A comprehensive review of drivers influencing flu vaccine acceptance in the Middle East over the last six years: using Health Belief Model

Abstract

Objectives

The objectives of this study were to review the literature covering the perceptions about influenza vaccines in the Middle East and to determine factors influencing the acceptance of vaccination using Health Belief Model (HBM).

Methods

A comprehensive literature search was performed utilizing PubMed and Google Scholar databases. Three keywords were used: Influenza vaccine, perceptions and Middle East. Empirical studies that dealt with people/healthcare worker (HCW) perceptions of influenza vaccine in the Middle East and written in English were included. The search covered articles published between January 2015 and November 2020.

Key Findings

A total of 34 cross-sectional studies covering a total of 35 518 participants from 22 countries were included in this review. The overall influenza vaccination rates were generally low (<50%) among general population, particularly among pregnant women and children. HCWs had relatively higher vaccination rates compared with general population. Old age, health comorbidities or working in high-risk environments were noted as major motivators to receive the vaccine. Concerns about adverse reactions and the lack of vaccine efficacy were the most predominant reported barriers to receiving the vaccines. Lastly, cues to actions included receiving advice from HCWs, influence of institutional requirement, awareness/educational pamphlets and influence from the media.

Summary

The HBM can be helpful in identifying and analysing motivators and barriers to vaccination. Additionally, by looking at the root causation, this model can help plan campaigns to increase vaccination rates in the region. Finally, we recommend empowering HCWs to proactively advocate for vaccination as part of preventive care.

influenza vaccine, review, driving factors, Middle East, Health Belief Model

Introduction

Seasonal influenza is an acute contagious viral infection that affects individuals of all age groups worldwide. According to World Health Organization (WHO) estimates, influenza viruses infect around 5–15% globally causing an estimated 3–5 million severe cases and up to 650 000 respiratory deaths annually.^{[1, 2]} This contributes to a global challenge in health care as hospitalization and complications continue to devastate vulnerable populations despite the use of modern medicine. The threat of influenza infections is especially compounded by the fact that asymptomatic patients can transmit the infection.

Despite the availability of antiviral drugs, the influenza vaccine remains the method of choice to prevent influenza hospitalizations, complications and healthcare costs. It is shown to be an effective, cost-effective and reliable intervention. The benefit is especially pronounced among healthcare workers (HCWs) in terms of nosocomial transmission and reduced productivity stemming from sick leaves. However, the psychology of preventive medicine is complex and the public openness to vaccination is a challenging topic to study. Influenza vaccination rates remain relatively inconsistent in many areas around the globe. This variability is concerning as it is likely caused by many interrelated factors that are difficult to account for especially in a diverse region such as the Middle East.

The confusion that arises from the variable and inconsistent vaccination rates in Middle East countries^{[3, 4]} calls for a reliable model to evaluate and predict preventive behaviour among individuals.^[4] This is precisely the reason the Health Belief Model (HBM) is a strongly endorsed predictive model. The HBM has five main constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers and cues to action which can influence the acceptance of vaccination.^{[4, 5]} There are multiple dimensions to this model that ultimately influence an individual’s health behaviours, starting from personal characteristics to one’s perceived likelihood of contracting an illness (perceived susceptibility) to the perception of the complications or consequences (perceived severity). Such an individual may then view the treatment of interest in a beneficial manner (perceived benefits) or may conversely face challenges to receive such treatments (perceived barriers).^[6] Lastly, the beliefs of others and society at large may be of great influence either in facilitating or in impairing one’s readiness to accept the preventive treatment.^{[7, 8]} As described, these components are intricate and comprehensive enough to provide a strong conceptual framework that could help predict population uptake of a preventive behaviour such as vaccination.

It is important to note that HCWs are a population distinct from the general public. Being essential frontline workers, it exposes them to great risk especially during pandemics.

Rationale and Objectives of the Review

As multiple trials for SARS-COV-2 vaccinations take place, there has been much discussion regarding their safety and effectiveness. Although the focus of the work reported in this paper study is on the perceptions of the influenza vaccine, the findings can help us gain a fundamental understanding of how the Middle Eastern population may perceive vaccinations for SARS-COV-2 through the lens of the HBM. The objectives of this study were to review existing literature covering the perceptions of HCWs and the general population about influenza vaccines in the Middle East over the last 6 years and to determine factors influencing the acceptance of vaccination using the HBM.

Methods

Information sources and search strategy

A comprehensive literature search was performed utilizing PubMed and Google Scholar databases. Studies that dealt with perceptions of influenza vaccine in the Middle East by both HCWs and a general population were included. The search covered articles published between January 2015 and November 2020. The following keywords were used: Influenza vaccine, perceptions and Middle East (see Supplementary Appendix A).

Eligibility criteria, selection and data collection process

The exclusion criteria were: non-primary literature sources, non-human studies, studies not related to the flu vaccine, studies that did not deal with perceptions or interventions, articles published in languages other than English and studies not conducted in the Middle East region. A total of 893 abstracts (213 on PubMed and 680 on Google scholar) were screened from October 2020 to November 2020 (Figure 1). Two authors independently screened the titles and abstracts of the selected articles to select potentially relevant articles. Subsequently, three authors independently read the full text of included articles to make sure they met the inclusion criteria. Lastly, duplicate articles were removed as were those without any results.

