Journal of Hospital Infection 96 (2017) 268e275

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
General Directorate of Health Affairs, Hail Region, Saudi Arabia
b
King Abdulla Medical City, Makkah, Saudi Arabia

A R T I C L E I N F O S U M M A R Y

Article history: Background: Influenza vaccination of healthcare workers (HCWs) is essential for patient
Received 12 December 2016 safety, their own safety, and hospital operation. However, despite its strong recommen-
Accepted 5 February 2017 dation, studies indicates a low rate of vaccine uptake.
Available online 9 February Aim: To assess rates of, and factors affecting, influenza vaccine uptake among HCWs.
2017 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, anon-
Keywords: ymous questionnaire was distributed to HCWs; this included questions on demographic
Vaccine characteristics, vaccine uptake, and knowledge, beliefs, attitude, and concern about
Influenza influenza vaccine.
Healthcare workers Findings: Out of 500 HCWs approached, 447 returned valid self-reported questionnaires
Compliance with response rate 89.4%. Overall, 88.3% of the participants reported receiving vaccination
Barriers 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 avoid-
ance 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

Seasonal influenza is an acute viral infection caused by

* Corresponding author. Address: General Directorate of Health influenza viruses; infected individuals are highly contagious
Affairs, Hail Region, P.O. Box, 2510, Hail, 81461, Saudi Arabia.
and can transmit influenza for 24 h before they are symptom-
Tel.: þ96 6507114741.
E-mail address: hassankasim@hotmail.com (H.K. Haridi).
atic.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.
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275
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 Jap-
anese 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 mortal-
ity, increase patient safety, and reduce work absenteeism
among healthcare workers.11e13
Vaccination coverage among HCWs varies substantially be-
tween different studies and countries, with lower rates of
uptake mostly reported. In a cross-sectional survey in 27 Eu-
ropean countries vaccination coverage in HCWs ranged be-
tween 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 improve-
ment in vaccine coverage was attributed mainly to more hos-
pitals 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 vac-
cine 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 health-
care 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 co-
morbid conditions.20 Being exposed to stressful physical con-
ditions puts them at risk of complicated and/or serious
269
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, ther-
apists, 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 vaccina-
tion 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 question-
naires 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 re-
spondents; uptake of seasonal influenza vaccine during 2014/
15, 2013/14, and 2012/13 seasons; vaccine availability, provi-
sion 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 recommenda-
tions. The instrument was reliable for internal consistency with
270 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275
calculated Cronbach’s alpha coefficient at 0.78. The consent-
ing subjects self-completed the questionnaire after distribu-
tion 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 con-
venience sample of 20 HCWs with professional and de-
mographic characteristics similar to those of the study
population to ensure clarity and ease of administration. Based
on respondents’ recommendations, some changes were incor-
porated 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 pro-
gramme. 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 inter-
ruption 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 pre-
dictors and outcome of interest. All statistical tests were two-
tailed 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 com-
parable to the surveyed population (P ¼ 0.207). The charac-
teristics 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
(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 unvac-
cinated respondents in 2014/15 season. The mean ages of re-
spondents 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 influ-
enza 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 un-
certain 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 differ-
ence 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 re-
ported themselves that they had insufficient knowledge about
the vaccine.
Variables associated with respondents’ vaccination
uptake
The potential predictors for compliance of seasonal influ-
enza 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 physi-
cians (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
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 271

