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Drugs - Real World Outcomes
https://doi.org/10.1007/s40801-025-00483-0
ORIGINAL RESEARCH ARTICLE
Influenza Vaccination Among Patients withNoncommunicable
Diseases: ASurvey About Awareness, Usage, andUnmet Needs
intheCzech Republic
ZdeněkZadražil1· LenkaCesneková2· JanKynčl3,4· ZuzanaKrištúfková5· LauraColombo6· SanjayHadigal7
Accepted: 27 January 2025
© The Author(s) 2025
Abstract
Background People with noncommunicable diseases (NCDs) are at a higher risk of contracting vaccine-preventable diseases,
such as influenza, with a higher likelihood of severity and complications. However, the immunization rates for the influenza
vaccine among this population in the Czech Republic are very low.
Objective This survey, among adults with NCDs in the Czech Republic, assessed the knowledge, attitudes, and gaps toward
vaccination in general and influenza vaccination in particular.
Methods The survey was conducted between February 2023 and March 2023 among patients with NCDs in the Czech
Republic. A structured web-based questionnaire with open-ended questions was administered. This study is a preplanned
subgroup ancillary analysis of a previous multicentric study conducted on 1106 patients.
Results In all, 120 patients were enrolled, with 62% (74) aged between 41 and 60 years. Approximately 30% (36) had taken
the influenza vaccine in the last 2 years and 70% (84) had not. Of the total sample, only 46% (55) had a positive opinion
about influenza vaccines; this increased to 91% (33) among those vaccinated against the influenza virus. The main drivers of
influenza vaccination were general physician (GP) recommendation [50% (18)] and patient initiative [47% (17)]. The main
barriers to the influenza vaccine were lack of belief regarding its need [52% (44)], experience of mild severity of influenza
[30% (25)], and lack of GP recommendation [25% (21)]. Physicians, dedicated websites, and family members are the most
common sources of information regarding influenza. Even among those vaccinated for influenza, only 17% (6) had informa-
tion about the risk of not taking the vaccine. A high level of dissatisfaction with the information was found among patients
not vaccinated against influenza. People wanted more information on who should not receive the influenza vaccination.
Unvaccinated patients sought information on side effects and efficacy. Only 40% (48) of the respondents said that they are
likely/extremely likely to take an influenza vaccination in the future.
Conclusions Healthcare practitioners are the key influencers for people to get vaccinated. The dissemination of information
about the importance of influenza vaccines for people with NCDs needs to be increased in the Czech Republic.
1 Introduction
The global annual mortality due to noncommunicable
diseases (NCDs) is 41 million, accounting for 74% of all
deaths. The leading causes among these are cardiovascu-
lar diseases (CVD) (17.9 million), cancers (9.3 million),
chronic respiratory diseases (4.1 million), and diabetes (2.0
million) [1]. People with NCDs are at a higher risk of con-
tracting vaccine-preventable diseases (VPDs) with a higher
likelihood of severity and complications [2]. VPDs such as
influenza significantly increase the risk of cardiovascular,
* Zdeněk Zadražil
zdenek.zadrazil@viatris.com
1 Medical Department, Viatris, Prague, CzechRepublic
2 Medical Department, Viatris, Bratislava, Slovakia
3 Department ofInfectious Diseases Epidemiology, National
Institute ofPublic Health, Prague, CzechRepublic
4 Department ofEpidemiology andBiostatistics, Third Faculty
ofMedicine, Charles University, Prague, CzechRepublic
5 Department ofEpidemiology, Faculty ofPublic Health,
Slovak Medical University, Bratislava, Slovakia
6 Global Medical Affairs, Viatris, Monza, Italy
7 Global Medical Affairs, Viatris, Bengaluru, India
Z.Zadražil et al.
Key Points for Decision‑Makers
More than two thirds of adults with noncommunicable
diseases, such as diabetes, cardiac disease, pulmonary
diseases, etc., in the Czech Republic believe that they do
not need the influenza vaccine as it is a mild disease.
General practitioners seem to have a good influence in
convincing people to take the influenza vaccine and are a
trusted source of information for the people.
Hence, general practitioners need to be involved in
educating people about the need for taking vaccines and
the risk of not taking the influenza vaccine among adults
with noncommunicable diseases in the Czech Republic.
Professional medical associations can take the lead by
conducting opinion polls among doctors about their
belief in vaccines. The results of such polls can be used
in campaigns and media reports to tackle vaccine hesi-
tancy among people.