Figure 1

The flowchart of selecting the studies meeting the review inclusion criteria. *Non-empirical studies: case study, report, guideline, review (literature or systematic, overview), commentary, opinion, book and thesis. **Two reasons: no perception and/or no flu vaccine and/or no Middle East. ***Three reasons: not include any of the inclusion criteria.

Three authors (specialist pharmacists) independently extracted information from the included studies to describe the flu vaccination status in each related country. The main components (title, first author name, country, publishing month/year, main objectives, study design, the number of participants and percentage of vaccination) of included studies were summarized and each study was given an ID. The HBM domains (personal characteristics, perceived susceptibility, perceived severity, perceived, benefits, perceived barriers and cues to action) were used to find the main drivers influencing the flu vaccination.

PRISMA 2020 checklist

The review met almost all criteria of the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 statement except the assessment of study risk of bias and effect measures,^[9] since this review was to extract items to populate the HBM (see Supplementary Appendix B).

Results

Study selection and overall characteristics

A total of 34 cross-sectional surveys conducted between 2015 and 2020 from 22 countries were included (Figure 1). The studies included a total of 35 518 participants. The participants were mostly from either HCWs (14 578) or the general population (20 940), and the samples ranged from 79 to 6334 respondents per study. The surveys were conducted in several languages (English, Arabic, Turkish, Farsi and Hebrew). The studies were mostly cross-sectional utilizing in-person,^{[3, 7, 10–27]} web-based,^{[2, 28–31]} or phone-based^[32–34] questionnaires. One study was qualitative and used in-depth interviews,^[35] and one study was an intervention to enhance the vaccination rate among HCWs.^[36]

Collectively, the goals of the included studies were to evaluate the attitudes of HCWs, the general public, parents of children, pregnant women and Hajj pilgrims about the influenzas vaccine, identify knowledge gaps and vaccination rates as well as exploring methods to increase vaccination coverage (Table 1).

