Pandemic influenza A/H1N1 vaccination uptake among health care workers in Qatar: motivators and barriers.

Abstract

Influenza A/H1N1 new vaccine helps control disease spread. Cross-sectional survey was conducted at PHC & Emergency Departments in Qatar to determine influenza A/H1N1 vaccination rate among HCWs and associated factors, 523 HCWs were enrolled. The study showed that 13.4% HCWs received vaccination. Feeling protected strongly influenced vaccination decision (OR = 14.5). Uncertainty about vaccine efficacy and fear of side effects strongly influenced decision to reject the vaccine (OR = 0.3 and 0.2 respectively). Vaccination coverage was very low. The most common barriers were uncertainty about vaccine efficacy and fear of side effects. Health authorities should build message highlighting how the benefit of vaccination outweighs risk.

Full text

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Vaccine 29 (2011) 2206–2211
Contents lists available at ScienceDirect
Vaccine
journal homepage: www.elsevier.com/locate/vaccine
Pandemic influenza A/H1N1 vaccination uptake among health care workers in
Qatar: Motivators and barriers?
Mohamed Ghaith Alkuwaria,1, Nagah A. Azizb,2, Zaher A.S. Nazzalc,∗, Saad A. Al-Nuaimid,3
aHealth Promotion and Community Medicine, Primary Health Care, Qatar
bPublic Health and Preventive Medicine, Primary Health Care, Qatar
cCommunity Medicine, CDC Department, Supreme Council of Health, Al Rayyan Street, Doha, Qatar
dA&E Department, Hamad Medical Corporation, Qatar
a r t i c l e i n f o
Article history:
Received 22 June 2010
Accepted 24 August 2010
Available online 15 September 2010
Keywords:
Influenza A/H1N1
Vaccination coverage
Healthcare workers
Qatar
a b s t r a c t
Influenza A/H1N1 new vaccine helps control disease spread. Cross-sectional survey was conducted at
PHC & Emergency Departments in Qatar to determine influenza A/H1N1 vaccination rate among HCWs
and associated factors, 523 HCWs were enrolled. The study showed that 13.4% HCWs received vaccina-
tion. Feeling protected strongly influenced vaccination decision (OR=14.5). Uncertainty about vaccine
efficacy and fear of side effects strongly influenced decision to reject the vaccine (OR=0.3 and 0.2 respec-
tively). Vaccination coverage was very low. The most common barriers were uncertainty about vaccine
efficacy and fear of side effects. Health authorities should build message highlighting how the benefit of
vaccination outweighs risk.
© 2010 Elsevier Ltd. All rights reserved.
1. Introduction
Influenza is a major health problem, and a significant clinical
and socioeconomic burden worldwide [1]. Influenza virus type A
that is frequently subjected to antigenic and genetic variation that
gaveorigintonovelsubtypesoftheviruswhichleadtoseveralpan-
demics during the last century [2]. In May 2009, a new influenza
A/H1N1 infected cases were reported in Mexico [3], and the WHO
declared the disease to be pandemic on June 2009 [4]. As of 31
January 2010, worldwide more than 209 countries and overseas
territories or communities have reported laboratory-confirmed
cases of pandemic influenza A/H1N1. In addition, at least 15,174
deaths related to this infection have been recorded [5].
OneofthemainconcernsrelatedtothecurrentpandemicH1N1
influenza 2009 is the overwhelming burden on medical structures
and resources that it poses and the consequent negative impact
?ThisisthefirstcomprehensivestudyonpandemicinfluenzaA/H1N1vaccination
among HCWs conducted in Qatar and to the best of our knowledge one of the first
studies that assess personal use of pandemic influenza vaccination in HMC and PHC
as well as physicians and nurses.
∗Corresponding author. Tel.: +974 4070194.
E-mail addresses: makuwari@hmc.org.qa (M.G. Alkuwari), nselim@hmc.org.qa
(N.A. Aziz), znazzal@hmc.org.qa, nazzalzaher@yahoo.com (Z.A.S. Nazzal),
drsaadaaa@yahoo.com (S.A. Al-Nuaimi).