In addition, influenza vaccines can be provided at phar-
macies and pharmacists can be encouraged to dissemi-
nate information about the need for this vaccine as they
are also a trusted source of information.
cerebrovascular, neurological, and renal complications fol-
lowing the acute illness. Moreover, patients with NCDs
hospitalized for VPDs such as influenza and coronavi-
rus disease-2019 (COVID-19) have poorer outcomes and
longer hospital stay [3]. Globally, seasonal influenza causes
severe illness in 3–5 million people and is responsible for
290,000–650,000 respiratory deaths [4, 5]. People with
chronic conditions such as diabetes, CVD, and chronic lung
disease are particularly at high risk [5, 6]. Respiratory infec-
tions associated with influenza lead to a six times higher risk
of myocardial infarction within a week [6] and are responsi-
ble for 50% of exacerbations of heart failure [7]. In patients
with acute myocardial infarction (MI) there is a twofold
higher likelihood of having suffered from a recent episode of
influenza or any other respiratory tract infection [8]. Stroke
is more common in the cold season and during influenza
epidemics. This could be partly owing to seasonal changes
in metabolic risk factors or cold-induced vascular stress [9].
Vaccination is an effective preventive measure for VPDs,
particularly in people with NCDs. Studies have shown that
vaccines reduce the incidence and burden of VPDs in adults
(particularly those with NCDs) [2]. A systematic review
showed that mortality due to CVD was significantly reduced
in patients who received the influenza vaccine [10]. Patients
with chronic obstructive pulmonary disease (COPD) who
were vaccinated for influenza had significantly fewer acute
exacerbations [11]. In patients with diabetes, influenza vac-
cination also significantly reduced the risk of all-cause mor-
tality, especially in people aged ≥ 65 years [12]. In 2003, the
World Health Organization (WHO) advised Member States
to increase influenza vaccination coverage among high-risk
people and target a ≥ 75% coverage among the elderly and
those with chronic illnesses by 2010 [13]. However, these
goals are far from being achieved [2].
In the Czech Republic (CZ), NCDs are responsible for
90% of deaths. CVD, chronic respiratory disease, and dia-
betes cause 44%, 4%, and 4% of all deaths, respectively.
[14]. Almost 34% of the population has hypertension, 10%
has diabetes, and about 29% has obesity [15]. Approxi-
mately 25% of the Czech population report having two or
more chronic conditions [16]. Between 2009 and 2019, the
prevalence of ischemic heart disease increased by 10.8%
[17]. Approximately 26% of the population is aged > 60
years and this proportion is expected to increase to 35.5%
by 2050 [14]. Among people aged 30–70 years, the risk of
premature death from NCDs is 15% [15, 16]
The CZ government recommends seasonal influenza vac-
cination to reduce morbidity and mortality related to VPDs.
The vaccine is free for people at high risk (those aged > 65
years and patients with chronic conditions). Nevertheless,
the immunization rates are very low. In 2019, only 23% of
people aged > 65 years took the influenza vaccine [com-
pared with a European Union (EU) average of 42%] [16].
During the 2012–2013 severe influenza season in the CZ,
the major risk factors among the 51 fatal cases were obe-
sity, smoking, and chronic cardiovascular, respiratory, or
hematological illnesses. Of the 51 patients who died, only
7 were vaccinated against influenza [18]. In a 2013–2014
survey about the uptake of influenza vaccination in the EU,
the average uptake for the whole group/diabetic group/non-
diabetic group in the EU was 24.7%, 41.0%, and 22.5%,
respectively. However, these proportions were low in the CZ
and Slovakia at 12.4%, 17.0%, and 11.6% and 13.0%, 16.7%,
and 8.9%, respectively [19]. There could be several reasons
for low vaccine uptake among adults. Hence, we conducted
this survey focusing on patients with NCDs in the CZ to
assess the knowledge, attitude, and gaps toward vaccination
in general and influenza vaccination in particular. This paper
describes a preplanned subgroup ancillary analysis, derived
from a prior multicentric study of 1106 patients, to further
investigate a specific subpopulation of the Czech Republic
and expand upon the original findings.
Influenza Vaccination Survey in the Czech Republic
2 Methods
This was a multi-country online survey conducted between
February 2023 and March 2023 among patients suffering
from NCDs. The countries included in the survey were
France, Italy, Spain, Germany, Poland, Belgium, Portugal,
and the Czech Republic. The detailed study design and
methodology have been published previously [20]. Briefly,
patients were recruited from a nationally representative
population panel of each country, which was augmented by
carefully selected and vetted supplemental permission-based
sample sources. Patients were contacted online via a third-
party company accountable for the field research.
Patients were included according to the following criteria:
(A) presence of at least one of the following NCDs in the
last 12 months: chronic asthma, COPD, type 1 or type 2
diabetes, hypertension, cancer, or cardiovascular diseases;
(B) vaccination against the flu between January 2021 and
December 2022 (vaccinated group) or no vaccination against
the flu in the last 2 years (unvaccinated group). Considering
the low vaccination rates in the CZ, the sample recruitment
was planned to include ∼ 80% of people aged ≤ 60 years
and ∼ 20% of people aged > 60 years.