Table 1

Summary of the included studies

ID	Title	Author	Country	Month/ year	Main objectives	Study design	Number of participants	Percentage of vaccination
1	Vaccinations against respiratory infections in Arabian Gulfcountries: Barriers and motivators	Amani S Alqahtani et al.	Arabian Gulf Countries(KSA, UAE, Qatar, Oman, Kuwait, Bahrain)	06/2017	To study the uptake, barriers and motivators of influenza, pneumococcal, meningococcal and pertussis vaccines among members of public in Arabian Gulf countries	Cross-sectional	1812 respondents from general population	17
2	Assessment of the belief and attitudes of Iranian healthcare personnel’s toward the influenza infection and influenza vaccination	H. Hosamirudsar et al.	Iran	09/2019	To identify the beliefs and attitudes of the Iranian HCWs about influenza and the influenza vaccine	Cross-sectional survey	378 HCWs	57.7
3	Knowledge and attitude about Seasonal Influenza in Clients visiting Primary Health Centers in Baghdad	Maha Faeq Majeed et al.	Iraq	01/2017	To assess knowledge and attitude about seasonal influenza To explore knowledge and attitude about influenza vaccine in clients attending primary health centres	Cross-sectional	323 participants from general population	21.7
4	Influenza vaccination motivators among healthcare personnel in a large acute care hospital in Israel	Amir Nutman et al.	Israel	10/2016	To evaluate knowledge, perceptions and attitudes regarding influenza vaccination among HCWs	Cross-sectional online survey was sent via mail	468 HCWs	30–56
5	Factors associated with childhood influenza vaccination in Israel: a cross-sectional evaluation	Aharona Glatman- Freedman et al.	Israel	11/2019	To examine childhood influenza vaccination practices and their associations with socio- demographic and relevant health variables	A cross-sectional language-specific telephone survey	1040 parents (general population)	29.4% of children
6	Influenza Vaccination Coverage Rates, Knowledge, Attitudes, and Beliefs in Jordan: A Comprehensive Study	Areej M. Assaf et al.	Jordan	08/2016	To assess vaccination coverageTo assess knowledge, attitudes, and practices toward influenza vaccination in Jordan during the year 2012 and the 5 years preceding it.To identify the barriers and motivations to receive the vaccine and the factors contributing to its uptake	Cross-sectional survey	3200 HCWs and general population	9.9–27.5
7	Knowledge, awareness and practices towards seasonal influenza and its vaccine: implications for future vaccination campaigns in Jordan	Eman Y. Abu-rish et al.	Jordan	12/2016	To identify the gaps of knowledge among Jordanian population towards influenza disease and vaccine. To identify the major determinants of accepting seasonal influenza vaccine in adults and children in Jordan	Cross-sectional study	941 respondents from general population	20
8	Influenza vaccine: Immunization rates, knowledge and attitudes of healthcare workers in Jordan	Lana Halaseh et al.	Jordan	11/2016	To determine the rate of influenza vaccination among Jordanian HCWs and to study the factors affecting these rates, including their knowledge and attitudes toward influenza infection and immunization	Cross-sectional	744 HCWs	30.8
9	Knowledge, attitudes and practices related to influenza illness and vaccination in children: Role of awareness campaigns in changing parents’ attitudes toward influenza vaccination in Jordan	Samah Awad et al.	Jordan	03/2019	To assess knowledge, attitudes and practices (KAP) related to influenza illness and vaccination in children in the Jordanian population and to study the effect of awareness campaigns on changing the attitudes of parents toward vaccinating their children	A cross-sectional questionnaire given via in-person interviews.	1241 respondents from general population	10.9% of children
10	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 et al.	KSA	07/2017	To evaluate rates of influenza vaccine uptake and the factors that affect it	Cross-sectional survey	447 HCWs	88.3
11	Uptake of influenza vaccination, awareness and its associated barriers among medical students of a University Hospital in Central Saudi Arabia	Mohammed S. Abalkhail et al.	KSA	09/2017	To evaluate the rate of vaccine uptake among medical studentsTo evaluate awareness and the barriers associated with the influenza vaccination	Cross-sectional survey	421 medical students	68
12	Knowledge and attitudes of Saudi populations regarding seasonal influenza vaccination	Abdulrahman S. Alqahtani et al.	KSA	11/2017	To assess the knowledge and attitudes of the general population regarding influenza vaccinations	A web-based cross-sectional survey	1298 respondents from general population	44.53
13	Knowledge and Beliefs of Immunization during Pregnancy among Reproductive Age Women in Saudi Arabia	Zainab Mohammed Al Eid et al.	KSA	01/2018	Explore the level of awareness about infectious diseases and importance of immunization, safety, and beliefs among reproductive-age women	Cross-sectional	783 females from general population
14	Influenza vaccination among Saudi Hajj pilgrims: Revealing the uptake and vaccination barriers	Mohammad Alfelali et al.	KSA	04/2018	To evaluate influenza vaccine uptake among Saudi Hajj pilgrims, and identify the key barriers to vaccination	Cross-sectional Questionnaire given to Haj pilgrims	6334 Haj pilgrims	51.3
15	Beliefs, attitudes, and barriers associated with the uptake of the seasonal influenza vaccine among patients visiting primary healthcare clinics	Saudi Med J et al.	KSA	07/2018	To assess beliefs, attitudes, and barriers associated with seasonal influenza vaccination among visitors to primary healthcare clinics	Cross-sectional, self-administered questionnaire	300 respondents from general population
16	Prevalence of seasonal influenza vaccination among primary healthcare workers in Arar city, Saudi Arabia	Bashayer Reda Alenazi et al.	KSA	08/2018	The study aimed to determine the prevalence of influenza vaccination among healthcare providers	Cross-sectional	204 HCWs	55.9
