
==== Front
Hum Vaccin Immunother
Hum Vaccin Immunother
Human Vaccines & Immunotherapeutics
2164-5515
2164-554X
Taylor & Francis

39286861
10.1080/21645515.2024.2397214
2397214
Version of Record
Research Article
Influenza
A cross-sectional study on the understanding and attitudes toward influenza and influenza vaccines among different occupational groups in China
X. ZHAO ET AL.
HUMAN VACCINES & IMMUNOTHERAPEUTICS
Zhao Xinkun a *
Hu Xin b *
Wang Junyi c
Shen Mingshuai a
Zhou Kaifeng d
Han Xianjie e
Thomas Milton f
Wang Kezhou a
Wang Li g
Wang Zhao a
a School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences , Jinan, China
b School of Politicl Science and Public Administration, Shandong University , Qingdao, China
c Department of Promotion, Linyi City Animal Husbandry Development and Promotion Center , Linyi, China
d Department of Promotion, Shandong Provincial Animal Husbandry General Station , Jinan, China
e College of Veterinary Medicine, Qingdao Agricultural University , Qingdao, China
f Department of Microbiology and immunology, University of Louisville , Louisville, Kentucky, USA
g Physical Factors Section, Occupational Diseases Hospital of Shandong First Medical University , Jinan, China
CONTACT Li Wang 1169525311@qq.com Physical Factors Section, Occupational Diseases Hospital of Shandong First Medical University , Jinan, China.
Zhao Wang wangzhao@sdfmu.edu.cn School of Laboratory Animal & Shandong Laboratory Animal Center, Shandong First Medical University & Shandong Academy of Medical Sciences , Jinan, China.
* These authors contributed equally to this work.

17 9 2024
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© 2024 The Author(s). Published with license by Taylor & Francis Group, LLC.
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The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

This study aimed to assess the level of knowledge regarding influenza viruses and vaccines among different professional groups to investigate the reasons for vaccine hesitancy. We collected 2190 questionnaires regarding influenza vaccines in China in 2022. The respondents were categorized into the general population (GP), foreign affairs workforce population (FAWP), and veterinary workforce population (VWP) according to their job positions. Linear regression was used to assess the association between multiple factors and influenza vaccination rates. The association between work and influenza vaccination rates was also assessed by grouping different workforce populations. The vaccination rate of the GP was higher than that of the VWP (odds ratio: 1.342, 95% confidence interval: 1.025–1.853), surpassing the rates reported in previous studies. This may be attributed to heightened concerns about infectious diseases influenced by the ongoing coronavirus disease 2019 pandemic. Despite the VWP’s more in-depth knowledge of the VWP on zoonotic diseases and their recognition of their importance, there was no significant difference in influenza knowledge among the three populations. This discrepancy contrasts with the observed differences in vaccination rates. Further investigation revealed that, compared with FAWP, the price of vaccines emerged as a primary influencing factor for vaccination rates (odds ratio:0.398, 95%CI; 0.280–0.564). General concerns regarding the protective effects and side effects of vaccines were also noted.

KEYWORDS

Zoonosis
influenza vaccine
vaccination rates
vaccination hesitancy
veterinary workforce population
foreign affairs workforce population
Innovation Project of Shandong Academy of Medical Sciences Technology Bureau “20 Colleges and Universities” 2021GXRC011 The Major Scientific and Technological Innovation Project 2023CXGC010705 Shandong Province Pig Industry Technology System SDAIT-08-17 National Natural Science Funds 32102750 The work was supported by the Innovation Project of Shandong Academy of Medical Sciences Technology Bureau “20 Colleges and Universities” [2021GXRC011]; The Major Scientific and Technological Innovation Project [2023CXGC010705]; Shandong Province Pig Industry Technology System [SDAIT-08-17]; National Natural Science Funds [32102750].
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pmcIntroduction