A sample size of 120 patients was planned from each
of the smaller countries, such as the Czech Republic. To
ensure that both the vaccinated and unvaccinated popula-
tions were well represented, the proportion of people vac-
cinated and unvaccinated against influenza in the last 2 years
was defined on the basis of the influenza vaccination cover-
age in the NCD group in each country. Since the CZ has
low influenza vaccination coverage [21], approximately 30%
of vaccinated subjects were planned to be recruited. There
was no prespecified proportion of the type of NCD patients
to be recruited. No quota was placed on gender, assuming
natural fallout. No weighting was applied to the age groups
or vaccination status to allow for a robust sample base for
the specific subgroups for further analysis
All participants provided informed consent in accordance
with the Declaration of Helsinki. Before answering the ques-
tionnaire, each participant received information explaining
the objective of the survey, how data would be handled, and
how the results would be used. To proceed with responses
to the questionnaire, participants had to provide consent or
else they were not allowed to take the survey.
The primary objective of the survey was to capture the
opinions of patients suffering from chronic NCDs regarding
influenza and influenza vaccination. In particular, the follow-
ing topics were explored:
• Understand what patients with NCDs think of influenza
vaccines, their reasons for getting vaccinated, and their
experience with the vaccine and influenza.
• Measure the level of awareness of the benefits of getting
an influenza vaccine and awareness of flu-related risks
and complications.
• Understand the different sources of information on influ-
enza vaccines that patients with NCDs are exposed to and
reveal any unmet needs.
A structured web-based questionnaire with closed-ended
questions was administered to subjects included in the sur-
vey. Certified translators translated the questionnaire to the
local language. The data were collected by third parties
and shared in an aggregated way with the study sponsor,
maintaining patient confidentiality according to the appli-
cable laws. The study was conducted in line with the mar-
ket research definition and in accordance with the European
Pharmaceutical Market Research Association (EPHMRA)
and British Healthcare Business Intelligence Association
(BHBIA) market research codes of conduct (https:// www.
ephmra. org/ sites/ defau lt/ files/ 202409/ 2024% 20EPH MRA%
20Code% 20of% 20Con duct% 20Fin al. pdf) [22]. Its only pur-
pose was to capture the opinion of the participants, and no
clinical parameter, efficacy, or safety endpoints related to any
treatment were investigated. Hence, in line with the guid-
ance provided by the EPHMRA, British Healthcare Busi-
ness Intelligence Association (BHIBIA), and the National
Health Service Health Research Authority (NHS HRA), the
research did not qualify as a clinical study, and Research
Ethics Committee review and approval were not required.
All methods were carried out following the relevant guide-
lines and regulations.
2.1 Questionnaire
The first part of the questionnaire comprised demographic
variables such as age, sex, country of residence, highest level
of education, employment status, income level, marital sta-
tus, number of people in the household, and diagnosed con-
ditions amongst the main NCDs.
The second part consisted of questions regarding the
following:
• Influenza vaccination status in the last 2 years (vacci-
nated in the last 2 years → vaccinated group; not vac-
cinated in the last 2 years → unvaccinated group).
• Vaccinations taken for other diseases in the last 2 years,
general perception and experience with vaccines, reasons
for taking/not taking the vaccines, sources of information
about vaccines, and satisfaction levels with the informa-
tion received.
• Reasons for getting/not getting vaccinated for influenza.
• General perception and experience with the influenza
vaccine.
Z.Zadražil et al.
• Level of awareness about flu-related risks.
• Patients’ direct experience with influenza and its impact
on their health.
• Level of awareness about the benefits of getting an influ-
enza vaccination.
• Intention to get vaccinated in the future and why/why not.
• What channel types and from which specific channels do
they prefer to obtain information.
• Willingness to receive further information.
2.2 Statistical Analysis
The responses to the questions are presented as frequencies
and percentages. All data from the quantitative survey were
analyzed through descriptive statistics such as distribution,
frequency count, and percentages. Comparative analyses
were conducted between sample subgroups (e.g., vaccinated
versus nonvaccinated and between countries) using t tests
to highlight statistically significant differences. Significance
was tested at 90% and 95% confidence interval (CI). Data
showing statistical significance differences at a 95% CI were
highlighted and reported. The analyses were also conducted
on the total sample as well as subgroups of subjects vacci-
nated and unvaccinated against influenza.
