|Year : 2021 | Volume
| Issue : 2 | Page : 783-790
Knowledge, attitude, and barriers of seasonal influenza vaccination among pregnant women visiting primary healthcare centers in Al-Ahsa, Saudi Arabia. 2019/2020
Huda Saleh Albattat, Alzahra Abdulaziz Alahmed, Fatimah Ahmed Alkadi, Ola Saleh Aldrees
Postgraduate Center of Family and Community Medicine, Ministry of Health, Alahsa, Saudi Arabia
|Date of Submission||22-Oct-2020|
|Date of Decision||03-Dec-2020|
|Date of Acceptance||16-Dec-2020|
|Date of Web Publication||27-Feb-2021|
Dr. Huda Saleh Albattat
Postgraduate Center of Family and Community Medicine in Al-Ahsa
Source of Support: None, Conflict of Interest: None
Background: The seasonal influenza vaccine is beneficial for both the pregnant women and their infants. It is considered as primary prevention for pregnant women and it decreases the serious outcomes when infection does occur. The present study was conducted to evaluate the knowledge, attitude, and barriers linked to uptake of seasonal influenza vaccine among pregnant women visiting primary healthcare centers (PHCs) in Al-Ahsa region of Saudi Arabia. Methods: A cross-sectional study done in Al-Ahsa with a target population of 410 Saudi pregnant women who attend antenatal care (ANC) clinics in PHCs in Al-Ahsa. The selection of participants was made by using multistage random sampling. A self-administered questionnaire was used as an instrument for data collection. Results: Two-thirds of the participants (66.1%) stated that they were not offered the flu vaccine by any doctor. Sixty percent of the participants (60.6%) show lack of knowledge regarding flu vaccine during pregnancy. One hundred and fifty-four of the participants (61.1%) have negative attitude toward the flu vaccine uptake during pregnancy. Concern regarding the side effects of the vaccine was the most mentioned barrier (80.9%). Conclusions: The uptake rate of influenza vaccine among pregnant women visiting Al-Ahsa PHCs is considerably low. In order to improve the uptake, we recommend increasing awareness among physicians working in PHCs of the importance of vaccination, enhancing the knowledge of women in childbearing age about influenza and its vaccine, and emphasizing the need to provide the influenza vaccine as part of routine ANC.
Keywords: Attitudes, knowledge of flu vaccine, pregnant women, Saudi Arabia, seasonal influenza vaccine
|How to cite this article:|
Albattat HS, Alahmed AA, Alkadi FA, Aldrees OS. Knowledge, attitude, and barriers of seasonal influenza vaccination among pregnant women visiting primary healthcare centers in Al-Ahsa, Saudi Arabia. 2019/2020. J Family Med Prim Care 2021;10:783-90
|How to cite this URL:|
Albattat HS, Alahmed AA, Alkadi FA, Aldrees OS. Knowledge, attitude, and barriers of seasonal influenza vaccination among pregnant women visiting primary healthcare centers in Al-Ahsa, Saudi Arabia. 2019/2020. J Family Med Prim Care [serial online] 2021 [cited 2021 Apr 21];10:783-90. Available from: https://www.jfmpc.com/text.asp?2021/10/2/783/310317
| Introduction|| |
Seasonal influenza is one of the most common infectious diseases globally. Although it is a preventable infectious disease with mostly acute mild respiratory symptoms like fever, sore throat, rhinorrhea, muscle aches, headache, and cough, however, it can also lead to serious complications like pneumonia, acute respiratory distress syndrome (ARDS), secondary bacterial infection, encephalopathy, and encephalitis.,,,
The global estimation of seasonal influenza by World Health Organization (WHO) is that 5–10% of adults and 20–30% of children acquire the infection every year. The cumulative incidence in the kingdom of Saudi Arabia from January to December 2018 was 17.52 per 100,000 population. Unfortunately, there is no estimation of seasonal influenza among pregnant women.
Pregnancy-associated immunological and physiological changes place women at greater risk for some infections and serious outcomes, such as infection with influenza viruses. During the influenza pandemics of 1918, 1957, and 2009, pregnant women were at higher risk of adverse outcomes such as severe illness, hospital and intensive care unit admission, and death.
There is a significant effect of both seasonal and pandemic influenza on the fetus and birth outcomes as well. Infection during pregnancy increases the risk for perinatal death, including abortion, stillbirths, and early neonatal morbidity and mortality. In addition, infection has been linked to increased risk of preterm, and often complicated delivery.
