Influenza Vaccine Uptake, Hesitancy and their Determinants among Lebanese Public Transportation Drivers during COVID-19

Abstract

Public transportation drivers are at a high risk of contracting and are potential super-spreaders of influenza. Protecting them through vaccination needs to be a primary health care (PHC) objective. A scoping review of articles published between 2016 and 2022 indicated that influenza vaccine uptake and hesitancy were not examined among this high-risk population within the Middle East North African (MENA) region.

This cross-sectional study measured the proportion of influenza vaccine uptake among a representative non-probability sample of Lebanese public transportation drivers during the COVID-19 pandemic and examined the determinants of vaccine uptake. The conceptual model of this study was inspired by the Theory of Reasoned Action/ Theory of Planned Behavior (TRA/TPB).

An interviewer-administered survey was conducted between January and March, 2023. A quota sample of 509 public transportation drivers were recruited using convenience sampling from 24 Lebanese districts regardless of their ethnicity, age or gender. A PhD student targeted these drivers at their resting stations, companies, syndicates, and the airport, and invited them to participate in the study. Those who provided verbal consents were included. Independent and predictors variables captured the main constructs of the TRA/TPB (External individual factors, attitude, norms and perceived behavioral control) and the 5Cs hesitancy scales (confidence, complacency, collective responsibility, constraints, and risk calculation). The main outcome was uptake of influenza vaccine and secondary outcome was intention to uptake in upcoming influenza season. Descriptive and bivariate statistical analyses, followed by hierarchical, ordinal, and linear regression analyses were performed. Mediation and cluster analysis were performed. Statistical significance was set at P<0.025 (two sided).

The proportion of drivers who received influenza and COVID-19 vaccine uptake was 28.9% and 71.7%, respectively. Moreover, 56.2% drivers intended to take the influenza vaccine in the upcoming influenza season if it will be offered for free, at a discounted price, or through a mobile vaccine clinic. Statistically significant determinants of influenza vaccine intent were: residing in Beirut or Mount Lebanon (adj.OR=1.28 [1.03-1.59]), being exposed to advice on influenza vaccine uptake (adj.OR=1.48 [1.21-1.83]), those who reported average financial status (adj.OR=0.71 [0.57-0.89]). Drivers who were not confident in influenza vaccines were (adj.OR=0.64 [0.51-0.81]) times less likely to take the vaccine in the future. Drivers who believed that influenza vaccines are advertised for commercial profiteering and those who preferred natural immunity over vaccines, were both less likely to get influenza vaccination in the future.

Statistically significant determinants of influenza vaccine uptake were: knowing a family, friend, or colleague who took the influenza vaccine (descriptive norm) (adj.OR=4.55[2.55-7.98]), advice by a family, friend, or colleague on taking the influenza vaccines (subjective norm) (adj.OR=2.16[1.15-4.07]), previous influenza infection (adj.OR=1.71[1.17-2.49]), COVID-19 vaccine uptake (adj.OR=11.39[4.84-26.83]), lack of confidence (adj.OR=0.81[0.66-0.99]), risk calculation (weighing the risks versus benefits of vaccines) (0.78[0.64-0.95]), and an interaction between the hesitancy dimension related to constraints and behavioral control 0.81[0.69-0.91].

Hierarchical cluster analysis showed two subgroups within the sample. Those drivers who were more likely to get the influenza vaccine had more work experience, were financially more comfortable, visited a physician annually, had better knowledge, had better perceptions of vaccine benefits, and had higher perceived severity of influenza. This subgroup reported higher influenza vaccine uptake compared to the other counter groups who had lower vaccine uptake.

Findings in this study are of particular interest to the Lebanese Ministry of Public Health, Directorate General of Land Transportation and Drivers' syndicates. Public transportation drivers can benefit from tailored interventions such as awareness campaigns to enhance their knowledge of influenza and its vaccines, alleviate their hesitancy, guide them to vaccine providers and support them to overcome any barrier such as vaccine cost and accessibility. At a global level, more research is needed targeting public transportation sector to assess their intention and uptake of influenza vaccine as well as to design interventional studies that can promote influenza vaccine uptake among drivers and subsequently public safety from influenza outbreaks.