3 Results
The survey enrolled 1106 adult participants overall, of which
120 were from the CZ. Of these participants, 48% (58) were
male patients. The majority [62% (74)] were between 41 and
60 years of age. The most common NCDs were hypertension
[62% (74)], type 2 diabetes mellitus [28% (37)], and asthma
[24% (29)]. About 30% (36) had taken the influenza (flu)
Table 1 Baseline characteristics
of subjects included in the
survey
Note that all percentages reported in the results are calculated on the basis of the number of patients in the
respective cohorts as follows: total sample—1106 individuals, including 507 vaccinated against influenza
and 599 unvaccinated
Total Czech
Respondents 1106 120
Male 48% (531) 48% (58)
Female 52% (575) 52% (62)
18–40 years 22% (243) 18% (22)
41–60 years 61% (674) 62% (74)
≥ 61 years 17% (188) 20% (24)
Vaccinated against the influenza within the last 2 years 46% (507) 30% (36)
Never been vaccinated against the flu 54% (599) 70% (84)
Hypertension 58% (642) 62% (74)
Type 2 diabetes 24% (266) 28% (34)
Chronic asthma 21% (232) 24% (29)
Cardiovascular disease (CVD) 10% (111) 10% (12)
Type 1 diabetes 7% (78) 6% (7)
Chronic obstructive pulmonary disease (COPD) 7% (78) 5% (6)
Cancer 6% (66) 5% (6)
Fig. 1 Vaccinations received in the last 2 years. The dotted boxes
indicate that the differences between the groups were significant
Influenza Vaccination Survey in the Czech Republic
vaccine in the last 2 years. The baseline characteristics of
the subjects are presented in Table1.
For the Czech Republic subset, the sample included
120 individuals, of whom 36 were vaccinated and 84 were
unvaccinated
3.1 Attitude About Vaccinations inGeneral
In the total sample, about 98% of the subjects vaccinated for
influenza had also taken other vaccines in the last 2 years;
this proportion was 100% in the CZ. The most common vac-
cine taken was the COVID-19 vaccine. However, among
those unvaccinated for influenza, the proportion that had
taken any other vaccines in the last 2 years was 80% in the
overall sample and 76% in the CZ.
The vaccination rates for individual diseases in the overall
sample ranged between 2 and 27%, except for coronavirus
disease-2019 (COVID-19) (83%). These rates were 0%,
37%, and 73%, respectively, in the CZ (Fig.1).
Overall, while 74% of people had a positive opinion about
vaccinations, this rate was only 67% in the CZ. However,
those unvaccinated for influenza, in general, had a less posi-
tive opinion than the vaccinated group. In the CZ, the dif-
ference in the proportion of people with positive opinions
among those vaccinated and unvaccinated for influenza was
very large, being 97% versus 53% (Fig.2).
Among those who took at least one vaccine in the last
2 years, excluding COVID-19 and/or influenza, the main
reasons for getting vaccinated were disease prevention and
doctor recommendations (Fig.3).
Fig. 2 General opinion about vaccinations. The dotted boxes indicate that the differences between the groups were significant
Fig. 3 Reasons for receiving at least one vaccine in the last 2 years
(excluding COVID-19 and influenza vaccines only)
Z.Zadražil et al.
3.2 Availability ofInformation onVaccines
inGeneral
Among patients who received at least one vaccine in the
last 2 years, protection against infection and the risks of
not getting vaccinated were the most common information
about vaccines received, followed by information about
possible side effects, duration of protection, and the need for
a booster dose. Most patients had clarity about the informa-
tion received. However, in the CZ, the main messages were
protection against infection, the duration of protection, and a
reduction in hospitalization and mortality owing to vaccines.
There was less focus on the information about the risks of
not getting vaccinated, as well as the side effects of vaccines,
and there was less clarity about these messages (Fig.4).
However, compared with the overall sample, there was less
clarity about some of the information received among people
in the CZ, e.g., clarity about risks of not taking the vaccina-
tion was reported by 86% of the overall cohort versus 67%
in the CZ cohort. Similarly, clarity about the possible side
effects of the vaccine was reported by 78% of the total cohort
versus 63% of CZ subjects.
3.3 Attitude Toward Vaccination Against Influenza
andInformation About Influenza Vaccine
Overall, about 60% of subjects had a positive opinion about
influenza vaccines. However, the percentage was low in the
CZ (46%). The CZ also had a high percentage of negative
opinion (20%). Notably, 91% of those vaccinated against
influenza had a strong positive opinion of influenza vaccines,
while a high proportion of those unvaccinated were mostly
indifferent about the vaccine (46%) (Fig.5).
In the vaccinated group within the total sample, key driv-
ers for taking the influenza vaccination were recommenda-
tions by general physicians (GPs) (61% overall), patient
initiative (31% overall), and the presence of underlying con-
ditions that make it necessary to be protected against influ-
enza (18%). In the CZ as well, the main drivers of influenza
Fig. 4 Information received about vaccines
Fig. 5 General opinion about influenza vaccinations. The dotted boxes indicate that the differences between the groups were significant, asterisks
show significant differences between vaccinated and unvaccinated subgroups
Influenza Vaccination Survey in the Czech Republic
vaccination were recommendations by GPs and patient
initiative; the percentages were 50% and 47%, respectively
(Fig.6). In the unvaccinated group within the total sample,
lack of belief in the need for an influenza vaccine (40%),
the treating GP not recommending it (39%), and experience
of mild severity of influenza (30%) were the main and most
important barriers in getting vaccinated against influenza. In
the CZ, the main reasons for not taking the influenza vac-
cine were lack of belief in the need for an influenza vaccine
(52%), experience of mild severity of influenza (30%), and
the treating GP not recommending it (25%) (Fig.6).