17	Prevalence, knowledge, attitude, and practices associatedwith influenza vaccination among healthcare workers in primary care centers in Jazan, Saudi Arabia: A cross- sectional study	Gasem Maoudhah Mojamamy et al.	KSA	11/2018	To assess the prevalence, knowledge, attitude and practices of healthcare workers (HCWs) in Jazan Province regarding the annual influenza vaccination program	Cross-sectional study	368 HCWs
18	Saudi Hajj pilgrims’ preparation and uptake of health preventive measures during Hajj 2017	Amani S. Alqahtani et al.	KSA	04/2019	Explored Hajj Pilgrims perceptions of health risks at Hajj or pretravel health-advice-seeking behaviour	Cross-sectional	344 pilgrims	67
19	Healthcare professionals’ knowledge, attitude and acceptance of influenza vaccination in Saudi Arabia: a multicenter cross- sectional study	Thamir M. Alshammari et al.	KSA	04/2019	To explore the attitude, awareness and knowledge of HCWs toward vaccination for influenza	Cross-sectional	364 HCWs
20	Knowledge, Attitudes, And Practices Regarding The Influenza Vaccine Among Adults Attending Primary Healthcare Clinics In Dammam, Saudi Arabia	Manar AlGhanim et al.	KSA	09/2019	To measure the uptake of influenza vaccine and to assess knowledge, attitudes, and practices towards influenza vaccine among adults attending primary healthcare centres in Dammam, Saudi Arabia	Cross-sectional	79 participants from general population	50.4
21	Seasonal Influenza Vaccination among Primary Health Care Workers in Southwestern Saudi Arabia	Nabil J. Awadalla et al.	KSA	10/2019	To assess seasonal influenza vaccination (SIV) coverage and the factors affecting SIV’s utilization among PHCWs	Cross-sectional	312 HCWs
22	Seasonal Influenza Vaccination among Saudi Children: Parental Barriers and Willingness to Vaccinate Their Children	Abdullah Alolayan et al.	KSA	10/2019	To evaluate the knowledge and attitudes of parents regarding the influenza vaccine and identify potential barriers to receiving vaccination	Cross-sectional survey	297 parents
23	Emergency Medical Services Providers’ Experiencesand Attitudes Toward Infection Prevention and Control Measures in Saudi Arabia: a Qualitative Study	Anas A. Khan	KSA	11/2019	Explores the experiences and practices of emergency medical services (EMS) providers, as well as the motivations that underpin perceptions toward standard infection prevention and control (IPC)	Qualitative study based on in-depth interviews (2 focus groups and 20 interviews)	30 HCWs
24	Parental Perception Towards Flu Vaccination for Asthmatic Children in Saudi Arabia	Alaa AlQurashi et al.	KSA	12/2019	To explore the perception of parents with asthmatic children towards flu vaccination and its effect on the decision to vaccinate their children	Cross-sectional	190 parents
25	Knowledge, Attitude, and Practice of Influenza Vaccine among Health- Care Employees in Sultan Bin Abdulaziz Humanitarian City	Mariam H. Alghamdi et al.	KSA	06/2020	To investigate the knowledge, attitudes, and practices (KAP) of health-care employees (HCEs) toward influenza vaccine	Cross-sectional	391 HCWs	66
26	Knowledge and practice toward seasonal influenza vaccine and its barriers at the community level in Riyadh, Saudi Arabia	Alaa A. Aljamili	KSA	4/2020	To explore the knowledge, practices, and barriers of a Saudi Arabian population toward influenza vaccination	Cross-sectional	778 respondents from general population	50
27	Attitudes and perceptions among the pediatric health care providers toward influenza vaccination in Qatar: A cross-sectional study	Ahmed Alhammad et al.	Qatar	07/2015	To estimate the percentage of vaccinated health care providers at paediatrics department and know their perception and attitudes toward influenza vaccinations	Cross-sectional	230 respondents from paediatrics healthcare professionals	67.7
28	Improving Influenza Vaccination Rate among Primary Healthcare Workers in Qatar	Khalid H. Elawad et al.	Qatar	10/2017	The purpose of this study was to improve influenza vaccination, and determine factors influencing vaccine declination among HCW in Qatar	Cross-sectional	Launched an influenza vaccination campaign to vaccinate around 4700 HCW	77
29	Improving influenza vaccination rates of healthcare workers: a multipronged approach in Qatar	Mulham Mustafa et al.	Qatar	11/2017	To determine whether an influenza vaccination campaign was effective at increasing vaccination rate in HCWs in 2 hospitals that had did not have mandatory influenza vaccination (IV) policy	Interventional. A campaign was implemented and data regarding vaccination	2 hospitals with 5017 HCWs	64.3
30	Factors effecting influenza vaccination uptake among health care workers: a multi-center cross- sectional study	Süheyl Asma et al.	Turkey	05/2016	To assess factors affecting vaccination for influenza among HCWs (physicians and nurses)	Cross-sectional survey given online	642 respondents from HCWs	9.2
31	Factors affecting uptake of influenza vaccination among family physicians	Akan H. et al.	Turkey	05/2016	To determine the factors that influenced the decisions of family physicians working in primary care health services to receive influenza vaccines	Cross-sectional survey	596 HCWs	27.3
32	Better knowledge and regular vaccination practices correlate well with higher seasonal influenza vaccine uptake in people at risk: Promising survey results from a university outpatient clinic	Işıl Adadan Güvenç et al.	Turkey	07/2017	To assess knowledge, beliefs, opinions, and attitudes of patients and their relatives regarding influenza vaccination	Cross-sectional survey	566 responders from general population	21.7
33	Women’s knowledge and beliefs towards vaccination for influenza during pregnancy in Turkey and underlying factors of misinformation: a single-centre cross-sectional study	Çiğdem Pulatoğlu et al.	Turkey	06/2020	To assess knowledge and perceptions about influenza vaccination in pregnant women presenting to a hospital and to determine the factors associated with it	Cross-sectional survey	250 pregnant women	2
34	Knowledge, attitude, and practice of influenzavaccine immunization among primary healthcare providers in Dubai health authority, 2016–2017	Lateefa Mohamed AlMarzooqi et al.	UAE	09/2018	To identify the percentage of vaccinated HCPs, identify the most common reason for receiving the vaccine or not and to identify the level of HCPs knowledge towards the influenza vaccine itself	Cross-sectional	431 HCWs	53.4

