Influenza Vaccination Among Patients with Noncommunicable Diseases: A Survey About Awareness, Usage, and Unmet Needs in the Czech Republic

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 information 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.

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 hesitancy among people.

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.

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 cardiovascular 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 contracting vaccine-preventable diseases (VPDs) with a higher likelihood of severity and complications [2]. VPDs such as influenza significantly increase the risk of cardiovascular, cerebrovascular, neurological, and renal complications following the acute illness. Moreover, patients with NCDs hospitalized for VPDs such as influenza and coronavirus 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 infections associated with influenza lead to a six times higher risk of myocardial infarction within a week [6] and are responsible 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 vaccination also significantly reduced the risk of all-cause mortality, 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 diabetes 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]. Approximately 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 vaccination 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 [compared 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 obesity, 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/nondiabetic 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.

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 populations were well represented, the proportion of people vaccinated and unvaccinated against influenza in the last 2 years was defined on the basis of the influenza vaccination coverage 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 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.

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 following 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 influenza 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 survey. 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 applicable laws. The study was conducted in line with the market 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/default/files/202409/2024%20EPHMRA%20Code%20of%20Conduct%20Final.pdf) [22]. 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, British Healthcare Business 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 guidelines and regulations.

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 status, number of people in the household, and diagnosed conditions amongst the main NCDs.

The second part consisted of questions regarding the following:

• Influenza vaccination status in the last 2 years (vaccinated in the last 2 years → vaccinated group; not vaccinated 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 information received.

• Reasons for getting/not getting vaccinated for influenza.

• General perception and experience with the influenza vaccine.

• 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 influenza 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.

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 vaccinated and unvaccinated against influenza.

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) vaccine in the last 2 years. The baseline characteristics of the subjects are presented in Table 1.

Table 1. Baseline characteristics of subjects included in the survey

	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)

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

For the Czech Republic subset, the sample included 120 individuals, of whom 36 were vaccinated and 84 were unvaccinated

Attitude About Vaccinations in General

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 vaccine 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).

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Fig. 1

Vaccinations received in the last 2 years. The dotted boxes indicate that the differences between the groups were significant

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 positive opinion than the vaccinated group. In the CZ, the difference in the proportion of people with positive opinions among those vaccinated and unvaccinated for influenza was very large, being 97% versus 53% (Fig. 2).

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Fig. 2

General opinion about vaccinations. The dotted boxes indicate that the differences between the groups were significant

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).

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Fig. 3

Reasons for receiving at least one vaccine in the last 2 years (excluding COVID-19 and influenza vaccines only)

Availability of Information on Vaccines in General

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 information 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 vaccination 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.

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Fig. 4

Information received about vaccines

Attitude Toward Vaccination Against Influenza and Information 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).

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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

In the vaccinated group within the total sample, key drivers for taking the influenza vaccination were recommendations by general physicians (GPs) (61% overall), patient initiative (31% overall), and the presence of underlying conditions that make it necessary to be protected against influenza (18%). In the CZ as well, the main drivers of influenza 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 vaccine 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).

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Fig. 6

Reasons for taking and not taking the influenza vaccine

Overall, the physician remained the most preferred and tapped resource for information on influenza vaccines, followed by dedicated websites. In the CZ, physicians, dedicated websites, and family members were the most common sources when looking for information on influenza, though the former two were highly preferred. Among those vaccinated 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).

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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

The largest proportion of the unvaccinated patients did not receive/look for information on influenza vaccines (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).

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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

Overall, additional information that the patients would like to receive on influenza vaccination is about side effects (49%), efficacy (42%), and the health complications and risks of influenza (38%). In the CZ, a significantly higher proportion of respondents compared with the total sample would like to receive information on who should not receive the influenza vaccination. Unvaccinated patients sought information on side effects and efficacy (Fig. 9).

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Fig. 9

Further information sought regarding the influenza vaccine. The dotted box indicates that the differences between the groups were significant, asterisks show significant differences between vaccinated and unvaccinated subgroups

Almost all patients with NCDs state that they are aware of influenza vaccine benefits, with reduced symptom 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 (Table 2). Nevertheless, 60% of those who were vaccinated sought more information about the influenza vaccine versus 48% among the unvaccinated group in the CZ.

Table 2. Awareness of the benefits of influenza vaccines

Awareness of flu vaccination benefits	Total sample		Vaccinated subgroup		Unvaccinated subgroup
	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 vulnerable 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)

Awareness of Flu-Related Complications

Understanding of flu-related complications is particularly widespread among patients who receive vaccines (Fig. 10).

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Fig. 10

Understanding of influenza-related complications, asterisks show significant differences between vaccinated and unvaccinated subgroups

More than 50% of vaccinated as well as unvaccinated patients in the CZ were interested in knowing more about the complications of influenza.

Experience of Suffering from Influenza in the Last 2 Years

Over one in three patients with a NCD in the overall sample, 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.

Likelihood of Getting Vaccinated for Influenza in the Future

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).

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Fig. 11

Likelihood of taking influenza vaccine in the future, asterisks show significant differences between vaccinated and unvaccinated subgroups

The main drivers for getting vaccinated in the future are physician recommendation and belief in the efficacy of influenza vaccines.

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.

Discussion

Our survey showed that, in general, the vaccination uptake in the CZ was lower than that in other EU countries. The 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 representative 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 et al. 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 acceptance 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 Republic, > 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 journals (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 importance, 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 vaccination coverage was 14.0%. The second largest group among those with NCDs were patients with COPD, with a vaccination 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 coverage 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 reasons 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 religious and cultural issues [30]. In our survey in the CZ, the main reasons for getting vaccinated were disease prevention 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 influenza vaccine were lack of belief in the need for an influenza vaccine, the treating GP not recommending it, and experiencing mild severity of influenza. The overall positive opinion 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 countries 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 following 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 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 chronically 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-European 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 interviews, the report stated that the relationship of the patient with the doctor, whether the doctor proactively shares information, and the healthcare professional’s belief in the vaccine 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 recommend 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 vaccination could be inadequate information provided by healthcare 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 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. 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 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 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 calculations 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. Furthermore, 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 epidemiological data. A final limitation is that the survey covered 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.

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-initiative. 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 common 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 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 pharmacists are other useful approaches in encouraging people to take the vaccine.

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 the European Pharmaceutical Market Research Association (EPHMRA) and British Healthcare Business Intelligence Association (BHBIA) market research codes 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 interpreting the data, and revising, reviewing, and approving the manuscript. Zdenek Zadrazil, Lenka Cesnekova, Jan Kyncl, and Zuzana Kristufkova contributed to interpreting the data and revising, reviewing, and approving the manuscript. All authors read and approved the final version.

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