Overall, the physician remained the most preferred and
tapped resource for information on influenza vaccines, fol-
lowed by dedicated websites. In the CZ, physicians, dedi-
cated websites, and family members were the most common
sources when looking for information on influenza, though
the former two were highly preferred. Among those vacci-
nated for the influenza within the total sample, 84% received
information from their physician versus only 47% among
those unvaccinated against influenza. These proportions
were 81% and 44% in the CZ.
Patients primarily received/looked for information
on efficacy, side effects, duration of protection, impact
on symptoms, and the risks of not taking the vaccine.
However, in the CZ only 10% of patients received/looked
for information on the risk of not taking the vaccine versus
26% in the total sample. Even among those who received
this information, only 58% of respondents reported that
it was clear versus 85% in the total sample (Fig.7). Even
among those vaccinated for influenza in the CZ, only 17%
had information about the risk of not taking the vaccine.
There was good clarity about the information received
(Fig.7).
The largest proportion of the unvaccinated patients
did not receive/look for information on influenza vac-
cines (36% overall and 35% in the CZ). Moreover, there
was only moderate clarity about the information received
(Fig.7).
A high level of dissatisfaction with the information
among patients not vaccinated against influenza was seen
in the CZ, at 79%. However, those vaccinated had a high
level of satisfaction with the information (Fig.8).
Overall, additional information that the patients would
like to receive on influenza vaccination is about side
effects (49%), efficacy (42%), and the health complica-
tions and risks of influenza (38%). In the CZ, a signifi-
cantly higher proportion of respondents compared with
the total sample would like to receive information on who
Fig. 6 Reasons for taking and not taking the influenza vaccine
Z.Zadražil et al.
should not receive the influenza vaccination. Unvaccinated
patients sought information on side effects and efficacy
(Fig.9).
Almost all patients with NCDs state that they are
aware of influenza vaccine benefits, with reduced symp-
tom severity and the risk of hospitalization being the most
known. However, awareness of the vaccine limiting the
spread of the influenza virus was not widely known among
the unvaccinated population (Table2). Nevertheless, 60%
of those who were vaccinated sought more information
about the influenza vaccine versus 48% among the unvac-
cinated group in the CZ.
3.4 Awareness ofFlu‑Related Complications
Understanding of flu-related complications is particularly
widespread among patients who receive vaccines (Fig.10).
More than 50% of vaccinated as well as unvaccinated
patients in the CZ were interested in knowing more about
the complications of influenza.
Fig. 8 Level of satisfaction with the information on influenza vaccination among patients. The dotted boxes indicate that the differences between
the groups were significant, asterisks show significant differences between vaccinated and unvaccinated subgroups
Fig. 7 Information received or looked for regarding influenza vaccinations. The dotted box indicates that the differences between the groups
were significant, asterisks show significant differences between vaccinated and unvaccinated subgroups
Influenza Vaccination Survey in the Czech Republic
3.5 Experience ofSuffering fromInfluenza
intheLast 2 Years
Over one in three patients with a NCD in the overall sam-
ple, as well as in the CZ, reported that they suffered from
symptoms of influenza in the past 2 years. Nevertheless,
the diagnosis was not confirmed through a laboratory test.
Among these patients, about 56% in the total sample and
44% in the CZ reported not suffering from any complications
due to influenza. The health of 20% of the patients in the CZ
experiencing complications was severely affected, leading to
hospitalization in half of the cases.
3.6 Likelihood ofGetting Vaccinated forInfluenza
intheFuture
Overall, 60% (664) of the respondents said that they are
likely/extremely likely to take an influenza vaccination in
the future; however, in the CZ, the proportion was only 40%
(48). Among the vaccinated group, 92% of respondents
in the overall sample and in the CZ sample said that they
are likely/extremely likely to take an influenza vaccine in
the future. In the unvaccinated group, while only 32% of
respondents in the overall sample said that they are likely/
extremely likely to take an influenza vaccine in the future,
the proportion was only 16% in the CZ (Fig.11).
The main drivers for getting vaccinated in the future are
physician recommendation and belief in the efficacy of influ-
enza vaccines.