HCWs, healthcare workers. Studies included HCWs = 2, 4, 8, 16, 17, 19, 21, 28, 29, 30, and 34.

HCWs versus general population and other special populations

Out of the 34 included studies, 11 looked at the perceptions of HCWs, and 22 studies dealt with the general population and one study covered medical students (Table 1). Only three studies investigated perceptions of parents about childhood flu vaccination.^{[24, 32, 37]} Additionally, pregnant women were exclusively surveyed in two studies (in Saudi Arabia and Turkey).^{[13, 38]} Only one study in Jordan had included both HCWs and non-HCWs and thus compared the two populations directly.^[15] In this study, HCWs were significantly more likely to have had the vaccine compared with the general population (OR: 95% CI = 1.5 (0.51–0.81), P < 0.05). Additionally, higher knowledge scores were noted in HCWs.^[15] Overall, similar attitudes and barriers were noted in HCWs compared with the general populations in most studies. Other than that, HCWs were the main subjects in 11 studies (Table 1). The rest of the studies included the general population.

Vaccination of children

As for studies that evaluated perceptions of parents towards vaccinating their children. In Kingdom of Saudi Arabia (KSA), two studies were focused on children’s vaccination. One investigated the perceptions of 297 parents. This survey found that children of most of the respondents (92.7%) were up to date with the child national vaccination program.^[24] Additionally, 190 parents of asthmatic children were surveyed in another study that noted the majority had agreed that children should receive the flu vaccine, whereas only a few disagreed. However, this belief was not reflected in the association with the children’s vaccine uptake as only 46.3% of the asthmatic children were vaccinated. In that study, acceptance of the influenza vaccination was significantly associated with physicians’ recommendations and opinions.^[37] One study in Israel evaluated childhood vaccination by interviewing 1040 parents. Only 29.4% of participants reported vaccinating their children. Additionally, we included one survey that intentionally studied the effect of awareness campaigns on the openness of parents towards vaccinating their children.^[10] The vaccine is reported to be free of charge to everyone in Israel according to the study.^[32]

Summary of studies in each country

Iraq

One study was included from Iraq, which noted that 21.7% of 323 respondents have received the vaccine. Additionally, 92.3% of participants (patients at primary healthcare centres) correctly identified methods of influenza prevention.^[14]

Iran

One study from Iran reported influenza vaccination coverage among HCWs to be 57.7%. Vaccination was free of charge to healthcare personnel. Interestingly, despite a decent knowledge score demonstrated by most HCWs (78%) regarding the influenza virus not being transmittable via vaccination, 13.1% expressed fear of transmission of the virus to other persons as a barrier to the vaccine.^[11]

Israel

Two studies were included from Israel, one of which focused on childhood vaccination: 3517 from the Jewish population and 3001 from the Arab population.^[32] The other study evaluated the perceptions of 468 HCWs on the influenza vaccine. It reported a higher likelihood to recommend vaccination to patients among HCWs who have vaccinated themselves (86% in vaccinated HCWs versus 54% in unvaccinated HCWs).^[2]

Jordan

Four studies were conducted in Jordan. In one study that examined the perceptions of 3200 individuals. The overall coverage rate ranged from 9.9% to 27.5%, and it was reported to be higher in HCWs than non-HCWs. Interestingly, despite higher knowledge, similar overall perceptions were observed in HCWs personnel. Physicians’ advice was reported to be a common motivator for individuals to receive the vaccine (reported as a reason by 25.8% vaccinated individuals).^[15] In another study, the reported vaccination rate was only 20% among 941 respondents.^[16] Although the cost of the vaccine was not observed to be a barrier in this study, multiple respondents mentioned they would receive it if it was free of charge. In another study that surveyed 744 (HCWs, the overall vaccination rate was 30.8%. In that study, it was noted that workers who had higher knowledge scores were more significantly vaccinated (5.86 ± 1.15 versus 5.32 ± 1.38, P < 0.001).^[17] The other study in Jordan observed that only 10.9% of parents vaccinated their children during 2015/2016 season. However, it was noted that awareness and educational pamphlets changed attitudes positively in 29% of parents who had refused to vaccinate their children.^[10]

Kingdom of Saudi Arabia

A total of 16 studies were also included from KSA. Two studies investigated childhood vaccination, two studies focused on Hajj pilgrim, one study surveyed healthcare students, 6 studies covered HCWs and the rest included regular populations (Table 1).

The vaccination rate across the Saudi studies ranged from 36.7% to 88.3%. In one study, the rate of vaccination was observed to be 88.3% of 447 in the 2014/2015 season.^[39] Another study focused on 421 medical students who reported a vaccination rate of 68%.^[12] However, a larger study involving 1298 respondents reported a much lower rate of 44.53% among the general population.^[28] One survey included 79 participants, 50.4% of respondents have received an influenza vaccine at least once and 57% of respondents had fairly good knowledge about the vaccine.^[22] One study that surveyed 783 women noted poor knowledge about vaccinations. Indeed, when asked whether pregnant women should receive influenza vaccine during influenza season, 40.2% of women denied this and 40.4% of women did not know.^[38] One study involved 300 patients visiting family doctors, 63.3% of respondents never received the vaccine, implying less than half of the respondents to be vaccinated before that point.^[19] In one study of 778 individuals, 41.8% expressed interest to receive the vaccine, 55.0% have already received it.

Two studies from KSA had evaluated perceptions of Hajj pilgrims. In one study that evaluated the opinions of 6974 Saudi pilgrims, 51.3% of those who have shared their vaccination history had reported being vaccinated before travelling to Hajj. In that study, from a sample of 1269 pilgrims who were reported to be at high risk, only 54.5% had received the vaccine.^[18]) In another study involving 344 pilgrims, 67% of respondents received an influenza vaccine.^[33]

Six studies conducted in KSA focused on HCWs. One of them found the overall rate to be 55.9% in 204 HCWs.^[20] Another survey of 368 HCWs observed that 62.5% had picked vaccination to be the best preventive measure.^[21] Another study of a similar size of 36, had reported a 67.6% vaccination rate.^[3] One study included 312 HCWs and reported a vaccination rate of 45.5% in the 2017–2018 vaccination season. Interestingly, it was noted that 32% of HCWs had inadequate knowledge of influenza disease.^[23] One study was qualitative and included 30 emergency service workers. In that survey, low effectiveness and harmful effects of the influenza vaccine, as well as low perceptions of influenza risks were observed to be very common. The study interestingly sheds light on the fact that while most participants had received the hepatitis B vaccine, the overall attitude toward the influenza vaccine seemed more negative.^[35] Lastly, out of 391 practitioners surveyed in another study, 66% had received the influenza vaccine.^[25]