Zoonoses are infectious diseases transmitted between non-human vertebrates and humans and is not dependent on an animal hosts.1 Six out of 10 infectious diseases originate from animal transmission,2 which can occur in both urban and rural areas where humans lives.3 Zoonoses, such as the 2009 “swine influenza” H1N1 outbreak, the 201–2016 Ebola outbreak in West Africa, and the 2019–2023 coronavirus disease 2019 (COVID-19) outbreak, significantly impact human lives and health.4–6 It is estimated that influenza A is responsible for 294,000–518,000 deaths annually,7 and is one of the most prevalent zoonotic diseases that has the potential to significantly affect impact human health and well-being. However, the awareness of zoonotic diseases is inadequate in poorer areas and hence poses a serious threat to public health security.8

Influenza is an acute, virulent respiratory infection caused by influenza viruses and a common form of zoonosis. Influenza viruses can infect a wide range of animals, including humans. Since 1918, there have been four worldwide influenza pandemics worldwide, with the “Spanish Flu” being the most devastating, which caused approximately 20,000,000 deaths worldwide.9,10 While the H1N1 pandemic was not as deadly as initially feared, the ability of influenza to spread worldwide in a short period of time underscores the public health threat posed by novel influenza viruses originating from non-human hosts.11 Influenza not only has a significant impact on human health and causes significant economic losses, with the indirect economic losses amounting to tens of billions of dollars globally each year.12 Over the past decade, china, a country with a high prevalence of influenza, has experienced significant economic losses due to seasonal influenza. According to official statistics, the annual economic impact of seasonal influenza in China from 2011 to 2019 has been estimated to range from 33 billion to 106 billion Renminbi (RMB), representing 0.03% to 0.1% of the gross domestic product of China in 2019. In 2019. The total national influenza-related economic burden in 2019 was 26.381 billion RMB, with hospitalized cases, emergency cases, and deaths caused by influenza accounting for 86.4%, 11.3%, and 2.4% of the total economic burden, respectively.13 Influenza virus infections in humans often occurs through close contact with pigs, particularly on pig farms or slaughterhouses. Between 2010 and 2021, over 700 confirmed cases were reported globally, primarily affecting young people or immunocompromised patients.14 Previous studies have shown sub-clinical infection rates of 15–40% among pig farm and abattoir workers,15 making the working population in livestock-related professions a priority for protection. Healthcare workers have been found to be at great risk of exposure to the flu vaccine, but factors such as powered organization have affected vaccination.16–18 Vaccination is a crucial option for preventing communicable diseases. Achieving a certain level of population vaccination coverage can significantly reduce the incidences of disease, disability, and death.19 Herd immunity attained through vaccination can also reduce infections in unvaccinated individuals, further reducing the risk of the disease.20 Despite efforts by the Chinese government’s efforts to promote and encourage influenza vaccination before the flu season, a significant proportion of the population who remains unvaccinated.

The total influenza vaccine coverage in China was 2.47%,21 which is considerably lower than that in other countries. For example, the United States and Brazil have coverage rates of 51.40%,22 and 57.35%,23 respectively. This phenomenon could be attributed to vaccine hesitancy, which is a global concern, and was listed by the World Health Organization as one of the top ten threats to global health in 2019.24 It has been shown that there is a very strong negative correlation between vaccine hesitancy and vaccination rates.25 The influenza vaccination rate of influenza vaccine in China is only 2.94%, which is far below the global average.26 Perceptions of the influenza vaccine vary widely between population groups; therefore, studying the perceptions about the influenza vaccine of different groups of people is one of the most important ways to explore the factors contributing to vaccine hesitancy. Previous research has demonstrated that several factors, including perceived ease of use, usefulness, health literacy, risk of influenza illness, and value can influence the judgment of some parents in China,27 which are shared concerns by parents in the United States.28 Many university students in developing countries do not recognize the need for influenza vaccination and lack knowledge about the influenza disease and influenza vaccines.29–31 Previous studies have examined various high-risk populations, such as healthcare workers, the elderly, and infants. However, FAWPs, who may be chronically susceptible to influenza, and VWPs, who frequently travel between countries and face increased exposure to influenza viruses, have been overlooked as high-risk occupational groups. These groups have been neglected in the current research. This study investigates the influenza vaccination status and factors influencing vaccination in FAWPs and VWPs, addressing this gap and offering new insights into the factors contributing to vaccine inactivity.