1Tel.: +974 4490636/4070344.
2Tel.: +974 4070341.
3Tel.: +974 5415108.
on mortality and morbidity. This situation puts healthcare work-
ers (HCWs) in the unusual position of being both the main actors
and one of the main targets of the prevention strategies against the
pandemic H1N1 influenza 2009, and considering also their usual
unavoidable risk of being an important vector for transmission
[6,7].
The WHO and other international agencies identified vacci-
nation as the most effective intervention in reducing pandemic
influenza A/H1N1 morbidity and mortality [8]; and advised all
countries to vaccinate their health care workers against A/H1N1 as
a first priority in order to protect the vital health infrastructure and
patients in addition, their behavior and attitude might be reflected
on the public that look for advice from HCWs [6,7,9].
However, Seasonal influenza vaccination coverage among
health care workers historically has consistently been low [10–13].
Efforts to vaccinate health care workers began when 2009 H1N1
vaccine first became available, but according to the behavioral risk
factor surveillance system (BRFSS) survey, during December 2009,
only 22% of health care workers reported having been vaccinated
[14]. Unvaccinated health care workers who become infected risk
transmitting the virus to their family members or patients, who
often are at high risk for severe influenza. The current high per-
centage of unvaccinated health care workers highlights the need to
strengthen measures to improve their influenza vaccination cover-
age [14].
It is a well-established fact that risk perceptions influence
influenza vaccine uptake [15,16], and that there is a need to con-
sider and understand factors underlying people’s decision about
0264-410X/$ – see front matter © 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.vaccine.2010.08.093

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M.G. Alkuwari et al. / Vaccine 29 (2011) 2206–2211
2207
vaccination to create an effective immunization program [17–19].
That is why it is so important to understand the behavior and atti-
tudes of HCWs in relation to the spreading pandemic.
In Qatar the health authorities have decided to embark in a
mass vaccination campaign to mitigate transmission of Influenza
A/H1N1 and launched vaccination of health care workers free of
charge in November 2009 to all HCWs in hospitals and primary
care centers.
Toourknowledge,informationonhealthcareworkersuptakeof
2009 pandemic influenza is sparse. Therefore, we aim to estimate
the actual vaccination coverage among HCWs in Qatar and investi-
gate their attitude towards vaccine and possible factors associated
with vaccine uptake.
2. Methods
We carried out a national cross-sectional survey from March to
April 2010 [post peak period phase and following national vaccina-
tion campaign against pandemic influenza and seasonal flu].
2.1. Participants
We recruited HCWs in primary health care centers (PHCs) and
all governmental Pediatric and Adult Accident & Emergency (A&E)
Departments in Qatar. These facilities provide health services for
almost all flu like-illness and H1N1 cases in Qatar and HCWs are at
highest risk for contracting infection.
All department heads and PHC directors were contacted per-
sonally, through telephone calls and/or invitation letters to obtain
their approval to send the questionnaires. Sample size was calcu-
latedusing95%confidencelevel,designeffect1;effectsize50%and
80% power. At the end proportionate stratified sampling technique
using physicians and nurses as two separate strata was employed
to select a total 275 Physicians and 350 nurses out of 2064 eligible
subjects. Those who were not in patient contact or on leave were
excluded from the sampling frame.
2.2. Survey instrument and administration
A self-administered anonymous 3 page survey was used. The
questions were developed iteratively by experts in emergency and
preventive medicine and public health guided by available evi-
dence on influenza A/H1N1. It consisted of 31 questions including
age, gender, frequency of patient contact, history of hospitaliza-
tion or chronic diseases, history of lab confirmed A/H1N1 influenza
infection, their personal use of influenza vaccination (A/H1N1 and/
seasonal flu) and reasons for using or not using the vaccine, their
perceptiontowardssusceptibility,seriousnessofA/H1N1infection,
perception towards safety, and efficacy of Influenza A/H1N1 vac-
cine.Responsecategoriesofperceptionquestionsincluded3points
Likertscale.Thesurveywaspre-testedwithaconvenientsampleof
physicians and nurses in order to ensure clarity and ease of admin-
istration.The study was approved by Ethics Committee of IRB at
Hamad Medical Corporation, State of Qatar and waiver of consent
was obtained from all participants before study entry.