Qatar

Three studied were included from Qatar, all of which had targeted HCWs. In one study that included 230 HCWs, it was noted that 67.7% had received influenza vaccination.^[7] A larger study had launched an influenza vaccination campaign to influence the perceptions and intake of 4700 HCWs. The campaign was based on handing information about the vaccine as well as offering it for free to all centres involved. The final vaccination rate was reported to be 77% which exceeded the target rate.^[34] One additional study was interventional. It employed a campaign that was both promotional and educational in two hospitals that did not have a mandatory influenza vaccine policy. The combined mean rate for influenza vaccination in both hospitals had increased for 2014/2015 (64.3%) compared with 2013/2014 (37.2%) and 2012/2013 (28.4%).^[36]

Turkey

Four studies were conducted in Turkey, two of which focused on HCWs, and one targeted pregnant women. One study reported an overall vaccination rate of 9.2% in 642 physicians and nurses, more specifically, 15.2% for physicians and 8.2% for nurses.^[29] Another study reported 27.3% of 596 surveyed HCWs to be regularly vaccinated.^[30] As for non-HCWs, one study found that 21.7% of 566 respondents were vaccinated during the 2015–2016 seasons. Interestingly, 57.8% did not want to be vaccinated.^[26] An additional study evaluated perceptions of 250 pregnant women presenting to a hospital regarding the influenza vaccine. Shockingly, 98.8% (n = 247) did not have any vaccination during their current pregnancy.^[13]

United Arab Emirates

One study was included from UAE, which included 431 evaluated HCWs 53.4% of respondents were noted to have received the vaccine. Despite demonstrating fairly good knowledge (63.3%), HCWs continue to have reservations with regard to the yearly influenza vaccination.^[27]

Multiple countries

One survey was conducted among Gulf Cooperation Council (GCC) countries which included countries such as KSA, Oman, Bahrain, Kuwait and others. In this study, 17% overall uptake was reported. More specifically, it was 21% among at-risk populations who are believed to be at higher risk. The uptake was variable depending on the country, and it ranged from 15% in Saudi Arabia to 24% in Qatar.^[40]

One survey was distributed to multiple countries in the Middle East and North Africa (Algeria, Iran, KSA, Lebanon, Libya, Morocco, Oman, Tunisia, Turkey and the UAE) to order to evaluate the surveillance system, vaccination, funding, burden of disease and access for the vaccine. In addition to that, this survey investigated drivers and barriers to influenza vaccination. It specifically targeted perceptions of professionally interviewed individuals and members of the regional influenza stakeholder network (Middle East/North Africa Influenza Stakeholder Network [MENA-ISN]). It was found that 9 countries (6 of them in the Middle East) had an influenza surveillance system and vaccination policy, 5 countries had Influenza vaccines obtainable through the Ministry of Health.^[41]

Suggested interventions

Some studies highlighted factors that had increased vaccination rates. For example, citing HCWs recommendations to be of influence in vaccine acceptance according to the surveys.^{[15, 16, 25, 26, 37, 39, 40]} Other contributing factors were the government,^[16] institutional requirement,^[12] supervisors,^[21] workplace requirements,^[40] infection control instructions,^[23] and the media.^[7] Lastly, one study evaluated the effects of an interventional awareness campaign on vaccine acceptance of HCWs in two hospitals in Qatar.^[36]

Summary of the Health Belief Model findings

Overall influenza vaccination rates varied depending on the study population and location. The lowest rate reported was 9.2% in one of the studies in Turkey. The highest rate reported for adult vaccination was 88.3% in KSA during the 2014/2015 season.^[39]

Additionally, while variable age ranges and personal characteristics were noted in each study, three studies (2 in Turkey and one in KSA) noted a significant association between being over 65 years old and vaccination uptake.^{[18, 26, 30]} Being over 40 years old was also positively and significantly associated with vaccination uptake in a study of paediatric HCWs in Qatar.^[7]

Regarding the HBM domains, perceived susceptibility was noted as an influencing factor in multiple studies that reported a perception of the threat of or fear of being infected with influenza (Table 2). This includes risk factors such as increased age, health comorbidities, low immunity, pregnancy and being HCWs. Those factors were mentioned in 16 studies (Table 2). Some of these factors were indirectly implied. Being an HCW or working in high-risk environments was mentioned in seven studies^{[2, 3, 7, 17, 20, 21, 29]} (Table 2).