This study, aimed to comprehend the factors contributing to influenza vaccine hesitancy among people working in different professions in China.

Methods

Survey population

This study was conducted in China, and the population was categorized as general population (GP), foreign affairs workforce population (FAWP), and veterinary workforce population (VWP). To qualify for FAWP, applicants must have been gainfully employed for at least six months in public-accessible locations, such as farms, slaughterhouses, and animal breeding facilities. Individuals seeking VWP status must demonstrate that they have traveled to a country at least twice within a 12-month period, have resided there for at least one week, and have regularly engaged in activities with the local population, including foreign students. The GP consisted of individuals outside the aforementioned other groups. Individuals who could not be vaccinated due to their physical and religious beliefs were excluded from the study. Studies involving human participants were reviewed and approved by the Ethics Committee of the Jinan Center for Disease Control and Prevention. The questionnaire was administered after the participants read the informed consent form and agreed to participate.

Sample size

The sample size was calculated using the cross-sectional survey formula, n = (Z (1-α/2)/δ)2 p(1-p); wherein, Z indicates standard normal distribution; α indicates the level of significance; δ indicates the allowable error; and p indicates the predicted vaccination rate. In this study, a sample size of 100 was used, with a Z-value of 1.96, an alpha value of 0.05, a beta value of 0.1, and a P-value calculated based on previous studies on vaccination rates in both general and high-risk populations. According to previous surveys, the vaccination rate of the GP in China is approximately 2.94% and that of the healthcare workforce is 27.65%.32 As there have been no studies on FAWP and VWP populations in relation to influenza vaccination rates, the FAWP and VWP were anticipated to be similar to the healthcare workforce. By considering α = 0.05 and δ = 0.1P, it was found that the required sample size was at least n = 287 for the GP, and at least n = 227 each for the VWO and the FVWP.

Questionnaire design

Before conducting the survey, a sample of 100 respondents was randomly selected from the target population of Jinan for testing purposes. The questionnaire was administered to 100 people from the Jinan farm, foreign students, and community workers. The questionnaire was modified to ensure the creation of an accurate and reliable instrument based on the feedback of the respondents regarding its clarity and comprehensibility.

The questionnaire was designed based on expert opinions and were categorized into three parts: (1) sociodemographic characteristics, (2) knowledge of veterinary diseases, human diseases, and influenza viruses, and (3) vaccination intentions.

The basic information component included questions on sex, age, educational level, marital status, smoking, and drinking. Smoking and drinking were mainly used to determine the respondents’ daily behavioral habits and their health status of the respondents.

The knowledge of zoonotic diseases component included four multiple-choice questions to assess the understanding of the respondents regarding zoonotic diseases. The questions covered identification, modes of transmission, and preventive measures, with one point assigned to each correct answer for a total of 32 points. The objective of this investigation was to determine whether respondents had received the influenza vaccine in the past five years to gain insight into their vaccination status. Additionally, we assessed respondents’ awareness of the influenza vaccine by evaluating their familiarity with influenza vaccination. Vaccine hesitancy, a primary factor in low vaccination rates, was examined through questions addressing factors influencing influenza vaccination, vaccine availability of the vaccine, and opinions on government-provided vaccination for biological or farming-related practitioners. The objective of this study was to investigate factors influencing vaccination, such as price, vaccine side effects, effectiveness, and other relevant factors. Additionally, the study examined the impact of external measures on flu vaccination uptake.