2.3. Data analysis
Data were entered and verified. Frequency tables and charts
were formulated for categorical data; proportions of vaccinated
HCWs were calculated. Univariate analysis was then carried out
using a chi-squared test in order to investigate the association
between the dependent variables and socio-demographic char-
acteristics, as well as perceived benefits and barriers. Moreover,
multiple logistic regression analyses were performed, using the
Table 1
Background characteristics of HCWs in Qatar 2010 (n=523).
CharacteristicPhysicians (n=203)*
Nurses (n=318)*
No. (%)No. (%)
Age
<30
30–39
40–49
≥50
Gender
Male
Female
Nationality
Qatari
Non-Qatari
Workplace
PHC
Adult A&E
Pediatric A&E
Work experience
≤5 year
6–15 year
>15 year
Patient contact/day
<25
25–50
>50
14 (6.9%)
77 (37.9%)
69 (31.0%)
49 (24.1%)
74 (23.3%)
168 (52.8%)
62 (19.5%)
14 (4.4%)
138 (68.0%)
64 (31.5%)
68 (21.4%)
250 (78.6%)
28 (13.8%)
169 (83.3%)
14 (4.4%)
297 (93.4%)
112 (55.2%)
69 (34. 0%)
22 (10.8%)
151 (47.5%)
105 (33.0%)
62 (19.5%)
72 (35.5%)
98 (48.3%)
32 (15.8%)
183 (57.5%)
105 (33.0%)
21 (6.6%)
45 (23.2%)
78 (38.4%)
78 (38.4%)
114 (39.3%)
76 (23.9%)
115 (36.2%)
PHC: primary health care; A&E: accident & emergency.
*Two respondents did not mention their job title.
backward elimination procedure. Variables associated in the uni-
variateanalysiswithvaccinatedHCWsatp≤0.10wereenteredinto
the regression models. The level of statistical significance was set
at a p value of ≤0.05. The statistical analysis was performed using
the statistical software SPSS version11.5.
3. Results
Of 625 questionnaire distributed, 523 completed questionnaire
were returned giving an overall response rate of 83.7%. Among 275
physicians and 350 nurses approached for the study, 203 (73.8%)
and318(90.8%)ofthemcompletedandreturnedthequestionnaire,
78% of nurses were female while 68% of physicians were male, and
approximately half of them worked in PHC and mostly non-Qatari
[Table 1].
Only 70 (13.4%) of the participants reported receiving the
A/H1N1 vaccine (Fig. 1). However, 30% of the participants are
willing to receive the vaccine next year if it is recommended. Vac-
cination rates were higher among HCWs working at adult A&E
department, HCWs ≥50 years old, HCWs with >15 years work
experience, and those who received seasonal flu vaccine [Table 2].
Vaccination status did not differ significantly by respondents’
nationality, gender, job title, or average daily patient contact. How-
ever,seasonalfluvaccinewasreceivedby53.5%oftheparticipants;
50.2% of physicians and 55.3% of nurses.
The primary reason(s) for being vaccinated or not being vac-
cinated are described in Table 3. The frequencies of reasons were
almost equal between physicians and nurses. The most common
Fig. 1. Proportion of HCWs reported receiving the A/H1N1 vaccine, Qatar 2010
(n=523).

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M.G. Alkuwari et al. / Vaccine 29 (2011) 2206–2211
Table 2
A/H1N1 Vaccine uptake according to background characteristics of HCWs, Qatar
2010.