Fig. 9 Further information sought regarding the influenza vaccine. The dotted box indicates that the differences between the groups were signifi-
cant, asterisks show significant differences between vaccinated and unvaccinated subgroups
Table 2 Awareness of the benefits of influenza vaccines
Awareness of flu vaccination benefits Total sample Vaccinated subgroup Unvaccinated sub-
group
Total CZ Total CZ Total CZ
The vaccination can reduce the severity of symptoms even if I still get sick
afterwards
78% (863) 82% (98) 80% (406) 78% (28) 77% (461) 84% (71)
The vaccination will reduce the risk of flu-related hospitalizations which
may/ may not be related to an underlying health condition
63% (697) 71% (85) 70% (355) 75% (27) 56% (335) 69% (58)
The vaccination will help prevent me from catching the flu 57% (631) 62% (74) 67% (340) 94% (34) 47% (282) 46% (39)
The vaccination will help protect those around me who are more vulner-
able to getting sick
53% (586) 46% (55) 60% (304) 72% (26) 47% (282) 33% (28)
The vaccination can reduce the risk of having a heart attack 20% (221) 30% (36) 25% (127) 41% (15) 16% (96) 25% (21)
None 3% (33) 2% (2) 6% (36) 3% (3)
Z.Zadražil et al.
In the CZ, the major reason for the reluctance to take
the vaccine in the future is the belief that a vaccine is not
needed because the patient is not prone to getting influenza,
followed by a lack of belief in its efficacy.
4 Discussion
Our survey showed that, in general, the vaccination uptake
in the CZ was lower than that in other EU countries. The
Fig. 10 Understanding of influenza-related complications, asterisks show significant differences between vaccinated and unvaccinated subgroups
Fig. 11 Likelihood of taking influenza vaccine in the future, asterisks show significant differences between vaccinated and unvaccinated sub-
groups
Influenza Vaccination Survey in the Czech Republic
general positive perception of vaccines in the CZ was also
lower than that in other EU countries; this difference was
higher in the unvaccinated group.
Previous studies have shown a general reluctance of
people in the CZ to get vaccinated. In a study conducted
during the COVID-19 pandemic, the acceptance rate of the
COVID-19 vaccine in CZ was around 65%, which was lower
than in most EU countries [23]. In a nationally representa-
tive survey, most respondents (90%) misjudged the doctors’
positive opinions of the COVID-19 vaccine. Most people
believed that only 50% of doctors trusted the vaccines.
However, in the same survey, about 90% of 9650 doctors
reported that they trust the vaccines. This clearly showed a
misperception among the people about the doctors’ trust in
the vaccine [23]. Kassianos etal. explored the acceptance
of the influenza vaccine among healthcare workers (mainly
general practitioners, specialist physicians, and nurses) and
if they would advocate it to others in six European countries,
including Bulgaria, the Czech Republic, Kosovo, Poland,
Romania, and the UK [24]. They found that vaccine accept-
ance was generally good in all countries, with a minority of
healthcare workers hesitant to take the vaccine. In the Czech
Republic, Poland, and the UK > 75% of healthcare workers
were inclined to take the influenza vaccination and had been
vaccinated against influenza in the past. In the Czech Repub-
lic, > 75% of healthcare workers were likely to recommend
influenza vaccination [24]. These results possibly indicate
a general reluctance toward the influenza vaccine despite
doctors’ advocacy for the vaccine in the Czech Republic.
A study published in 2013 reported an increasing trend of
routine vaccination refusal for their children among parents
compared with the situation in 2004 (p < 0.001). The most
important factors associated with this trend were distrust
of vaccination, fear of some vaccine components, and fear
of adverse reactions. Parents who agreed with vaccination
usually relied on specialists’ recommendations [25]. A 2022
study among healthcare workers in the CZ during the human
monkeypox virus (HMPXV) outbreak found that only 8.8%
of the participants agreed to receive vaccination against
HMPXV owing to several misconceptions. Scientific jour-
nals (5.6%), the European Centre for Disease Prevention and
Control (5%), and the US Centers for Disease Control and
Prevention (1.5%) were the least common sources used by
them to search for factual information [26].
In 2018, the European Commission published the first
“State of Vaccine Confidence in the EU” report. The report
used the vaccine confidence index survey tool to examine
levels of public confidence in immunization across the 27
EU Member States. The overall confidence in the impor-
tance, safety, effectiveness, and compatibility with beliefs for
vaccines was on the lower side in countries such as the CZ,
Estonia, Malta, and Bulgaria and was lowest in Slovakia and
Latvia [27]. Based on data from health insurance companies,
the overall vaccination coverage among Slovakian residents
in the 2021/22 season was 4.9%, and in those aged > 60
years, it was 12.%. The highest proportion of NCDs was
attributed to diabetes, and in this population, the vaccina-
tion coverage was 14.0%. The second largest group among
those with NCDs were patients with COPD, with a vaccina-
tion rate of 14.3%. Patients with oncological diseases had a
vaccination rate of 11.6%. The highest vaccination rate was
seen in persons with dementia, at 28.9% [28].
In the Seasonal Influenza Vaccination in Europe report
2007–2008 to 2014–2015, the influenza vaccination cover-
age rates among people with chronic diseases were lowest
in the CZ and there were no data available for coverage
among healthcare workers [29]. Among the leading rea-
sons for general vaccine hesitancy according to the EU
“Vaccination and Patients with Chronic Conditions” report
were vaccine safety concerns, risk–benefit gap, and lack of
knowledge of vaccination and its importance, besides reli-
gious and cultural issues [30]. In our survey in the CZ, the
main reasons for getting vaccinated were disease preven-
tion and healthcare practitioner (HCP) recommendations.
