%) (9.9%) (10.2%) (6.40 5.54)
0.160
0.125
0.294 0.290
0.384
169 (37.8%) 269 (60.2%) 9 (2.0%)
147 (87.5%) 241 (89.6%) 6 (66.7%)
21 (12.5%) 28 (10.4%) 3 (33.3%)
179 (40.0%) 268 (60.0%)
162 (90.5%) 232 (86.9%)
17 (9.5%) 35 (13.1%)
385 (85.9%) 63 (14.1%)
337 (87.5%) 57 (93.4%)
48 (12.5%) 4 (6.6%)
273 (61.2%) 173 (38.8%)
251 (63.7%) 143 (36.3%)
22 (42.3%) 30 (57.7%)
243(54.5%) 203 (45.5%)
223 (56.6%) 171 (43.4%)
20 (38.5%) 32 (61.5%)
383 (86.8%) 58 (13.2%) 16 (16.03 5.86)
353 (90.5%) 30 (58.8%) 16 (15.80 5.98)
37 (9.5%) 21 (41.2%) 16 (15.80 5.98)
0.185 0.099
0.244 0.181
0.003
0.014
<0.001 0.315
HCWs, healthcare workers.
knowledge about the vaccine (1.63; 1.11e2.41; P < 0.05); recommending the vaccine to family members (1.95; 1.14e3.33; P < 0.05); and participants’ agreement with regard to mandating vaccination for all HCWs. In the multivariate logistic regression analysis intended to capture predictors that were independently associated with the compliance of vaccine uptake, the model identified
reading Ministry of Health influenza vaccine circulars/guidelines (OR: 1.94; 95% CI: 1.29e2.93; P < 0.01) and intention to receive the vaccine next season (4.45; 2.00e9.91; P < 0.001). Compared to physicians, nurses (3.54; 1.76e7.71; P < 0.01) and other HCWs (2.65; 1.30e5.40; P < 0.01), longer length of practice (5e9 years) compared to those with <5 years’ practice (1.85; 1.14-3.00; P < 0.05), and age >40 years (2.69;
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8
2014/2015
2013/2014
100 Influenza vaccine uptake (%)
90
5
2012/2013
93.3
88.3
86.9
83.1
80 70 60
68.9 61.1
61.2 54.5
57.8
51.5
50
53.9
42.4
40 30 20 10 0
Overall
Physicians
Nurses
Other HCWs
Figure 1. Influenza vaccine uptake (%) for influenza vaccination seasons 2014/15, 2013/14 and 2012/13 among healthcare workers (HCWs) in King Abdulla Medical City, Makkah, Saudi Arabia.
Table II Logistic regression analysis of demographic, professional, and institutional factors associated with compliance with seasonal influenza vaccine uptake among 447 healthcare workers in King Abdulla Medical City, Makkah, KSA, 2015 Variables
Vaccination compliancea No
Assignment Physicians 70 Nurses 99 Other HCWs 96 Gender Male 133 Female 132 Age (years) <40 229 40 36 Length of practice in years <5 112 <5e9 80 10 73 Marital status Single 108 Married/Others 157 Education (highest) Less than Bachelor 20 Bachelor 142 Postgraduate degree 103 Have a chronic medical condition No 233 Yes 33 Have children aged <16 years No 163 Yes 102 Intend to receive the vaccine next season No 50 Yes 213
Univariate OR (95% CI)
Adjusted OR (95% CI)
1 3.54 (1.76e7.12)** 2.65 (1.30e5.40)**
Yes
(70.7%) (51.3%) (61.9%)
29 (29.3%) 94 (48.7%) 59 (38.1%)
1 2.29 (1.37e3.84)** 1.48 (0.86e2.55)
(60.2%) (58.4%)
88 (39.8%) 94 (41.6%)
1 1.08 (0.74e1.57)
(61.2%) (49.3%)
145 (38.8%) 37 (50.7%)
1 1.62 (0.98e2.69)
1 2.69 (1.30e5.58)**
(66.7%) (52.6%) (57.5%)
56 (33.3%) 72 (47.4%) 54 (42.5%)
1 1.80 (1.15e2.83)* 1.48 (0.92e2.38)
1 1.85 (1.14e3.00)* 1.56 (0.86e2.84)
(63.9%) (56.5%)
61 (36.1%) 121 (43.5%)
1 1.37 (0.92e2.02)
(74.1%) (54.2%) (65.2%)
7 (25.9%) 120 (45.8%) 55 (34.8%)
1 2.42 (0.99e5.90) 1.53 (0.61e3.83)
(60.5%) (52.4%)
152 (39.5%) 30 (47.6%)
1 1.39 (0.82e2.38)
(60.8%) (57.0%)
105 (39.2%) 77 (43.0%)
1 0.85 (0.58e1.25)
(86.2%) (55.5%)
8 (13.8%) 171 (44.5%)
1 5.02 (2.32e10.87)***
1 4.45 (2.00e9.91)***
(continued on next page) Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
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H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8
Table II (continued ) Variables
Vaccination compliancea No
The vaccine is available at my workplace all the time No 89 (63.1%) Yes 172 (57.3%) Read/offered Ministry of Health circular/guidelines No 170 (68.8%) Yes 94 (47.2%) Feel have sufficient vaccine knowledge No 124 (66.0%) Yes 140 (54.3%) Believe the vaccine is valuable in influenza prevention No 75 (64.1%) Yes 189 (57.8%) I recommend the vaccine to the target groups No 56 (65.9%) Yes 209 (57.7%) I recommend the vaccine to my family members No 56 (71.8%) Yes 209 (56.6%) All HCWs should receive the vaccine (agreement) Uncertain/Not agree/Strongly disagree 51 (69.9%) Strongly agree/Agree 214 (57.2%) I have concern about the vaccine side-effects or efficacy No 119 (59.2%) Yes 146 (59.3%) Knowledge of influenza disease 16 (15.80 5.98) and vaccine score (out of 32 points) [median (mean SD)]