CharacteristicVaccinated staff (%) Unvaccinated staff (%)
p-Value
Age
<30
30–39
40–49
≥50
Gender
Male
Female
Nationality
Qatari
Non-Qatari
Job title
Physician
Nurse
Workplace
PHC
Adult A&E
Pediatric A&E
Work experience
≤5 years
6–15 years
>15 years
Patient contact
<25
25–50
>50
Received seasonal flu vaccine
Yes
No
Exposed to A/H1N1 infected cases
Yes
No
Current smoker
Yes
No
Have chronic disease
Yes
No
10(11.5%)
29(12.0%)
15(11.9%)
16(25.0%)
77(88.5%)
213(88.0%)
111(88.1%)
48(75.0%)
0.04
33(16.2%)
37(11.8%)
171(83.8%)
277(88.2%)
0.098
3(7.1%)
64(13.8%)
39(92.9%)
400(86.2%)
0.339
25(12.3%)
45(14.3%)
178(87.7%)
269(85.7%)
0.599
28(10.7%)
36(20.7%)
6(7.1%)
233(89.3%)
138(79.3%)
78(92.9%)
0.002
33(13.1%)
21(10.3%)
14(26.4%)
219(86.9%)
182(89.7%)
39(73.6%)
0.009
25(14.6%)
16(10.5%)
29(14.9%)
146(85.4%)
136(89.5%)
165(85.1%)
0.432
60(21.5%)
10(4.2%)
219(78.5%)
230(95.8%
<0.001
60(14.5%)
10(9.6%)
354(85.5%)
94(90.4%)
0.269
6(25.0%)
64(12.9%)
18(75.0%)
431(87.1%)
0.118
9(21.4%)
61(12.8%)
33(78.6%)
416(87.2%)
0.153
reasons for being vaccinated were wishing to be protected, being
a HCW, and being afraid of transmitting A/H1N1 to family. The
mostcommonreasonsfornotbeingvaccinatedwereconcernabout
vaccine adverse reactions and its efficacy. No significant difference
detected between physicians and nurses was found except for con-
cerning about getting influenza from vaccine; it was listed as a
reasonforrejectingthevaccineby20%ofnursescomparedto11.2%
of physician.
Respondents rated their level of agreement for a series of state-
ments regarding A/H1N1 disease and vaccine [Table 4]. About 76%
and58%ofthevaccinatedgroupreportedthattheyareatriskofand
wereconcernedaboutgettingA/H1N1infectioncomparedto63.8%
and 44% of the unvaccinated group. Regarding perceived severity,
61.2% of the vaccinated group considered it as severe disease and
29.4% as fatal disease compared to 39.4% and 22.7% of the unvac-
cinated group respectively. Majority of the vaccinated group feel
protected when receiving the vaccine in contrary to the unvacci-
nated group.
The commonest reasons rated by the unvaccinated participants
as a barrier to receive the vaccine were fear of A/H1N1 vaccine side
effects and doubt about its efficacy. About half of the unvaccinated
participants were concerned that WHO over-estimated the disease
occurrence [Table 4].
The influence of age, gender, workplace, work experience,
history of seasonal influenza immunization, and the perceived
severity, risk, threats, benefits, and barriers of the disease and its
vaccine were investigated by multivariable logistic regression. The
factors positively associated with vaccination were feeling of the
vaccine protective, history of receiving seasonal influenza vaccine,
and perceive the disease severe; the factors negatively associated
withbeingvaccinatedwereconcernaboutthevaccineefficacy,fear
of its side effects and the concern that WHO over-estimates the
disease occurrence [Table 5].
4. Discussion
This is the first comprehensive study on pandemic influenza
A/H1N1 vaccination among HCWs conducted in Qatar. The study
revealed a very low uptake for the vaccine among first-line HCWs
in Qatar with only 13.4% have been vaccinated. In comparison with
other studies, this rate was lower than what has been reported in
the United States (34.7%) [8], and slightly lower than the uptake
level in most of countries. For instance studies showed that it was
17% in Greece [20], 16.5% in Spain [21], 15.3% in Germany [22]. On
the other hand, it was higher than in France 10.9% [23]. This rate
even similar to the rate has been reported among publics (17%) in
France [23].