Compared with other EU countries, there was less focus
on the dissemination of information about the risks of not
getting vaccinated as well as the side effects of vaccines.
Lack of adequate information about the risks of not getting
vaccinated could be one of the reasons for the low uptake
of vaccines. This is further corroborated by the high level
of dissatisfaction with the information among patients not
vaccinated against influenza in the CZ (79%). However,
those who were vaccinated had a high level of satisfaction
with the information.
The main drivers of influenza vaccination in the CZ were
recommendations by GPs and patient initiative. There was a
very low influence of specialist recommendations to take the
influenza vaccine. The main reasons for not taking the influ-
enza vaccine were lack of belief in the need for an influenza
vaccine, the treating GP not recommending it, and experi-
encing mild severity of influenza. The overall positive opin-
ion about influenza vaccines among those not vaccinated
for influenza was lower in the CZ compared with other EU
countries in our survey. There was a general indifference to
the influenza vaccine in this population. According to the
report “Vaccination and Patients with Chronic Conditions”
by the European Patients’ Forum 2018, none of the EU coun-
tries achieved the target of 75% coverage for the influenza
vaccine. According to the report, there may be a general
perception that diseases being prevented by vaccination are
“not so dangerous” and will not cause major harm [30]. In a
previous survey among medical students in the CZ follow-
ing the influenza A (H1N1) 2009 pandemic, the proportion
of students regularly vaccinated against seasonal influenza
was low (4%). Students rated the risk of H1N1 as relatively
low and there was no increase in interest in vaccination even
Z.Zadražil et al.
during the influenza pandemic; only 5% expressed interest
in getting vaccinated. In fact, approximately two thirds of
vaccine doses bought by the CZ were intended for chroni-
cally ill people, pregnant women, health professionals, and
state authorities. However, these groups were not interested
in vaccination and this stock was provided on a free basis to
the general population [31]. Data from the Eurostat-Euro-
pean Health Interview Survey (EUROSTAT- EHIS, 2017)
showed that the CZ had among the highest percentages of
individuals never vaccinated against influenza, at 79%, and
the vaccination coverage was 5.4% in the 65 years and older
age group [32]. In 2021, there was a planned import of only
1,080,000 influenza vaccine doses, which were adequate to
cover only 10.1% of adults [33].
Physicians, dedicated websites, and family members are
the most common sources when looking for information on
influenza. Only 10% of patients in the CZ received/looked
for information on the risk of not taking the vaccine versus
26% in the total sample. Even among those who received
this information, only 58% of respondents in the CZ reported
that it was clear versus 85% in the total sample of all eight
countries. Among those vaccinated for influenza in the CZ,
only 17% had information about the risk of not taking the
vaccine versus 37% in the total sample. This indicates a
major gap in the dissemination of information about the risk
of not taking the vaccine. According to the EU “Vaccination
and Patients with Chronic Conditions” report, patients with
chronic diseases may not find specific information easily or
from their regular sources [30]. On the basis of patient inter-
views, the report stated that the relationship of the patient
with the doctor, whether the doctor proactively shares infor-
mation, and the healthcare professional’s belief in the vac-
cine can affect vaccination uptake by the patient [30].
In the unvaccinated group, in our survey, only 16% said
that they are likely/extremely likely to take an influenza
vaccine in the future [30]. On the basis of the results of
the survey and the above review of literature, we recom-
mend the following actions to increase seasonal influenza
vaccination uptake in the CZ. More efforts are necessary
for the dissemination of information regarding the influenza
vaccine, particularly, its benefits, the risks of not taking the
vaccine, and its safety. The dissemination of information
needs to be driven by the government. As stated in the EU
“Vaccination and Patients with Chronic Conditions” report,
healthcare professionals, including nurses, medical doctors,
dentists, and pharmacists, are key providers of information
and are the key messengers for recommending vaccination,
being trusted by patients [30]. A major barrier to vaccina-
tion could be inadequate information provided by health-
care professionals and/or lack of assertiveness by them.
This lack of assertiveness might be perceived by patients as
“vaccines are not needed.” Hence, the government should
encourage doctors to recommend patients with NCDs to take
the influenza vaccine. Healthcare professionals need to be
trained to ensure that vaccination is included in the treat-
ment of chronic diseases, and they should discuss it with
patients during consultation. There is also a need to involve
specialists in disseminating information about the risks of
not taking the influenza vaccine among people with NCDs.