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 P
Vaccinated Unvaccinated
Assignment 0.0121
Physician 99 (22.1%) 86 (86.9%) 13 (13.1%)
Nurse 193 (43.2%) 180 (93.3%) 13 (6.7%)
Other HCWs 155 (34.7%) 128 (83.1%) 26 (16.9%)
Gender 0.160
Male 221 (49.4%) 200 (90.5%) 21 (9.5%)
Female 226 (50.6%) 194 (86.2%) 31 (13.8%)
Age (years) 0.125
25 53 (11.9%) 46 (86.8%) 7 (13.2%)
26e30 197 (44.1%) 174 (88.8%) 22 (11.2%)
31e35 80 (17.9%) 65 (81.3%) 15 (18.8%)
36e40 62 (13.9%) 59 (95.2%) 3 (4.8%)
>40 55 (12.3%) 50 (90.9%) 5 (9.1%)
Median (mean  SD) 30 (32.35  7.78) 30 (32.50  7.89) 29 (31.29  6.96) 0.294
Education (highest degree) 0.290
Less than Bachelor 27 (6.0%) 22 (81.5%) 5 (18.5%)
Bachelor 262 (58.6%) 235 (90.0%) 26 (10.0%)
Postgraduate (Diploma/Master) 80 (17.9%) 67 (83.8%) 13 (16.3%)
Postgraduate (Board/PhD/MD) 78 (17.4%) 70 (89.7%) 8 (10.3%)
Length of practice (years) 0.384
<5 168 (37.6%) 143 (85.6%) 24 (914.4%)
5e9 152 (34.0%) 137 (90.1%) 15 (9.9%)
10 127 (28.4%) 114 (89.8%) 13 (10.2%)
Median (mean  SD) 6 (7.46  6.17) 6 (7.61  6.24) 5 (6.40  5.54) 0.185
Marital status 0.099
Single 169 (37.8%) 147 (87.5%) 21 (12.5%)
Married 269 (60.2%) 241 (89.6%) 28 (10.4%)
Others (divorced, widowed) 9 (2.0%) 6 (66.7%) 3 (33.3%)
Have children aged <16 years
Yes 179 (40.0%) 162 (90.5%) 17 (9.5%) 0.244
No 268 (60.0%) 232 (86.9%) 35 (13.1%)
Have any chronic disease 0.181
No 385 (85.9%) 337 (87.5%) 48 (12.5%)
Yes 63 (14.1%) 57 (93.4%) 4 (6.6%)
Vaccinated 2013/2014 season 0.003
Yes 273 (61.2%) 251 (63.7%) 22 (42.3%)
No 173 (38.8%) 143 (36.3%) 30 (57.7%)
Vaccinated 2012/2013 season 0.014
Yes 243(54.5%) 223 (56.6%) 20 (38.5%)
No 203 (45.5%) 171 (43.4%) 32 (61.5%)
Intend to receive the vaccine next season
Yes 383 (86.8%) 353 (90.5%) 37 (9.5%) <0.001
No 58 (13.2%) 30 (58.8%) 21 (41.2%)
Knowledge score about influenza and vaccine 16 (16.03  5.86) 16 (15.80  5.98) 16 (15.80  5.98) 0.315
[median (mean  SD)]
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/guide-
lines (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;
272 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275

2014/2015 2013/2014 2012/2013

100
93.3
90 88.3 86.9
83.1
Influenza vaccine uptake (%)

80
68.9
70
61.2 61.1
60 57.8
54.5 53.9
51.5
50
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 Univariate OR (95% CI) Adjusted OR (95% CI)
No Yes
Assignment
Physicians 70 (70.7%) 29 (29.3%) 1 1
Nurses 99 (51.3%) 94 (48.7%) 2.29 (1.37e3.84)** 3.54 (1.76e7.12)**
Other HCWs 96 (61.9%) 59 (38.1%) 1.48 (0.86e2.55) 2.65 (1.30e5.40)**
Gender
Male 133 (60.2%) 88 (39.8%) 1
Female 132 (58.4%) 94 (41.6%) 1.08 (0.74e1.57)
Age (years)
<40 229 (61.2%) 145 (38.8%) 1 1
40 36 (49.3%) 37 (50.7%) 1.62 (0.98e2.69) 2.69 (1.30e5.58)**
Length of practice in years
<5 112 (66.7%) 56 (33.3%) 1 1
<5e9 80 (52.6%) 72 (47.4%) 1.80 (1.15e2.83)* 1.85 (1.14e3.00)*
10 73 (57.5%) 54 (42.5%) 1.48 (0.92e2.38) 1.56 (0.86e2.84)
Marital status
Single 108 (63.9%) 61 (36.1%) 1
Married/Others 157 (56.5%) 121 (43.5%) 1.37 (0.92e2.02)
Education (highest)
Less than Bachelor 20 (74.1%) 7 (25.9%) 1
Bachelor 142 (54.2%) 120 (45.8%) 2.42 (0.99e5.90)
Postgraduate degree 103 (65.2%) 55 (34.8%) 1.53 (0.61e3.83)
Have a chronic medical condition
No 233 (60.5%) 152 (39.5%) 1
Yes 33 (52.4%) 30 (47.6%) 1.39 (0.82e2.38)
Have children aged <16 years
No 163 (60.8%) 105 (39.2%) 1
Yes 102 (57.0%) 77 (43.0%) 0.85 (0.58e1.25)
Intend to receive the vaccine next season
No 50 (86.2%) 8 (13.8%) 1 1
Yes 213 (55.5%) 171 (44.5%) 5.02 (2.32e10.87)*** 4.45 (2.00e9.91)***
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 273