Multiple preventive measures are known to prevent the spread of the infection, such as avoiding close contact with sick people, good hand hygiene, coverage of mouth and nose, and avoidance of touching the eyes, nose, or mouth. However, annual seasonal vaccination remains the most effective preventive method.
According to The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices' (ACIP) recommendations, all persons aged 6 months and older and have no contraindications should receive the Influenza vaccine annually. However, there are specific populations which are considered by the CDC to be of priority for vaccination against Influenza, because of their increased risk for severe illness, and development of Influenza-related complications. Among these high-risk groups are pregnant women, or women who are planning to be pregnant during the influenza season.
The American College of Obstetricians and Gynecologists (ACOG) also recommends that women who are or will be pregnant during the Influenza season should be given the inactivated vaccine, and it can safely be given during any trimester.
The seasonal influenza vaccine is beneficial for both the pregnant women and their infants. For pregnant women, the vaccine is considered the primary prevention and it decreases the serious outcome of influenza when infection does occur. The passive immunization by transmission of maternal antibodies to the fetus through the placenta is the best protective method for infants since the influenza vaccine is not licensed for children less than 6 months of age.,
In the post-2009 pandemic years, there was a notable rise in the number of articles discussing influenza vaccination when compared with the pre-2009 pandemic years. A thorough literature review revealed that there was no single report conducted in Al-Ahsa about knowledge, attitude, and barriers linked to the uptake of seasonal influenza vaccine among pregnant women.
Zaraket et al. conducted a systemic review to examine the influenza vaccination status in the Eastern Mediterranean Region between 2006 and 2016. Most of the papers reviewed reported low uptake of vaccine among high risk populations. Inadequate level of knowledge and awareness are the major barriers to influenza vaccination.
In Saudi Arabia, a cross-sectional study was conducted by Mayet et al. in the ANC clinic at King Khalid University Hospital in Riyadh in 2013. The knowledge of Saudi pregnant women, attitudes, beliefs, and factors associated with uptake of the influenza vaccination was evaluated using a face-to-face questionnaire. The results showed low knowledge and uptake of influenza vaccine. One quarter was against the vaccine during pregnancy. About 18% of pregnant women received the vaccine and only 13.1% considered the flu vaccine to be safe during pregnancy. Moreover, it was found that physicians rarely offer their patients the flu vaccine (3.0%).
The goal of this study is to assess the level of knowledge, attitude, and barriers associated with uptake of seasonal influenza vaccine among Saudi pregnant women visiting primary healthcare centers (PHCs) in Al-Ahsa. Additional objectives were to measure the uptake rate of influenza vaccine and identify factors which are positively influencing influenza vaccine uptake.
| Methodology|| |
This cross-sectional study was conducted among Saudi pregnant women who attended antenatal clinics (ANC) in PHCs in Al-Ahsa area, Eastern province, Ministry of health. Data were collected and analyzed from March 2019 to April 2020.
The inclusion criteria consisted of Saudi pregnant women following at PHCs. Non- Saudi non-pregnant women, women who were included in the pilot study, and pregnant women who followed up in very distant PHCs were excluded from the study.
According to the latest statistics, the number of pregnant women visiting the ANC clinics in PHCs in Al-Ahsa area, for the year 1439 was about 12,724 (after application of exclusion criteria). The sample confidence level used is 95% with confidence interval of 5%, and presumed prevalence of 50%, so the estimated sample size was 373, and to increase the response rate, an extra 10% was added which made the final sample size of 410 women. For calculation of sample size, Openepi, an epidimiologic calculator, was used. According to the latest Ministry of Health (MOH) statistical yearbook, there are 72 PHCs in Al-Ahsa area, and these are divided into three geographical sectors: Omran sector, Hofuf sector, and Mubarraz sector. The latest statistics on number of pregnant women served by each sector were obtained, and they were as follows: Omran sector served 47%, Hofuf sector served 32.8%, and Mubarraz sector served 20.2% of the population.
The sample was selected using multistage random sampling. The first stage of sampling was done using cluster sampling of PHCs within each sector. Sample size was allocated to each sector based on percentage of population it served. From each randomly selected PHC, the participants were allocated and non-randomly selected through convenience sampling.
Data was collected using a self-administered questionnaire. Modified validated questionnaires, were used. It was composed of questions on demographic characteristics, previous vaccination history, knowledge about the influenza vaccine, attitude, and factors influencing vaccination and non-vaccination. It was translated into Arabic language, and the validity and reliability were tested through a Pilot Study.