Table 2

The included studies covered each domain of the Health Belief Model

HBM domain	Number of listed studies	Citation of the studies (ID numbers as in Table 1)
Personal characteristics AgeOlder than 65 years old are more likely to received vaccination*Older over 40 years old are more likely to received vaccination**	4	14, 31, 32*27**
Pregnant women	2	13, 33
ProfessionHealthcare workers (HCWs)Both HCWs and general populations***	12	2, 4, 8, 16, 17, 19, 21, 28, 29, 30, 346***
Parents’ perception towards children vaccination	3	5, 22, 24
Perceived flu threat- Perceived flu susceptibility
◦ Being a healthcare worker (HCW) or working in high-risk environments	7	4, 8, 16, 17, 19, 27, 30
◦ Having risk factors (increased age, health comorbidities, low immunity, pregnancy)	16	1, 3, 6, 7, 813, 14, 15, 16, 17, 18, 21, 27, 30, 31, 32
- Perceived flu severity
◦ Causing severe illness or complications	10	2, 7, 13, 16, 17, 22, 25, 26, 31, 34
◦ Causing death	2	8, 22
Perceived flu vaccine benefit
◦ To prevent or reduce of infections (general)	24	1, 2, 3, 4, 5, 6, 7, 10, 11, 12, 13, 16, 17, 18, 19, 20, 22, 23, 24, 26, 30, 31, 32, 34
◦ To prevent disease transmission to family	15	2, 3, 4, 5, 7, 10, 11, 21,22, 23, 24 30, 31, 32, 34
◦ To prevent disease transmission to patients	9	2, 8, 10, 11, 16, 21, 30, 31, 34
◦ To reduce severity (complications or hospitalization) of influenza disease	4	5, 12, 26, 32
◦ To reduce workload or reduce missed hours	3	8, 30, 31
Perceived barrier
◦ Concerns about side effects	29	1–8, 10–12, 14–29, 32–33
◦ Concerns about lack of efficacy	16	2, 6, 7, 10, 11, 14, 17, 18, 21,22, 23, 25–27, 29, 32
◦ Cost of the vaccine	6	1, 7, 8, 14, 18, 32
◦ Unawareness or lack of knowledge about the vaccine	8	1, 3, 7, 14, 18, 20, 26, 27
◦ Lack of time	6	3, 4, 7, 11, 25, 34
Cues to actions
Advice from healthcare workers (HCWs)	6	1, 6, 7, 24, 26, 32
Being encouraged by others (family and friends)	1	3
Awareness and educational pamphlets	1	9
Institutional requirement or supervisors	4	1, 10, 17, 21
Media effects	1	26

*Older than 65 years old are more likely to received vaccination; **Older over 40 years old are more likely to received vaccination; ***Both HCWs and general populations.

Perceived severity of influenza infection was noted in most studies. Participants from 10 studies acknowledged that influenza disease is a serious illness that can cause complications (Table 2). Additionally, participants feared that the disease may cause death in two studies.^{[17, 24]}

In addition to the perception of threat, perception of vaccine benefit was also noted in most studies. The belief in the vaccine’s ability to protect and reduce infections overall was noted in 24 studies. Additionally, the belief in the vaccine’s ability to protect family members was noted in 15 studies or patients in nine studies (Table 2). Perception of benefit was also noted in participants who reported their belief that the vaccine could reduce the severity of infections, including complications and hospitalizations. This was reported in four studies.^{[26, 28, 31, 32]} Reducing workload was also indicated in three studies^{[17, 29, 30]} (Table 2).

Many barriers were reported. Concerns about adverse effects were reported in 29 studies (Table 2). Concerns about lack of efficacy were noted in 16 studies (Table 2). Six studies reported concerns about cost.^{[16–18, 26, 33, 40]} Lack of knowledge or awareness was observed in eight studies.^{[7, 14, 16, 18, 22, 31, 33, 40]} Lastly, lack of time was noted in six studies^{[2, 12, 14, 16, 27, 37]} (Table 2).

As for cues to take action, influence or advice from HCWs were reported in six articles.^{[15, 16, 26, 31, 37, 40]} The influence of institutional requirements or supervisors at work was noted in four studies.^{[21, 23, 39, 40]} Awareness and educational pamphlets were noted in one Jordanian study.^[10] Advice from family members was only noted in an Iraqi study.^[14] Influence from the media was reported in one Saudi study^[31] (Table 2).

Discussion

This literature review has identified the views about influenza vaccination of the general population as well as HCWs. It included 22 countries in the Middle East over 6 years. In the Middle East, HCWs have a relatively higher rate of influenza vaccination compared with the general population who had a low vaccination rate (<50%) and varied among countries. The lowest vaccination rate was in Jordan (9.9%)^[15] and the highest (50.4%) was in KSA.^[22] The main barriers facing people to take the vaccine are the concerns of adverse reactions and the lack of vaccine efficacy.

The study had some limitations including use of only two search engines although they are the most comprehensive engines for such topics. Additionally, the study was a comprehensive review without conducting meta-analysis. The risk of bias was not assessed in this review because almost all studies had similar (cross-sectional) design with convenience sampling which can include certain selection bias relying on their way of surveying. Finally, the distribution of studies was unequal across countries with 16 studies conducted in KSA, and only 1 study for Iraq and Iran.