Methods of investigation

A random sampling method was used in this study. Samples were collected nationwide using the Questionnaire Star online website (https://www.wjx.cn/), which may have caused selection bias; therefore, we used an online tool to find as many people as possible without internet access to complete the form. Quality control measures were implemented as follows: (1) a A specific quality control question was designed, and incorrect answers rendered the questionnaire invalid: (2) the respondents were required to complete all questions before submitting the questionnaire: and (3) the questionnaires that took less than 5 minutes to complete were judged to be invalid.

Data analysis

The data were considered as categorical variables and were summarized using frequency tables. A chi-square test was used to compare differences in the distribution between different professional populations based on sociodemographic characteristics, knowledge of zoonotic diseases, and influenza, and vaccination status. Differences between populations were evaluated by calculating 95% confidence intervals and risk ratios. A t-test was used to determine the differences in the perception of zoonotic diseases among different populations. Multifunctional logistic regression models were used to analyze the causes of the differences between different populations. Data were analyzed using SPSS 18.0 and R 4.2.1 software. Statistical significance was set at p < .05.

Results

Sample collection and basic characteristics

A total of 2,190 valid questionnaires were collected from 31 of the 34 provinces, municipalities, and autonomous regions China; 15 invalid questionnaires were excluded (validity rate = 99.32%; Figure 1). Of the total, 936 valid questionnaires were collected from the GP, 230 valid questionnaires were collected from the FAWP, and 1009 valid questionnaires were collected from the VWP. All the groups met the expected minimum sample sizes. Figure 1. Geographic distribution of the questionnaire sources. China has 34 provincial-level administrative regions, including 23 provinces, 5 autonomous regions, 4 municipalities directly under the central government, and 2 special administrative regions. The questionnaires collected for this study came data from 31 provincial administrative regions.

Among the 2175 participants, both the GP and FAWP exhibited similar gender distributions, while the VWP were predominantly male (n = 707, 70.06%) because of the specific nature of their profession. Regarding age and marital status, there was a notable concentration of individuals aged 18–25 years (n = 794, 84.82%) and unmarried individuals (n = 814, 86.97%) in the GP. This concentration posed the potential for systematic errors, and corrective statistical measures were implemented in the later stages of the study to mitigate their impact. In terms of education level, both the GP and FAWP demonstrated higher educational attainment, with 97.11% and 95.65% holding a bachelor’s degrees or higher, respectively. In contrast, the VWP group had a relatively lower level of education. All three populations exhibited healthy lifestyles, with a low number of smokers and alcohol consumers (Table 1).Table 1. Basic characteristics of different population groups.

Characteristic	General population	FAW population	VW population	P value	
Number	Percent (%)	Number	Percent (%)	Number	Percent (%)	
Sex	
Male	418	44.65	96	41.73	707	70.06	p < .05	
Female	518	55.34	134	58.27	302	29.94	
Age groups (years)	
18 ~ 25	794	84.82	20	8.70	148	14.67	p < .05	
26 ~ 30	45	4.81	30	13.04	77	7.63	
31 ~ 40	61	6.52	97	42.17	337	33.41	
41 ~ 50	25	2.67	55	23.91	299	29.63	
51 ~ 60	7	0.75	24	10.43	141	13.97	
60~	4	0.43	4	1.74	7	0.69	
Education	
Junior high school	10	1.07	4	1.74	120	11.89	p < .05	
Senior high school	17	1.82	6	2.61	118	11.69	
Undergraduate	869	92.84	117	50.87	555	55.02	
Master degree candidate	32	3.42	96	41.74	163	16.15	
Doctoral candidate	8	0.85	7	3.04	53	5.25	
Marriage	
Never married	814	86.97	55	23.92	205	20.31	p < .05	
Married	112	11.97	168	73.04	797	78.99	
Other	10	1.07	7	3.04	7	0.70	
Whether you smoke or not	
Yes,a lot	57	6.09	18	7.83	141	13.97	p < .05	
Yes,occasionally	88	9.40	21	9.13	137	13.58	
No	791	84.51	191	83.04	731	72.45	
Whether to drink	
Yes,a lot	34	3.63	14	6.09	116	11.50	p < .05	
Yes,occasionally	586	62.61	138	60.00	542	53.72	
No	316	33.76	78	33.91	351	34.79	