After data collection, data was entered into a personal computer and analyzed using SPSS. All variables were coded before entry and were checked before analysis. Continuous data was presented in the form of mean, median, range, and standard deviation. Categorical data was presented in the form of frequency distributions and percentage. Relation between the dependent and independent variables was tested by t-test for continuous variables and Chi-square test for categorical variables. A P value of 0.05 or less was used as indicative of statistical significance.
A request letter for approval to conduct the research in Al-Ahsa PHCs was sent to Public Health Administration in General Directorate of Health Affairs in Al-Ahsa. The letter clarified the objectives of the study, the importance of the responses, as well as the assurance of confidentiality of the individuals participating in the study. The researcher explained to patients the study purpose and ensured the confidentiality of their own data Ethical approval was obtained from the Institutional Review Board vide letter No. 1420798/4/26/41 dated 13/03/2019 and informed written consent was taken from all participants in the study.
| Results|| |
Of the 410 questionnaires that were distributed, 404 of them were completed, and 6 were discarded because they were incomplete, giving a response rate of 98.5%. The mean age of the participants was 29.37 years ± 6.17 standard deviation. Almost half of them (51.2%) were below 30 years of age. More than one half (57%) of participants had an educational level at university level and above. About two-thirds of the participants were unemployed (69%). Among employed participants, the majority were working in education (7.7%) and health (6.4%) fields. In addition, most of the participants (86.9%) did not have any chronic diseases. The details of the sociodemographic data are shown in [Table 1].
The majority of participants (79.7%) did not take flu vaccine during pregnancy. Among those who have taken the vaccine, half of them (50%) took it in the current pregnancy. About two-thirds of the participants (66.8%) stated that they were not advised to take the flu vaccine by any doctor. Among those who were offered the flu vaccine by their physician, most of them (73.9%) were offered it by their obstetrician [Table 2].
The question that had the most correct answers was: “Flu viruses are most common during the fall and winter” with (84.4%). While the question with the least correct answers was: “Studies have shown that the flu vaccine can cause birth defects.” with (25.7%). About 60% of the participants (60.6) showed lack of knowledge regarding influenza vaccine during pregnancy. The frequencies and percentages of correct and incorrect answers to questions about knowledge of influenza and influenza vaccine among participants and knowledge score are shown in [Table 3] and [Table 4].
One hundred and fifty-four of the participants (61.1%) had negative attitude toward the flu vaccine uptake during pregnancy. Recommendation by the Ministry of Health carried the most positive influence on influenza vaccine uptake among pregnant women who have taken the vaccine (87.8%) [Table 5]. Concern about vaccine's side effects was the most mentioned barrier (81.2%), whereas forgetting was the least mentioned barrier (30.3%) [Table 6].
|Table 6: Barri ers that prevent pregnant women from receiving the influenza vaccine|
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In relation to education, participants who have postgraduate degrees had significantly superior knowledge score (P = 0.0001). In addition, participants who have jobs had significantly greater knowledge score (P = 0.0001). Moreover, participants who work in health field in particular also had a significantly better knowledge score (P = 0.0001) There was no significant relationship between knowledge and age or having chronic disease. [Table 7].
There was a significant relationship between vaccine uptake and good knowledge score. On the other hand, age, education, occupation, and history of chronic disease showed no significance. [Table 8] There was no significant association between gender, education, occupation, or chronic diseases and the attitude toward influenza vaccine.
|Table 8: Vaccine uptake relation with demographics of the participants and knowledge score|
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The statistical test (Chi-square) was performed to compare the independent variables with the barriers to having the flu vaccine among respondents. Logistic regressions were done to statistically significant items [Table 9],[Table 10],[Table 11]. There was a significant relationship between education and the following barriers: “avoid medications,” “side effects,” “flu shot will make them sick,” and “bad experience” (P = 0.0001, P = 0.031, P = 0.009, P = 0.002, respectively) [Table 9]. There is a significant relationship between occupation and the following barriers: “vaccine not being recommended,” “fear of injection,” “flu shot will make me sick,” “do not know from where to get the vaccine,” and “bad experience” (P = 0.029, P = 0.022, P = 0.007, P = 0.024, and P = 0.009, respectively) [Table 10]. Not having any chronic disease had significant relationship with the following barriers: “side effects of vaccine,” “chance of acquiring flu is low,” “vaccine not recommended,” and “not obligatory” (P = 0.035, P = 0.022, P = 0.029, and P = 0.016, respectively) [Table 11]. Otherwise, no statistically significant differences were found to barriers (the flu is simple disease), (concern regarding side effects of the vaccine) or (believe the vaccine is not effective) with participants' characteristics.
|Table 9: Logistic regression for level of education affecting barriers to having influenza vaccine|
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|Table 10: Logistic regression of occupations affecting barriers to having influenza vaccine|
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|Table 11: Logistic regression of history of chronic disease affecting barriers to having influenza vaccine|
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| Discussion|| |
The current study was conducted to assess the knowledge, attitude, and barriers associated with uptake of seasonal influenza vaccine among pregnant women visiting PHCs in Al-Ahsa region of Saudi Arabia.