Table II (continued )
Variables Vaccination compliancea Univariate OR (95% CI) Adjusted OR (95% CI)
No Yes
The vaccine is available at my workplace all the time
No 89 (63.1%) 52 (36.9%) 1
Yes 172 (57.3%) 128 (42.7%) 1.27 (0.84e1.93)
Read/offered Ministry of Health circular/guidelines
No 170 (68.8%) 77 (31.2%) 1 1
Yes 94 (47.2%) 105 (52.8%) 2.47 (1.67e3.63)*** 1.94 (1.29e2.93)**
Feel have sufficient vaccine knowledge
No 124 (66.0%) 64 (34.0%) 1
Yes 140 (54.3%) 118 (45.7%) 1.63 (1.11e2.41)*
Believe the vaccine is valuable in influenza prevention
No 75 (64.1%) 42 (35.9%) 1
Yes 189 (57.8%) 138 (42.2%) 1.30 (0.84e2.02)
I recommend the vaccine to the target groups
No 56 (65.9%) 29 (34.1%) 1
Yes 209 (57.7%) 153 (42.3%) 1.41 (0.86e2.32)
I recommend the vaccine to my family members
No 56 (71.8%) 22 (28.2%) 1
Yes 209 (56.6%) 160 (43.4%) 1.95 (1.14e3.33%)*
All HCWs should receive the vaccine (agreement)
Uncertain/Not agree/Strongly disagree 51 (69.9%) 22 (30.1%) 1
Strongly agree/Agree 214 (57.2%) 160 (42.8%) 1.73 (1.01e2.98%)*
I have concern about the vaccine side-effects or efficacy
No 119 (59.2%) 82 (40.8%) 1
Yes 146 (59.3%) 100 (40.7%) 0.99 (0.68e1.45)
Knowledge of influenza disease 16 (15.80  5.98) 16 (16.37  5.66) 1.07 (0.98e1.05)
and vaccine score (out of 32 points)
[median (mean  SD)]
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 vac-
cine. The most cited reasons for being vaccinated were: self-
protection (81.5%), to protect patients (74.4%), as an institu-
tional 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 miscon-
ception 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. Subse-
quently, 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
274 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275
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 Frequencya
Uptake (N ¼ 394)
Protect myself 321 (81.5%)
Protect patients 293 (74.4%)
Required by my institution 219 (55.6%)
Prevent cross-infection 180 (45.7%)
Having children contact at home 127 (32.2%)
Avoidance (N ¼ 52)
Vaccine causes influenza 20 (38.5%)
Concern about vaccine efficacy 17 (32.7%)
Trust in/wish to challenge my natural immunity 11 (21.2%)
The vaccine was not available 6 (11.5%)
Not all stains are covered 5 (9.6%)
Prior experience of severe localize reaction 5 (9.6%)
a
A respondent could mention more than one reason.
programme in which participants receive a financial and non-
financial incentives. A good coverage rate (88.3%) was ach-
ieved, 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 fac-
tors 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 impor-
tant 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 volun-
tary 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 up-
take was the intention to receive the vaccine next season (OR:
4.45; P < 0.001). This finding supports the results of other
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 in-
dependent 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-pro-
tection’ (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 fac-
tors 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 repre-
sentation 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 evidence-
based information about nosocomial influenza and influenza
vaccine guidelines, and to address concerns about vaccine ef-
ficacy and side-effects. It may be of value to focus efforts on
HCWs who 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 vacci-
nation 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.
 H.K. Haridi et al. / Journal of Hospital Infection 96 (2017) 268e275 275
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