Perceptions of zoonotic diseases varied widely among populations

According to the scoring of the questionnaires completed by different groups of people, it was found that the GP, the FAWP, and the VWP had a large difference in their knowledge of zoonosis, with the VWP having a more in-depth knowledge of zoonosis (score: 17.32), while the GP had a relatively shallow knowledge (score: 13.56: Table 2). In terms of the willingness to disseminate knowledge about zoonosis, there is also a significant difference between the GP and the VWP (Figure 2). The VWP was more willing to disseminate some relevant knowledge relevant knowledge; therefore, it is reasonable to believe that the VWP was more willing to accept knowledge of zoonosis. The VWP differed from the other two populations, technical aspects of zoonosis prevention were emphasized. The GP and the FAWP were more policy-oriented. Figure 2. Forest plots on the differences between the different populations regarding their awareness of influenza. (a) The GP compared to the FAWP; (b) the GP compared to VWP; and (c) the FAWP compared to the VWP. The red color represents a statistically significant difference between the two populations (p < .05).

Table 2. Evaluation table on the perception of zoonosis in different populations.

 	 	General population	FAW population	VW population	
Which of the following are zoonotic diseases？	Epidemics in humans can be transmitted to animals	388	107	520	
Diseases in animals can be transmitted to humans	563	153	772	
People and animals infect each other with diseases	590	179	836	
Vectors are needed for transmission between humans and animals	464	122	548	
Other	160	14	74	
What do you think are the modes of transmission of zoonotic diseases？	Direct contact with infectious agents (scratches and bites)	833	208	958	
Indirect exposure to infectious agents (droplet inhalation)	610	171	852	
Through intermediate vectors (mosquito bites)	684	177	888	
Foodborne transmission	400	108	673	
Waterborne transmission	376	104	616	
What do you think are zoonotic diseases?	Avian influenza	676	174	733	
Microchip	742	193	834	
Swine fever	354	88	114	
HIV	221	59	211	
Hantavirus	95	14	106	
Swine influenza	279	78	281	
African swine fever	228	59	88	
Brucella	117	41	652	
Canine influenza	177	37	74	
COVID-19	230	62	335	
Mad cow disease	230	80	328	
Epidemic encephalitis B	125	39	317	
Toxoplasmosis	237	74	452	
Lyme disease	76	15	92	
Hepatitis E	89	13	136	
Salmonella	160	58	404	
Psittacosis	179	49	184	
Preventive measures to avoid contracting zoonotic diseases？	Wash hands immediately after contact with animals	788	207	938	
Try to avoid animal bites and scratches	797	217	961	
Protection from mosquito, tick and flea bites	624	175	880	
Consumption of raw milk	160	35	223	
Avoid eating and drinking in animal enclosures	534	146	758	
Wear a mask and gloves when in contact with sick animals	627	165	863	
Maintaining cleanliness in the breeding area	609	155	801	
Avoid accumulation of manure in farming areas and maintain ventilation	651	168	791	
Overall score	12691	3424	17471	
Number of questionnaires	936	230	1009	
Score per capita	13.56	14.89	17.32	

Perceptions of influenza varied significantly across populations

It was observed that the VWP were more aware of influenza than the GP and FAWP, followed by the FAWP (Figure 2). The VWP group exhibited a heightened awareness of the severity of influenza, with only 27.85% (281/1009) being unaware of the disease. In contrast, a higher proportion of the GP lacked awareness of influenza as a disease (362/936, 38.68%) and even disregarded its potential impact (292/936, 31.20%). The perception of the GP closely resembled that of the FAWP. Notably, 45.65% (105/230) of the FAWP held the mistaken belief that influenza was not a serious disease, which may be one of the contributing factors affecting the vaccination rates within this group. In terms of knowledge of the flu vaccine, the GP was not aware of the timeliness of the vaccine, whereas the VWP and FAWP had clear knowledge of it as a high-risk occupation, which may also limit vaccination uptake.