Most of the participants are in the reproductive age group as the mean age of our sample was 29.37 years. More than half (57%) of the participants' educational level was at university level and above, and this reflects that the majority of PHC patients in this age group are highly educated. Only a small percentage of the participants (13.1%) had a chronic disease and this was to be expected, since more than half of them were below 30 years of age.
Only (20.3%) of participants reported being vaccinated against influenza which is lower than the study conducted in New South Wales (27%) and Managua (42%)., However, similar studies done in Riyadh, Toronto, Shiraz, and Naples have shown a comparatively lower uptake rate of influenza vaccine.,,,
In our survey, 66.8% of all pregnant women were not offered the flu vaccine by any doctor during their pregnancy, which might be one of the possible explanations to not getting the vaccine. Another finding which validates this is the significant relationship shown between higher knowledge scores and vaccine uptake (P = 0.0001). A similar result was reported in the Italy study, more than one third of those unvaccinated did not receive advice from their healthcare provider regarding vaccination. This finding is in agreement with other studies done in Riyadh in Saudi Arabia Iran and Thailand also show a similar finding.,,
Regarding the knowledge level of participants, about 60% of them (60.6%) had a poor knowledge score. This finding is likely to be another contributor to the low uptake rate. This is consistent with the Riyadh study (2013), which showed that most participants (63.9%) had a poor knowledge score. Similarly, the studies done in Canada, Italy, and China had the same result of poor knowledge.,,
The most misconception identified was that the flu vaccine can lead to birth defects. Same result was found in the Canada study, 80% of pregnant women incorrectly believed that the vaccine can lead to birth defects.
In our study, participants who work in health field and those who have postgraduate degree had a significantly superior knowledge score (P = 0.0001). This finding may be because their chances of exposure to knowledge about influenza and its vaccine are higher than others.
As most of participants had poor knowledge, more than half of them (61.1%) had a negative attitude toward vaccination during pregnancy.
People who had positive attitude toward the vaccine mention recommendation of the vaccine by the ministry of health as having the most influence on them.
The barriers believed by the participants to prevent vaccine uptake were variable. The most common barrier encountered was concern about vaccine's side effects (81.2%). Other reported barriers were a desire to avoid medication, the fact that the Ministry of Health has not made vaccination obligatory, the belief that the vaccine is ineffective, the belief that the flu is a simple disease, fear of injection, and least one was forgetting. Our findings were in line with several previous studies in different countries.,,
For example, China study indicated that unvaccinated women reported a variety of reasons for not taking the vaccine including worries that the vaccine can cause a person to get sick with influenza (17.7%), 16% of them reported that it is not an effective way to prevent a pregnant woman from acquiring the infection, and 14.9% of them worried that it is not safe during pregnancy.
This is a cross-sectional study, so it has limitation in evaluating temporality and causality of the observed relationship.
The other limitation is that this research only covers those visiting PHCs. It doesn't include those following up in hospitals. So, it may not represent Al-Ahsa Saudi women in general.
| Conclusion and Recommendations|| |
From this study, it was found that uptake rate of influenza vaccine among pregnant women visiting Al-Ahsa PHCs is considerably low. The leading cause of that was demonstrated to be the vaccine not being offered to pregnant women by their physicians, along with an inadequate level of knowledge on influenza and its vaccine among pregnant women. As preventive services are an essential part of the comprehensive care provided by the primary care physician, we delineate in this study the importance of family physicians' roles in increasing vaccination rates.
In order to improve the rate of vaccination among pregnant women, we make the following recommendations:
- Increase awareness among physicians working in PHCs of the importance of influenza vaccination.
- Work on enhancing the knowledge of women in childbearing age about influenza and its vaccine. Some examples of efforts that could be made to improve knowledge include health education during the clinical visit, making use of social media to increase awareness, use of pamphlets and brochures, and health education campaigns.
- Emphasize the need to provide the influenza vaccine as part of routine antenatal care.
- Despite proven importance of influenza vaccination for pregnant women, vaccination rates remain low in PHCs in Al-Ahsa.
- Main obstacles against vaccination are lack of knowledge among pregnant women, and vaccine not being offered to them.