This result comes lower than the expected uptake level among
HCWs that predicted by the preliminary studies on attitudes
and behaviors towards acceptance of A/H1N1 vaccine before it
was licensed, which illustrated that the intention to get vacci-
nated against pandemic A/H1N1 influenza 2009 was generally low
between physicians and nurses. For example in Italy, 29.4% of
females HCWs and 49.2% of male HCWS showed their willingness
toreceiveA/H1N1vaccine[24].WhileinHongKongthewillingness
to be vaccinated among health care workers was 47.9% [25].
Our result showed that vaccine uptake in Qatar is significantly
moreamongHCWsworkingatA&Edepartment,agedover50years,
working for than 15 years. Such finding is not matched with the
Table 3
Reasons cited for being vaccinated/Rejecting A/H1N1 vaccination among healthcare workers, Qatar 2010.
Reasons for being vaccinated Physicians (n=25) Nurses (n=45)
p-Value
Wish to be protected
Being HCW
Afraid of transmitting A/H1N1 to my family
Afraid of transmitting A/H1N1 to my patients
Work place mandate
Have chronic disease
Reasons for rejecting A/H1N1 vaccine
Concerned about side effects
Concerned about vaccine efficacy
Did not want to be vaccinated
Concerned about getting influenza from vaccine
Not afraid of getting A/H1N1infection
Not the right time to be vaccinated
I have limited contact with high risk patients
A/H1N1 vaccine is contraindicated for me
21(95.5%)
15(68.2%)
15(68.2%)
14(63.6%)
7(31.8%)
1(4.5%)
36(85.7%)
31(73.8%)
30(71.4%)
25(59.5%)
20(47.6%)
5(11.9%)
0.297
0.532
0.948
0.581
0.097
0.413
127(72.2%)
75(42.6%)
46(26.1%)
21(11.9%)
31(17.6%)
8(4.5%)
10(5.7%)
2(1.1%)
184(68.7%)
91(34.0%)
78(29.1%)
60(22.4%)
38(14.2%)
25(9.3%)
15(5.6%)
20(7.5%)
0.448
0.065
0.599
0.006
0.307
0.61
0.969
0.003

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2209
Table 4
HCWs perception of influenza A/H1N1 disease and vaccine and vaccination status, Qatar 2010.
StatementsVaccinated (n=70) (%)Unvaccinated (n=453) (%)
p Value
Perceived risk (susceptibility, threats)
I am at risk of getting A/H1N1 infection
I am concerned about getting A/H1N1 infection
I am concerned about getting complications of A/H1N1
Perceived severity of infection
A/H1N1 is potentially a severe disease
A/H1N1 is a fatal disease
My work (career) will be affected when getting A/H1N1
Perceived benefits/barriers to A/H1N1 vaccine
I feel protected if I receive A/H1N1 vaccination
I fear of A/H1N1 vaccine side effects
I doubt about the efficacy of A/H1N1 vaccine
I worry that many of the reports of serious side effects from vaccine are accurate
I am concerned that WHO underestimates the vaccine side effects
I think, receiving both seasonal flu and A/H1N1 vaccine will increase the risk of vaccine side effects
I think vaccination does more harm than good
I will be vaccinated if my doctor, friend/relative are vaccinated
Concerned that WHO over-estimates the disease occurrence
75.7
58.0
55.2
63.8
44.0
53.7
0.033
0.025
0.503
61.2
29.4
38.8
39.4
22.7
40.0
0.001
0.157
0.451
85.3
23.2
14.5
24.0
19.4
19.1
10.3
17.6
33.8
21.6
72.6
53.2
49.5
41.8
31.2
27.0
9.8
52.1
<0.001
<0.001
<0.001
<0.001
0.001
0.023
0.005
0.05
0.002
study from Hong Kong that found younger HCWs and whose work-
ing experience was less than 5 years were more willing to accept
vaccination [25].