Specialists should receive training and information on the
importance of vaccination for people with NCDs and include
it in the treatment plan [30]. Professional medical associa-
tions can take the lead by conducting opinion polls among
doctors about their belief in vaccines. The results of such
polls can be used in campaigns and media reports to tackle
vaccine hesitancy among people [23]. In addition, influenza
vaccines can be provided at pharmacies and pharmacists can
be encouraged to disseminate information about the need for
this vaccine as they are also a trusted source of information.
There were some limitations to our survey. The sample
size for the survey was not based on statistical calcula-
tions but was only used as a meaningful number in the field
research for opinions. Owing to the small sample size, we
could not assess the attitudes and perceptions by age group
and disease. There was a lack of control over the survey
environment and the respondents’ behavior. For example,
respondents may have been distracted, rushed, dishonest,
or influenced by others while answering the survey. Fur-
thermore, there could have been a response bias, which
may occur in the case of surveys with numerous questions.
We also did not investigate whether specific country-level
policies were barriers or drivers of flu vaccine uptake. The
proportion of vaccinated and unvaccinated patients, as well
as the prevalence of each NCD, do not reflect actual epide-
miological data. A final limitation is that the survey cov-
ered only one season. It was conducted immediately after
the COVID-19 pandemic when many people were likely to
be suffering from vaccine fatigue. This could have impacted
the flu vaccine uptake.
5 Conclusions
Our survey showed that, in general, the influenza vaccination
uptake among patients with NCDs in the CZ is quite low.
Less than half of those surveyed had a positive opinion about
influenza vaccines. The major motivators among those who
took the vaccine were GP recommendations or self-initia-
tive. The main barriers against the influenza vaccine were
lack of belief about its need, experience of mild severity
of influenza, and lack of GP recommendation. Physicians,
dedicated websites, and family members are the most com-
mon sources of information about influenza. More efforts are
necessary for the dissemination of information regarding the
influenza vaccine, particularly its benefits, the risks of not
Influenza Vaccination Survey in the Czech Republic
taking the vaccine, and its safety. Healthcare professionals
need to be trained to ensure that vaccination is included in
the treatment of chronic diseases and they should discuss
it with patients during consultation. There is also a need to
involve specialists in disseminating information about the
risks of not taking the influenza vaccine among people with
NCDs. Multidisciplinary approaches such as involving phar-
macists are other useful approaches in encouraging people
to take the vaccine.
Supplementary Information The online version contains supplemen-
tary material available at https:// doi. org/ 10. 1007/ s40801- 025- 00483-0.
Acknowledgements Writing support for the manuscript was provided
by Dr. Sangeeta Dhanuka.
Declarations
Consent for publication Not applicable.
Availability of data and materials The datasets used and/or analyzed
during the current study are available from the corresponding author
on reasonable request.
Financial interests Zdenek Zadrazil, Lenka Cesnekova, Laura
Colombo, and Sanjay Hadigal are employees of Viatris. Other authors
have no financial interests to declare.
Nonfinancial interests The authors have no nonfinancial interests to
declare.
Funding This study was funded by Viatris.
Consent to participate All participants provided informed consent
in accordance with the Declaration of Helsinki. Before answering
the questionnaire, each participant received information explaining
the objective of the survey, how data would be handled, and how the
results would be used. To proceed with responses to the questionnaire,
participants had to provide consent, or else they were not allowed to
take the survey.
Ethics approval The study was conducted in line with the market
research definition and in accordance with theEuropean Pharmaceuti-
cal Market Research Association (EPHMRA) and British Healthcare
Business Intelligence Association (BHBIA) market researchcodes of
conduct. Its only purpose was to capture the opinion of the participants,
and no clinical parameter, efficacy, or safety endpoints related to any
treatment were investigated. Hence, in line with the guidance provided
by the EPHMRA, the BHIBIA, and the National Health Service Health
Research Authority (NHS HRA), the research does not qualify as a
clinical study and Research Ethics Committee review and approval
was not required. All methods were carried out following the relevant
guidelines and regulations.
Author contributions Laura Colombo and Sanjay Hadigal equally
contributed to conceptualizing the study design, analyzing and inter-
preting the data, and revising, reviewing, and approving the manu-
script. Zdenek Zadrazil, Lenka Cesnekova, Jan Kyncl, and Zuzana
Kristufkova contributed to interpreting the data and revising, review-
ing, and approving the manuscript. All authors read and approved the
final version.
Open Access This article is licensed under a Creative Commons Attri-
bution-NonCommercial 4.0 International License, which permits any
non-commercial use, sharing, adaptation, distribution and reproduction
in any medium or format, as long as you give appropriate credit to the
original author(s) and the source, provide a link to the Creative Com-
mons licence, and indicate if changes were made. The images or other
third party material in this article are included in the article's Creative
Commons licence, unless indicated otherwise in a credit line to the
material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regula-
tion or exceeds the permitted use, you will need to obtain permission
directly from the copyright holder. To view a copy of this licence, visit
http:// creat iveco mmons. org/ licen ses/ by- nc/4. 0/.
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