Vaccination of the different populations

There were significant differences in the influenza vaccination rates among the different populations. The GP had a vaccination rate of 58.01% (543/936), the FAWP had a vaccination rate of 39.13% (90/230), and the VWP had a vaccination rate of 31.83% (321/1009: Figure 3a). Unexpectedly, the VWP had the lowest vaccination rate, whereas the GP had the highest vaccination rate, which was contrary to expected results. It may be attributed to the impact of the COVID-19 pandemic and the localized influenza outbreak in China in 2019, which prompted increased attention to influenza preparedness. A higher number of individuals from the GP were unaware of the influenza vaccine than those from the FAWP and VWP (Figure 3b). Furthermore, a lower percentage of individuals from the GP received relevant recommendations (Figure 3c), potentially serving as one of the factors that influenced the vaccination rates. Despite a high level of awareness among VWPs regarding zoonotic diseases, vaccination rates remain paradoxically low. Our findings revealed that VWPs were more likely to be unable to receive vaccinations due to medical reasons and had heightened concerns about potential vaccine side effects, especially the risk of infection during the vaccination process. (Figure 4) In addition to the promotion of vaccines, vaccine hesitancy is an important factor contributing to the low vaccination rates. Figure 3. Bar charts on influenza vaccination and publicity. (a) Vaccination rate, (b) vaccine prevalence, (c) and vaccine publicity, * represents p < .05,**p < .01, *** p < .001.

Figure 4. Forest plots of the different populations for prevention of transmission of zoonotic diseases and factors influencing vaccination. (a) The GP compared with the FAWP; (b) the GP compared with the VWP; (c) the FAWP compared with the VWP. “●” represents veterinary human disease-related issues and “■” represents influenza vaccine-related issues. The red color represents a statistically significant difference between the two populations (p < .05).

Factors influencing vaccination among the different populations

The reasons for vaccine hesitancy varied significantly among occupational groups. The GP and FAWP shared similar attitudes toward knowledge of zoonotic disease transmission and influenza vaccination but diverged significantly concerning vaccination. Vaccination rates were much higher in the GP than in the FAWP, probably because of the higher level of educational level in the GP. The GP and FAWP expressed concerns about the vaccine being overpriced and its potential side effects, but the VWP are different in that they focused more on the effectiveness of the vaccine itself. (Figure 4a). This discrepancy may stem from the relatively higher incomes of the FAWP and their frequent travel to pandemic-prone countries, where the risk of contracting infectious diseases is high. Consequently, the FAWP may prioritize the vaccine’s protective effects of the vaccine over concerns about its cost and side effects. The GP are more aware of zoonotic diseases and more willing to disseminate virus-related than the VWP. Similar to the FAWP, the VWP belongs to the high-risk group and is more concerned about the protective effect of the vaccine and its price and side effects of the vaccine (Figure 4b). All three populations expressed differing concerns about the effectiveness of the vaccines in comparison to each other. This distinction lies in the fact that the GP raised concerns regarding the price, side effects, and infections related to the vaccine.

Discussion

Zoonosis is of great relevance to human health, especially infections with highly virulent pathogens, which have the potential to cause national or even global pandemics and high mortality rates.22 Influenza, a major zoonotic disease, has previously triggered a worldwide pandemic. While the current threat of the influenza virus remains uncertain, research suggests that the next pandemic is likely to be zoonotic, posing a significant public health challenge in preventing influenza.23 Vaccination is crucial for preventing infectious diseases; however, the influenza vaccination rate in China remains low. Possible reasons are the following: China has not yet incorporated the influenza vaccine into its national immunization program; limited coverage in areas where free vaccination policies are implemented; insufficient awareness of influenza and influenza vaccine among the population; insufficient vaccine supply; the availability of only a single type of influenza vaccine available; and the need for annual re-vaccination.33 This study explored the perceived levels of zoonotic and influenza vaccination among people working in different professions to investigate the factors that contributing to vaccine hesitancy.