As the current study investigated receiving H1N1 vaccine based
ontheexplanationofhealthbeliefmodel,theresultsindicatedthat
who received vaccine were more in perceiving risk of infection and
severity as well as the benefit of the vaccine in protecting them
from infection, which agreed with the previous studies [21], our
resultfoundthatintentionofsubjecttoprotectingthemselvesfrom
illness,andasbeingaHCW,andpreventingtransmittingofA/H1N1
to their families, were identified as the main reasons for receiving
A/H1N1 vaccine.
ThestudyfoundthatvaccinatedHCWsaremoreperceivingthat
A/H1N1 a severe illness but not fatal in comparison with unvacci-
nated HCWs. Moreover vaccinated HCWs perceived more benefits
intermofprotection.Thesefindingagreedwithotherfindingsfrom
Table 5
Factors influencing uptake of pandemic influenza A/H1N1 vaccine among HCWs in
Qatar 2010 (multivariate analysis).
VariablesOR (95% CI)a
p-Value
Age
<30*
30–39
40–49
≥50
A/H1N1is a severe disease
Disagree*
Agree
I feel protected if I receive A/H1N1 vaccination
Disagree*
Agree
I fear of A/H1N1 vaccine side effects
Disagree*
Agree
I doubt about the efficacy of A/H1N1 vaccine
Disagree*
Agree
Concern that WHO over-estimates the disease occurrence
Disagree*
Agree
Received seasonal flu vaccine
No*
Yes
1
0.22 (0.06–0.67)
0.27 (0.08–0.92)
0.51 (0.16–2.07)
0.007
0.034
0.303
1
1.9 (1.13–4.92)
0.022
1 <0.001
14.5 (6.37–33.8)
1
0.3 (0.12–0.74)
0.010
1
0.2 (0.09–0.44)
<0.001
0.45 (.21–0.97) 0.043
1
5.6 (2.2–12.1)
<0.001
aThe odds ratios (OR) and 95% confidence intervals (CI) were estimated using
multivariate logistic regression.
*Reference category. Only the factors with a p value of <0.05 are shown.
researchers have identified the history of seasonal influenza vacci-
nation and perceived likelihood of being infected as the strongest
predictors to accept A/H1N1 vaccine [25], and it is clearly consis-
tent with concept of health belief model as perceiving seriousness
of the H1N1 considered as a major element in decision process for
up-takingimmunization,howeveritshouldinteractwithotherele-
mentsespeciallyperceivedsusceptibilityfromgettingtheinfection
and the benefit from vaccine [26].
Although the current study found that up-taking seasonal
flu vaccine was considered as a positive predictor for up-taking
A/H1N1 vaccine as the uptake of A/H1N1 vaccination was higher
among who received the seasonal vaccine compared to who did
not receive (21.5% vs. 4.2%), this rate was very low in comparison
to the efforts to vaccine all HCWs in Qatar with seasonal flu since
2008 through dedicated campaigns.
Moreover, the advance analysis has showed that those who
received A/H1N1 vaccine are 6 times more likely received sea-
sonal flu vaccine. Such finding agreed with the findings from
previous researches, which considered history of receiving sea-
sonal influenza vaccine as positive predictor for receiving A/H1N1
vaccine [25]. For example, a French study has showed that GPs
receiving seasonal vaccines every year were four times more likely
to accept A/H1N1 pandemic vaccination than those who were
never vaccinated in the prior 3 years [23]. Also an Australian study
has determined that annual influenza recipients were significantly
more likely to accept the pandemic A/H1N1 2009 influenza vaccine
compared to their unvaccinated counterparts, as many likened the
A/H1N1 influenza strain to being a non-serious strain of influenza
[27]. However, studies showed that HCWs still perceived that the
pandemic vaccine to be less safe than the seasonal flu vaccine [28].