Univariate OR (95% CI)
Adjusted OR (95% CI)
Yes
52 (36.9%) 128 (42.7%)
1 1.27 (0.84e1.93)
77 (31.2%) 105 (52.8%)
1 2.47 (1.67e3.63)***
64 (34.0%) 118 (45.7%)
1 1.63 (1.11e2.41)*
42 (35.9%) 138 (42.2%)
1 1.30 (0.84e2.02)
29 (34.1%) 153 (42.3%)
1 1.41 (0.86e2.32)
22 (28.2%) 160 (43.4%)
1 1.95 (1.14e3.33%)*
22 (30.1%) 160 (42.8%)
1 1.73 (1.01e2.98%)*
82 (40.8%) 100 (40.7%) 16 (16.37 5.66)
1 0.99 (0.68e1.45) 1.07 (0.98e1.05)
1 1.94 (1.29e2.93)**
OR, odds ratio; CI, confidence interval; HCWs, healthcare workers. *P < 0.05; **P < 0.01; ***P < 0.001. Final model: e2*log-likelihood: 534.09; interactions: 5; c2 ¼ 55.80; df: 7; P < 0.001. a Received vaccination in the last three seasons.
1.30e5.58; P < 0.01) were factors independently associated with vaccine uptake.
Reasons for acceptance or avoidance to receive seasonal influenza vaccine Table III presents the most frequent reasons cited by the respondents for having or not having seasonal influenza vaccine. The most cited reasons for being vaccinated were: selfprotection (81.5%), to protect patients (74.4%), as an institutional requirement (55.6%), to prevent cross-infection (45.7%), and having contact with household children (32.2%). The most cited reasons for not getting the vaccine were: the misconception that the vaccine causes influenza (38.5%), concerns about vaccine efficacy (32.7%), trust in/wish to challenge natural immunity (21.2%), the vaccine was not available (11.5%), not all strains of the virus are covered (9.6%), and experience of severe localized reaction in previous vaccination (9.6%).
Discussion Our study was a cross-sectional survey among healthcare workers in King Abdulla Medical City, a tertiary care hospital,
located in holy Makkah, Saudi Arabia, that opened in 2010. The hospital serves pilgrims among other patients during Hajj and Omra seasons for Muslims, which host the largest annual mass gatherings of people in the world. In the first two years after the hospital opened, vaccine uptake by HCWs was low (23e29%), despite the vaccine being strongly recommended and provided free of charge. Subsequently, campaigns were implemented every season to encourage staff to accept vaccination including awareness sessions and easy accessibility to the vaccine. These campaigns at best merely convinced only half of the staff to be vaccinated. In response to low rates of voluntary uptake of influenza vaccine by HCWs, and the high vulnerability of many pilgrims during the Hajj seasons, in 2013 the Ministry of Health in Saudi Arabia adopted a mandatory vaccination policy for HCWs in all healthcare facilities in Makkah and Madinah. The aim was to ensure an acceptable level of vaccination to ensure patient safety and prevent any impact on hospital activities.2 There were no penalties for unvaccinated staff. The observed effect size of this change in policy was modest, vaccination coverage increasing only by 6.7%, from 54.5% in 2012/13 to 61.2%. In the following season, 2014/15 (the year of the study), mandatory vaccination was associated with a consequence of not permitting the unvaccinated staff to participate in the Hajj
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8 Table III Most frequent reasons cited by healthcare workers for accepting or declining to receive seasonal influenza vaccine in King Abdulla Medical City, Holy Makkah, 2015 Reasons for vaccine uptake or avoidance
Uptake (N ¼ 394) Protect myself Protect patients Required by my institution Prevent cross-infection Having children contact at home Avoidance (N ¼ 52) Vaccine causes influenza Concern about vaccine efficacy Trust in/wish to challenge my natural immunity The vaccine was not available Not all stains are covered Prior experience of severe localize reaction a
Frequencya
321 293 219 180 127
(81.5%) (74.4%) (55.6%) (45.7%) (32.2%)
20 17 11 6 5 5
(38.5%) (32.7%) (21.2%) (11.5%) (9.6%) (9.6%)
A respondent could mention more than one reason.