HCWs are generally more willing to be vaccinated than the general public across the studies. This is consistent with another systematic review which included 20 studies between January 2005 and December 2011 and covered multiple regions.^[42] Acceptance by HCWs can be attributed to multiple factors, one of which is working in a higher-risk environment, which in itself can be a form of perceived risk (Table 2). Another explanation is more knowledge of influenza infection and vaccination among HCWs. However, higher knowledge scores did not always necessarily translate to complete absence of misconceptions. One of the studies in Jordan reported that similar misconceptions were held by both the general public and HCWs, despite the higher HCW knowledge scores.^[15]

Additionally, despite our general observation of higher vaccine acceptances by HCWs, not every study reported consistently high vaccination rates from HCWs. Even though the vaccination rate of HCWs was as high as 88.3% in KSA,^[39] it was extremely low (9.2%) in Turkey.^[29] Thus, it is hard to generalize the vaccine uptake rate in the Middle East. There seems to be an indirect but obvious connection between the opinions of HCWs and the public uptake of influenza vaccine. Not only did clinicians’ opinions influence the opinions of others, but the HCW recommendations were cited as reasons to vaccinate by several studies.^{[15, 16, 26, 37, 40]} For that reason, we recommend working on improving the acceptance of HCWs as a root strategy to improve the intake of the general public.

Vaccination rates seemed to differ between particular populations. For example, Hajj pilgrims in KSA had a higher rate of flu vaccination (51.3–67%)^{[18, 33]} compared with the general population. This might be due to the mandatory vaccination policy set for Hajj pilgrims. In contrast, pregnant women and children had the lowest rate of vaccination, 2%,^[13] and a range of 10.9–29.4%,^{[32, 43]} respectively. A study in Turkey found a very low rate (2.0%) of flu vaccination among pregnant women due to their belief that it could harm the baby.^[13] On the other hand, a study conducted in the USA found about 30% of pregnant women received the flu vaccine outside of typical healthcare settings.^[44]

Health Belief Model domains

The HBM was shown to be a good lens through which to understand the challenges and concerns about the flu vaccine among both the HCWs and the public (Table 2).

Of note, the review has highlighted an association between the demographic data and preventive behaviours towards vaccination, particularly during epidemic situations. The perception of risk is consistently seen in participants who were older or had risk factors such as the existence of multiple disease states, low immune function or pregnancy. In terms of HBM domain classification, such factors can serve both as personal characteristics as well as perceived risks. In addition to this, other factors were linked to the perception of threat such as working in a high-risk environment.

Several barriers were highlighted throughout the review, such as the cost of the vaccine, inadequate knowledge and misconception about vaccine safety and efficiency (Table 2). Interestingly, the cost of vaccine was only mentioned in six studies, which could be because most Arabic countries provide the vaccine free of charge in public healthcare settings. In contrast, an important barrier was fear of adverse reactions to the influenza vaccine. This concern was heavily cited by a variety of participants across 26 studies as reasons to refuse the influenza vaccine (Table 2).

Another barrier identified by nearly half of the studies was the concern about vaccine efficacy. These predominant findings highlight the benefit of educating the public about the vaccine’s overall benefits as well as the common side effects to be expected as a normal part of an immune response.

Multiple cues to action were evident in our review. For example, HCWs’ recommendations, the opinions of family members, supervisors and institutional requirements were all shown to have a positive impact on vaccination uptake^{[15, 16, 26, 37, 40]} (Table 2). A study conducted in the UK found that adopting a wide range of communication strategies, and providing incentives are effective cues to action to promote influenza vaccination.^[45] Additionally, several interventions aimed to increase the vaccination coverage were considered in some included studies. Those were either through direct recommendations from the HCWs or done as part of a preventive requirement set up by an institution. Because of the influence of others or workplace culture, we considered those to be similar to cues to action in our review, as they were evident in a previous systemic review^[42] (Table 2).

Recommendations to promote vaccination

Finally, using the HBM we may be able to extrapolate from this review and make more general recommendations to improve vaccination rates. For example, addressing perceived threats (e.g. fear of side effects) could be achieved by providing information on the actual likelihood of an adverse event occurring challenging existing misconceptions. Further greater public uptake of the vaccination may be achieved if HCWs set an example. The findings of this review may also be transferable in terms of developing strategies to enhance vaccination rates during the COVID-19 pandemic.

Conclusions

In general, the flu vaccination was low (<50%) among the general population particularly pregnant women and children in the Middle East countries. HCWs have a relatively higher rate of vaccination compared with the general population. Concern about adverse reactions and the lack of vaccine efficacy are the main barriers to vaccination. Positive perceptions toward vaccination are not always associated with a high vaccination rate. Based on the HBM, this review has identified facilitators and barriers to vaccine acceptance that can be taken into account in service planning. We recommend evaluating the root causes behind vaccine hesitancy and empowering healthcare personnel to proactively promote vaccination as part of preventive care.

Author Contributions

Z.A.A. participated in the acquisition of data, analysis, and interpretation of data, drafting the article and revising it critically for important intellectual content. A.A.A. participated in the conception and design of the study, analysis, and interpretation of data, drafting the article, revising it critically for important intellectual content. F.Y.A. participated in the acquisition of data and drafting the article. All three authors participated in the final approval of the version to be submitted.

Funding

No external fund was received.

Conflict of Interest

None declared.

Registration and Protocol

The study was registered at the Central Scientific Committee of University of Baghdad College of Pharmacy.

Data Availability

The study information is available in Table 1.