On the other hand, Health Belief Model used in this study illus-
tratedthemainbarriersthataffecttheirvaccineuptake.Fearsabout
vaccine adverse reactions and its efficacy was the main reason for
rejecting the vaccine. Such fears were reported by different studies
inGreece[20].Thisfindingismatchedwithprevioussurveys,which
have identified fear of side effects and doubts about the efficacy of
the A/H1N1 vaccine in comparison to the seasonal flu vaccine as
major barriers to receive A/H1N1 vaccine [21,25].
Lack of data on safety and efficacy was the reason for health
workers’ unwillingness as well as public to take up vaccination
[21,25]. It is well known from public health perspective that these
concernsareusuallyassociatedwithaboutusingnewvaccinesdur-
ingapandemicwithemergingpublichealththreat[17].However,it
was documented that such concern on side effect was not detected

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as recent reports form found that the safety profile of A/H1N1 vac-
cine is similar to that for seasonal influenza vaccines, which have
an excellent safety record [29].
Concerns on safety can be tackled by education campaigns that
address how mild the common side effects are and that more
severe adverse effects are extremely rare in comparison with ben-
efits of A/H1N1 vaccine for healthcare workers such as the 85–90%
effectiveness in preventing influenza and reduce absenteeism of
HCWs which will allow health care systems to continue running
at proper levels during epidemics [7]. Such campaign before vac-
cination take place can play an important role in altering vaccine
acceptance behavior among health care workers through reduc-
ing fear and reassuring individuals if the contents of educational
messagetailoredonHealthBeliefModelconcept[30,31].Suchedu-
cational campaign before the vaccination campaign was missed in
Qatar as it was not tailored on any behavioral change theories, and
started simultaneously with vaccination launching which did not
give enough time to decide to take the vaccine or not.
More interestingly, more than half of HCWs who refused vac-
cine thought that WHO over-estimates the disease occurrence,
declared an influenza A/H1N1 pandemic very quickly in mid of
2009.
Moreover, HCWs play major role in advising public to uptake
the vaccine, as given the fact that it has been found that most of
patients showed higher rates of compliance for physician recom-
mended vaccination, than for government recommendation [27].
Such low uptake of A/H1N1 vaccine in Qatar may indicates indi-
rectly the low uptake among public, especially that there is no
information available about vaccine coverage among public.
Inconclusion,thecoveragerateofA/H1N1vaccineamongHCWs
in Qatar was very low with significant difference between ages,
perceived seriousness of infection, and perceived benefits of vac-
cine. The most common barriers were uncertain about vaccine
efficacy and fear of side effects. Health authorities should build
their message on highlighting how the benefit of vaccination in
protection of community outweighs the associated side effect .The
findings of this study are subject to certain limitations. All results
arebasedonself-reportedinformationtherefore,findingsmightbe
over-estimated. However we are convinced of the validity of the
self-report answers, since it is unlikely that participants spent time
giving unreliable and biased views of their attitudes and behaviors
as well as anonymity of the survey. Despite that, our survey covers
almostallprimarycareandemergencycareprovidersinthestateof
Qatar,andfocusedonthosewhodealwithA/H1N1suspectedcases
this might add strength. In addition, our survey could be a useful
toolforQataridecisionmakerstopromoteprogramandcampaigns
aimed at informing and educating HCW. The results could also be
used to motivate HCW to adopt attitudes and decisions which cor-
respondtopublichealthpolicies.Finally,thisstudycouldalsoassist
in building up tailored message on highlighting how the benefit of
vaccination outweighs the associate side effects.
Acknowledgements
Wethanktheparticipants;datacollectorsfortheirparticipation
and support in data collection.
Funding support: The funding of this study was received from
research committee at Hamad Medical Corporation, state of Qatar.
Howeverithadnoroleinstudydesign;datacollection,analysis,and
interpretation, the writing of the paper, or the decision to submit
this paper for publication.
Competing interest: None declared.
Ethical approval: Approval of Ethics Committee of IRB at Hamad
Medical Corporation, State of Qatar and waiver of consent was
obtained from all participants before study entry.
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