A comparison of the basic characteristics of three populations revealed differences in sex, education level, and living habits, wherein the GP and the FAWP had relatively high levels of education, whereas the VWP had relatively low levels of education. Previous studies on sociodemographic characteristics have demonstrated that influenza vaccination is correlated with sex, education, marital status, and area of residence. Groups with higher educational backgrounds and incomes had greater access to correct health information.33 This is consistent with the trend in the questionnaire vaccination rates in the survey, wherein the GP had high vaccination rates, but the VWP had relatively low vaccination rates. Surprisingly, we found that the VWP is more aware and willing to spread knowledge of zoonosis: hence, it is more familiar with the importance of zoonotic diseases. We found that the GP and FAWP had a higher level of education than the VWP, which may have had an impact on vaccination rates. This outcome may have been influenced by performing the survey during the COVID-19 pandemic, which had a profound impact on the lives of people. During the pandemic, health education was strengthened, leading to a deeper understanding of healthy living. For example, the health awareness and behavioral patterns of obese people in China changed significantly during the epidemic.34,35 The outbreak of the SARS-CoV-2 virus in Wuhan in 2019 had a profound global impact, drawing attention to various infectious diseases, including influenza. This study found that the FAWP exhibited a greater awareness of the importance of zoonosis and placed a stronger emphasis than the GP on preventing zoonosis at a technical level. The VWP, with its extensive involvement in the veterinary biotechnology industry and greater knowledge of veterinary and zoonotic aspects, displayed a more in-depth understanding. We hypothesized that there would be a large difference in influenza awareness among the three populations, however, the results were the opposite. This may be due to the time of investigation in this study, which was during the COVID-19 pandemic. Perceptions of influenza were extremely similar among the GP, FAWP, and VWP. The three populations had a large difference in willingness to receive the flu vaccine, with the VWP being more willing to be vaccinated, but the GP and the FAWP were not as willing. Interestingly, despite the VWP’s heightened awareness of the dangers of influenza dangers and greater willingness to be vaccinated, the actual vaccination rate remained relatively low. It was observed that the VWP and FAWP had a higher proportion of individuals unable to receive vaccination for physical reasons, potentially serving as a primary factor contributing to vaccine hesitancy among the FAWP.

Further investigation of the factors contributing to vaccine hesitancy showed that all three populations were concerned about the protective effects and side effects of the vaccine. In addition to these concerns, the high price of the vaccine is also an important reason for its low vaccination rate. This is consistent with the results of previous studies on vaccine hesitancy, where economic conditions had a greater impact on vaccination.36 The relatively low economic income of the VWP is likely a crucial factor contributing to their relatively low vaccination rate in the VWP, despite their heightened awareness of influenza dangers and vaccines.

The study results indicate that knowledge about influenza varies across different populations, and this variation is a key factor influencing vaccination rates.Although FAWPs and VWPs are more aware of influenza, their vaccination rates remain low.Our research found that vaccine cost significantly impacts FAWPs, likely due to their lower economic status.In contrast, VWPs, who belong to a higher income group, are more concerned about vaccine effectiveness, side effects, and the safety of the vaccination process, despite their focus on physical health. This study helps identify groups more likely to be reluctant to vaccinate, allowing for targeted actions to address their concerns.27,37 Knowledge about the influenza virus is a crucial factor affecting vaccination. Government health agencies should improve public knowledge about the influenza virus and conduct regular awareness campaigns across different venues, targeting various age groups. Income is a significant factor influencing the vaccination willingness of the general and low-income populations. Government health agencies should provide subsidies to reduce or eliminate vaccination costs for highly exposed populations. Vaccine efficacy and side effects are also crucial factors influencing vaccination decisions. Government health agencies should increase awareness of vaccine effectiveness, emphasize vaccination benefits, and enhance environmental monitoring of vaccination centers to ensure a safe vaccination environment.