- Efforts to improve vaccine uptake include health education and increasing physicians' awareness.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Ma Y, Li T, Chen W, Chen J, Li M, Yang Z. Knowledge, attitudes and practices (KAP) toward seasonal influenza vaccine among young workers in South China. Hum Vaccin Immunother 2018;14:1283–93.
Dass von Perbandt E, Hornung R, Thanner M. Influenza vaccination coverage of health care workers: A cross-sectional study based on data from a Swiss gynaecological hospital. GMS Infect Dis 2018;6:Doc02. doi: 10.3205/id000037.
Jung H, Oh J, Lee H, Jung HE, Oh JE, Lee HK. Cell-penetrating Mx1 enhances anti-viral resistance against mucosal influenza viral infection. Viruses 2019;11:109.
Moghoofei M, Monavari SH, Mostafaei S, Hadifar S, Ghasemi A, Babaei F, et al
. Prevalence of influenza A infection in the Middle-East: A systematic review and meta-analysis. Clin Respir J 2018;12:1787–801.
Rasmussen SA, Jamieson DJ, Uyeki TM. Effects of influenza on pregnant women and infants. Am J Obstet Gynecol 2012;207:S3–8.
Memoli MJ, Harvey H, Morens DM, Taubenberger JK. Influenza in pregnancy. Influenza Other Respir Viruses 2013;7:1033–9.
Grohskopf LA, Sokolow LZ, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 influenza season. MMWR Recomm Rep 2018;67:1–20.
ACOG Committee on Obstetric Practice. ACOG Committee Opinion No. 732: Influenza vaccination during pregnancy. Obstet Gynecol. 2018; 131(4): 109-114.
Zaman K, Roy E, Arifeen SE, Rahman M, Raqib R, Wilson E, et al
. Effectiveness of maternal influenza immunization in mothers and infants. N Engl J Med 2008;359:1555–64.
Zaraket H, Melhem N, Malik M, Khan WM, Dbaibo G, Abubakar A. Review of seasonal influenza vaccination in the Eastern Mediterranean Region: Policies, use and barriers. J Infect Public Health 2019;12:472-478.
Mayet AY, Al-Shaikh GK, Al-Mandeel HM, Alsaleh NA, Hamad AF. Knowledge, attitudes, beliefs, and barriers associated with the uptake of influenza vaccine among pregnant women. Saudi Pharm J 2017;25:76–82.
Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source [Internet]. Epidemiologic Statistics for Public Health; 2013 [updated 2013 April 06; cited 2019 Feb 23]. Available from: www.OpenEpi.com.
Yudin MH, Salaripour M, Sgro MD. Pregnant women's knowledge of influenza and the use and safety of the influenza vaccine during pregnancy. J Obstet Gynaecol Can 2009;31:120–5.
Sagor KH, AlAteeq MA. Beliefs, attitudes, and barriers associated with the uptake of the seasonal influenza vaccine among patients visiting primary healthcare clinics. Saudi Med J 2018;39:690–6.
Wiley KE, Massey PD, Cooper SC, Wood NJ, Ho J, Quinn HE, et al
. Uptake of influenza vaccine by pregnant women: A cross-sectional survey. Med J Aust 2013;198:373–5.
Arriola CS, Vasconez N, Bresee J, Ropero AM. Knowledge, attitudes and practices about influenza vaccination among pregnant women and healthcare providers serving pregnant women in Managua, Nicaragua. Vaccine 2018;36:3686–93.
Honarvar B, Odoomi N, Mahmoodi M, Kashkoli GS, Khavandegaran F, Bagheri Lankarani K, et al
. Acceptance and rejection of influenza vaccination by pregnant women in southern Iran: Physicians' role and barriers. Hum Vaccin Immunother 2012;8:1860–6.
Napolitano F, Napolitano P, Angelillo IF. Seasonal influenza vaccination in pregnant women: Knowledge, attitudes, and behaviors in Italy. BMC Infect Dis 2017;17:48.
Ditsungnoen D, Greenbaum A, Praphasiri P, Dawood FS, Thompson MG, Yoocharoen P, et al
. Knowledge, attitudes and beliefs related to seasonal influenza vaccine among pregnant women in Thailand. Vaccine 2016;34:2141–6.
Hu Y, Wang Y, Liang H, Chen Y. Seasonal influenza vaccine acceptance among pregnant women in Zhejiang Province, China: Evidence based on health belief model. Int J Environ Res Public Health 2017;14:1551.
Bettinger JA, Greyson D, Money D. Attitudes and beliefs of pregnant women and new mothers regarding influenza vaccination in British Columbia. J Obstet Gynaecol Can 2016;38:1045–52.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]