programme in which participants receive a financial and nonfinancial incentives. A good coverage rate (88.3%) was achieved, with an increase of 33.8% compared to the 2012/13 season before adoption of this strategy, a coverage rate approaching US standards (90%) and exceeding the EU goal (75%).25,26 This strategy was shown to be effective in other reports and to have a rational and ethical justification.14,27e30 The mandatory vaccination policy in the last season 2014/ 2015, masked almost all predictors of voluntary vaccination found in the previous seasons, which entail that this approach defeated the barriers of suboptimal vaccination among HCWs. However, relying on mandatory vaccination policy to reach a satisfactory level of influenza vaccine uptake among HCWs does not eliminate the need to understand and deal with factors that enhances voluntary vaccine uptake. As seen from our results, despite the good vaccine coverage triggered by the mandatory vaccination policy, important misconceptions and inadequate knowledge about influenza vaccine remained. Moreover, a considerable number of HCWs also had concerns about the vaccine efficacy and side-effects, as in previous research.16,23 Thus orientation programmes may be crucial to correct misconceptions and close the knowledge gap of the HCWs. Good knowledge about influenza vaccine is not only important for sustaining good vaccine uptake, but is also important for commitment of the HCWs to prescribe the vaccine to the vulnerable target groups of patients and high-risk people. Vaccination of physicians together with their opinions on the effectiveness of the vaccine was a predictor of vaccination coverage in their patients.31,32 Our study also examined the potential predictors of voluntary influenza vaccination among HCWs. Awareness of HCWs with influenza vaccine guidelines was an independent driver for vaccination (OR: 1.94; P < 0.01), which implies the importance of supplying HCWs with evidence-based guidelines and ensuring that these guidelines are accessed and comprehended. A major independent driver for the voluntary vaccine uptake was the intention to receive the vaccine next season (OR: 4.45; P < 0.001). This finding supports the results of other
7
studies which showed that intention to be vaccinated is a good predictor of the behaviour to get vaccinated.33 In contrast with several previous studies that have reported that influenza vaccination uptake is higher among physicians than among other HCWs e including nurses24 e physicians in our study were less likely to voluntarily get vaccinated compared to nurses and other HCWs. Consistent with other studies, older age (>40 years) was independently associated with voluntary influenza vaccine uptake in our study.23,24,31 This could be explained by old age being a risk factor for influenza complications and chronic disease onset. Longer duration of practice in our study was also found to be an independent predictor of influenza vaccination uptake, which could be explained by superior professional experience and scientific knowledge, thus becoming more aware of the increased risk of the disease and more convinced of the vaccine efficacy. The most frequent motivating reasons cited by HCWs of getting vaccinated in our study were dominated by ‘self-protection’ (81.5%), which other studies have noted, followed by ‘patient protection’ (74.4%).18,23 This imply the importance to focus attention of HCWs on the top priority of culture of patient safety. Other cited motivating factors to receive the vaccine were: ‘required by my institution’, ‘prevent cross-infection’ and ‘having children contact at home’; these motivating factors that influenced HCWs’ decision to take influenza vaccine were also demonstrated by other studies.11,16,19,23 On the other hand, concerns about the vaccine efficacy and side effects were the most important reasons cited by the participants for vaccination avoidance; a findings consistent with prior research.15,16,18,19,23,24 The large sample size, high response rate, accurate representation of the hospital HCWs, and the large number of items explored through the questionnaire represent strengths of our study. The cross-sectional nature of the study design, HCWs’ self-reporting of vaccine uptake which was not cross-checked with records due to anonymity of the questionnaire, and possible recall bias are the main limitations. In conclusion, our results show a good uptake of seasonal influenza vaccine during the 2014/15 season, after adoption of mandatory vaccination policy. Awareness programmes are needed to supply evidencebased information about nosocomial influenza and influenza vaccine guidelines, and to address concerns about vaccine efficacy and side-effects. It may be of value to focus efforts on HCWs whoo are less compliant to receive vaccination, especially younger HCWs and physicians. Based on large effect size, high acceptance, and minimal contradiction, we recommend extension of mandatory vaccination policy to other health facilities.
Acknowledgement We thank the study participants, who devoted their time to give valuable information. Conflict of interest statement None declared. The views in this paper are the personal views of the authors and do not necessarily represent the views of the institutions of which we are members.
Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005
8
H.K. Haridi et al. / Journal of Hospital Infection xxx (2017) 1e8 Funding sources None.
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Please cite this article in press as: Haridi HK, et al., Influenza vaccine uptake, determinants, motivators, and barriers of the vaccine receipt among healthcare workers in a tertiary care hospital in Saudi Arabia, Journal of Hospital Infection (2017), http://dx.doi.org/10.1016/ j.jhin.2017.02.005