This study has some limitations. First, the use of an online questionnaire may have introduced variability into the judgment criteria for the questions, potentially leading to systematic errors. The use of online platforms is limited to an audience of people who have access to the internet, creating a certain selection bias and the convenience sampling method employed could have also resulted in the limited representativeness of our findings. However, to mitigate this limitation, we included participants from all 31 administrative regions of China, aiming for a relatively large sample size. Second, although the respondents were drawn from different provinces in China, the questionnaires differed between provinces, which may have been influenced by the local level of education, resulting in some degree of selection bias. Finally, our survey neglected to investigate perceptions of the influenza virus itself, which could have been used to investigate the relationship between the perceptions of people on how influenza viruses are transmitted, their susceptibility, and vaccine hesitancy. Future studies should incorporate these factors to gain a more comprehensive understanding.

Conclusions

This study contributed to the advancement of knowledge regarding influenza vaccine hesitancy by examining the perceptions of two at-risk groups: the FAWP and VWP. Individuals with more comprehensive influenza-related knowledge exhibited a stronger inclination to be vaccinated against influenza, yet they were not vaccinated. This is primarily attributed to economic factors, which were significant determining factors in the context of a similar level of knowledge about influenza. Furthermore, participants demonstrated heightened awareness of the influenza virus compared to previous studies. It is plausible that this is attributable to the fact that the infectious disease aspect was popularized during the COIVD-19 epidemic; hence, healthcare professionals should further disseminate knowledge about influenza. Health authorities should adjust vaccination strategies and reduce or waive fees for high-risk occupational groups to lessen their economic burden. Additionally, vaccination departments should ensure a safe vaccination environment and enhance public awareness. These measures can effectively address the shortage of FAWP and VWP vaccines and increase influenza vaccination coverage.

Supplementary Material

Supplementary material Survey.docx

Zhao Wang is an Associate Professor at the College of Laboratory Animals, Shandong First Medical University, a member of the Expert Committee on Prevention and Control of Animal Diseases in Shandong Province, and a member of the Expert Committee on Prevention and Control of Veterinary and Human Infectious Diseases in Shandong Province.He got his PhD from South Dakota state university in US. His research mainly focuses on the pathogenesis and immunology of zoonotic diseases such as influenza.

Li Wang is an attending physician at the Shandong First Medical University Occupational Disease Hospital (Shandong Province Occupational Disease Hospital), where she received her degree from Shandong University in 2009. She has been involved in occupational disease research for a long time, with an in-depth understanding of the causative agents of occupational diseases, as well as the difficulties in preventing and controlling occupational diseases.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Supplementary material

Supplemental data for this article can be accessed on the publisher’s website at https://doi.org/10.1080/21645515.2024.2397214

Availability of data and material

The data that supporting the study results are available upon reasonable request. For the research data to be used in further comparative validation studies, please contact the corresponding author.

Author contributions

Zhao Wang designed the study. Xinkun Zhao and Xin Hu conducted the survey and participated in data collection. Mingshuai Shen supervised all aspects of the data collection. Xinkun Zhao and Junyi Wang analyzed and interpreted the data. Xinkun Zhao and Xin Hu drafted the manuscript. Kaifeng Zhou, Xianjie Han, Milton Thomas, Kezhou Wang, and Li Wang critically revised the manuscript for intellectual content. All authors have approved the final published version of the manuscript and agreed to take responsibility for all aspects of this work.

Ethical approval

The studies involving human participants were reviewed and approved by the Ethics Committee of the Jinan Center for Disease Control and Prevention. The questionnaire was administered after the participants read the informed consent form and agreed to participate. In this instance, we were informed that the data was used for scientific research purposes and that respondents had provided their consent. The dataset does not contain any personally identifiable information about the respondents. Any data obtained from this study will be used exclusively for scientific research within our laboratory and will not be disclosed to the public.
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